Guest post: Lessons in preparedness – the response to the COVID-19 pandemic by a surgical department in Singapore

Min-Hoe Chew1, Lester WL Ong1, Frederick H Koh1, Aven Ng1, YHA Tan1, Biauw-Chi Ong2

1 Department of General Surgery, Sengkang General Hospital, Singapore

2 Department of Anaesthesiology, Chairman Medical Board, Sengkang General Hospital, Singapore

Background

On 11th March 2020, World Health Organization declared the coronavirus disease (COVID-19) outbreak a pandemic. [1] Over 509,164 people have been infected worldwide with 23,335 deaths [2]. (case fatality-rate 4.6%)

The first imported case of COVID-19 in Singapore occurred on 23rd January 2020. [3] Local transmission was confirmed on 4th February 2020 and the Disease Outbreak Response System Condition (DORSCON) was raised (Orange) on 7th February 2020 [4-5]. As of 27th March 2020, there have been 732 cases in Singapore and 2 deaths. [6] Sengkang General Hospital (SKH) is a 1,400-bed hospital serving a population of 900,000. SKH confirmed its first case on 26th January 2020 and has managed 32 cases to date. [7] SKH Department of General Surgery (GS) has developed response measures to ensure all staff were ready to perform surgery for COVID-19 cases, reduce risks of nosocomial infection, and ensure continuity of care for patients. We describe the Preparation Phase in the initial outbreak, the Evolution Phase (DORSCON Orange), and Crisis Phase planning norms (DORSCON Red). [8-9]

Preparation Phase

Preparation Phasebegan before the first case was reported in Singapore. Cases were initially limited to China [10].  Information was limited; thus, planning was based on experience with Severe Acute Respiratory Syndrome (SARS) outbreak in 2002 [11-12]. A departmental task force was formed to enforce measures implemented by the hospital and develop knowledge specific workflows. Importantly, besides fever and upper respiratory tract symptoms, COVID-19 patients could mimic surgical conditions and have diarrhoea and abdominal pain [13-15].

Communication

The task force ensured accuracy of information disseminated. This suppressed falsehood from social media and maintained morale. This also allowed rapid and effective communication between junior and senior staff, and obtained feedback regarding policies.

Internal surveillance measures

Staff conducted twice daily temperature monitoring. Temperatures were entered into web-based forms via personal smartphones. All staff had Radiofrequency Identification tags facilitating contact tracing should there be exposure. Staff who developed symptoms were to only seek medical consultation within the hospital staff clinic. This enabled symptomatic staff to be identified promptly. 

Training and rehearsals

Hospital-wide refresher training on the use of Personal Protective Equipment (PPE) was conducted. This included N95 mask fitting as well as training on Powered Air-Purifying Respirators (PAPR) (CleanSpace® HALOTM, CleanSpace Technology Pty Ltd, Artarmon, NSW, Australia).

Business Continuity Plan (BCP)

The GS department split into two working teams. One team handled all inpatient services, which included emergency admissions, elective and emergency surgeries and ward rounds; the other team managed outpatient clinics and endoscopy procedures. Every seven days, teams would exchange duties.

The segregation of teams ensured that the department would remain functional should any team member fall ill. Under Singapore guidelines, close contacts of confirmed COVID-19 cases without adequate PPE, will serve a 14-day quarantine. [16] A seven-day cycle was appropriate in view of the reported mean incubation period of 5 days. [10]

Evolution phase

This BCP was executed when Singapore raised the DORSCON level (Orange) on 7th Feb 2020.

Elective and emergency surgeries

Non-urgent, non-cancer surgeries were postponed. Time-sensitive surgeries, such as cancer-related work and limb salvage procedures, could proceed. Surgeons performed elective surgeries during designated weeks.

Outpatient clinics and endoscopy

Outpatient clinic patient volume was reduced by 30%. Non-urgent endoscopy procedures were postponed. Patients attending appointments had temperature checks and performed declarations of travel history and symptoms. Ill patients were diverted to the Emergency Department (ED).

Operational demands

There was a spontaneous reduction in hospital attendances. ED admissions to the surgical department fell 11% (from a median of 156 per week) initially. (Figure 1) OR utility for surgeries reduced by 13% (from a median of 155 per week). (Figure 2) Median outpatient clinic attendances also decreased by 22% compared to the same period (1674 per week in 2019), without any hospital-initiated postponement. (Figure 3)

However, between the fifth and seventh week, the number of emergency admissions increased by 7 to 14% compared to the past year. OR utility returned to normal and outpatient clinic numbers surpassed previous year numbers by 24% in the seventh week.  This was likely due to increased public confidence in Singapore’s response. [17]

Team segregation was subsequently stopped for junior staff to meet manpower demands. Team segregation for senior staff continued.

Crisis Phase (Preparing for DORSCON Red)

In a Crisis phase, it would necessitate expansion of departments such as ED and Intensive Care Unit (ICU). The objective of Crisis Phase planning was to facilitate manpower allocation while maintaining essential surgical capabilities. (Figure 4)

Key aspects of the Crisis Phase plan are:

  1. Reducing OR workload to allow anesthetists to support ICU
  2. Reducing outpatient clinic and endoscopy workload to free staff for deployment
Figure 4. DORSCON escalation planning norms for Department of General Surgery, Sengkang General Hospital

Discussion

The course for the COVID-19 pandemic is likely to be protracted. [18] A surgical department must plan a stepwise reduction of elective work to allow for sustained deployment of manpower to frontline departments, and team segregation to allow for continuity of essential services.

The protection of healthcare staff is vital. Ng et al. reported 85% of 41 healthcare workers were exposed to a COVID-19 patient during an aerosol generating procedure [19]. None acquired the infection even though not all were in N95. Standard hand hygiene practices remain important.

Our department statistics provide a snapshot of Singapore’s health-seeking behaviors. Postponing elective surgeries did not reduce workload and more patients were admitted as emergency cases.

We acknowledge that we have had a very controlled increase in the number of COVID-19 cases; much of this is a result of a national strategy of rapid detection and isolation of cases and aggressive contact tracing. [20] Nonetheless, it is challenging to strike a balance between complacency and overreaction. Premature implementation of drastic measures can lead to staff burnout and resource wastage. Indecisive action however, may result in nosocomial spread and a loss of confidence in hospital leadership. The department has benefitted from the hindsight of the SARS outbreak in 2002.

Conclusion

In the COVID-19 pandemic battle, there are multiple considerations in how a surgical unit functions. Phases of Preparation, Evolution and Crisis will require hard decisions, strong leadership and decisive communication. A robust BCP is essential to ensure that surgical patients continue to have quality care.

References

1. Ghebreyesus TA. World Health Organization. Coronavirus disease 2019 (COVID-19).  WHO Director-General’s opening remarks at the media briefing on COVID-19 – 11 March 2020. March 11, 2020. Available at:  https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19—11-march-2020. Accessed March 11, 2020.

2. WHO Coronavirus Situation Report 67. Available at: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200327-sitrep-67-covid-19.pdf?sfvrsn=b65f68eb_4. Accessed 28th March, 2020.

3. Abdullah Z, Salamat H. Singapore confirms first case of Wuhan virus. January 23, 2020. Available at:  https://www.channelnewsasia.com/news/singapore/wuhan-virus-pneumonia-singapore-confirms-first-case-12312860. Accessed March 14, 2020.

4. Ministry of Health, Singapore. Confirmed cases of local transmission of novel coronavirus infection in Singapore. February 4, 2020. Available at: https://www.moh.gov.sg/news-highlights/details/confirmed-cases-of-local-transmission-of-novel-coronavirus-infection-in-singapore. Accessed March 14, 2020.

5. Ministry of Health, Singapore. Risk assessment raised to DORSCON Orange. February 7, 2020. Available at: https://www.moh.gov.sg/news-highlights/details/risk-assessment-raised-to-dorscon-orange. Accessed March 15, 2020.

6. Ministry of Health Singapore Updates on COVID-19 Local situation. Available on: https://www.moh.gov.sg/covid-19. Accessed March 28, 2020.

7. Channelnewsasia. 4th confirmed case of Wuhan virus in Singapore: MOH. January 26, 2020. Available at:  https://www.channelnewsasia.com/news/singapore/4th-confirmed-case-of-wuhan-pneumonia-virus-in-singapore-moh-12339912. Accessed March 14, 2020.

8. Yeo C, Kaushal S, Yeo D. Enteric involvement of coronaviruses: is faecal-oral transmission of SARS-CoV-2 possible? Lancet Gastroenterol Hepatol. 2020 Apr;5(4):335-337.

9. Ministry of Health, Singapore. Ministry of Health Singapore pandemic readiness and response plan for influenza and other acute respiratory disaeses (revised April 2014). April, 2014. Available from: https://www.moh.gov.sg/docs/librariesprovider5/diseases-updates/interim-pandemic-plan-public-ver-_april-2014.pdf. Accessed on March 20, 2020.

10. Li Q, Guan X, Wu P, et al. Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus-Infected Pneumonia. N Engl J Med. 2020 Jan 29. doi: 10.1056/NEJMoa2001316. [Epub ahead of print]

11. Tan CC. SARS in Singapore–key lessons from an epidemic. Ann Acad Med Singapore. 2006 May;35(5):345-9.

12. Chow KYLee CELing ML, et al. Outbreak of severe acute respiratory syndrome in a tertiary hospital in Singapore, linked to an index patient with atypical presentation: epidemiological study. BMJ. 2004 Jan 24;328(7433):195.

13. Chen N, Zhou M, Dong X, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet 2020; 395: 507-13.

14. Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease, (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. JAMA. 2020 Feb 24. doi: 10.1001/jama.2020.2648. [Epub ahead of print]

15. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan. China. Lancet 2020; 395: 497-506.

16. Ministry of Health, Singapore. Multiple lines of defence to guard against local spread of COVID-19. March 13, 2020. Available from: https://www.gov.sg/article/multiple-lines-of-defence-to-guard-against-local-spread. Accessed on March 22, 2020.

17. Ipsos. Singaporeans are confident in the Government amidst fears of the COVID-19 outbreak. March 16, 2020. Available from: https://www.ipsos.com/en-sg/singaporeans-are-confident-government-amidst-fears-covid-19-outbreak. Accessed on March 22, 2020.

18. Tan A. Covid-19 likely to last till end-2020 at least: Experts. March 9, 2020. Available from: https://www.straitstimes.com/singapore/health/coronavirus-covid-19-likely-to-last-till-end-2020-at-least-experts. Accessed on March 22, 2020.

19. Ng K, Poon BN, Kiat Puar TH, et al. COVID-19 and the risk to health care workers: a case report. Ann Intern Med 2020 Mar 16. Doi:10.7326/L20-0175 (Epub ahead of print)

20. Wong JEL, Leo YS, Tan CC. COVID-19 in Singapore-Current Experience: Critical Global Issues That Require Attention and Action. JAMA. 2020 Feb 20. doi: 10.1001/jama.2020.2467. [Epub ahead of print]

BJSOpen April 2020 issue published.

BJSOpen is a fully-online and open access journal & is proud to publish high-quality surgical research. This month, papers span surgical oncology, methdology, benign disease, and global surgery. The full table of contents is here.

We would also like to draw your attention to the EHS/AHS guidelines on primary hernias in rare locations or special circumstances.

images from this months BJS open
Some of the key images from this months papers

Methodology

Anyone submitting papers to a journal will be familiar with the role of checklists. These are intended to improve the quality of reporting of publications. This review has assessed how well benefits and harms of treatments are reported in surgical trials. It shows that the surgical community needs to do better; outcomes were poorly described, or presented in a manner where it was not possible to interpret effect sizes with any degree of precision.

Randomised trials

Whilst breast cancer surgery aims to conserve breast tissue, mastectomy is still an important tool for the breast surgeon. One of the problems seen here is with bleeding from this typically vascular area. This Norwegian trial randomised 208 patients to either topical tranexamic acid or topical saline to wound edges for haemostasis. There was reduced drain output in the TXA group. There was also a non-significant (but interesting) reduction in the rate of haematomas. 

The pilonidal sinus is a sadly unloved condition. This is despite being a constant presence for the colorectal surgeon. This RCT compared alginate vs DACC (hydrophobic-type) dressings in wound healing after excision of pilonidal sinus. There was no difference in wound healing at 75 days on the per-protocol analysis. The trial needed 222 patients to complete to reach power calculations and managed to retain 200 patients. There might be other things to learn about trial management. This population is quite young and may pose problems with recruiting to trials

Surgical oncology

Other surgical oncology papers this month include a review of outcomes of immediate and delayed autologous breast reconstruction in post-mastectomy radiotherapy. This is a well conducted review and highlights the issues with the literature. On a related note, this patient survey on immediate breast reconstruction is interesting. It looks at some of the important socioeconomic factors that drive patient decision making around this treatment.

For the HPB surgeons, a cohort study shows the outcomes of resection for HCC with tumour thrombus extending into the IVC. In practice, this is a small group with advanced disease and this is shown by a 20 year case series. And not forgetting the oesophagogastric surgeons, we have a retrospective cohort study comparing laparoscopic proximal gastrectomy with double‐flap technique versus laparoscopic subtotal gastrectomy for proximal early gastric cancer. This study was intended to assess the impact on nutrition between these two approaches. No difference in these outcomes were seen.

Advanced cancer

This is a growing field, and this growth is reflected in the many submissions we receive on this topic.Two of the big questions are on the prediction of development of peritoneal disease, and the role of chemotherapy dosing in HIPEC.

A large cohort study from the Danish Colorectal Database has tried to answer the first of these questions. Rates of metastatic peritoneal disease were low, but factors such as advanced tumour or node stage were associated with early presentations, whereas R1 resection was associated with recurrence at 3 years.

The second question was addressed by the PRODIGE 7 trial, which suggested cytoreductive surgery was key in treatment of peritoneal disease. This is reflected in a cohort study of ‘real world’ experience from the Netherlands. This has compared intraperitoneal chemotherapy outcomes based on agents used and adjusted for body surface area. It doesn’t seem to disagree with PRODIGE 7… 

On a related note, the introduction of new technology demands robust assessment. For surgeons this typically follows the IDEAL framework. This review has looked at reports on the development of Pressurized intraperitoneal aerosol chemotherapy (PIPAC), which is based on laparoscopy to deliver intraperitoneal chemotherapy for peritoneal metastases. We now know that we are following the rules with this technology. However, progress is slow and we need bigger definitive studies to understand efficacy.

Global surgery

There are two papers on global surgery this month. One highlights the challenges related to deployment of electrosurgical and laparoscopic kit in LMICS. This shows that equipment is available, but surgeons still had problems using or maintaining it. The second paper shows that traumatic brain injury is common in Uganda, with a male preponderance. The mortality rate in this group is 33%. The authors suggest this may be influenced by limited access to CT and ICP monitoring.

Summary

These are just some of the papers published in this issue of BJSOpen. We welcome direct submissions to the journal. If you think your work would fit in here, please have a look at the instructions for authors page.

Guest post: To control or be controlled by the coronavirus disease 2019 (Covid-19)?

A hypothesis paper on alternating population quarantine instead of lockdowns: a surgeon’s approach to the problem.

The Covid-19 pandemic is spreading quickly, threatening healthcare systems and the world economy. Test and tracing methods used efficiently in Asian countries are not feasible in countries with scarce test capacities. Current lockdown strategies are insufficient as not everyone can be quarantined for 2 weeks at the same time. An alternative strategy to extensive lockdown – namely an alternating home quarantine of half the population for 2 weeks at a time – is described in this post. This may be an efficient way to stop the spreading of the disease, buying time to establish test routines and a vaccine. At the same time it may prevent the economy and healthcare systems from collapsing.

As the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is newly identified, the actual case fatality rate (CFR) and susceptibility in the population are uncertain. During the Chinese outbreak the CFR was calculated to be 2.9% in the Hubei province compared to 0.4% outside Hubei (overall 2.8%) . In Italy it is at the moment 8.5% . The actual CFR is probably closer to 1% with optimal treatment capacities and early and complete detection. No natural immunity against the SARS-CoV-2 has been shown. Post exposure immunity after sub clinic infection is however probable, which would explain why the Chinese outbreaks outside Wuhan were less intense. Neither a vaccine nor approved treatment are currently available, although there are ongoing trials with several drugs both for treatment and prophylaxis.

Both South Korea and Singapore are conducting widespread testing of symptomatic patients combined with short-term lockdowns and tracing of close contacts to infected individuals. This strategy seems to have been very successful. Also China, where the virus originated, appears to have stopped the outbreak with combination of complete lockdown in hotspots, intensive testing and tracing, as well as restrictions in people’s mobility combined with partial lockdowns in other regions.

The rest of the world faces the challenge of widespread virus dissemination, which makes conventional containment measures as well as intensive test and tracing methods infeasible. Frankly, one doesn’t know where to look. In Italy, the European epicentre of the Covid-19 outbreak, a national lockdown was imposed the 9th of March. Several countries have introduced similar interventions with the aim “to flatten the curve”. The idea is to postpone and lower the peak of the epidemic curve to enable healthcare systems to cope, particularly with the high demand for mechanical ventilation. Another aspect of postponing instead of stopping the pandemic is the hope for so called “herd immunity” which will help to prevent later outbreaks.

All above-mentioned community interventions come at a very high cost. The world economy is starting to halt. As the current measures will need to be in place for a very long time, they may hinder sufficient supply of urgently needed equipment. Furthermore, it is uncertain whether the imposed actions are even close to slowing the pandemic sufficiently. The disease is highly contagious (R0 has been estimated between 2.4 and 3 in the Hubei Province and between 2.3 and 14.8 at the start of the Diamond Princess cruise ship outbreak) and even severe currently used community interventions will not entirely stop community transmission. Data from Italy for March 23rd show that the number of patients was still rising on average 14% the 10 preceding days; even in the region of Lombardy (first lockdowns February 27th) this figure was still 11% (down from 26% between Feb 23rd – Mar 3rd) although the number of new cases is finally declining. The Italian healthcare system is on the verge of collapse (Figure 1).

Figure 1: Newly diagnosed infections, active Covid-19 patients and Covid-19 patients in ICU in Italy, February and March 2020. The Intensive care unit (ICU) demand per million inhabitants raises proportional with the total number of patients with an ongoing Covid-19 infection. At the end of the period there are approximately 0.2% of the Lombardian population reported as Covid-19 positive creating a demand for 120 ICU beds per million Inhabitants. Even if the number of reported cases represents only 5% of the actual number it is clear that no healthcare system of the world can cope with a full-blown epidemic. (Data: Italian Ministry of health)

Currently, approximately 50,000 Italians are reported to have an ongoing Covid-19 infection. Even if the correct number was 20 fold (ascertainment in Wuhan was previously estimated to 5% (95%CI, 3.6–7.4)) that would be < 2% of the Italian population. One can only but imagine the consequences of 40% being infected. Currently, other European countries are struggling to prepare for the coming pandemic and consequently little aid is offered to Italy. The situation in the US is also currently escalating.

Hypothesis: A coordinated alternating nation- or region-wide quarantine of the whole population is an efficient way to stop the Covid-19 pandemic, with less impact on economies and on everyday life than the currently imposed partial lockdowns.

The idea is to divide the whole population in two groups (A and B) for a period of eight weeks. Both groups will stay in alternating home quarantine for two weeks at a time (quarantine length recommended by the WHO for Covid-19) while the other group attends to daily life. All symptomatic individuals during quarantine are either tested or need to remain in quarantine with their households. Positive tested individuals and their household members remain in home isolation until negative test result. Individuals in home-quarantine at the start of the first period are allocated to group A.

During this four-week period, other interventions should continue (cough and hand hygiene, social distancing, no public meetings, shut-down of cinema/theatres). Patients at risk should preferably be isolated for the whole period and some critical personnel might need to work the whole period (Figure2). The cycle may need to be repeated at the end of week 4 if there are many newly diagnosed patients in group A after the quarantine.

Figure 2: Schematic illustration of alternating quarantine. Preferably, the group of critically needed personnel should be as small as possible and avoid all contact with those practicing home quarantine. For personnel in regular contact with Covid-19 patients there should be a low threshold for testing. As reinfections are unlikely, healed personnel can work the whole period. Crossovers between from Group A to B are possible, for example if there is an urgent shortage of personnel or in case of emergency admissions, crossover from B to A is undesirable. Group A should preferably be a bit larger than group B in order to account for crossovers due to quarantines in Group B. To get a quick control of the situation in hotspots, Group A may be much larger than group B. Current restrictions like closed stores, cinemas, public meeting points, should be maintained at least for the first 4 weeks. If there are many new infections in group A at the end of week 4, the cycle needs to be repeated.

There are five prerequisites for this intervention to be effective:

  1. It is essential that all members of one household are in the same group.
  2. The group in home quarantine needs to stay at home and either buy all supplies for 2 weeks before the start of the period, or be supplied by the community (i.e. by the group that is not quarantined); this is to prevent new infections. Only few exceptions should be made (for example chronically ill or acutely unwell patients in need of hospital treatment and patients receiving home nursing or staying in institutions).
  3. There should be as little contact as possible (preferably no contact) between the groups when switching quarantine periods. Non-avoidable contacts need to be traceable.
  4. The start of the two periods needs to be coordinated for large areas, preferably whole countries, or country unions (for example the whole European Community).
  5. At the end of each period, public areas and workspaces need to be disinfected thoroughly due to the long-lasting stability of the virus on surfaces.

There are different ways to allocate the population to the groups – community wise, according to where people work (for example a whole factory may pause for 2 weeks as long as household members of employees are allocated to the same group), by postal code or house number. The optimal way may differ between countries and communities. Group A may be larger than group B in order to get a quick control of the situation, especially in Hotspots. The whole 4-week circle needs to be followed by an active surveillance with intensive testing. A detailed plan by domestic health authorities for workers in critical positions who need to work throughout the whole period can minimize the chance of “contamination” of Group A and B after the home quarantine periods (for example home delivery of food to those working with Covid-19 patients). Figure 3 shows a very simplified model of the effect of social distancing and lockdowns compared to alternating quarantine.

Figure 3: Simplified model of the effect of moderate community interventions, partial lockdowns and alternating population quarantine to prevent the spread of Covid-19.

Figure 3a & 3b: Number of infected individuals at the end of a four week period with two different scenarios of community interventions if 2 out of 500 were infected at the start: 3a Local lockdowns, travel restrictions and other interventions, daily increase of infected individuals by 10% assumed (current situation in Italy, at the beginning of the outbreak the daily increase was >20%). 3b Rigid lockdown as effectuated in Italy the 9th of March. This intervention is here estimated to reduce the daily increase to 7%; the effect is expected to be visible on the epidemic curves the coming days and may be larger.

Figure 3c – 3f: The effect of an alternating home quarantine (gridlines) assuming a daily increase of infected individuals of 10% in the not quarantined population. In a perfect situation with all patients becoming symptomatic, all would be detected and isolated at the end of week 4. However, the model is neither accounting for not quarantined asymptomatic patients living in other household than symptomatic patients, nor for insufficient test capacities at the end of the period being in the way for testing also individuals with little symptoms, which is why the circle needs to be repeated if there are many new infections in Group A at the end of week 4.

The main strength of alternating population quarantine is that the risk of community acquired Covid-19 infection is reduced to a minimum already after week 2. Furthermore, this concept would enable countries to stop the pandemic quickly locally. The impact on economy would be minimalized as several businesses can run for a short period of time with half the workforce. Temporary working hour adjustments or reduction in activity may compensate for the loss of work force.

The concept has some drawbacks. It requires either complete compliance by the population or effective control mechanisms with law enforcement. However, when confronted with the alternative of a never-ending partial shutdown combined with a probable major recession or that of staying at home for a limited time, the choice should be easy and politicians should be able to motivate the majority of the public to stay at home for two weeks at a time.

Another aspect is the susceptibility of the population for a new outbreak due to lack of immunity. However, the cycle of home quarantine can be repeated if necessary until sufficient test capacities, vaccines or treatments are available which is still preferable to a never-ending partial lockdown. Asymptomatic Covid-19 positive patients may prevent the success of this method. The proportion of asymptomatic patients has been estimated to be 18% during the Diamond Princess cruise ship outbreak.

It is likely that asymptomatic individuals will often be in close relation to symptomatic ones. A double cycle could allow us to identify almost all; it is however even more difficult to conduct. Experience from Asian countries shows that quarantine and isolation measures do work and that it is sufficient to test those who are symptomatic in order to find asymptomatic transmitters. When new clusters are detected, the method may even be repeated in affected areas. Many adaptions of this method are possible. Advanced epidemiological models and increasing knowledge about the disease may help to optimize it. The main principle however remains: to reliably separate the infected population from the non-infected in space and time.

At the moment, many countries are expanding ICU capacities. In my own hospital, this is possibly to a six-fold of normal capacity, and this may not even be enough. Furthermore, the current pandemic already prevents elective patients from receiving care. In addition, the current situation causes major damage to the world economy. Although the number of newly infected patients in Italy has been falling the last two days, there may be a quick raise again once restrictions are lifted. We should therefore do whatever we can to stop the pandemic rather than postpone its peak. This is not only to protect the old and vulnerable, but also to save our healthcare systems and our societies from collapsing and to avoid a new era of Great Depression. To quote one principle of damage control surgery: “the treatment of bleeding is to stop the bleeding”. The current approach is similar to treating a bleeding patient with transfusions and a simple bandage to slow the bleeding.

Ethical aspects 

One might argue that it is unethical to expose group B for transmission longer than group A. However, the risk of infection for group B will be reduced considerably compared to what it is now already in when group A is quarantined. Furthermore, the exposure for Group B could be minimized by increasing the Size of group A. Two weeks of strict home quarantine may also increase the risk of home violence; this is however not much different from lockdowns. 

Conclusion 

With the current knowledge about Covid-19, the current strategy of delaying the pandemic seems to hazardous. The present hypothesis of alternating home quarantine can only be tested by governments of countries or provinces, but time is precious. 

Acknowledgements 

I would like to thank my colleagues and family for critical discussions. I would also like to thank Sheraz Yaqub and Ørjan Olsvik for a critical review of the paper. Further, I thank my Italian colleagues Michela Monteleone and Dario Tartaglia for inside information from the epicenter of the European outbreak. 

Disclosures 

None other than a close bond to Italy, #tuttoandrabene! Funding: none.

Johannes Kurt Schultz is a surgeon at the Akershus university Hospital in Norway.

Covid19

Guest post: The effects of COVID-19 on surgeons and patients

When the first cases of the disease that would have been later named COVID-19 (Coronavirus Disease 2019) caused by SARS-CoV2 were described in Wuhan approximately three months ago, it would have been difficult to predict the impact and the burden that the subsequent outbreak would have had globally. The first case was tracked back to November 2019, indeed the spread COVID-19 proved to be incredibly rapid, and is currently causing several challenges to most health systems.

On the 11th March the World Health Organization (WHO) declared COVID-19 pandemic. Between the last week of February and the first week of March, the number of cases outside China increased 13-fold and the numbers of affected countries tripled. By the time the present piece is being typed, 164 837 cases were recorded globally, with 6470 deaths, 146 countries involved. 

Among European countries, Italy has been hit first and more deeply, the reasons for this still being analysed, and no agreed explanation available. Since the first cases were described on the 30th January 2020, two Chinese tourists, the outbreak showed a logarithmic growth, and by today (16/03/2020), the overall number of individuals who tested positive was 24 747 (20 603 still positive) with 1809 deaths. This would mean a mortality rate overall as high as 7.3%, and 43.6% of those who had an outcome. Of those currently infected, approximately 8% is in serious/critical conditions. Lombardy, considered the economic heart of Italy, where an ideal health system is in place, registered the highest number of COVID-19, exceeding 13 200 patients, more than half than all Italian cases. The outbreak is rapidly spreading to the entire peninsula, islands not being spared: almost 1000 cases between South and Islands (3.73%). Even if these figures might not seem worrisome, they actually are, as facilities and infrastructures might not be prepared to afford a similar outbreak as that observed in Northern Italy, and the system could collapse. Restrictive measures had to be taken, and the Italian Government ordered an unpreceded lockdown effective as the 12th March 2020, and its effect and meaning are well testified by the empty Italian cities. Florence’s Uffizi Gallery is closed; St. Peter’s Square in Rome is empty.  

These images are self-explanatory.  Similar measures are being taken in other European countries, even if the strategies to face COVID-19 were not consistent. Spain followed a similar pathway observed in Italy, with 7753 cases and 288 death as of today, mainly in Madrid, and adopted the same measures. 

The impact of COVID-19 on our society is already immense, and some have suggested that the post-pandemic era is likely to blow away the world as we used to know it. 

COVID-19 and Cancer

Liang et al. analysed the cases of COVID-19 in China, and found that patients with cancers were at higher risk of developing the symptoms from SARS-CoV2 infection. Out of 1590 COVID-19 cases analysed, an history of cancer was found in 1% of them, versus 0.29% observed in the general population. One out of four had received chemotherapy or surgery within 30 days from infection, whereas another 25% were on follow-up after treatment. This might suggest that cancer patients might be at increased risk, even after curative treatment of the disease, for reasons that are not completely understood. Liang et al. also suggested that severe events were more common in cancer patients with COVID-19, as more patients in this population required invasive treatment measures or died compared with patients without cancer (even [39%] of 18 patients vs 124 [8%] of 1572 patients; Fisher’s exact p=0·0003); the risk was even higher if chemotherapy or surgery were performed in the last month, administered. These findings raise concerns on the ideal care to provide to such patients and whether or not should chemotherapy be continued during the outbreak, or at least stopped or reduced in selected patients at higher risk of infection. Of note, the actual impact of COVID-19 on the outcome of cancer patients in this specific cohort remains to be clearly proven, as the age of this cohort was higher than that of non-cancer patients with COVID-19. Moreover, they were more frequently smokers, and more frequently had polypnea. These considerations advocate for prudence at the time of interpreting the findings of studies which are currently being published on the topic, due to the limited knowledge available and to the relatively low (yet) number of cases described in these publications, which might be underpowered to show clinically relevant findings.

Similar concerns are applicable to patients who are chronically immunodepressed and to those with chronic conditions that might expose them to an increased risk of contracting COVID-19, and with potentially detrimental outcomes.

COVID-19 and usual hospital routine

The effects on COVID-19 on patients with chronic diseases or cancers are more extensive than the risk of contracting the virus for carriers of these conditions. The health system is almost collapsing in several countries, with few available beds in intensive care units. Elective surgery has been stopped in many hospitals, giving priority to cancer patients and to emergency. The personnel is being shortened to the minimum necessary to deliver the basic services, and, while intensive care units and medical wards are saturated, the current appearance of surgical wards is appalling.

Notwithstanding the effort put in treating as many cancer patients as possible, the timeliness of cures is inevitably delayed, and the outcomes of treatment might well be affected in the long-term.  At the same time, screening is not being offered consistently.  A delayed diagnosis is associated with worse outcome in cancer surgery. Sanjeevi et al. showed that potentially curable pancreatic cancers had 0% unresectability rate at surgery when the interval between imaging and resection was shorter than 23 days, highlighting the importance of acting within a window of opportunity to achieve optimal survival results. An analysis of a US National Cancer database with over 60 thousands patients with curable colon cancer, found that overall survival was longer in patients operated on within 16 days from diagnosis compared with those operated on after 37 days or more (5-year survival 75.4 vs 71.9%, 10-year survival 56.6 vs 49.7%, both p<0.001). Moreover, the long-term effects and associated indirect costs of cancer surgery include the assessment of lost work-hours due to sick leave after surgery. Postoperative recovery after colorectal cancer surgery might be slower than thought, and advanced disease further impair return to work, suggesting that delaying diagnosis and surgery impacts the economy further.

Many chronic conditions are likely to be affected by delayed treatment. Patients waiting for transplantation are another facet to consider. Discussions are ongoing globally in order to face these difficult situations, and how to deal with the current status of things still remains to be clarified.

Patients, family, and COVID-19 

During crisis, priorities are being reorganized, meaning that priority is given to patients with more worrisome conditions or those more likely to benefit from a treatment. However, this generates a stressful environment and brings about nonnegligible consequences to individuals’ wellbeing. Surgical patients with conditions that are not being regarded as priority may feel let down by the doctors and the health system, and they need appropriate support to face this new condition, and their families to be cared for, and this will be much more relevant once the current acme of the outbreak has settled. Many societies and patients’ associations have made available for patients’ guidance and suggestions to help them during these difficult times. 

Moreover, family visits to patients who are currently being hospitalized are being strictly controlled, so that the postoperative recovery or the in-hospital stay in general are made even more challenging by an overwhelming sense of loneliness.     

Facing COVID-19: ongoing initiatives, collaboration

Emergencies can bring to light the worst aspects of humanity, but they can also strengthen the spirit of collaboration against a common issue. Even if many have been forced in isolation or quarantined, even if travel is forbidden from and to several countries, social media proved again to be a powerful means to disseminate knowledge, to facilitate discussions, and to establish collaborative initiatives on a global scale.

The response to the fears of doctors and patients on how to deal with COVID-19 and how to act during the outbreak has been immediate, and several scientific societies have provided documents and platforms to be used as guidance. The Spanish Association of Surgeons (Asociación Española de Cirujanos, AEC) released on the 15th March a Position Statement that can be freely accessed on the measures to be taken for patients needing surgery during the pandemic, and a similar initiative has been announced by the Spanish Association of Coloproctology (Asociación Española de Coloproctología, AECP), with specific focus on patients needing surgery for colorectal conditions. These documents are being developed with an innovative format, meaning that they are solidly grounded on available evidence but they are dynamic, open to updating that can occur within hours. 

This is relevant at a time when no agreed policy has been decided to face the COVID-19 pandemic. As of today, not all nations have decided to adopt the same stringent measures acting in Italy and Spain, and likely to be extended to France and other countries. For example, UK has announced a different strategy, relying on the development of an immunity against COVID-19, with no need for restrictive measures. Indeed, this was not agreed by the entire scientific community, and hundreds of UK scientists signed an open letter pressing the Government to enforce social distancing. It is difficult to identify which strategy is the more appropriate, but a common effort towards an agreed strategy is desirable in the following months.

A joint GI Society Message on COVID-19 was released on the 16th March by the American Gastroenterology Association, the American Association for Liver Disease, the American College of Gastroenterology, and the American Society for Gastrointestinal Endoscopy. The document deals with recommendations to provide care, including endoscopy, to patients with gastrointestinal conditions during the pandemic.

The European Crohn’s and Colitis Organisation (ECCO) launched a questionnaire aiming to identify the fears and difficulties that IBD doctors are facing while practising during the COVID-19 pandemic, in order to take actions and provide support. An international, online, secure database has been started to report information on IBD patients diagnosed with COVID-19.

An initiative that rapidly captured the attention of the surgical community globally was the launch of an international prospective registry of patients operated on for whichever condition while positive for COVID-19. The initiative was launched by Aneel Bhangu on the 14th March on Twitter and is open for registration. A draft protocol is available to access and registration can be performed at this link.

These initiatives will hopefully help to clarify the actual impact of COVID-19 on surgical patients, and help to define the ideal pathways and perioperative management of these patients.

Impact on psychical well-being of healthcare professionals: who cares for the carers? 

Last but not least, healthcare professionals are being exposed on the frontline. They are working in extremely difficult conditions, far different from what most of them were trained to work. The intensely stressful conditions in which doctors, surgeons and all healthcare professionals are called to work, is exposing them and their families to unpredictable consequences. 

Not being able to treat everyone, the need to do extra shifts, wearing protective equipment during the entire shifts as well as the lack of protective devices, the fear of getting infected, all contribute to a potential burnout. 

Doctors are choosing to isolate themselves from their relatives, in order to protect them, even if asymptomatic. The fear of being tested positive, apart from the fact that being affected already implies, brings about the necessity of being quarantined, and further reduces the number of available team members. This is further aggravated by the required quarantine for those colleagues who were in contact with the index healthcare professional tested positive.

Indeed, many institutions and entities are providing help to doctors struggling with the current crisis. The Physician Council of Barcelona (Colegio de Medicos de Barcelona, COMB), for example, established a telephone-based service to support doctors who are experiencing psychological stress and difficulties while in isolation, and a similar service was offered to struggling doctors at local hospitals (e.g. Hospital Vall d’Hebron in Barcelona). Similar initiatives are needed, and must not be limited to the emergency only, but should last long after this has been controlled.

Things are changing rapidly with COVID-19. A financial crisis is likely to occur, that will require to be faced jointly when the emergency has been resolved. It is however needed to maintain our focus on what we are doing every day with every single patient, and those of us who are isolated need not to forget that this is part of caring for the others. Doctors, surgeons, nurses, all the healthcare professionals need to feel backed by the institutions and by the people. In Italy and Spain, people under lockdown have started clapping their hands as a tribute to healthcare professionals. During such difficult times, similar spontaneous acts are fuel for our practice and help us to cope with the burden and the negativity that COVID-19 has spread, while scanning the horizon in search of the end of the current crisis.

Gianluca Pellino (@GianlucaPellino) and Antonino Spinelli (@AntoninoSpin) are surgeons from Italy.

zebras

Bowel cancer is not just a disease of older people

A young surgeon’s experience as a patient with bowel cancer

If you ask any clinician, becoming a patient is an unusual experience. When you couple that with the naivety of youth, embracing the role of a patient is particularly challenging. 

“We are taught that we when we hear hoof beats, we should think horses, not zebras.”

As part of surgical training, and even in medical school, there are specific red flags that are taught to all of us. ‘Bowel habit change’ and ‘per rectal bleeding’ are not a great combination. We are also taught that we when we hear hoof beats, we should think horses, not zebras. So when I developed these symptoms I just assumed that I probably had a benign cause of bleeding. I assumed this for six weeks while I worked in a high volume liver and kidney transplant unit until I decided it was bothersome. I picked up the phone to one of my mentors, a colorectal surgeon. She subsequently performed my low anterior resection.

My story is different. I class myself as one of the lucky ones. I was aged 33, with no significant family history, only stage 3. I underwent a low anterior resection, fertility treatment and then 6 months of adjuvant FOLFOX. FOLFOX was not very kind. I didn’t require neoadjuvant radiotherapy, had clear margins and only 2 positive nodes. It is amazing how different your perspective is after such an unexpected life interruption. My life changed completely in one single moment.

From the beginning I called myself a lucky unlucky person. I had encountered young people with colorectal cancer in my surgical training, however, in clinics with 30-50 people being followed up in our public health system, it was still a rarity. When I was diagnosed in 2018 I only really began to appreciate the growing trend of young people being diagnosed with colorectal cancer. People that are not considered at risk. People under the age of 50. Where screening programs exist, all of these people would be too young to be screened. The age for screening in the United States has recently been lowered. It is still not practical for many reasons to extend population based screening to include those who are even younger. While the figures are alarming us all and steadily climbing, they still don’t meet criteria to support population based screening. 

“Becoming a patient reveals so much more about patient care and management.”

What is practical and even more alarming is these people’s stories. Bowel Cancer Australia and Bowel Cancer UK frequently highlight individuals who I never thought I would relate to. I am one of many in a long list of patients who are only too happy to tell their story in hope that someone might not have to go through and live with the effects of cancer. Becoming a patient reveals so much more about patient care and management. The anxiety relating to waiting, having scans, and to having your first operation as such a major one. The knowing too much, from the very beginning. After I was told that my surgeon found a cancer, I know I asked where it was. I meant anatomically. I asked this as I knew what the next investigations would be and what treatment (if I wasn’t metastatic) was being considered. It’s not a normal opening question from any other patient.  

It is really encouraging to see increasing attention being paid by researchers and surgical journal editors to the rising rate of colorectal cancer in young people, because it means that the message is being delivered regarding the need to investigate symptomatic people. This is separate to any screening argument. I have been part of the #Never2Young campaign and consider myself obliged to advocate for such awareness campaigns not only as a health professional, but as a colorectal cancer patient. I have become a statistic. I am one of those people diagnosed with a left sided colorectal cancer in the age group 20-49. 

Publishing real data and real stories and disseminating them will reach our communities and our clinicians working on the front line, trying to sort through who to investigate further or not. The message is becoming clearer for them now. Symptomatic people need investigating. I have seen firsthand only too many young people who have dismissed their own symptoms or had them dismissed by all levels of care. There are barriers to appropriate investigation with colonoscopy for many reasons. We need to make sure patients are better supported. 

Cancer does not discriminate.

I have completed treatment. I have had highs and lows within my surveillance already. I am lucky enough to have returned to work finishing my time in general surgical training. Navigating through life post treatment has days of uncertainty and sadness. I never stay sad too long. I constantly get reminders of just how lucky I am to still have this life that could have so easily been taken from me.

Cancer does not discriminate. It will choose anyone at any time. Anyone with symptoms needs to be investigated, as sometimes those hoof beats are actually zebras.

Katherine Goodall is a general surgical registrar from Queensland Australia

Surgical research in Plain English

Randomized controlled trial of plain English and visual abstracts for disseminating surgical research via social media

BJS started with the aim of of being a medium through which surgeons “can make our voice intelligibly heard”, according to Sir Rickman Godlee, President of the Royal College of Surgeons of England in 1913.

The aim of a recently published paper in BJS was to increase the engagement (defined compositely as the total number of replies, retweets, or likes on Twitter) of clinicians and patients in the communication of surgical research – part of the core values of BJS.

Ibrahim et al. showed in the Annals of Surgery that visual abstracts increased engagement on Twitter in their case-control study, but plain English summaries have not previously been studied in the context of surgical research. Plain English summaries are becoming a real priority for funders (e.g. NIHR), as well as for clinical practice (BMJ, AoMRC). Patients are involved in the development of research, and need to have access to it.

This was a three-arm, randomized controlled trial with crossover of two intervention arms. Manuscripts that were eligible for inclusion were randomly allocated to three arms and disseminated via Twitter. The arms were standard tweets, plain English abstracts & visual abstracts.

Visual abstracts are a simplified graphical summary of a study’s scientific abstract. Plain English abstracts were developed according to NIHR INVOLVE ‘make it clear’ guidance and edited to satisfy a minimum readability index.

The primary outcome was online engagement by the public within 14 days of dissemination. The secondary outcome was online engagement by healthcare professionals.

The results can be seen in the visual abstract, with more details available in the paper. Overall: visual abstracts attracted a greater number of total engagements than plain English abstracts, and engagement by members of the public was low across all abstract types.

Note that this study only looked for the potential benefits from the point of view of the journal – not data from the perspective of patients, although a Twitter poll suggested that there was an appetite for informing the public about the findings of research studies.

More work needs to be done in collaboration with the public to understand how and in what format they prefer to engage with surgical research. We need to avoid soundbites of results, and instead provide a balanced & educated interpretation, to help to counter the avalanche of false information to which the public is exposed.