A tale of three pandemics: Shining a light on a hidden problem

An "epidemic" is an event in which a disease, infectious or non-infectious, is actively spreading within a population and designated area. The term "pandemic" is defined as "an epidemic occurring worldwide, or over a very wide area, crossing international boundaries and usually affecting a large number of people".The global response to the COVID-19 pandemic has not been seen since the outbreak of Human Immunodeficiency Virus in the early eighties. But there is another unseen pandemic running alongside the current COVID-19 pandemic, which affects a vast number of people, crossing international boundaries and occurring in every single country world-wide. The pandemic of traumatic injuries. Traumatic injuries account for 11% of the current Global Burden of Disease, resulting in nearly 5 million deaths annually and is the third-leading cause of death worldwide. For every trauma-related death, it is estimated that up to 50 people sustain permanent or temporary disabilities. Furthermore, traumatic injuries occur at disproportionately higher rates in low-and middle-income countries, with approximately 90% of injuries and more than 90% of global deaths from injury occurring these countries.Injuries are increasing worldwide, crossing international boundaries and affecting a large number of people, in the same manner Human Immunodeficiency Virus did in the 1980's and COVID-19 is today. The tremendous global effort to tackle the COVID-19 and Human Immunodeficiency Virus pandemics has occurred whilst ignoring the comparable pandemic of injury. Without change and future engagement with policy makers and in-ternational donors this disparity is likely to continue.(c) 2021 Published by Elsevier Ltd on behalf of Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland.

Low 30-day mortality in South African orthopaedic patients undergoing surgery at an academic hospital during the first wave of the COVID-19 pandemic: It was safe to perform orthopaedic procedures at our hospital during the first COVID-19 peak.

BACKGROUND:  Initial local and global evidence suggests that SARS-CoV-2-infected patients who undergo surgery, and those who become infected perioperatively, have an increased mortality risk post surgery. OBJECTIVES: To analyse and describe the 30-day mortality, presurgical COVID-19 status and hospital-acquired SARS-CoV-2 infection rates of patients, both SARS-CoV-2-positive and negative, undergoing orthopaedic surgery at a tertiary academic hospital in South Africa (SA) during the first COVID-19 peak. METHODS: This single-centre, observational, prospective study included patients who underwent orthopaedic procedures from 1 April 2020 (beginning of the COVID-19 case increase in SA) to 31 July 2020 (first COVID-19 peak in SA). All patients were screened for COVID-19 and were confirmed positive if they had a positive laboratory quantitative polymerase chain reaction test for SARS-CoV-2 RNA on a nasopharyngeal or oral swab. Thirty-day mortality, presurgical COVID-19 status and hospital-acquired SARS-CoV-2 infection were assessed. RESULTS:  Overall, a total of 433 operations were performed on 346 patients during the timeframe. Of these patients, 65.9% (n=228) were male and 34.1% (n=118) were female. The mean (standard deviation) age was 42.5 (16.8) years (range 9 - 89). Of the patients, 5 (1.4%) were identified as COVID-19 patients under investigation (PUI) on admission and tested positive for SARS-CoV-2 before surgery, and 1 (0.3%) contracted SARS-CoV-2 perioperatively; all survived 30 days post surgery. Twenty-nine patients were lost to follow-up, and data were missing for 6 patients. The final analysis was performed excluding these 35 patients. Of the 311 patients included in the final 30-day mortality analysis, 303 (97%) had a follow-up observation ≥30 days after the operation. The overall 30-day mortality for these patients was 2.5% (n=8 deaths). None of the recorded deaths were of screened COVID-19 PUI. CONCLUSIONS: We report a low 30-day mortality rate of 2.5% (n=8) for patients undergoing orthopaedic surgery at our hospital during the first COVID-19 peak. None of the deaths were COVID-19 related, and all patients who tested SARS-CoV-2-positive, before or after surgery, survived. Our overall 30-day mortality rate correlates with several other reports of orthopaedic centres analysing over similar timeframes during the first peak of the COVID-19 pandemic. Regarding mortality and SARS-CoV-2 infection risk, we can conclude that with the appropriate measures taken, it was safe to undergo orthopaedic procedures at our hospital during the first peak of the COVID-19 pandemic in SA.

The effect of lockdown on intentional and nonintentional injury during the COVID-19 pandemic in Cape Town, South Africa: a preliminary report

Background. In response to the coronavirus pandemic, lockdown restrictions and a ban on alcohol sales were introduced in South Africa. Objectives. To investigate the impact of lockdown measures on the number of patients who visited a tertiary urban trauma centre. Methods. The period of investigation was from 1 February to 30 June 2020 and was segmented into three intervals: pre-lockdown (February and March 2020), hard lockdown (April and May 2020) and immediately post lockdown (June 2020). The electronic HECTIS health record registry was interrogated for the total number of patients that were seen per month. These were further categorised according to mechanism of injury (stab, gunshot, blunt assault and road traffic injuries). Penetrating (stab and gunshot) and blunt assault victims were collectively grouped as violent trauma. Results. The mean total number of patients seen decreased by 53% during the hard lockdown period. There was a moderate reduction (15%) in patients with gunshot injuries seen during the hard lockdown phase, but there was an 80% increase in the post-lockdown period. The proportion of patients injured in road traffic collisions pre lockdown, hard lockdown and immediate post lockdown was 16.4%, 8.9% and 11.1%, respectively. Patients injured in road traffic collisions decreased by 74% during the hard lockdown period and maintained a reduction of 32% during the immediate post-lockdown period. The mean total number of patients who visited the trauma unit returned to pre-lockdown levels in June. Conclusions. There was an overall trend of reduced number of patients who visited the trauma unit during the hard lockdown period;however, these numbers returned to pre-lockdown levels during the immediate post-lockdown period. The number of road traffic injury admissions remained reduced during all three phases of lockdown, while the number of gunshot victims increased substantially during the post-lockdown period.

Drastic reduction of orthopaedic services at an urban tertiary hospital in South Africa during COVID-19: Lessons for the future response to the pandemic.

BACKGROUND: The COVID-19 pandemic has impacted on the global surgery landscape. OBJECTIVES: To analyse and describe the initial impact of the COVID-19 pandemic on orthopaedic surgery at Groote Schuur Hospital, a tertiary academic hospital in South Africa. METHODS: The number of orthopaedic surgical cases, emergency theatre patient waiting times, and numbers of outpatient clinic visits, ward admissions, bed occupancies and total inpatient days for January - April 2019 (pre-COVID-19) were compared with the same time frame in 2020 (COVID-19). The COVID-19 timeframe included initiation of a national 'hard lockdown' from 26 March 2020, in preparation for an increasing volume of COVID-19 cases. RESULTS: April 2020, the time of the imposed hard lockdown, was the most affected month, although the number of surgical cases had started to decrease slowly during the 3 preceding months. The total number of surgeries, outpatient visits and ward admissions decreased significantly during April 2020 (55.2%, 69.1% and 60.6%, respectively) compared with April 2019 (p<0.05). Trauma cases were reduced by 40% in April 2020. Overall emergency theatre patient waiting time was 30% lower for April 2020 compared with 2019. CONCLUSIONS: COVID-19 and the associated lockdown has heavily impacted on both orthopaedic inpatient and outpatient services. Lockdown led to a larger reduction in the orthopaedic trauma burden than in international centres, but the overall reduction in surgeries, outpatient visits and hospital admissions was less. This lesser reduction was probably due to local factors, but also to a conscious decision to avoid total collapse of our surgical services.

The effect of lockdown on intentional and nonintentional injury during the COVID-19 pandemic in Cape Town, South Africa: A preliminary report.

BACKGROUND: In response to the coronavirus pandemic, lockdown restrictions and a ban on alcohol sales were introduced in South Africa. Objectives. To investigate the impact of lockdown measures on the number of patients who visited a tertiary urban trauma centre. Methods. The period of investigation was from 1 February to 30 June 2020 and was segmented into three intervals: pre-lockdown (February and March 2020), hard lockdown (April and May 2020) and immediately post lockdown (June 2020). The electronic HECTIS health record registry was interrogated for the total number of patients that were seen per month. These were further categorised according to mechanism of injury (stab, gunshot, blunt assault and road traffic injuries). Penetrating (stab and gunshot) and blunt assault victims were collectively grouped as violent trauma. Results. The mean total number of patients seen decreased by 53% during the hard lockdown period. There was a moderate reduction (15%) in patients with gunshot injuries seen during the hard lockdown phase, but there was an 80% increase in the post-lockdown period. The proportion of patients injured in road traffic collisions pre lockdown, hard lockdown and immediate post lockdown was 16.4%, 8.9% and 11.1%, respectively. Patients injured in road traffic collisions decreased by 74% during the hard lockdown period and maintained a reduction of 32% during the immediate post-lockdown period. The mean total number of patients who visited the trauma unit returned to pre-lockdown levels in June. Conclusions. There was an overall trend of reduced number of patients who visited the trauma unit during the hard lockdown period; however, these numbers returned to pre-lockdown levels during the immediate post-lockdown period. The number of road traffic injury admissions remained reduced during all three phases of lockdown, while the number of gunshot victims increased substantially during the post-lockdown period.