Written By: Aimee Wilkinson
Bristol Medical School
One year since the first cases of COVID-19 were reported in Wuhan, China (1), the global impact of the coronavirus pandemic on paediatric populations remains difficult to quantify (2). Although global statistics suggest that those over 65 have largely experienced the most severe effects of the virus (3,4), evidence now suggests unique and indirect implications for younger populations (2). This article discusses some of these potential challenges facing paediatric surgeons in the context of the global coronavirus pandemic.
Irrespective of geographical location, older age has been proved a consistent risk factor for poorer patient outcomes. Early data from the Chinese Center for Disease Control and Prevention identified that less than 1% of COVID-19 cases were in children below 10 years (5); this pattern has since been replicated internationally (6). Children who are infected with the SARS-COV-2 virus have typically suffered milder symptomatology or have been asymptomatic (7,8), and though this means that children are largely spared associated health risks (9), they are believed more likely to spread the virus (10).
This may initially sound like good news for younger populations such as that of sub-Saharan Africa, where over 63% of people are below the age of 25 (11). However, the impact of concurrently high rates of HIV infection, tuberculosis, malnutrition and poverty in these areas on the spread of the virus is unclear (12). In addition, paediatric surgical patients typically present later to healthcare centres as compared with parts of the developed world (13) and patients are more likely to have complicated disease that is not amenable to non-surgical treatment options (14). Given that more complex pathology incurs increased length of hospital stay, there is an increased risk of acquiring the virus while in hospital (15).
The admittance of children to hospitals for surgical and non-surgical procedures further increases transmission risk due to the greater involvement of family and guardians (16, 17). In parts of the developing world, families often live a longer distance from medical care and so it is common for guardians to live on hospital grounds while their child receives treatment. Overcrowding in hospitals combined with these high numbers of accompanying guardians has been reported in Malawi (18), and thus inevitably leading to difficulty enforcing social distancing policies and, potentially, accelerated viral transmission.
Efforts to manage risk during a global pandemic largely focus on sustaining provision of emergency operations and protecting healthcare professionals against the virus (12,19). Prioritisation of these aims necessitates a reduction in non-essential surgeries in accordance with international guidance (12,19), such that elective surgeries have been postponed in a number of countries including Zimbabwe (20), South Africa (21), Kenya (22) and Malawi.
While decisions of what services to keep, divert or curtail may be clear-cut in some regions, a more nuanced discussion exists in a number of African provinces; the risk of treating acutely unwell patients must be balanced against that of exacerbating an already overwhelming surgical burden (12,23) of complex, predominantly late-presenting patients (13). Post-pandemic modelling has predicted large waiting lists for paediatric cancers (24), but these operations are only part of the larger 28 million surgical operations that were necessarily cancelled in low and middle-income countries (LMICs) (24,25).
Population “lockdown” strategies in which persons are asked to stay home and limit unnecessary travel also have repercussions for children’s health. Within the context of closed safe spaces such as religious buildings, schools and shelters, the incidence of violence against children and accidental household injuries such as burns has risen (26, 27). This poses unique challenges for paediatric surgeons in terms of managing traumatic injuries as well as for protecting children from further harm, which includes the harm of admitting patients to hospital where the risk of hospital-acquired infection may be high (28,29,30).
Lastly, the reduction of elective surgical cases and clinics has resulted in diminished teacher-trainee interaction and fewer opportunities for surgical education (31,32,33). Delays in training and thus reaching educational milestones further exacerbates the existing workforce deficit in LMICs (34). Although the pandemic has birthed new opportunities for online education and collaborative learning, for example with the PanSurg initiative (35), it is unclear if current efforts to minimise the disruption of COVID-19 to surgical education have been sufficient.
References
Li Q, Guan X, Wu P, et al. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med 2020;382:1199–207
Mazingi D, Ihediwa G, Ford K, et al. Mitigating the impact of COVID-19 on children's surgery in Africa. BMJ Global Health 2020;5:e003016.doi:10.1136/ bmjgh-20
Petrilli CM, Jones SA, Yang J, Rajagopalan H, O’Donnell L, Chernyak Y et al. Factors associated with hospital admission and critical illness among 5279 people with coronavirus disease 2019 in New York City: prospective cohort study BMJ 2020; 369 :m1966
Ioannou GN, Locke E, Green P, Berry K, O'Hare AM, Shah JA, Crothers K, Eastment MC, Dominitz JA, Fan VS. Risk Factors for Hospitalization, Mechanical Ventilation, or Death Among 10 131 US Veterans With SARS-CoV-2 Infection. JAMA Netw Open. 2020 Sep 1;3(9):e2022310. doi: 10.1001/jamanetworkopen.2020.22310. PMID: 32965502; PMCID: PMC7512055.
Wu Z, McGoogan JM. 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 center for disease control and prevention. JAMA 2020;323:1239–42
Mehboob R, Lavezzi AM. Neuropathological explanation of minimal COVID-19 infection rate in newborns, infants and children - a mystery so far. New insight into the role of Substance P. J Neurol Sci. 2020 Dec 17;420:117276. doi: 10.1016/j.jns.2020.117276. Epub ahead of print. PMID: 33360484.
Castagnoli R, Votto M, Licari A, et al. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in children and adolescents: a systematic review. JAMA Pediatr 2020. doi:10.1001/ jamapediatrics.2020.1467. [Epub ahead of print: 22 Apr 2020]
Dong Y, Mo X, Hu Y, et al. Epidemiology of COVID-19 among children in China. Pediatrics 2020;145:e20200702.
Xie Z. Pay attention to SARS‐CoV‐2 infection in children. Pediatr Investig 2020;4:1–4
Kelvin AA, Halperin S. COVID-19 in children: the link in the transmission chain. Lancet Infect Dis 2020;20:633–4.
United Nations. World population prospects 2019: highlights. New York: United Nations, Department of Economic and Social Affairs, Population Division, 2019. https://population.un.org/wpp/ Publications/Files/WPP2019_Highlights.pdf
Ademuyiwa AO, Bekele A, Berhea AB, et al. COVID-19 preparedness within the surgical, obstetric and anesthetic ecosystem in sub Saharan Africa. Ann Surg 2020. doi:10.1097/ SLA.0000000000003964. [Epub ahead of print: 13 Apr 2020].
Pilkington M, Situma M, Winthrop A, et al. Quantifying delays and self-identified barriers to timely access to pediatric surgery at Mbarara regional referral Hospital, Uganda. J Pediatr Surg 2018;53:1073–9.
Kong VY, Sartorius B, Clarke DL. Acute appendicitis in the developing world is a morbid disease. Ann R Coll Surg Engl 2015;97:390–5
Knaapen M, van der Lee JH, Heij HA, et al. Clinical recovery in children with uncomplicated appendicitis undergoing non-operative treatment: secondary analysis of a prospective cohort study. Eur J Pediatr 2019;178:235–42
Basu L, Frescas R, Kiwelu H. Patient guardians as an instrument for person centered care. Global Health 2014;10:33.
Makworo D, Bwibo N, Omoni G. Parental involvement in the management of hospitalised children in Kenya: policy and practice. Afr J Midwifery Womens Health 2014;8:183–8.
Hoffman M, Mofolo I, Salima C, et al. Utilization of family members to provide hospital care in Malawi: the role of hospital guardians. Malawi Med J 2012;24:74–8.
Collaborative C, COVIDSurg Collaborative. Global guidance for surgical care during the COVID-19 pandemic. Br J Surg;23.
SSZ COVID-19 Subcommittee. Statement on the conduct of surgical services during the COVID-19 outbreak, 2020.
ASSA Executive Council. Association of surgeons of south africa’s statement on covid-19, 2020. Available: http://www.surgeon.co.za/ wp-content/uploads/2020/03/ASSAletterCOVID.pdf [Accessed 30 Apr 2020].
Surgical Society of Kenya Council. COVID-19: SSK statement on recommendations for surgical procedures and outpatient clinics, 2020. Available: https://www.ssk.or.ke/wp-content/uploads/2020/03/ SSK-covid-19-statement.pdf [Accessed 30 Apr 2020].
Gona CV. Letter to the editor: cancellation of elective surgery during the COVID-19 pandemic. East and Central African Journal of Surgery 2020;25.
Vanderpuye V, Elhassan MMA, Simonds H. Preparedness for COVID-19 in the oncology community in Africa. Lancet Oncol 2020;21:621–2.
Nepogodiev D, Bhangu A. Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans. BJS.
Campbell AM. An increasing risk of family violence during the Covid-19 pandemic: strengthening community collaborations to save lives. Forensic Science International: Reports 2020;2:100089.
Barret JP, Chong SJ, Depetris N, et al. Burn center function during the COVID-19 pandemic: an international multi-center report of strategy and experience. Burns 2020. doi:10.1016/j. burns.2020.04.003. [Epub ahead of print: 10 Apr 2020].
Magoteaux S, Gilbert M, Langlais CS, et al. Should children with suspected Nonaccidental injury be admitted to a surgical service? J Am Coll Surg 2016;222:838–43.
Escobar MA, Wallenstein KG, Christison-Lagay ER, et al. Child abuse and the pediatric surgeon: a position statement from the trauma Committee, the Board of governors and the membership of the American pediatric surgical association. J Pediatr Surg 2019;54:1277–85.
Scott D, Lonne B, Higgins D. Public health models for preventing child maltreatment: applications from the field of injury prevention. Trauma Violence Abuse 2016;17:408–19.
Coe TM, Jogerst KM, Sell NM, et al. Practical techniques to adapt surgical resident education to the COVID-19 era. Ann Surg 2020. doi:10.1097/SLA.0000000000003993. [Epub ahead of print: 29 Apr 2020].
Bryan DS, Benjamin AJ, Schneider AB, et al. Nimble, together: a training program's response to the COVID-19 pandemic. Ann Surg 2020. doi:10.1097/SLA.0000000000003994. [Epub ahead of print: 29 Apr 2020].
Calhoun KE, Yale LA, Whipple ME, et al. The impact of COVID-19 on medical student surgical education: implementing extreme pandemic response measures in a widely distributed surgical clerkship experience. Am J Surg 2020. doi:10.1016/j.amjsurg.2020.04.024. [Epub ahead of print: 28 Apr 2020].
Krishnaswami S, Nwomeh BC, Ameh EA. The pediatric surgery workforce in low- and middle-income countries: problems and priorities. Semin Pediatr Surg 2016;25:32–42
PanSurg. Research and education to fight COVID-19. 2020. Available at: https://www.pansurg.org/ [Accessed28th December 2020]