دو ماهنامه سلامت کار ایران
سال هفدهم شماره 1 (فروردین و اردیبهشت 1399)

 Presently, human kind is challenging with a highly contagious disease, COVID-19, caused by a newly emerged virus, SARS-COV2. Health care providers are at the front line of fighting, as well as, at the risk of getting infected.  Many attempts have been made to combat the disease are mostly focused on hospital settings rather than outpatient settings so far. Therefore, addressing the clinics and medical offices with numerous health care workers seems necessary.

 Using keywords COVID-19  OR SARS-COV-2 OR Corona virus, AND  Infection control OR Prevention  AND ( Outpatient settings) OR clinics OR (medical offices)  AND  (health care workers)  OR (health care personnel) in  databases and pertinent sites : PubMed, Cochrane Library, Scopus, Up - to-date, Clinical Key, Google Scholar, guidelines, and health organization like  CDC, W.H.O., high impact journals, and publications of Iran ministry of health related to outpatient settings, we searched  the medical literature for all published full text articles  pertinent to medical practice in clinics and medical offices and  COVID-19 disease. We collected all pertinent data, and then organized them in a step by step guide for health care workers. 

 Based on our findings, the majority of patients (80%) with COVID-19 have mild disease and no need to primarily be admitted to hospitals. Since these patients are the source of infection, referrals to all clinics and hospitals have the risk of transmission of the infection to medical staff as well as, other non-COVID patients. They could be quarantined at home, evaluated by physicians via telemedicine, receive appropriate medical advice, and followed up regularly.
Tele visit: Tele visit via telephone or video call eliminates unnecessary public or private transportation and the risk of transmission, as well as, face to face visits and exposing health care workers and other patients to the virus. Regarding limited health care resources, face to face unnecessary visits impose dual pressure upon an already overloaded health care system. Emergency departments and hospitals should be dedicated to the remaining 20% of COVID patients with moderate to severe disease.  Signs and Symptoms: Signs and symptoms of myriads of COVID-19 patients have been assessed. 27 signs and symptoms have been found common to patients. 4 out of 27 signs and symptoms most consistent with the disease are: fever, headache, fatigue, and myalgia/arthralgia. Moreover, one of the relatively characteristic symptoms of COVID-19 disease is, sudden and recently- onset loss of smell and taste in the context of other signs and symptoms. It should be differentiated from chronic and already present loss of smell, associated with chronic diseases like nasal polyposis, chronic sinusitis and neurologic problems. Other alarming Signs and symptoms that need to be sought are: hemodynamic instability (hypotension and reduced urine output), decreased level of consciousness, and chest pain. Patients with these conditions need to be admitted to hospitals. Approaching patients with dyspnea remotely, Physicians should consider differential diagnoses like exacerbation of asthma or chronic obstructive pulmonary disease (COPD), severe pneumonia, heart failure, pulmonary embolism, pericarditis, and anxiety.Oxygen saturation evaluation:   Patients could be instructed to monitor their oxygen saturation by home pulse oximeters twice a day and report it to physicians. If oxygen saturation is 95% or more with room air, and not having other risk factors, they could remain quarantined at home. Patients with oxygen saturation of 94% or less should be visited face to face in medical centers. Elevator etiquette: If you have flu-like symptoms, do not use the elevator. Keep a distance of 1.5 meter from other riders. If the space is not enough, wait for the next turn ride or use the stairs.  Don’t touch the buttons with naked hands; Touch them with tissue paper or your elbow instead. Have disinfectant available and disinfect your hands before and after touching the buttons. Do not touch your eyes, mouth and nose after touching the buttons. Stay facing the walls of the elevator. Wash or disinfect your hands with warm water immediately after getting off the elevator in case of touching buttons.At the entrance of the clinic: Place posters, and stands with alarming and educational matters about COVID- 19 disease.  Screen all patients, as well as, companions for the signs and symptoms of COVID-19. Limit the entrance of companions to the clinic and not allow those who were exposed to COVID patients in recent two weeks. Get all patients to wear masks and disinfect their hands with alcohol based disinfectant solutions before entering the clinic.Waiting room: Limit the number of patients at the waiting room. The distance between patients should be at least two meters. Put partition between them if it is possible. Open the windows and doors 6-12 times per hour. Have disinfectant solutions in the waiting room and soap in the washing closet available to all patients. Cough etiquette: Cover your mouth and nose with tissue paper or your internal surface of your elbow in case of coughing or sneezing. Discard the tissues in dustbin after coughing or sneezing and wash your hands. Physician’s room: Use a paperless system for transmitting data medical records between physicians and secretory or para clinics. The distance between physician and patient should be at least 2 meters. Physicians should change the gloves after each visit. The disposable table cloth should be changed and the table and all the surfaces touched by the patient should be disinfected after each visit. Follow up of patients at home: Patients at home should be first followed up regularly at daily basis and then setting up the frequency and duration of follow ups based on patient health condition.Personal protective equipment: Medical staff should wear full personal protective equipment including N95 Masks, goggles, face shields, gowns and gloves.Monitoring medical and allied health care staff: Signs and symptoms of COVID-19 should be monitored regularly and the test RT-PCR should be performed every 3 days for health care workers in close contact with suspected COVID-19 patients.Return to work place : Health care personnel could return to work from 10 to 20 days after onset of the disease, provided that symptoms have resolved and had been afebrile without the use of antipyretics for at least 24 hours.   Donning andDoffing: Errors in donning and doffing have been observed even among experienced personnel. Therefore, the order of donning and doffing of personal protective equipment should be followed for prevention of infection.Nebulizers and aerosol producing procedures: Given dispersing the virus particles by nebulizers around 10 meters, nebulizers and aerosol producing procedures, should not be used routinely in clinics unless the patient is isolated, the doors closed, and the personnel out of the room. 

 COVID-19 is a newly emerged and highly contagious disease. Its diagnosis is based on multiple signs and symptoms, as well as, laboratory and imaging findings. This disease has no approved treatment and all medications are used based on clinical trials so far. Therefore, the best practice policy is prevention. One of the available facilities that could help in prevention of the disease is telemedicine. Around 80% of patients, who have mild disease, could be followed up, quarantined and managed at home and managed by telemedicine. Those at home should be monitored daily and if their condition worsened need to be admitted to special centers dedicated to COVID-19 patients. They should not be referred to all clinics or admitted to all hospital wards. Unnecessary referrals lead to spread of the infection. Hospitals and clinics are already overloaded and medical personnel exhausted. Medical personnel, as national resources should be preserved for the remaining 20% of patients with moderate to severe disease. Since health care workers are exposed to the high load of the virus and they may receive the viral load from multiple sources, their disease is often more severe, the risk of mortality and the risk of transmitting the infection to others is higher than the general population. Therefore, providing them with full personal protective equipment and monitoring their health condition is essential.

Coronaviruses are important pathogens in humans and animals. In late 2019, a new coronavirus was identified as the cause of a group of pneumonia cases in Wuhan, Hubei Province, China. The disease spread rapidly, resulting in epidemics in China and reports of sporadic cases worldwide. In February 2020, the World Health Organization (WHO) identified COVID-19, which stands for Coronavirus 2019. The virus that causes COVID-19 has been identified as the Coronavirus virus, Severe acute respiratory syndrome 2 (SARS-CoV-2), formerly known as 2019-nCoV. Coronavirus disease 2019 (COVID-19) is a name for the disease, and the virus that causes it is known SARS-CoV-2. The very rapid spread of the COVID-19 in China and in many other countries has caused fear among people across the world. The novel coronavirus outbreak declared a Public Health Emergency of International Concern on 30 January 2020. Due to the fact that one of the ways of transmitting the coronavirus is through respiration, one of the most important ways to prevent coronavirus is to use personal protective equipment, including masks, so the knowledge around the use of masks by the general public prevention COVID-19 disease transmission is advancing rapidly. Policymakers require guidance on how to use masks and how to use them for people in the community to combat the COVID-19 disease pandemic. In this article, the relevant literature to inform multiple areas include transmission characteristics of COVID-19 disease, filtering characteristics and efficacy of masks and estimated population impacts of widespread community mask use were synthesized.

In this descriptive review study was examinesd all articles on mask wear and its effect on the prevention of transmission of pandemic diseases, including COVID-19 and influenza, which were published in Farsi and English. PubMed, Web of Science, Google Scholar, Scopus and Embase databases were used to search for articles, focusing on the use of masks and the prevention of COVID-19 disease, and combining appropriate keywords (Masks, SARS-CoV-2, COVID-19, Influenza, Epidemic, Prevention and Transmission) without restricting the type of study.

Corona virus size ranges from 80 to 160 nanometers, which can help in choosing the appropriate mask and respiratory protection. Anyone who comes in close contact (less than  of two meters away) with a person with respiratory symptoms (such as sneezing, coughing, etc.) is at risk for exposure to potentially infectious respiratory particles. A main route of transmission of COVID-19 disease is likely via small respiratory droplets, and is known to be transmissible from presymptomatic and asymptomatic individuals that come out in talking, coughing or sneezing. The most common droplet size is at least 5 to 10 micrometers. SARS-CoV-2 has a high transmission potential and its transmission rate to individuals is about 2.4. Disease spread was reduced by restrict contacts of infected individuals via physical distancing, contact tracing with appropriate quarantine and reduce the transmission probability percent act by wearing masks in public. The evidence indicates that mask wearing reduces the transmissibility per contact by reducing transmission of infected droplets. Public mask wearing is most effective at stopping spread of the virus when compliance is high.  Therefore, one of the most important ways to prevent the coronavirus is to use personal protective equipment, including masks. The standard masks recommended by reputable organizations are surgical masks and N95 masks. The use of cloth masks is recommended as a last resort, and it has been stated that these types of masks are not part of personal protective equipment. Especially in people who are part of the medical staff and do patient care work. Because of the ability of these masks to protect the person is unknown, and caution should be exercised when using these masks. Ideally, these masks should be used with a protective device that covers the entire front of the face (chin and underneath) and both sides of the face. The N95 mask (American standard; equivalent to FFP2 in Europe) is recommended as a mask for health care workers who perform clinical care for patients with COVID-19 disease. So that if these people use these masks well and according to the instructions, they will not have any problems during the epidemic. In this article, the use of surgical and clean masks by medical staff in medical centers to prevent Rhinovirus infection is recommended and similar studies show that fabric masks have less filtration to the rhinovirus. The results of the above study on the use or non-use of fabric masks in the community cannot be used to control the source of coronavirus, which is a seasonal coronavirus. Another point is that wearing a mask as a source control is largely a cessation of this process, as large droplets become smaller particles suspended in the air that can spread more into the air. Homemade masks have the ability to filter out the normal range of droplets, just as they are effective in blocking droplets and particles, meaning that these masks help keep the droplets from spreading in space. There is no RCT study to evaluate the effect of masks on social transmission during a coronary heart disease. While there is evidence of a flu outbreak, the current global epidemic is a unique challenge. According to a conservative assessment of COVID-19, the initial rate of proliferation is estimated at 2.4. If the mask is used and the efficiency of the mask is 50%, this amount will be reduced to 1.35.The spread of the disease. If the spread of the disease is completely stopped, the initial rate of proliferation will be less than one. As a result, the spread of the disease ends in the community. Wearing a mask may be critical to preventing a second wave of infection in the health care system - more research is needed.

A review of the use of masks in this article showed that proper use of masks at the community level has a significant impact on reducing the rate of disease transmission among people in the community. Non-medical masks use substances that prevent the release of droplets of the required size. Non-medical masks are very effective in reducing the transmission of influenza. The results show that non-medical masks are effective in small trials in blocking coronavirus transmission and in areas and periods when the use of masks was required and widely used; the transmission of the disease has decreased in the community. People are usually infected in the early period after infection, which usually has few or no symptoms during this period. It is also suggested that the general use of cloth masks is more effective than other health strategies, distance and patient diagnosis strategies in reducing the rate of disease transmission. It is suggested that government officials and relevant organizations strongly encourage the use of masks by the public and crowded environments as a requirement to reduce disease transmission. To reduce the transmission of respiratory viral disease, the following interventions should be preferred, preferably in combination:- Frequent washing with or without side disinfectants - Create a retainer such as using gloves, clothing and a mask equipped with a filter - Identify suspicious individuals by isolating possible cases However, it has been warned that long-term routine administration of some of the evaluated measures may be contagious without the threat of disease. Health officials need to provide specific guidelines for the production, use and disinfection or reuse of facial masks and to review their distribution on a regular basis so that they do not become deficient. According to the precautionary principle, the positive effect of wearing a public mask is "scientifically acceptable but unclear." While researchers may logically disagree about the degree of reduction and flexibility of the transfer rate, it seems that the relatively low benefits due to the exponential distribution of the transfer process can be collectively profitable. Models show that wearing public masks is most effective in preventing the spread of the virus when acceptance is high. This is the situation we see with vaccines.Therefore, the use of masks should be done extensively with confidence based on this principle in society. All countries suggest that masking is a low-risk but highly potentially positive action, so that many countries with a high prevalence of the disease have been able to reduce mortality with the widespread use of masks. It is recommended that governments apply the requirements for the use of masks, and that organizations that provide public services, such as public transport providers or stores, apply the rules: "Without masks, no services are provided." These rules should be accompanied by measures to ensure that people have access to masks, possibly without problems in the mechanisms of distribution and storage of masks, and to focus on the benefits of public health. Health officials also need to provide specific guidelines for the production, use and disinfection or reuse of face masks, and review their distribution on a regular basis to avoid deficiencies. Also, clear and applicable guidelines can help increase public acceptance of the use of masks at the community level and reduce communities to the goal of ultimately stopping the spread of COVID-19.

Coronavirus Disease 2019 (COVID-19) is mainly a respiratory disease which is caused by the SARS-CoV-2 Virus. The outbreak first began in Wuhan, China, in December 2019 and then expanded globally. COVID-19 can result in illness ranging from mild to severe. However, some of the affected individuals might be asymptomatic. Symptoms of the disease may appear in as few as 2 days or as long as 14 days after exposure. The main rout of disease transmission is person to person contacts. Nevertheless, touching contaminated surfaces is also asserted to be the alternative way of transmitting the virus. Since the emergence of COVID-19 pandemic, due to the high rate of person to person transmission of SARS-CoV-2, widespread restrictions have been introduced all over the world to prevent the disease expansion. Apparently, work settings have not been exempted from these restrictions as well. The precise socioeconomic burden of the pandemic has not been precisely estimated so far, however, it apparently contributes to many adverse health- related issues in either the individuals who have to be present in their workplaces in this circumstance or the ones who must stay home. A considerable proportion of the affected individuals are working people who have to return to their workplace after the end of the isolation period. Considering the direct and indirect impacts of this situation on economic activities, it is crucial to decide on employees’ returning to work in a way that cutting the chains of transmission is maintained. In other words, while evaluating an individual’s return to work the duration of the disease transmission ought to be taken into consideration. Furthermore, this should assess the individual in terms of the disease complications which may have an impact on his performance or might make him more vulnerable to hazardous occupational exposures. The objective of this article is to carry out a review of the current guidelines about deciding on the end of the isolation and return to work of employees recovered from COVID-19.

The Google Scholar, PubMed, and Scopus databases were reviewed from 2019 to 2020.  Furthermore, other relevant websites were also scrutinized including Centers for Disease Control and Prevention (CDC), Occupational Safety and Health Administration (OSHA), National Health Service (NHS) and Iran Ministry of Health and Medical Education guidelines.

Based on this review different strategies may be pursued regarding work resumption. In many countries making decision is mainly based on CDC guidelines. However, national health policy has been the major contributing factor in defining the return to work strategies in other parts of the world. Generally, determining the timing of return to work in employees recovered from COVID-19 is mainly based on clinical symptoms (symptom-based strategy) and or Reverse Transcription Polymerase Chain Reaction) RT-PCR (test (test-based strategy). In the light of the potential limitations, deciding on choosing either symptom-based or test-based strategy should be made on a case-by-case basis. For instance, considering that RT-PCR test may remain positive for even three months after the onset of the symptoms it is likely that test-based strategy unnecessarily prolongs the period of isolation and work absence. In other words, prolonged virus shedding might not necessarily be an indicator of contagiousness or transmissibility. On the other hand, relatively high price of this molecular test alongside its inconclusive sensitivity are other factors limiting RT-PCR test. Recently, serology tests investigating antibodies (immunoglobulin G and M) have also been addressed in addition to the aforementioned assessments. Immunoglobulin G and immunoglobulin M (IgG and IgM) are usually detectable in serum after the second week of the disease but the exact duration in which these antibodies can be found following infection is not known. Notably, due to the fact that some individuals do not develop detectable IgG or IgM at all, negative serology test result does not necessarily rule out that they have previously been infected. It is noteworthy to mention that some cross reactions have been determined between SARS-CoV-2 and other types of coroviruses which might contribute to false positive serology test results. On account of current limitations of such tests, their results should be interpreted alongside RT-PCR test, otherwise they would be challenging and misleading. In the light of the fact that the risk of Covid-19 transmission is not similar for all job categories, as well as different tasks in one work setting, another factor which should be taken into account is occupational exposures. Hence, performing detailed risk assessment by experts has a vital role in deciding on work resumption. This process should be meticulously carried out on an individual basis for all specific work places and also for each job or group of jobs within a work setting. Each risk assessment should consider the environment, the task, the threat, and the available resources, as well as ongoing preventive measures such as risk elimination strategies, engineering controls (such as physical barriers or proper ventilation) and personal protective equipment. On top of that, employers should be informed about the significance of the employees’ participation in this process which can apparently guarantee the success of implementing preventive measures in the workplace. It is noteworthy that while deciding on an individual’s return to work, the severity of the disease should also be taken into consideration since a severe illness can have a considerable impact on the person’s work ability and performance. This is specially the case for those who were admitted to intensive care units (ICU) due to their critical illness. Therefore, gradual return to the previous tasks and activities, in terms of work intensity and duration, should be encouraged in such cases.

There is a general consensus on ending isolation and return to work of the recovered individuals in a 10 to14-day period after the onset of symptoms and clinical improvement in the non-test-based strategy. Regarding test-based strategy, current guidelines require two consecutive negative RT-PCR tests with at least 24-hour interval. Presently, serologic tests are not recommended for making decision about returning persons to the workplace in the guidelines. Other important factors that ought not be overlooked include detailed risk assessment and the disease severity.

Despite the unprecedented mobilization of people and resources to confront the COVID-19 Phenomenon, the identification and treatment of ever-increasing number of patients has put the health systems of many countries under an unprecedented pressure beyond their capacity. On the frontline of this battle, the employees of the health systems, especially nurses are among the people who have been impacted the most by this natural disaster. This editorial aims to have a comprehensive look at the various dimensions of the barriers and problems that nurses have faced during the pandemic. Based on investigations, early into the pandemic, shortage of preventive and diagnosis equipment, as well as low usability of personal protective equipment were the most important challenge of nursing. Nursing job characteristics have also undergone a major transformation by an adverse increase in the physical and mental workload of the profession. Moreover, nurses’ working condition has been so inevitably affected by the phenomenon’s characteristics of fear and uncertainty. This unprecedented situation has also hindered the hospitals in providing an appropriate physical environment for their patients and employees. On the other hand, in spite of having great importance, scant attention have been paid to organizational (i.e., shortage of specialized workforce, lack of training for new nurses, and inefficiency of break time) and extra-organizational (i.e., sanctions and stigma) issues. Lastly, the consequence of such difficult and grueling conditions has been various psychosomatic disorders which can be a serious threat not only to nurses’ health and quality of care, but also to the proper functioning of the health systems of countries.

 Work environments are constantly changing under the influence of various factors and newer risks are introduced. Rapid changes in science and technology, increasing the complexity of the industry, increased system integration and other factors have been shown to increase total risk in the past few decades. As well, risk management becomes increasingly critical in decreasing incidents, improving safety, and related outcomes. Risk identification is known as the heart of a risk assessment and management process. Risk assessment is a concept that outlines the way in which you Identify hazards and risk factors that are likely to cause damage (hazard identification),and evaluating any associated risks within a workplace (risk analysis, and risk evaluation). Risk assessment and management consists of an objective evaluation of risk in which assumptions and uncertainties are clearly considered and presented. This included identification of hazard (what can happen and why), the potential consequences, the likelihood of occurrence, the detectability and acceptability of the risk, and ways to decrease or reduce the probability and severity of the risk. Basically, it also involves documentation of the hazard identification, related risk assessment and its results, implementation of control methods, and review of the assessment, coupled with updates when necessary.  With this view, the COVID 19 coronavirus and people infected with it, or suspected of being infected is considered a hazard. This is because of such a person, in addition to endangering their own health, is able to infect others, and threatening their health, especially their colleagues. Given the huge population of workers in the country, their daily commute and close relationship with family and friends, and coworkers it is essentially a need to present a suitable method for identification, evaluation, and management of risks associated with such coronavirus. In this regard, the present study was designed and implemented in order to design a rapid method for assessing and managing the risk of people suspected of being infected with the coronavirus in the workplace.

 In this study, at first a framework for defining risk was introduced and appropriate criteria for hazard identification section were acquired using expert judgments. In the risk evaluation section, the number and nature of risk parameters, categorization, and descriptions of each of them with consideration to conventional risk evaluation and the opinions of experts were determined. At this stage, the opinions of experts on the importance of each criterion were collected. Then, using the single sample t-test in SPSS 21 software, important criteria were selected. Next, health risks assessment methods suitable for COVID 19 were collected and analyzed based on converging of selected criteria in hazard identification according to expert judgments and methods yielding the highest score was selected. To identify suitable accident analysis methods, related articles Searched in reputable databases such as Iran Medex, Science Database (SID)،Google scholar، Science Direct، PubMed، Scopus, and Web of Science. Keywords used included hazard identification, risk assessment and management, COVID 19, workplace, occupational, individual risk assessment, and health hazard analysis. In the following, by carefully examining the selected method and opinions extracted from experts, strengths and weaknesses of the selected methods were identified, and based on that, the proposed method "Rapid COVID Hazard Assessment", short for RCHA for workplaces application was developed. In the last step, the usefulness of the RCHA was examined by the successful application of it in six different workplaces.

 The RCHA method was introduced as the outcome of this study. In this method data sources for hazards, identification include engineering senses, knowledge management, patient history, personal interview, fever measurement, and examination of personal files. In terms of hazard identification, the introduced method is very similar to methods that benefit from a primary database such as preliminary hazard list and preliminary hazard analysis with the same pros and cons viz. low cost for employment, no quantitative data is needed, the possibility of use in the early stages of system life (early stages of disease formation), and rapid implementation. In this method, the risk obtained of multiplying three parameters included the severity of consequences, Probability of infection, and Individual health attitude level. The consequences severity parameter has four dimensions included personal life, the nature and type of workplace, Individual health status, and symptoms of Covid-19. In this parameter, each dimension has six classes, which are signed with symbols 1 to 6. Two other parameters that constitute risk has four classes with symbols of 1 to 4. The use of the three-dimensional method in risk assessment in this technique is similar to the approach used in several studies. The 3D risk matrix of this method is similar to the ones used in many well-known methods. Currently, literature reflects the fact that increasing the number of risk parameters can increase the accuracy of evaluation and provide more precise prioritization of identified risks. In the present study, due to the nature of the hazard, the targets are may be different and this issue in the analysis of risk is considered. The variety of factors take into account in estimating the severity of COVID 19 exposure is similar to the results of studies. According to research the degree of importance and therefore the weight of the risk parameters are not equal. The findings of this study also showed that the importance weight of the consequence of exposure is greater than the other two parameters. According to opinions of experts (risk assessment stage), the identified risks categorized at three levels including acceptable (X≤4), “as low as reasonably practicable- ALARP (440).In this study, 11 related methods were identified for the design of the RCHA technique. After the initial evaluations, the number of selected techniques reached 5 as follows: Health Hazard Analysis (HHA), Preliminary Hazard Analysis (PHA), Job Hazard Analysis (JHA), Healthcare Failure Modes and Effects Analysis (HFMEA) and Health Risk Assessments (HRAs). In the final step of the study, after performing the necessary training, the technique was tested separately and independently in two stages before and after in 6 units and organizations including the petrochemical industry, ceramic tile production, food production, steel, assembly of industrial parts and hospital.

 The main purpose of the present study was to introduce a simple, rapid, low-cost, and precise method for screening infected or suspected people to COVID 19 in the workplace. So, after the identification of associated criteria and methods through a comprehensive survey, the principals of that were envisaged. Application of the RCHA in six types of industry in different provinces showed that HSE professionals are able to use it to identify sensitive and infected people in the shortest (acceptable) time. Conflicts of interest: There is no conflict of interest. Funding: This study is supported by Hamadan University of Medical Sciences, Iran (grant No. 9904031915).

Considering the high prevalence and lack of standard treatment for the new coronavirus, the best way in the current situation is to avoid infection and prevent its spread. In occupational environments, especially industries, due to air pollution with dust, gases and vapors and allergens and irritants, workers are susceptible to COVID-19 infection. Respiratory exposure of workers to these contaminants can adversely affect the function of their respiratory system and predispose them to respiratory diseases. In some industrial environments, due to the nature of work, workers are forced to work close to each other or use common tools and devices, thereby increasing the risk of the coronavirus outbreaks. Due to the high population density in factories and companies, it is necessary to study the prevention of the coronavirus and application of control measures. Therefore, the present study aimed to investigate the prevention of coronavirus in industry.

This is a descriptive cross-sectional study that was performed after the pandemic of Covid-19 in April 2020. Three hundred and fifty Iranian industries were investigated in this study. In order to assess the status of Covid-19 prevention in industrial environments, a researcher-made questionnaire was used to perform the study. This study was conducted in three phases including checklist design, checklist validation and industry evaluation. The checklist questions were designed based on the latest recommendations offered by reputable international organizations. The initial questionnaire had 40 questions. To determine the validity, the questionnaire was checked carefully by a panel of experts, including 15 professors and experts in safety and emergency management. Content validity index (CVI) and content validity ratio (CVR) were also used to assess validity. Moreover, Cronbachchr(chr('39')39chr('39'))s alpha coefficient was used to determine the reliability of the questionnaire. After designing and validating the checklist, in order to maintain ethical issues and prevent theCovid-19 outbreak the completion of the checklists’ items, the checklists were prepared electronically and distributed in more than 50 social networks of occupational health professionals and HSE. The purpose of the study and how to answer the questions were fully explained to the occupational health and HSE officials. Next, the information was extracted and analyzed by SPSS software version 23.

After checking the validity of the designed checklist, 13 questions were removed and 27 questions remained in total. The results of face validity showed that the transparency, appropriateness and overall simplicity of the questionnaire were equal to 0.90, 0.93 and 0.91, respectively. The lowest and highest values of validity index were 0.79 and 1, respectively. Also, the minimum and maximum content validity ratios were, respectively, equal to 0.65 and 1. Total CVI and CVR values of the questionnaire were determined to be 0.87 and 0.92. Furthermore, based on the results of completed questionnaires by the industries, the Cronbachchr(chr('39')39chr('39'))s alpha coefficient of the questionnaire was calculated to be 0.92. The findings of the evaluation showed that the commitment of management to the implementation of prevention programs in the industries is in good condition and most of the surveyed industries have a developed program to prevent of Covid-19. However, some areas such as telecommuting, distancing, and procuring some essential items were in poor condition. It was found that only 36.4% of the industries have taken action to strengthen local and general ventilation systems and more than 90% of them have held training programs for prevention. The most and the least supplied items were related to detergents (95.1%) and respirators (37.8%). Moreover, few industries have used the teleworking protocol (48.1%) and created an isolated room (26.1%) to isolate suspicious cases in emergencies.

The results of this study showed that the designed checklist has a high reliability and can help the management of the organization in assessing the current situation to manage the prevention of Covid-19. The results of the evaluation illustrated that the commitment of management to implement prevention programs in industries is in good condition and most of the industries surveyed have a developed program to combat Covid-19. However, some areas, such as teleworking, spacing, and the provision of some essential items, were in an unfavorable position, requiring the strengthening of discovered weaknesses.

After the Covid-19 pandemic and the great threats it posed to the health of the world, many researchers have studied this field and many finding have been discovered. Extensive research and accurate information are important. In this study, the research team presented the latest findings by reviewing studies and evidence published in databases.

In this narrative review study, articles published up to December 2020 in the databases including SID, PubMed, Scopus, Web of science, Google scholar, Science direct, Up To Date, as well as WHO and CDC sites were surveyed. 653 articles were found and 63 articles were selected by removing duplicate and irrelevant items and initial evaluation of articles. After reviewing the full text of the articles, 35 articles were finally reviewed.

Covid-19 pandemic has affected many countries in the world, including Iran. According to global statistics, the mortality rate is 3.4% for this disease. Early symptoms of Covid-19 include pneumonia, fever, muscle aches, and fatigue. To date, no successful vaccine or antiviral drug for this disease has been clinically approved and available. Therefore, prevention and control of infection and observance of hygienic principles by the general public is a priority.

Epidemic and new virus control of Corona virus family has become a health crisis in the world, but due to prevention methods and management of effective factors in its transmission, it can be prevented. Given the origin of Covid-19 disease, it seems that the nutritional and health recommendations of Islam, especially halal food and hygiene should be considered more than ever. It is very important not to create stress and anxiety among the people, to advise and educate the people to observe the principles of health and to keep the people calm to deal with this disease. It is hoped that the prevention, control and treatment of Covid-19 disease will be achieved through the production of vaccines and drugs as well as health care measures in the near future.

COVID-19 is one of the most dangerous pandemics of the 21st century, which has caused disease in humans and has had various consequences for humans. One of the most at-risk groups are bank employees. Therefore, this study was conducted to investigate the predictors of protective behaviors against COVID-19 in bank employees of Sirjan.

This descriptive-analytical cross-sectional study was conducted in 2020 in Sirjan. The participants in this study were 280 bank employees who were selected randomly. The data collection tool was a questionnaire in three sections, including demographic information, knowledge, and questions related to the Protection Motivation Theory, which was self administered. After collecting the data, descriptive tests (frequency and percentage), Pearson correlation and linear regression were used to analyze the data in SPSS 23.

The mean age of participants was 41.6±2.16 years. The results of correlation coefficients showed that there was a significant correlation between perceived susceptibilityand perceived severity. However, it should be noted that there were positive correlations between protection motivation with perceived susceptibility (r = .414, P <0.001), perceived severity (r = .354, P <0.001), response efficiency(r =. 411, P <0.001), self-efficacy (r = .508, P <0.001), and fear (r = .484, P <0.001),; and negative correlations between response costwith rewards (r = -. 104, P = <0.05) and response cost(r = -. 237, P = 0.002) . According to the linear regression test, 0.585 percent of protection motivation was predicted by perceived susceptibility and severity, response efficiency, self-efficacy, fear, among which the role of perceived fear (β = 0.28) was stronger than other variables.

The results of this study showed the effectiveness of the application of the protection motivation theory in predicting the behaviors for preventingCOVID-19. Therefore, these structures, especially the perceived fear structure can be used in the development of educational programs and intervention techniques to change the attitude and behavior of bank employees.

Recently, the respiratory acute syndrome or Covid-19 disease has been become as one of the most important concerns in the national and global level. Covid-19 disease is caused by the virus SARS-CoV-2 or Covid-19. Covid-19 virus is spreading through saliva drops or nasal discharge when coughing or sneezing. Covid-19 disease not only has significantly negative affect on the general health of the society but also on job activities of the people like business, economy and industries activities so that outlook of this disease create stress and concern for the workers and employees about the affecting this disease in the workplace and this stress can be transferred to other workers, family and customers.  Occupational Health and Safety Administration (OSHA) has classified the workplaces into 4 categories in terms of potential of disease: very high risk, high risk, intermediate risk and low risk. Jobs classification include: 1. Very high exposure risk jobs are those with very high potential to meet the discovered cases or suspected of Covid-19 disease during medical cares, after death or during clinical experiments like healthcare stuff and laboratories stuff. 2- High exposure risk jobs: jobs with high potential and lower than previous class jobs to meet the discovered cases or suspected of Covid-19 disease like healthcare and support services employees, medical transportation and funeral workers. 3. Medium exposure risk jobs: jobs where workers are in repeated contact with other workers, public or in close contact with people those possibly with Covid-19 disease but are not diagnosed as suspected ill. These jobs include schools, some crowded retails and activities with high population density. 4. Low exposure risk jobs:  jobs where workers are not in close and continuous contact with other works, public or people suspected of Covid-19 disease. The work international organization announced people who are affected to Covid-19 in the workplace must have access  to healthcare and treatment services including usual medical cares, specialized cares( inside and outside of the hospital) pharmaceutical , hospital and medical rehabilitation services. On the other hand, since no vaccine or certain treatment is known for this disease till now, the best way to prevent and decrease this disease is to raise the awareness and information about this virus, how this disease is created and how it spreads.so, the present study was conducted with the aim of determining the hygienic performance and effect of training in order to confronting with the Covid-19 virus in the metal industries staff.

This analytical-descriptive study is cross-sectional in terms of time. 5 metal industries were studied by the census method in Isfahan province (3 industries) and Chaharmahal and Bakhtiari province (2 industries). The studied units include employers and directors, administrative, production, Facilities (Technical) and services stuff. To collect data, researcher-made checklist was used to evaluate the personal hygienic of stuff and to evaluate the industry environment and building, environment checklist was used. Totally 569 stuff and 11 checklists were studied to consider environmental health status in the studied industries buildings. Research team was composed of 2 experts. One expert was required to study the personal health of stuff and buildings environments hygiene and the other was responsible to teach stuff. The education subjects included properties of Covid-19 virus, symptoms of affecting to disease, disease transmission methods, methods of preventing the spread of the disease and importance to observe the personal health and the correct method to use the mask and gloves. After studying the personal health by the checklist, stuff specially who did not observed the personal health were trained for 10-15 minutes. Training was performed face to face while observing the hygienic protocols and standard physical distance. In order to study the effect of training in the personal health observance, the studied industries were referred after 3 weeks and personal health checklist was completed for all workers participating in the research. Data analysis was performed by the SPSS 21 software and paired-samples T-test.

The total studied stuff was 569 persons, 7.38% were women and 92.62% were men. The age average of stuff was 36.7± 8.31 years and 81.27% were married. Before training, 23.73% of stuff used mask and gloves and 30.93% just used mask. Also 78.21% observed the appropriate distance with others and 76.8% observed using personal devices or common surfaces disinfectant solution and 31.46% had hand disinfectant solution. But after training, the personal health observance was raised significantly so that the significant relation (PValue<0.001) was obtained between before and after training personal health observance. Table 1 shows the results of studying stuff personal health after and before of training. Table 1. Results of studying stuff personal health after and before of training variable   amount Using the personal protection devices (n=569)   Observance of physical distance (n=569) Personal devices (pencil, pen, etc.) (n=569) Hand disinfectant solution (n=569) Only mask Only gloves Mask and gloves None Distance observance Lack of observance use Lack of use Having personal solution No having personal solution Frequency percentage (frequency) before the training 30.93 (176) 28.64 (163) 23.73 (135) 16.7 (95) 78.21 (445) 21.79 (124) 76.8 (437) 23.2 (132) 31.46 (179) 68.54 (390) Frequency percentage (frequency) After the training 47.62 (271) 4.38 (25) 37.1 (211) 10.9 (62) 81.9 (466) 18.1 (103) 87.7 (499) 12.3 (70) 59.23 (337) 40.77 (232) PValue <0.001 0.003 <0.001 0.002 <0.001 <0.001 <0.001   Results of the environmental health study suggested that cases like 1. Personnel fever test when coming factory, 2. Installment of Covid-19 dealing with disease training poster and stand, 3. Training personnel about this disease, 4. Instruction installation of washing hands in WC, 5. Preparation of enough detergents, disinfectants and cleaning equipment, 6. Existence of ventilation system in WC, 7. Preventing presence of workers suspected of Covid-19, 8. Use of special personnel as responsible for cleaning and disinfection, 9. Using mask, gloves, and work cloth of personnel when cleaning and disinfecting, 10. Observance of method of cleaning and disinfecting instruction, 11. Separation of napkin bucket and cleaning and disinfecting supplies from other devices and parts, 12. Discharge of buckets at the end of work shift, 13. Using of personal items for prayer, 14. Existence of liquid soap piping system with contained having hand washing liquid, 15. Keep doors and windows open, 16. Deactivating finger presence and absence system in more than half of studied saloons were observed. While other cases of observing environmental health including 1.workerschr('39') blood oxygen test when entering the factory (9.1%), 2. Installment of dealing with Covid-19 environmental control guide (18.2%), 3. Daily Cleaning and disinfecting (45.45%), 4. Collecting rubbishes in the pedal bucket with lid (45.45%), 5. Availability of first aid box (27.27%), 6. Removing water coolers (0), 7. Placing hand disinfecting solution in the entrance of buildings and next to elevators (36.36%), 8. Existence of smart toilet or foot pedal faucet (9.1%) was less observed.

More than half of workers observed the personal health but increasing their information about these diseases, methods of transmission and preventing outlook of it caused workers to pay more attention to preventive actions and follow personal health instructions seriously. Also environmental health actions in the studied industries buildings were observed but were not observed in some cases due to lack of awareness or economic problems of industrial factory. So, to achieve the best performance in control and decreasing the Covid-19 disease, 3 essential actions are required: 1. Preparation of health supplies (like: mask, gloves, disinfectant solution) and delivering the health supplies to the workers daily 2.  Training workers about the correct method of using the health supplies 3. Supervising use of the health supplies and implementation of health protocols. It should be noted that since Covid-19 disease is a new and unknown disease, training about this disease should be continuously performed and according to updated information.

The outbreak of COVID-19 is currently a major concern, and timely understanding of peoplechr('39')s mental health status in the workplace has become an important issue. Physical-psychological parameters such as mental workload and job stress are among the most important components in determining the job performance of employees in work environments. This study aimed to evaluate the effect of COVID-19 epidemic on job stress and mental workload of employees in a chemical industry.

This longitudinal study was conducted in two stages (before and during the COVID-19 outbreak in Iran) from December 2019 to May 2020 in a chemical industry in Bushehr province. It should be noted that the first phase of this study was conducted before the outbreak of coronavirus in the form of a cross-sectional study. However, after the outbreak of coronavirus and in order to investigate the changing trend in the parameters of mental workload and job stress among participants, this study was performed in two stages in the form of a longitudinal study.  The statistical population included all employees working in a chemical industry. The sample size was calculated using Cochranchr('39')s formula with an error level of 0.05 and included 182 workers who were selected by simple random sampling method. The inclusion criterion was having at least one year of work experience and exclusion criteria were the presence of chronic mental illness, the use of sedatives, and insufficient willingness to participate in the study. Participants were able to drop out of the study at any stage if they were unwilling. Before starting the study and completing the questionnaires, all the necessary information about how to complete the questionnaires was explained to the staff and they expressed their willingness to take part in the study. However, to prevent a decrease in the number of participants in the study, the number of employees who entered the study included 200 people (182 people + 10% of the total sample size (18 worker)). The NASA-TLX mental workload questionnaire and the HSE job stress questionnaire were used to evaluate mental workload and job stress, respectively. The data collected during the present study were analyzed using IBM SPSS statistical software version 25. The Kolmogorov-Smirnov test was used to test the normality of data distribution. The findings of this statistical test showed that the distribution of data was normal in all cases (p >0.05). Descriptive statistics (mean, standard deviation, frequency) were reported and statistical analysis was performed using paired sample t-test (to compare the mean of characteristics of the two psychological components of mental workload and job stress before and during the outbreak of coronavirus) as well as Chi-Square / Fisherchr('39')s exact test. All tests were performed at a significance level of 0.05.

The means of age and work experience of the subjects were 32.88±9.53 and 9.45±4.23 years, respectively. The results of mental workload assessment based on the NASA-TLX index showed that the mean score of mental workload before and during the prevalence of coronavirus disease was 56.32± 9.58 and 66.45±11.82, respectively, and  that there was a significant relationship between these values (p <0.05). Furthermore, a significant correlation was observed between the mean score of the dimensions of mental demand, overall performance, and frustration level before and during the outbreak of coronavirus. It was also found that the average score of all aspects of mental workload, except for temporal demand and overall performance, increased during the outbreak of coronavirus. The greatest increase was observed in the values of mental demand components and frustration level (Table 2). The results of the job stress assessment showed that the mean score of job stress before and during the outbreak of coronavirus disease was 80.78±18/29 and 68.88±12.74, respectively. Moreover, it was found that the prevalence of coronavirus disease significantly increased the job stress level of employees (p <0.05). Ultimately, these findings showed a significant relationship between the values of mental workload and job stress in employees before and during the coronavirus disease (p<0.05).

An examination of peoplechr('39')s mental workload based on the NASA-TLX index revealed that the prevalence of COVID-19 significantly increased the mental workload of the studied staff. It was found that the mean values of the dimensions of mental demand and the frustration level were significantly increased at the time of the outbreak of COVID-19. The findings revealed that the prevalence of COVID-19 had increased the level of mental workload imposed on employees, as well as the level of frustration, insecurity, and stress of employees when performing their duties. It was also found that the COVID-19 epidemic significantly reduced employee performance, making staff less satisfied with their overall performance in the workplace. Previous studies have also shown that the spread of viral diseases can increase a personchr('39')s workload, which is consistent with the results of the present study. The study revealed that occupational stress levels increased during the outbreak of coronavirus. Previous studies have shown that the spread of viral diseases such as Mers and COVID-19 increases the level of anxiety, stress, insomnia, and depression among people. A study by Kim et al. revealed that after the outbreak of viral diseases such as Middle East Respiratory Syndrome (MERS-COV), a personchr('39')s level of burnout and stress increased, which could severely affect a one’s job performance, which is in tandem with the results of the present study. The present study was conducted for the first time to investigate the effect of coronavirus outbreak on physical-psychological components in the industrial sector in Iran. Therefore, the results of the present study can provide a novel insight into the impact of coronavirus epidemic on the components of mental workload and job stress in different work environments. The findings of the present study revealed that the prevalence of coronavirus disease has been able to affect different physical and psychological dimensions of personnel in the workplace. Therefore, psychological intervention is essential to improve the mental health of employees during and after the COVID-19 epidemic.

Over the past year, millions of people around the world have infected with the COVID-19 virus. The SARS-CoV-2 replicate efficiently in the human upper respiratory tract. Infected people produce large amounts of the virus in their upper respiratory tract during an introductory period, which leads to more spread of the virus to other people. The World Health Organization has suggested that acute respiratory syndrome SARS-CoV-2 is transmitted through person-to-person transmission and contact with contaminated surfaces. However, the rapid spread of the disease suggests that other routes, such as airborne transmission, may play a role. Several research studies have been performed to evaluate the possible transmission of the virus through the air. Although some studies have found no evidence of airborne transmission, recent work has confirmed the presence of SARS-CoV-2 even in public places. Past experience and knowledge of the mechanism of similar viruses such as SARS-CoV also support this hypothesis.  During COVID-19 pandemic, while the hospitals can be one of the most important centers in providing health care services, due to the inappropriate air ventilation and purification system, high traffic of people; some of them have been introduced themselves as one of the most high-risk sources of SARS-CoV-2 transmission. The present study aimed to assess the SARS-CoV-2 in the air and surfaces of ICU ward in one of the designated hospitals in Tehran; so that in addition to determining the possibility of inhalation and contact exposure in ICU, which is the main ward for presenting special medical care to patients with severe acute respiratory infections, it aimed to assess a hypothesis of SARS-CoV-2 airborne transmission.

This cross-sectional experimental study was performed on April 29, 2020 in the Covid-19 ICU ward in one of the designated hospitals, Tehran, Iran. The area of ward was 50 m2 and has seven beds, all of which were occupied at the time of sampling, and five medical staff were involving there. All patients were equipped with oxygen masks and all the staff used all conventional personal protective equipment such as Honeywell-75FFP100NL respirators. On average, surface disinfection was performed three times a day. The general ventilation system included the ceiling diffuser to supply fresh air into the room and wall-mounted exhaust vent and did not use natural ventilation (such as opening the window). It should be noted that the exhaust system didnchr(chr('39')39chr('39'))t work well at the time of sampling. This study was carried out in two phases including surface and air sampling. Impinger method was applied to air sampling. Thus, at a distance of 1.5 to 1.8 meters from the ground, the air of the ICU ward was passed through a sampling pump with an flow rate of 1.5 l/min into the porous midget impeller-30 ml containing 15 ml of virus transmission medium (PVTM) for 45 minutes. To reverse the presence of SARS-CoV-2 in air samples, the reverse polymerase chain reaction (RT-PCR) reaction method was used. Sampling of surfaces was done with the help of swabs impregnated with the solution of the Viral Transport Medium from a certain area (25 cm2) from the desired part and putting it inside the vial containing the transfer medium (protein stabilizer, antibiotic and buffer solution). They are also were analyzed by RT-PCR technique. Prior to sampling, all laboratory equipment used was sterilized and autoclaved using a 70% alcohol solution according to the US Centers for Disease Control and Prevention (CDC) protocol. The air sampling was done at a distance of 1.5 to 2 meters from the patientchr(chr('39')39chr('39'))s bed. The devices used to measure temperature, humidity and air velocity were multi-purpose anemometer (China BENETE, GM8910,) and air pressure, digital barometer (AIRFLOW, DB2, USA). The mean parameters of weather conditions included: air temperature 24 ° C, humidity 35%, air pressure 1005 mb and air velocity of 0.09 m / s.

Of the ten air samples, 6 were positive (60%), with the highest RNA concentrations observed at the point between beds 6 and 7 (3913 copies per ml). Most of the reported negative air samples were from the middle of the ward, which was further away from the patientschr(chr('39')39chr('39')) beds. The mean RNA concentration of the virus was obtained 820 ± 2601 copies per milliliter. Also, of ten samples taken from different surfaces of the ward, 4 samples were positive (40%) and the highest concentration (8318 copies per ml) was related to the table next to bed number 3. All positive samples were observed close to the patientchr(chr('39')39chr('39'))s bed, and the mean RNA concentration of the virus was 3227 ± 3674 copies per milliliter.

The results of the study indicated that the virus was present in the inhaled air of the ward and its surfaces, especially in areas close to the bed of patients. These findings underscore the airborne transmission of the virus along with other ways of transmission, such as person-to-person contact and contact with contaminated surfaces. Due to the environmental pollution of the studied ICU ward to the SARS-CoV-2 virus, the effective implementation of air isolation methods such as the use of respiratory protection equipment (N95 mask) and powered air-purifying respirator as well as ensuring the correct function of hospital ventilation systems and improving it, is essential for the protection of health care staff. Health care workers need to be continuously monitored and screened from a COVID-19 perspective, and infection prevention and control protocols (IPCs), such as respiratory protection, regular cleaning of the environment, and effective disinfection of areas have been implemented. In the case of the virus, the spread of the disease through both direct methods (drops and person-to-person) as well as indirect contact (contaminated objects and airborne transmission) has almost been proven, which reaffirms the need for precautionary measures regarding airborne isolation against the virus. It  has been suggested that in order to more accurately assess the transmission behavior of the virus, similar studies but longitudinal ones have been done from the admission to discharge of the patients  in different wards of the hospitals, moreover, the role of natural and mechanical ventilation systems more comprehensively examined in the presence of airborne virus.

Nowadays, Covid-19 is considered as a pandemic. According to the World Health Organization (WHO), as of March 25, 2020, in more than 156 countries, about 664,731,000 new cases of the disease and 30,892 deaths were reported. Iran is one of the countries with the highest incidence. Although there is a possibility of occupational accident in all health care provision environments, the offices is the main dangerous health care provider in terms of occupational infections in health systems. Ensuring the safety of employees in offices is not only crucial in protecting them against the virus but also in preventing the transmission of the virus. Protective behaviors are effective in prevention of occurrence of the disease. Protection motivation theory (PMT) helps to understand preventive behaviors better and can be used in occupational injury training programs. Considering the importance of identifying the factors of the preventive behaviours of Covid-19 in the development and implementation of preventive programs, this study was conducted for predicting the preventive behaviour againt Covid-19 based on the PMT among employees in crowded offices in Qom, Iran.

In this cross sectional study, 232 employees in crowded offices in Qom, Iran have been selected using random clustering sampling method. Data collection instrument included demographic characteristics,  protective behaviors against Covid-19, and PMT scale. The PMT constructs were assessed by questions composed and 7 subscales as follows: perceived vulnerability (2 items); perceived severity (2 items); perceived fear (2 items); self-efficacy (3 items); response efficacy (3 items); response cost (2 items); and protection motivation (1 items). The items were rated on a five-point scale ranging from 1 (strongly disagree) to 5 (strongly agree). According to the theoretical assumptions, the threat appraisal score is the sum of the perceived susceptibility and severity scores. Also, the coping appraisal score is the sum of the self-efficacy and response efficacy scores minus the response cost score. Eight items scale by a three-point rated ‘always’, ‘sometimes’ and ‘never scored 2, 1 and 0, respectively measured Covid-19 preventive behaviours. The validity of the scale was confirmed using the viewpoints of health-education experts. The reliability of the scale was investigated by calculating internal consistency. Data have been analyzed via descriptive statistics and structural equations through SmartPLS statistical software. In the structural model, path coefficient, and R square were used to measure relationships among constructs. The predictive power of the model was examined by calculating Q2 indexes of behavior. Finally, a goodness of fit (GoF) index was calculated to display the model fit to the model.

Mean and standard deviation of participants’ age has been 39.8 8.7; and, 90.1% of them have been male. More than half of participants (53.8%) have shown protective behaviors higher than average. There has been a significant relationship between coping appraisal and protection motivation ( =0.297 and p-value˂0.05). However, there has been no significant relationship between threat appraisal and fear constructs and protection motivation ( =0.060 and p-value>0.05). Also, there has been significant positive relationship between protection motivation and protective behaviors ( =0.214 and p-value˂0.05). Fit indices of the model have been desirable and the model could predict overall 5% of changes in performing protective behaviors. GoF was 0.503, indicating the model good fit.

According to the results, coping appraisals were identified to be the significant positive associations with protection motivation. Contrary to the expectations based on the PMT, it is generally seen that none of the threat appraisals (severity, vulnerability, and fear) predicted protection motivation and preventive behaviour against Covid-19. Protection motivation is predictor factor of the protective behaviors. The results can be used in formulating training programs to optimize protective behaviors among employees working in offices.

Health economics is a branch of economics science and has a great share in the economic situation of countries. Hospitals, as the largest, main and most important center for providing health care, occupy a large part of the resources, so the information related to costs in hospitals is one of the most important inputs in the decision making process. Today, costs are rising, so if hospitals do not work to increase their own revenue and reduce running costs, they will certainly face a serious challenge. Currently in Iran, while the economic situation of the society does not seem to be very favorable due to the oppressive sanctions, the outbreak of Covid-19 disease has also had a negative impact on this trend and has provided hospitals with their costs have run into problems. Factors such as allocating some hospitals as a reception center for Covid-19 patients, non-receipt of money from hospitalized patients, duration of treatment, the need for follow-up after discharge of patients and the construction of convalescents has been increase the costs of medical centers. On the other hand, the cancellation of elective surgeries, the provision of personal protective equipment, ‌ providing facilities and welfare facilities for medical staff and the need to pay attention to various aspects of public health and public education, ‌ has reduced their income. This disruption in the process of production and consumption of financial resources in medical centers can cause problems for the health system. The effects of this epidemic are not limited to the period of its outbreak and is one of the issues that can remain on the health economy for a long time and have adverse effects. One of these is the negative attitude of the community towards Covid-19 reference hospitals, which causes hospitals to have low incomes long after the epidemic. Considering that patientschr(chr('39')39chr('39')) preference is quality and safety of care services and consequently in choosing a hospital for hospitalization and treatment, the contagious and dangerous label of this disease can damage the safe image of the reference hospitals. In addition to patients, medical staff must care in a completely safe environment and have the necessary and sufficient focus on treating patients. One of the most critical factors that can play an important and active role in increasing safety is the availability of facilities and resources needed for care. Financials can negatively affect the performance of care team staff. Due to the limited financial resources of the hospitals that are selected as the center of Covid-19, this lack of financial resources can have a great impact on staff payments and cause their dissatisfaction. High workload during this period and financial pressures on personnel can cause burnout and mental fatigue along with their physical fatigue and endanger their health. This in itself can indirectly affect the quality of service they provide. Staff fatigue, especially in the long run as a result of these conditions can affect their concentration and ability to work and therefore will be affected the quality of care delivery. Since staff satisfaction and quality of work is a multidimensional phenomenon that can be affected by various factors such as workplace stress and regular payments, so health organizations should consider these issues. It seems necessary that the relevant officials in the Ministry of Health, by forming specialized working groups in the fields of psychology, sociology and health economics, act as soon as possible to control the stigma caused by the disease rather than harm. Prevent deadly effects on the health of the country. In this regard, educational interventions are suggested along with launching social campaigns to increase awareness and improve community attitudes and thus eliminate the stigma of Covid-19.