Introduction
An outbreak of the disease known as COVID-19, which originated in Wuhan in the Hubei
province of China, has rapidly spread to all continents of the globe.1 First detected
via local hospital surveillance systems as a ‘pneumonia of unknown aetiology’ in late
December 2019,2 the disease has since been declared a public health emergency of international
concern by the WHO and reached pandemic status.
It is uncertain what the eventual toll of the pandemic will be in Africa; however,
there has been a suspicion that the looming pandemic may hit harder than it has the
rest of the world.3 4 Africa has baseline weaknesses in healthcare resource allocation,
and her fragile healthcare systems are particularly vulnerable to being overwhelmed
by this illness.5 6 Available statistics, to date, however, seem to show that the
pandemic has been slow to begin. As of 26 May, 115 346 cases and 3471 deaths have
been reported across the whole African continent, constituting 2% of all cases in
the globe.7 African nations have had an opportunity to prepare for the coming onslaught,
learn from the experience in other countries3 and choose interventions that are tailor-made
for the unique socioeconomic context.6
While old age has consistently been associated with a higher risk of poor outcome,
children appear to have escaped the worst of the disease.8 In a recent series from
the Chinese Center for Disease Control and Prevention, less than 1% of the 73 314
cases were children below 10 years of age.9 Children of all ages may be affected,
but they typically manifest mild or asymptomatic disease.10 11 This has important
implications for the African pandemic: sub-Saharan Africa is the youngest continent
in the globe with 63% of its population below the age of 25 years.12 The demography
of Africa appears to portend a favourable course through the pandemic; however, it
is unknown how the high prevalence of HIV infection, tuberculosis, malnutrition and
the scourge of poverty will affect the human impact of the disease.13
The COVID-19 pandemic has placed unprecedented strain on health services around the
world, and paediatric surgical services are no exception.14 15 Responses from surgical
societies around the world thus far have focused on maintaining provision of emergency
and urgent elective services while protecting healthcare workers (HCWs).13 16 There
is a risk of healthcare resources being diverted away from surgical care, potentially
impeding progress towards global surgery goals for 2030.17 Paediatric surgical care
may only be tangentially affected by this pandemic; however, there are unique considerations
that deserve special attention. This article explores the wider implications for children's
surgery in Africa, drawing lessons from the past and giving recommendations for the
current pandemic and future (table 1).
Table 1
Recommendations for paediatric surgery during the COVID-19 pandemic based on the domains
identified including justification
Domain
Recommendations
Justification
Surgical rationing
Consider continuing surgery for paediatric malignancies.
Consider adding waiting list length to inform surgical rationing in addition to urgency
classifications.
To minimise a precipitous drop in surgical volumes that the service may not recover
from
Surgical provision
Consider surgical approaches that minimise length of hospital stay.
To minimise the chance of nosocomial spread
HCW welfare
HCW life insurance cover in the event of death or incapacitation.19
Psychological support.13
Frequent personal protective equipment training and retraining.
To protect HCWs
Guardian policy
Designate a ‘resident/in-hospital guardian’ who lives on hospital grounds and is isolated
from outside visitors.
Limit in-hospital guardians to one person to prevent overcrowding.
Hand hygiene for in-hospital guardians.49
To facilitate social distancing and minimise the chance of nosocomial spread
Visitor policy
Restrict all non-essential visitors.49
Restrict visitors for suspected or confirmed cases.49
Restrict visitation by any ill individual or family member.49
To reduce the number of vectors and minimise the chance of nosocomial spread
Child protection
Designate areas separate from general wards for children who may require protection
during the pandemic.
Strengthen social service structures during pandemics.
To protect children
Training
Training programmes to introduce virtual didactics.
Consider altering trainee minimum requirements in light of declines in surgical volume
and learning time.
Increased collaborative learning between training programmes across borders.
To minimise the disruption to paediatric surgery workforce growthTo strengthen surgical
training programs
HCW, healthcare worker.
Rationing of surgical services
Non-essential surgical and non-surgical activities should be curtailed to provide
surge capacity for the expected pandemic-related influx. This is consistent with guidelines
from many surgical societies worldwide13 16; however, heavy-handed shutdown policies
have been discouraged in the African context because they risk exacerbating the already
formidable surgical disease burden with disastrous consequences.13 18 Elective surgical
activity has been postponed in Zimbabwe,19 South Africa,20 Kenya21 and Malawi, among
many other countries. Negative effects should be anticipated if the past is anything
to go by. During the 2003 severe acute respiratory syndrome-related coronavirus (SARS-CoV)-1
outbreak in Toronto, stringent restrictions on non-essential surgical services were
thought to have aggravated precipitous declines in surgical volume, with only small
increases in surge capacity for the outbreak.22 Postpandemic waiting lists for paediatric
cancer are also expected to be sizeable.4 A recent modelling study from the ‘COVIDSurg
Collaborative’ paints a grim picture. Twenty-eight million surgical operations are
estimated to be cancelled and low-income and middle-income countries (LMICs) such
as Africa will be hardest hit.23 The expectation that surgical volumes will bounce
back rapidly is implausible, particularly in countries where there was already baseline
fragility, and it may take longer than the 45 weeks forecast to make up the backlog.23
Current surgical rationing policies are based on a classification of the urgency of
the patient’s intervention, such as the National Confidential Enquiry into Patient
Outcome and Death system.19 24
Effects on surgical practice
Paediatric surgical services in Africa are characterised by significant delays in
health-seeking and within the referral chain.25 The mobility restrictions imposed
on patients by shelter-in-place measures, as well as reduced income during the pandemic,
will presumably cause further delays in presentation that may adversely affect outcomes.
The change to non-operative treatment in eligible patients for certain conditions,
for example, appendicitis that is being contemplated, may find less success in Africa,
where a higher proportion of patients have complicated disease not amenable to non-operative
treatment.26 It also has the potential to prolong hospital stay,27 which increases
the chances of nosocomial transmission of the virus.
Preoperative screening and testing
Perinatal transmission of SARS-CoV-2 has not yet been demonstrated in recent small
case series and a systematic review.28–30 This is consistent with findings during
the SARS-CoV-131 and Middle East respiratory syndrome (MERS-CoV) epidemics32 and should
reassure surgeons working with neonates. However, neonates can still acquire infection
from an infected mother's respiratory secretions.33 Also, Xu et al reported on eight
infants who tested positive on rectal swabs even after having tested negative by nasopharyngeal
swabs.34 This was thought to potentially represent faeco-oral viral transmission and
has implications for surgeons of the gastrointestinal tract. SARS-CoV-2 has also been
isolated in peritoneal fluid.35 Larger studies are needed to determine the significance
of these findings. Airborne and contact precautions are indicated in all HCWs working
with children of all ages.
Healthcare workers
Experience from previous pandemics has demonstrated that HCWs are the lynchpin of
resilient surgical systems during an outbreak. During the Ebola outbreak, the unfortunate
death of 25% of the surgeons in one institution has led to a 97% reduction in surgical
volumes,36 while trepidation on the part of HCWs and lack of personal protective equipment
have led to a reluctance to work during the SARS-CoV-1,37 MERS-CoV38 and Ebola39 outbreaks.
This is particularly damaging in Africa, where HCW morale is already low.40 HCW should
be first in the minds of policy-makers because the axiom that there is no health without
a workforce is as true during a pandemic as it is at any other time.41
Children have been called ‘the link in the transmission chain’ because of their importance
in facilitating and amplifying viral transmission.42 Paediatric care in Africa is
typically characterised by significant involvement by guardians and other family members
who support the child during hospital admission, assist the overburdened healthcare
workforce and act as care advocates.43 44 They frequently live on the hospital grounds
because of long distances from home and prohibitive transportation costs.43 A study
from Malawi showed that overcrowding in the hospital was a major issue due to the
large population of guardians in the hospital.45 This is at odds with social distancing
policies and has the potential to accelerate nosocomial transmission. Guardians should
be limited to the minimum practical number per patient (table 1). Guardian policy
should also take into account ‘parental presence at induction of anaesthesia’, a common
practice that facilitates administration of anaesthesia but potentially places the
parent at risk during an aerosol-generating procedure.
Hospital visitors have been implicated as vectors in pathogen transmission during
the SARS-CoV-1 outbreak of 2002–2004,46 47 and hospital visitor policies were changed
accordingly.48 The evidence linking restrictive visiting policies with prevention
of nosocomial transmission during outbreaks is scant; however, it is a rational approach
until better evidence comes to light. Expert guidelines from the Society for Healthcare
Epidemiology of America give recommendations for guardian and visitor policy based
on a systematic review of the literature and are incorporated in our recommendations49
(table 1).
Child protection during pandemics
Experiences from this and past epidemics show that in health emergencies children,
the most vulnerable members of society suffer disproportionately.50
51 52 The ‘Agenda for Action’ recently announced by UNICEF is a timely intervention
aimed at preventing the pandemic from becoming a child’s-rights crisis.
The incidence of family violence53 and accidental household trauma, for example, burn
injuries, are anticipated to rise during the pandemic and is associated with shelter-in-place
measures.54 Paediatric surgeons have a unique role in management of the traumatic
injuries, protection of children from a dangerous household and in tertiary prevention
(minimising the effects of child physical abuse and preventing recurrence).52 55 56
Churches, schools and shelters, which would otherwise be safe havens, may be closed
and healthcare facilities may be the option of last report. Bringing a child into
a potentially hazardous hospital environment with the risks of nosocomial infection
brings up difficult choices.
Impact on training
Surgical training programmes are an additional casualty of the social distancing measures
and surgical rationing. The reduction in elective surgical cases and clinics, as well
as contact between teachers and trainees, has brought challenges in the delivery of
surgical education worldwide.57–59 Academic training programmes have had to adapt
rapidly to maintain the integrity of training programmes, ensure trainee welfare and
comply with local laws. Postgraduate qualifying examinations of the West60 and South
African61 colleges of surgeons scheduled for April and July, respectively, have been
postponed; however, the examination of the College of Surgeons of East, Central and
Southern Africa (COSECSA) scheduled for November have not yet been impacted.
A recent global review of paediatric surgical workforce density showed that a minimum
of four paediatric surgeons per million children under 15 years of age would be required
to achieve a survival of >80% for a group of four bellwether paediatric surgical conditions.62
This translates to a deficit of 6967 additional paediatric surgeons in LMICs required
to attend to the almost 1742 billion children living there.62 The paediatric surgical
workforce deficit in Africa is particularly large,63 and disruption of training programmes
is likely to significantly affect achievement of workforce goals.
The pandemic has also presented opportunities for surgical education. Virtual didactics
are poised to increase the size of the classroom and to allow easier collaborative
learning between teams in different hospitals or countries. This is occurring all
over the continent and the practice may persist long after the pandemic is over.
Conclusions
The inexorable spread of COVID-19 around the world continues unabated and threatens
to affect every clinical specialty. Children have unique needs and suffer disproportionately
during health emergencies and therefore require enhanced protection. Paediatric surgeons
in Africa have an important role during times such as these and should use tailor-made,
context-appropriate strategies to minimise the impact on our patients and HCWs. Protection
for HCWs should be the foremost in the minds of policy-makers as they are a precious
and irreplaceable resource.