Paediatric Surgery during COVID19
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.
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