• Users Online: 1141
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
EDITORIAL
Year : 2021  |  Volume : 11  |  Issue : 2  |  Page : 141-142

COVID-19 and its impact on surgery in kwazulu-natal, South Africa: A wholistic overview


Department of Surgery, University of KwaZulu-Natal, NRMSM, Congella; Trauma Service, Inkosi Albert Luthuli Central Hospital, Mayville; Durban University of Technology, Durban, South Africa

Date of Submission10-Feb-2021
Date of Acceptance15-Feb-2021
Date of Web Publication31-Mar-2021

Correspondence Address:
Timothy Craig Hardcastle
Department of Surgery, University of KwaZulu-Natal, NRMSM, Congella; Inkosi Albert Luthuli Central Hospital, Mayville; Durban University of Technology, Durban
South Africa
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aihb.aihb_13_21

Rights and Permissions

How to cite this article:
Hardcastle TC. COVID-19 and its impact on surgery in kwazulu-natal, South Africa: A wholistic overview. Adv Hum Biol 2021;11:141-2

How to cite this URL:
Hardcastle TC. COVID-19 and its impact on surgery in kwazulu-natal, South Africa: A wholistic overview. Adv Hum Biol [serial online] 2021 [cited 2021 Sep 25];11:141-2. Available from: https://www.aihbonline.com/text.asp?2021/11/2/141/312809





COVID-19, the clinical pandemic caused by the SARS-CoV2 virus, or its variants, is a current global disaster of social, economic, and emotional proportions.[1] COVID-19 hits the South African shores in February 2020, and by the end of March 2020, the country was facing a major lockdown, with curfew hours and restricted work categories allowed to continue normal business, with most people staying home and some working from home.[2]

The impact on the health sector was no less drastic, with most health facilities reorganising the layout and flow of services to cope with the expected major rush of infected patients. The resulting restructuring of intensive care unit (ICU) facilities led to restrictions of the number of general ICU beds for non-COVID patients and closure or severe reduction in outpatient services, both for medical and surgical units.

Staff from the clinical disciplines who had any experience in ICU (including surgical disciplines and anaesthesiology) were relocated to the designated COVID units and prepared for treating these patients. This resulted in a severe reduction in planned surgical services and the closure thereof at many facilities. This all led to a reduction in access to ICU facilities for patients with other ICU-requiring conditions, such as trauma, sepsis and cancer surgery.

To counter this threat, the hospital management established joint operating committees (JOC) to manage the hospital to ensure that there was no undue increase in collateral damage in the form of deaths due to delays in surgery. Nationally, a COVID surgical screening tool was developed by the NSOAP group and accepted by the Ministerial Advisory Committee in August 2020.[3]

The decision of the JOC at this author's facility was that the trauma-specific ICU would act as the general ICU and the beds were expanded to cope with the influx. The decision further was that all planned surgical patients would be tested for COVID with a polymerase chain reaction (PCR) before planned surgery, while surgery for life and limb compromising pathology should proceed pending the test result, and if positive, the patient would transfer to the COVID unit. This enabled the surgical services to provide care to trauma, sepsis (not COVID related), cancer surgery and limb-threatening vascular surgery (ischemic and aneurysmal).

Obviously with the reduction in operation slates, the necessity also arose to provide surgical cover for patients with COVID who had a surgical pathology or complication. A designated ICU and ward to operation room pathway was designed and a designated room identified. This was in proximity to the COVID ICU for reducing the risk of contamination.

All this planning has paid off. The trauma ICU, an 8-bedded unit, had an additional eight high-care beds added, and over the period from “lock down” announced on the 23rd of March 2020 till the end of January, the unit treated 398 patients in total, of whom 123 were “non-trauma” cases including tumour surgery for brain tumours, various cancers and also major vascular or liver surgery. Lots of ENT/plastics cases were also admitted for airway support.

Of this total, we only identified 19 “unexpected” COVID-positive cases (4.8%), of whom 11 were in emergency trauma admissions and the other eight were non-trauma cases, suggesting that our screening of everyone with a test was working. The eight non-trauma-positive cases resulted in a policy change such that planned cancer or other urgent non-trauma surgery would only be allowed to proceed after being proven COVID-negative on PCR test. This was in light of the COVIDSurg study findings showing worse outcomes for planned surgery in COVID-positive cases.[4] There was a clear association with spikes of positive cases during both the first and second “wave” of infections in South Africa. During the entire time under review the mortality rate for the ICU stood at 15% (13% for trauma and 16% for the non-trauma cases) for the non-COVID patients.

It must be highlighted that the trauma burden did not really reduce overall, apart from briefly during the alcohol ban for part of the first wave. Severe trauma did not really change, and gender-based violence probably increased. Thereafter, trauma numbers increased again, but trauma did reduce over Christmas and New Year during the second alcohol ban in a remarkable fashion with major trauma facilities around the country reporting their quietest period in many decades. This was evidenced by a number of recent publications highlighting this fact from around South Africa.[5],[6],[7],[8]

The preceding discussion applies mainly to the South African public sector. The private sector, catering to the 16% of the population with private medical insurance, mostly followed a similar pattern; however, there were isolated facilities that elected not to admit any COVID-positive patients and continued with their normal surgical cases.

Overall, the postponement of purely planned elective surgery, such as joint replacements, hernia repairs (if asymptomatic) and similar surgical procedures, in the public and private sectors has resulted in a huge backlog of such cases, worsening the already long delays for these cases in the public sector.[9]

In terms of trauma care and emergency surgery, there were still some undue delays resulting from a prolonged pre-hospital time due to the shortages of emergency medical services. This was from shortages of personnel (COVID infected or exposed and the need to self-isolate), vehicles (since they were so busy transporting COVID-positive cases) and restrictions around access during certain hours of the night. This led to worsening of the already long waiting times for inter-facility transfers. KwaZulu-Natal, a largely rural province, suffers from the devil of distance, covering over 94,000 km2 and with many mountains and hills, making straight-line transfer impossible. With limited aeromedical services, only day-time operational, night transfers became more difficult than usual.

In terms of the trauma patterns over the lock down period, we noticed an increase in inter-personal and gun violence and an expected reduction of the motor vehicle-related trauma with a penetrating trauma ratio that changed from one with over 65% blunt trauma at the specialised unit[10] to a more “South African” rate of over 40% penetrating trauma and 55% intentional trauma.[11]

Overall, the COVID pandemic has placed much strain on the personnel, particularly since the vaccine is not yet available for use in South Africa, and the recent information suggests that it may be ineffective against the recently described “South African” variant of the virus.[12],[13]

In conclusion, we can only hope that the people of the country respect the request to mask up and abide by the various restrictions, while we as surgeons aim to address what we can during this difficult time.



 
  References Top

1.
Saladino V, Algeri D, Auriemma V. The psychological and social impact of COVID-19: New perspectives of well-being. Front Psychol 2020;11:577684. [doi: 10.3389/fpsyg.2020.577684].  Back to cited text no. 1
    
2.
Ramaphoza C. Statement by President Cyril Ramaphosa on Escalation of Measures to Combat COVID-19 Epidemic. Available from: https://ewn.co.za/2020/03/23/president-ramaphosa-s-full-coronavirus-lock-down-speech. [Last accessed on 2021 Feb 09].  Back to cited text no. 2
    
3.
Department of Health RSA Surgery Recommendations. Available from: https://sacoronavirus.co.za/2020/08/28/covid-surgery-recommendations-and-risk-calculator/. [Last accessed on 2021 Feb 09].  Back to cited text no. 3
    
4.
COVIDSurg Collaborative. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: An international cohort study. Lancet 2020;396:27-38.  Back to cited text no. 4
    
5.
Morris D, Rogers M, Kissmer N, Du Preez A, Dufourq N. Impact of lockdown measures implemented during the COVID-19 pandemic on the burden of trauma presentations to a regional emergency department in Kwa-Zulu Natal, South Africa. Afr J Emerg Med 2020;10:193-6.  Back to cited text no. 5
    
6.
Venter A, Lewis CM, Saffy P, Chadinha LP. Locked down: Impact of COVID-19 restrictions on trauma presentations to the emergency department. S Afr Med J 2020;111:52-6.  Back to cited text no. 6
    
7.
Hofman K, Madhi S. The unanticipated costs of COVID-19 to South Africa's quadruple disease burden. S Afr Med J 2020;110:698-9.  Back to cited text no. 7
    
8.
Zsilavecz A, Wain H, Bruce JL, Smith MTD, Bekker W, Laing GL, et al. Trauma patterns during the COVID-19 lockdown in South Africa expose vulnerability of women. S Afr Med J 2020;110:1110-2.  Back to cited text no. 8
    
9.
Hardcastle TC, Chu KM. Global surgery: A South African action plan. S Afr J Surg 2020;58:176-7.  Back to cited text no. 9
    
10.
Cheddie S, Muckart DJ, Hardcastle TC, Den Hollander D, Cassimjee H, Moodley S. An audit of a new level 1 Trauma Unit in urban KwaZulu-Natal. S Afr Med J 2011;101:176-8.  Back to cited text no. 10
    
11.
Lutge E, Moodley N, Tefera A, Sartorius B, Hardcastle TC, Clarke DL. A hospital based surveillance system to assess the burden of trauma in Kwa-Zulu Natal Province South Africa. Injury 2016;47:135-40.  Back to cited text no. 11
    
12.
Cohen J. South Africa suspends use of AstraZeneca's COVID-19 vaccine after it fails to clearly stop virus variant. February 2021. Available from: https://www.sciencemag.org/news/2021/02/south-africa-suspends-use-astrazenecas-covid-19-vaccine-after-it-fails-clearly-stop. [Last accessed on 2021 Feb 09].  Back to cited text no. 12
    
13.
Department of Government Communication and Information Systems. COVID-19 Vaccines and the 501y.v2 Variant Talking Points: 8 February, 2021. Press release. Republic of South Africa. Pretoria, South Africa; 8 February, 2021.  Back to cited text no. 13
    




 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
References

 Article Access Statistics
    Viewed1129    
    Printed29    
    Emailed0    
    PDF Downloaded103    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]