key: cord-0784224-pk9oxdyt authors: Ogundele, I. O.; Alakaloko, F. M.; Nwokoro, C. C.; Ameh, E. A. title: Early Impact of COVID-19 Pandemic on Paediatric Surgical Practice in Nigeria: a National Survey of Paediatric Surgeons. date: 2020-05-25 journal: nan DOI: 10.1101/2020.05.24.20112326 sha: 70ccc3ca00a1c5d1a7ddd92c646cf46d2e44b493 doc_id: 784224 cord_uid: pk9oxdyt Introduction The novel Coronavirus disease has had significant impact on healthcare globally. Knowledge of this virus is evolving, definitive care is not yet known, and mortality is increasing. We assessed its initial impact on paediatric surgical practice in Nigeria, creating a benchmark for recommendations and future reference. Methods Survey of 120 paediatric surgeons from 50 centres to assess socio-demographics and specific domains of impact of COVID-19 on their services and training in Nigeria. Seventy four surgeons adequately responded. Responses have been analysed. Duplicate submissions for centres were excluded by combining and averaging the responses from centres with multiple respondents. Results Forty-six (92%) centres had suspended elective surgeries. All centres continued emergency surgeries but volume reduced in March by 31%. Eleven (22%) centres reported 13 suspended elective cases presenting as emergencies in March, accounting for 3% of total emergency surgeries. Nine (18%) centres adopted new modalities for managing selected surgical conditions: non-operative reduction of intussusception in 1(2%), antibiotic management of uncomplicated acute appendicitis in 5(10%), more conservative management of trauma and replacement of laparoscopic appendectomy with open surgery in 3(6%) respectively. Low perception of adequacy of Personal Protective Equipment (PPE) was reported in 35(70%) centres. Forty (80%) centres did not offer telemedicine for patients follow up. Twenty-nine (58%) centres had suspended academic training. Perception of safety to operate was low in 37(50%) respondents, indifferent in 24% and high in 26%. Conclusion Majority of paediatric surgical centres reported cessation of elective surgeries whilst continuing emergencies. There is however an acute decline in the volume of emergency surgeries. Adequate PPE need to be provided and preparations towards handling backlog of elective surgeries once the pandemic recedes. Further study is planned to more conclusively understand the full impact of this pandemic on children's surgery. Key words pandemic, COVID-19, children's surgery. Results Forty-six (92%) centres had suspended elective surgeries. All centres continued emergency surgeries but volume reduced in March by 31%. Eleven (22%) centres reported 13 suspended elective cases presenting as emergencies in March, accounting for 3% of total emergency surgeries. Nine (18%) centres adopted new modalities for managing selected surgical conditions: non-operative reduction of intussusception in 1(2%), antibiotic management of uncomplicated acute appendicitis in 5(10%), more conservative management of trauma and replacement of laparoscopic appendectomy with open surgery in 3(6%) respectively. Low perception of adequacy of Personal Protective Equipment (PPE) was reported in 35(70%) centres. Forty (80%) centres did not offer telemedicine for patients follow up. Twenty-nine (58%) centres had suspended academic training. Perception of safety to operate was low in 37(50%) respondents, indifferent in 24% and high in 26%. Conclusion Majority of paediatric surgical centres reported cessation of elective surgeries whilst continuing emergencies. There is however an acute decline in the volume of emergency surgeries. Adequate PPE need to be provided and preparations towards handling . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 25, 2020. . https://doi.org/10.1101/2020.05.24.20112326 doi: medRxiv preprint 3 backlog of elective surgeries once the pandemic recedes. Further study is planned to more conclusively understand the full impact of this pandemic on children's surgery. Key words: pandemic, COVID-19, children's surgery. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 25, 2020. . https://doi.org/10.1101/2020.05.24.20112326 doi: medRxiv preprint Anecdotal evidence suggests that elective surgeries in children have been suspended due to COVID-19 pandemic. Our study shows that most centres have suspended elective surgeries. All centres continued emergency surgeries but the volume reduced by 31% in March 2020. Moreover, 3% of the emergency surgeries were some of the suspended elective cases presenting as emergencies. Almost 20% of centres have newly adopted non-operative modalities for managing selected emergency surgical conditions. This data shows an urgent need for consensus guidelines for emergency services and protocols for handling backlog of elective surgeries in children once the pandemic recedes. Outcome of the modifications in treatment may be subject to future research. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 25, 2020. pandemic on their practice in the initial stages of the outbreak. Data obtained would be used for recommendations and future reference. Relevant information was obtained from paediatric surgeons (consultants and senior registrars) currently practising in Nigeria, using a pre-tested questionnaire designed on Microsoft Word version 10 (Microsoft Seattle, WA, USA) and transcribed to google form. The questions were based on 5-point Likert scale (Strongly agree, agree, neither agree nor disagree, disagree, strongly disagree). We circulated the forms to the predetermined group of specialists by email and online chat rooms and kept them open from 10th to 17th April 2020. Daily reminders were also sent. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 25, 2020. . https://doi.org/10.1101/2020.05.24.20112326 doi: medRxiv preprint Participants were required to provide socio-demographic data, information on patient traffic and decision on management of specific conditions, availability of PPE, impact on surgeon's psyche, their academic programs and institutions infrastructure. A total of 120 paediatric surgeons were sent the survey. Eighty-three paediatric surgeons responded but 74 were adequately completed. For the purpose of analysis, the 5-point Likert scale was reduced to 3 points (Agree, neutral, disagree). Duplicate submissions for centres were excluded by combining and averaging the responses from centres with multiple responses. Responses were analysed using SPSS version 22 and presented as categorical data and percentages. This research was done without patient involvement. Patients were not invited to comment on the study design and were not consulted to develop patient relevant outcomes or interpret the results. Patients were not invited to contribute to the writing or editing of this document for readability or accuracy. University Teaching Hospital, Sagamu, Ogun State, Nigeria (OOUTH/HREC/339/2020AP). The response rate was 74(61%). The 74 completed responses represented 50 centres across the country. Table 1 shows the socio-demographic characteristics of respondents. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 25, 2020. . https://doi.org/10.1101/2020.05.24.20112326 doi: medRxiv preprint . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 25, 2020. . https://doi.org/10.1101/2020.05.24.20112326 doi: medRxiv preprint 8 Twenty (40%) centres suspended their elective surgeries less than 2 weeks prior to the survey in April, 26(52%) centres stopped a month earlier and 4(8%) had suspended their elective list for over a month. Eleven (22%) centres reported at least one of the elective cases suspended due to COVID-19 pandemic presenting as emergency in March. There were 13 of such patients accounting for an estimated 3% of the total emergency surgeries for the month. They included inguinoscrotal hernias (10) with obstruction, sub-acute appendicitis (2) and previously decompressing anovestibular fistula with intestinal obstruction (1). Nine (18%) centres have newly adopted non-operative modalities for managing selected surgical conditions in response to the pandemic. One (2%) centre adopted non-operative reduction of intussusception while 5(10%) centres adopted management of uncomplicated acute appendicitis with antibiotics and 3(6%) took a more conservative approach to management of trauma. Three (6%) centres replaced laparoscopic appendectomy with open surgery. Protocol for the management of urgent cases such as cancers, symptomatic hernias in the early period of COVID-19 was to continue to immediately operate in 31(62%) centres, delayed intervention in 12(24%), masterly inactivity in 2(4%) and follow up in 5(10%). Paediatric surgeons' perception of safety to operate during the pandemic and their willingness to operate on COVID-19 positive patients are shown in figure 2 . Perception of safety to . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 25, 2020. Fifty-seven (77%) agreed to a need for paediatric surgeons to have additional training in management of surgical patients during epidemics, 6(8%) were neutral, while 11(15%) disagreed. Those willing to attend such training were 47(64%), 15(20%) were neutral and 12(16%) were unwilling. Twenty-nine (58%) centres had suspended academic training during the pandemic, 13(26%) engaged "WhatsApp" chat rooms, while 3(6%) made use of Video-conferencing and 5(10%) still carried out their academic training through physical meetings but with social distancing. Pandemics usually run ravaging course with unpredictable health, social and economic disruptions (4) . The impact can be difficult to assess and is an area of active research. While . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 25, 2020. This has sparked various adaptations in healthcare responses and management, with unpredictable outcomes heightened by depletion of resources. For example, the only paediatric surgery care facility in Liberia run by Médecins Sans Frontières (MSF) has been temporarily suspended due to travel restrictions (12) . Children are more susceptible to viral respiratory diseases but ironically, statistics on COVID-19 have shown low incidence in this age group. An analysis of 72 314 cases of COVID-19 from the Chinese Centre for Disease Control and Prevention showed a low incidence in children with those younger than 10 years accounting for only 1% of cases (13) . A recent observational cohort study of 36 children with COVID-19 found that all the patients had mild (47%) or moderate (53%) type of COVID-19 with large proportion (28%) being asymptomatic (14) . This clinical pattern of COVID-19 in the paediatric population could make children important facilitators of viral transmission, and may thus place providers of health care in them at increased risk of infection (14) (15) (16) . . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) 1 1 Our survey showed that majority of the paediatric surgeons have stopped operating on all elective conditions in both public and private tertiary health institutions to minimise contact with potential carriers of the virus and conserve resources. This is consistent with the American College of Surgeons COVID 19: Elective Case Triage Guidelines for Surgical Care which recommended that surgery should be performed only if delaying the procedure is likely to prolong hospital stay, increase the likelihood of later hospital admission or cause harm to the patient (17) . A recent article recognises the higher frequency of highly symptomatic patients on the elective operation list in LMICs compared to HICs but still advocates that truly elective operations should be postponed to preserve PPE, staff and facility capacity as important resources during a surge response (18) . The ACS advocates that "children who have failed attempts at medical management of a surgical condition should be considered for surgery" (17) . Our study revealed an increased uptake of non-operative management of some surgical conditions such as intussusception, uncomplicated appendicitis and some cases of trauma. This modality of care was probably adopted to reduce exposure to surgery during the pandemic. Outcome of these modifications in management protocol may be subject to future research. Some suspended elective cases had presented as emergencies. They included incarcerated inguinoscrotal hernias, sub-acute appendicitis and previously decompressing anovestibular fistula that developed partial obstruction. This is an indirect impact of the pandemic due to reduced assess to routine care in these patients. Official tele-medicine platforms for follow up care of patients may aid early detection of complications or other needs for hospital visits while elective surgeries remain suspended, outpatient clinics locked down and patients are being given long appointments. Few centers in our survey have an official tele-medicine platform for follow up care of patients especially during this period of covid-19 pandemic. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 25, 2020. . https://doi.org/10.1101/2020.05.24.20112326 doi: medRxiv preprint 1 2 The ACS recommends that tele-medicine and tele-consult services should be used for patient and physician interaction when available (19) . In this report, all centres continued to operate on emergencies and there was consistent . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 25, 2020. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 25, 2020. . https://doi.org/10.1101/2020.05.24.20112326 doi: medRxiv preprint Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease-2019 (COVID-19): The epidemic and the challenges COVID-19 infection: Origin, transmission, and characteristics of human coronaviruses Department of Health and Human Services. Pandemic Influenza Plan Pandemics: Risks, Impacts, and Mitigation -Disease Control Priorities: Improving Health and Reducing Poverty -NCBI Bookshelf A novel coronavirus outbreak of global health concern Coronavirus, primi due casi in Italia: sono due turisti cinesi -Corriere.it World Health Organization. COVID-19 cases top 10 000 in Africa _ WHO _ Regional Office for Africa Nigeria responds to COVID-19; first case detected in sub-Saharan Africa WHO Director-General's opening remarks at the media briefing on COVID-19 World Health Organization. Mariana N (2020) Coronavirus disease 2019 (COVID-19) situation report 69 COVID-19 Interrupts the Only Pediatric Surgery Care in Liberia _ Doctors Without Borders -USA Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Centre for Disease Control and Prevention Clinical and epidemiological features of 36 children with coronavirus disease 2019 (COVID-19) in Zhejiang, China: an observational cohort study COVID-19 in children : the link in the transmission chain The role of children in the transmission of SARS-CoV-2 (COVID-19) -a rapid review [Barns rolle i spredning av SARS-CoV-19 (Covid-19) -en hurtigoversikt] Rapid review American College of Surgeons (2020) COVID 19 : Elective Case Triage Guidelines for Surgical Care COVID-19 preparedness within the surgical, obstetric and anesthetic ecosystem in Sub Saharan Africa American College of Surgeons. COVID-19 Guidelines for Triage of Pediatric Patients International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)The copyright holder for this preprint this version posted May 25, 2020. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 25, 2020. . https://doi.org/10.1101/2020.05.24.20112326 doi: medRxiv preprint . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 25, 2020. . https://doi.org/10.1101/2020.05.24.20112326 doi: medRxiv preprint . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 25, 2020. . https://doi.org/10.1101/2020.05.24.20112326 doi: medRxiv preprint . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)The copyright holder for this preprint this version posted May 25, 2020. . https://doi.org/10.1101/2020.05.24.20112326 doi: medRxiv preprint