ABSTRACT
Introduction The onset of the COVID-19 pandemic in early 2020 triggered reorganisation of hospital departments around the world as resources were configured to prioritise critical care. In spring 2020, NHS England issued national guidance proposing acceptable time intervals for postponing different types of surgical procedures for patients with cancer and other conditions. The 'Consider-19' study sought to investigate prioritisation decisions in practice, with in-depth examination of colorectal cancer surgery as a case-study, given recommendations that these procedures could be delayed by up to 12 weeks. Methods Twenty-seven semi-structured interviews were conducted with healthcare professionals between June - November 2020. A key informant sampling approach was used, followed by snowballing to achieve maximum regional variation across the UK. Data were analysed thematically using the constant comparison approach. Results Interviewees reported a spectrum of perceived disruption to colorectal cancer surgery services in the early phase of the pandemic, with some services reporting greater scarcity of resources than others. Nonetheless, all reported a need to prioritise patients based on local judgments. Prioritisation was framed by many as unfamiliar territory, requiring significant deliberation and emotional effort. Whilst national guidance provided a framework for prioritising, it was largely left to local teams to devise processes for prioritising within surgical specialities and then between different specialities, resulting in much local variation in practice. Discussion The pandemic necessitated a significant change in practice as surgeons, in a tense and uncertain situation, found themselves having to navigate clinically, emotionally, and ethically- charged decisions about how best to use limited surgical resources. Whilst unavoidable, many felt uncomfortable with the task and the consequences for their patients. The findings point to a need to better support surgeons tasked with prioritising patients and raise questions about who should be involved in this activity.
ABSTRACT
Background: Middle East respiratory syndrome coronavirus (MERS-CoV) is an emerging coronavirus that is endemic in dromedary camels. Kenya's >3 million camels have high seroprevalence of antibodies against MERS-CoV, with scant evidence of human infection, possibly due to a lower zoonotic potential of Clade C viruses, predominantly found in African camels. Methods: Between April 2018-March 2020, we followed camels aged 0-24 months from 33 camel-keeping homesteads within 50Km of Marsabit town through collecting deep nasal swabs and documenting signs of illness in camels every two weeks. Swabs were screened for MERS-CoV by reverse transcriptase (RT)-polymerase chain reaction (PCR) testing and virus isolation performed on PCR positive samples with cycle threshold (CT) <20. Both the isolates and swab samples (CT <30) were subjected to whole genome sequencing. Human camel handlers were also swabbed and screened for symptoms monthly and samples tested for MERS-CoV by RT-PCR. Results: Among 243 calves, 68 illnesses were recorded in 58 camels (53.9%);50/68 (73.5%) of illnesses were recorded in 2019, and 39 (57.3%) were respiratory symptoms (nasal discharge, hyperlacrimation and coughing). A total of 124/4,702 camel swabs (2.6%) from 83 (34.2%) calves in 15 (45.5%) enrolled compounds were positive for MERS-CoV RNA. Cases were detected between May-September 2019 with three infection peaks, a similar period when three (1.1%) human PCR-positive but asymptomatic cases were detected among 262 persons handling these herds. Sequencing of camel specimens revealed a Clade C2 virus with identical 12 nucleotide deletion at the 3' end of OFR3 region and one nucleotide insertion at the 5' region but lacked the signature ORF4b deletions of other Clade C viruses. Interpretation: We found high levels of transmission of distinct Clade C MERS-CoV among camels in Northern Kenya, with likely spillover infection to humans. These findings update our understanding of MERS-CoV epidemiology in this region.