The COVID-19 pandemic has impacted healthcare around the world. Patients who have vascular disease (problems with their arteries or veins), are at high-risk of having complications if they develop COVID-19. This is because patients with vascular disease usually have many medical problems. Some of them are also elderly and might be frail. We do not know how the COVID-19 pandemic might have affected the care of patients with vascular disease.
The COVER study is an international study trying to assess how the COVID-19 pandemic changed the medical care of patients with vascular disease. The first part of the COVER study was an internet survey. In this survey, doctors and healthcare professionals were asked questions (every week) about the care of vascular patients at their hospital. The results were published in this article.
The results showed that the COVID‐19 pandemic had a major impact on vascular services worldwide. Most of the 249 hospitals taking part from 53 countries, reported big reductions in numbers of operations performed and the types of services they could offer to patients with vascular disease. Almost half of the hospitals stopped doing routine scans to detect artery problems and a third had to stop all clinics in the height of the pandemic. There were major changes in the resources available to treat blocked leg arteries. Most non-urgent operations, especially for vein problems, were cancelled.
In the months during recovery from the pandemic peaks, there will be a big backlog of patients with vascular disease needing surgery or review by vascular specialists.
One of the consequences of COVID-19 has been greater attention on the risks of infection to clinicians. Much has been made of the need for personal protective equipment, including FFP3 masks, visors, and respirator hoods. Unfortunately these can also impact on communication. This can be due to muffled speech, or loss of ability to read lips. This is important in an operating theatre, where clear communication is critical.
Experience suggests that surgeons probably use some gestures to aid communication when operating. The use of sign language in clinical settings has been previously addressed in the literature, mainly as a proposal to manage increased noise levels in the OR. Sign language has also been suggested as an alternative to handle language differences in surgical team members of varied nationalities, as well as to improve action response within a procedure.
A new sign-language?
To reduce verbal communication that may be limited by impaired speech or hearing, the authors have proposed a surgery-specific sign language. The vocabulary consists of technical information that is easy to learn and replicate and allows fluent communication in the OR. These are summarised in the video above.
A full version of this article can be found in special correspondence to the editor on the BJS website.
James Ashcroft (@JamesAshcroftMD) Academic Clinical Fellow, Department of Surgery, Cambridge, UK;
Salomone Di Saverio (@salo75) Consultant General and Colorectal Surgeon, Professor of Surgery, University of Insubria, Regione Lombardia, Italy;
Justin Davies (@jdcamcolorectal) Consultant General and Colorectal Surgeon and Deputy Medical Director, Addenbrooke’s Hospital, Cambridge, UK.
Key questions in the diagnosis and management of appendicitis
Throughout my surgical training, decision making and risk prediction in patients with a clinical suspicion of appendicitis has been a prominent challenge. The accurate diagnosis of appendicitis should lead to improved healthcare provision to the patient, however there is still debate amongst the use of tools and imaging to assist this. The appropriate use of antibiotics to manage appendicitis, and the use of operative techniques to remove the appendix, have recently become a global debate.
Diagnosis of appendicitis
I have personally found the diagnosis of appendicitis to be challenging, with presenting history and examination of patients with right iliac fossa pain variable and often confounded. Clinical risk scores have recently been investigated through prospective international collaborative studies.1 The Alvarado score was one of the earliest scores demonstrating efficacy in appendicitis diagnosis when confirmed to histopathological diagnosis leading to its widespread uptake.2 However, this been superseded by the Appendicitis Inflammatory Response score (AIRS) in males and Adult Appendicitis Score (AAS) in females which have demonstrated improved performance in a pragmatic clinical setting.1
I have often been taught that appendicitis is a diagnosis made on clinical judgement alone and I feel this has become one of the most prominent dogmas present in surgical practice. The use of AIRS and AAS have been recognised to decrease negative appendicectomy rates in low-risk groups and reduce the need for imaging.1,3 I believe that the use of risk scoring should be taught to all surgical trainees routinely as a standard work up for the assessment of right iliac fossa pain.
Recent news reports have disseminated to the public that “Thousands of young women have their appendix removed unnecessarily”4 and although this may represent the appropriate conservative approach to imaging in females, it emphasises that we cannot justify ignoring the diagnostic tools at our disposal. Point of care ultrasound is recommended by the World Society of Emergency Surgery for decision making as a first point of call in both adults and children, however operator variability is noted.3
In my experience, and as per the general consensus of the departments I have worked in, ultrasound imaging is often useful in female patients to identify any ovarian cause of right iliac fossa pain and inconclusive for appendicitis. However, I can envision the use of ultrasound as part of clinical-radiological scores to enhance the sensitivity of diagnosis and could assist in avoiding radiation exposure through CT scan, which remains a pertinent research question.
Non-operative and operative management of appendicitis
Mirroring teachings in the diagnosis of appendicitis, in my experience it is taught that there is only one definitive management plan for simple appendicitis – an emergency appendicectomy. When considering modern sources of evidence, my belief is that the UK national normal appendicectomy rate (NAR) of around 20% is too high, when compared to countries such as Switzerland where the NAR has been found to be around 6%.5 The high NAR in the UK was again picked up by British media outlets who published headlines such as ‘Unnecessary appendix surgery performed on thousands in UK’.4
Antibiotic-first strategy has been found to be safe and effective in selected patients with uncomplicated acute appendicitis however, the risk of recurrence has been suggested to be up to 39% after 5 years.3 A 2019 meta-analytical review of 20 studies (7 prospective RCTs, 8 prospective cohort studies, 4 retrospective cohort studies and 1 quasirandomised study) investigated outcomes in non-operative management with antibiotics in appendicitis with an overall moderate quality of evidence when regarding complications and treatment efficacy.6 Overall antibiotic therapy achieved a significantly lower post-intervention complication rate including postoperative abscesses, surgical site infections, incisional hernias, obstructive symptoms, and other general operative complications at 5 years compared to index event surgery.6 However, there was a lower complication free treatment success rate and a non-significantly higher rate of complicated appendicitis with delayed surgery in patients receiving initial antibiotic therapy.6
I feel that the stratifying of patients by risk and utilisation of outpatient surgical ambulatory units with repeated history taking, observations, and blood tests could be effective in reducing the NAR in the UK with or without imaging. Accurate diagnostic imaging in the form of a CT scan could reduce the UK’s NAR further, improving patient outcomes, surgical planning, and healthcare service provision at an organisational level. This may outweigh the impact of radiation exposure of a CT abdomen scan which has been well described by Aneel Bhangu the lead director of the RIFT/West Midlands Collaborative as giving “the same radiation as flying to New York”.4 T
his is a risk which I believe many would not be concerned about when travelling. This view is in opposition to that of the recently updated World Society of Emergency Surgery guidelines which suggest that CT imaging may be avoided prior to laparoscopic operation, but it should be noted that there was debate regarding this within the writing committee.3
I believe that more care must be taken in patients with suspected appendicitis to undertake a discussion around imaging use, operative management, and non-operative management which is unbiased and evidence based. Those opting for conservative management should be warned of the possibility of failure and misdiagnosis of complicated appendicitis. In my training so far, conservative management has been discussed in those judged to be low-risk however this does not come without the risk of the on call surgeon’s bias seeping into conversation. Further research should be undertaken to identify precisely which cohort of patients are optimal for non-operative outpatient management.
Appendicitis and COVID-19
Recent research into risk scoring in appendicitis has demonstrated a clear benefit in stratifying patients into risk categories to guide management plans.1,3 As highlighted I believe that all patients presenting with right iliac fossa pain should undergo scoring, by either AIRS or AAS. It has been suggested that due to local population characteristics and health systems, risk scores should be validated locally prior to routine adoption.7 It has further been emphasised that risk score models should not replace clinical judgement and should be used as an adjunct to enhance decision making.8
In the current COVID-19 pandemic the use of non‐operative management has been suggested to be increased for acute surgical conditions such as appendicitis9 and this has been the experience of my department. The evidence at present suggests that this is safe and feasible, and therefore the COVID-19 pandemic presents a unique period for investigation.10 It could be a valuable endeavour for all centres to perform local analyses of the impact of conservative management on patients presenting with right iliac fossa pain in the COVID-19 period.
This is also being undertaken on a national level in the COVID- HAREM Study: Had Appendicitis and Resolved/Recurred Emergency Morbidity/Mortality. Locally, one year clinical outcomes could be measured for those diagnosed with appendicitis pre-COVID and during the COVID period. Finally, with the restoration of normal patient pathways post-COVID, risk scoring could be introduced to local departments with a pre-COVID / post-COVID comparison to allow for the clear demonstration of any benefit to the patient.
1. The RIFT Study Group and the West Midlands Research Collaborative. Evaluation of appendicitis risk prediction models in adults with suspected appendicitis. Br J Surg. 2019:73-86. doi:10.1002/bjs.11440
2. Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med. 1986;15(5):557-564. doi:10.1016/S0196-0644(86)80993-3
3. Di Saverio S, Podda M, De Simone B, et al. Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World J Emerg Surg. 2020;15(1):1-42. doi:10.1186/s13017-020-00306-3
5. Güller U, Rosella L, McCall J, Brügger LE, Candinas D. Negative appendicectomy and perforation rates in patients undergoing laparoscopic surgery for suspected appendicitis. Br J Surg. 2011;98(4):589-595. doi:10.1002/bjs.7395
6. Podda M, Gerardi C, Cillara N, et al. Antibiotic treatment and appendectomy for uncomplicated acute appendicitis in adults and children: A systematic review and meta-analysis. Ann Surg. 2019;270(6):1028-1040. doi:10.1097/SLA.0000000000003225
7. The RIFT Study Group and the West Midlands Research Collaborative. Author response to: Comment on: Evaluation of appendicitis risk prediction models in adults with suspected appendicitis. Br J Surg. 2020:2020. doi:10.1002/bjs.11542
8. The RIFT Study Group and the West Midlands Research Collaborative. Author response to: RIFT study and management of suspected appendicitis. Br J Surg. 2020:2020. doi:10.1002/bjs.11552
9. Di Saverio S, Pata F, Gallo G, et al. Coronavirus pandemic and Colorectal surgery: practical advice based on the Italian experience. Colorectal Dis. 2020. doi:10.1111/codi.15056
10. COVIDSurg Collaborative. Global guidance for surgical care during the COVID-19 pandemic. Br J Surg. 2020;(March). doi:10.1002/bjs.11646
Michal Daniluk, Jagiellonian University Medical College, Krakow, Poland
Antonio M. Lacy, Department of Surgery, Hospital Clinic, University of Barcelona
Tomasz G Rogula, Case Western Reserve University School of Medicine & Jagiellonian University Medical College, Krakow, Poland
Antoni M. Szczepanik, First Department of General, Oncological and Gastroenterological Surgery, Jagiellonian University Medical College, Krakow, Poland
Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is the virus responsible for the 2019 Coronavirus Disease (COVID-19). The main route of transmission is through droplets and close contact.1,2 As a result of their mass, droplets spread in space is limited to 1-2 meters from the source of production. Aerosolized particles, on the other hand, are smaller in size (0.3 to 100 micrometers) and have been documented to linger in the air longer than droplets and travel up to hundreds of meters before settling on a surface.3 The role of aerosolized particles in the spread of SARS-CoV-2 in the community has yet to be proven, however, their presence in the hospital setting has been of greater concern.4–6
The earliest documentation of infection coming out of Wuhan, China showed that 40 out of the first 138 (29%) people infected by SARS-CoV-2 were healthcare workers.7 In an effort to help minimize the spread of SARS-CoV-2, several hospitals have published their approach to the surgical management of infected or suspected COVID-19 patients. A recent PubMed search for “COVID-19” and ”surgery” yielded 224 results, of which 13 papers proposed detailed precautions when surgically managing a COVID-19 positive or suspected patient. From setup to post-operative management, this review will draw from the suggestions of these papers and outline some of the most commonly mentioned precautions. As many institutions have never experienced such a dramatic shift from their day-to-day operations, this document may provide useful information with regards to safe practice.
The Role of Hospital Management:
The majority of COVID-19 infected or suspected patients will not require surgical intervention throughout the course of their disease. Therefore, mainstream procedures and precautions focus on the management of respiratory distress, proper isolation of patients, safety of ICU personnel and emergency department organization.8 Senior surgeons should be heavily involved in the supervision of focused training and the development and update of protocols.9 All personnel should be familiarized with specific procedures related to 1) COVID-19 patient transport to the operating room (OR) 2) intra-operative, and 3) post-operative care.
A predesignated route should be the shortest possible distance from isolation to the OR. It should be cleared by security, use isolated elevators and have minimal contact with others.10 A recent study by van Doremalen et al. found that the survival time of SARS-CoV-2 on plastic and steel surfaces such as elevator buttons can last as long as 72 hours, thus supporting the notion of using separate lifts and routes for patient transportation.4
With Regards to operating theatres, all studies suggested the use of negative pressure environment to reduce the dissemination of viral particles.1,5,11–21 Van Doremalen et al. also found that in aerosolized form, SARS-CoV-2 can remain viable for up to three hours.4 Applicably, the use of a high frequency (25/hour) air exchange can significantly reduce viral load within the OR.17 All drugs and equipment should be prepared before the start of surgery to limit movement of staff in and out of the OR.17 Anaesthetic drugs should be placed on a tray to limit contact and potential contamination of the drug trolley. Hand washing and glove change should be performed in any case were additional supplies must be accessed from the trolley.20 Monitors, ultrasound machines and other devices that are difficult to disinfect, should be covered by transparent plastic wrap to decrease the risk of contamination.17
Personal Protective Equipment
Of the 13 studies reviewed, all recommended the use of eye protection in the form of goggles or a face shield as well as a filtered face-piece respirator (N95).1,5,11–21 Five out of 13 studies recommended the use of powered air purifying respirators (PAPRs)(protection factor of 25-1000) as a superior alternative to N95 respirators (protection factor of 10).1,11,17,18,20,22 In addition to the higher protection factor, PAPRs provide eye protection and unlike the N95 respirator, do not require fit testing.18,17 Finally, five out of 13 studies suggested the use of double gloves during intubation and/or surgery.12,17–19,23 Forrester et al. also recommended the implementation of a buddy system during donning and doffing to identify any breaches in protection which can be decontaminating using alcohol spray.5
Intra-Operative Precautions: Anaesthesia and Surgical Smoke
Five of the 13 papers analyzed were sent to anaesthesiology journals and focused mainly on the minimalization of viral aerosolization during induction of anaesthesia and extubation.1,15,17,19,20 Some suggestions include the use of shortest acting drugs at lowest possible dose, avoidance of awake intubation and aggressive post-operative antiemetic prophylaxis to avoid aerosol production during emesis.1,17 Four studies recommended that pre-assessment, induction and post-operative anaesthesia recovery should all take place within the procedure room.12,17,19,20 Patient documentation should be done electronically, if possible, on a tablet or iPad, which can be disinfected after handling.17
Previous studies have demonstrated that ultrasonic scalpels and electrocautery equipment produce surgical smoke or plume, capable of transmitting active viruses in aerosolized form.24–26 The risk of SARS-CoV-2 aerosolization via electrical surgical equipment has not yet been shown, however, several sources recommend the implementation of appropriate precautions. A recent publication by Zheng et al. suggested that the aerosol formed during laparoscopic surgery accumulates in the abdominal cavity.14 Sudden release of trocar valves and deflation of pneumoperitoneum may expose the healthcare team to aerosolized viral particles.21 Therefore, some collegiate bodies suggest the use of laparoscopy, only in select cases where clinical benefit to the patient substantially exceeds the risk of potential viral transmission to the environment and OR staff.27
Other committees indicate that the evidence of such viral transmission during minimally invasive surgery is weak, but nevertheless proper safety measures are recommended. The Society of Gastrointestinal and Endoscopic Surgeons (SAGES) and the American College of Surgeons recommend the liberal use of suction devices and smoke evacuators to limit surgical smoke release into the OR.14,16 Gas filtration systems such as the ultralow particulate air filter (ULPA) might potentially achieve COVID-19 purification of the surgical plume, but this has still to be confirmed.28
When doffing PPE, the first pair of gloves must be removed first, followed by the surgical gown, shoe covers, cap and goggles. The face mask must then be removed by the ear laces, taking care not to touch the external side. The second pair of gloves must be removed last.29 Upon leaving the operating theatre, all staff should take a whole-body shower before changing into clean scrubs and returning to their clinical duties.12,16,17,20
With regards to disinfection, the United States Environmental Protection Agency (EPA) has created a list of products for use against SARS-CoV-2.30 The most commonly mentioned protocols suggest the use of sodium hypochlorite, chlorine containing disinfectant, wipes that contain quaternary ammonium and alcohol, hydrogen peroxide vaporization, and ultraviolet (UV-C) light (for inactivation of aerosolized viruses).15,17,19,20,31
A major constraint reported by several centers is the shortage of PPE such as masks and gowns. Dr. Peter Tsai, the inventor of the N95 respirator, has made several suggestions regarding the re-usability of his equipment. The first recommendation is air drying for 3-4 days.32 Alternatively, masks can be oven dried for 30 minutes at 70oC.32,33 More recently, a study out of Duke University evaluated the utilization of hydrogen peroxide vapor to decontaminate N95 respirators. This validation study concluded that N95 respirators still met performance requirements even after 50 disinfections.34 It is important to note, however, that these recommendations are constantly changing and it is of utmost importance that healthcare professionals regularly assess the most up-to-date guidelines regarding N95 re-usability and the disinfection process.
The conclusions drawn from the present literature are limited by the novelty of this disease. Most of the studies presented in this review were viewpoints and recommendations based on personal experience. Due to limited experience of single institutions, efforts should be made to increase international collaboration in the era of this unprecedented pandemic. Specific data on the risk of infection among surgeons has not yet been documented, however, this should not undermine the importance of strong occupational safety. The included studies suggest a need to develop a universal, effective and affordable protocol for perioperative management of COVID-19 patients to ensure surgical staff wellbeing.
1. Rajan N, Joshi GP. The COVID-19: Role of Ambulatory Surgery Facilities in This Global Pandemic. Anesth Analg. 2020. doi:10.1213/ane.0000000000004847
6. Ong SWX, Tan YK, Chia PY, et al. Air, Surface Environmental, and Personal Protective Equipment Contamination by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS- CoV-2) From a Symptomatic Patient. JAMA. March 2020. doi:10.1001/jama.2020.3227.
7. Wang D, Hu B, Hu C, et al. Clinical characteristics of 138 hospitalized patients with, novel coronavirus–infected pneumonia in Wuhan, China. JAMA 2019; DOI: https://doi.org/10.1001/ jama.2020.1585.
8. Ahmed S, Wei T, Glenn L, Chong Y. Surgical Response to COVID-19 Pandemic: A Singapore Perspective. J Am Coll Surg. 2020.
9. Lancaster EM, Sosa JA, Sammann A, et al. Journal Pre-proof Rapid Response of an Academic Surgical Department to the COVID-19 Pandemic: Implications for Patients, Surgeons, and the Community Rapid Response of an Academic Surgical Department to the COVID-19.
10. Ti, LK, Ang LS, Foong TW, Ng BS. What we do when a COVID- 19 patient needs an operation: operating room preparation and guidance. Can J Anesth 2020; 67. DOI: https://doi.org/10.1007/ s12630-020-01617-4. 31.
11. Vukkadala N, Qian ZJ, Holsinger FC, Patel ZM, Rosenthal E. COVID-19 and the otolaryngologist – preliminary evidence-based review. Laryngoscope. 2020. doi:10.1002/lary.28672
12. Di Saverio S, Pata F, Gallo G, et al. Coronavirus pandemic and Colorectal surgery: practical advice based on the Italian experience. Colorectal Dis. 2020. doi:10.1111/codi.15056
14. Zheng MH, Boni L, Fingerhut A. Minimally Invasive Surgery and the Novel Coronavirus Outbreak. Ann Surg. 2020:1. doi:10.1097/sla.0000000000003924
15. Chen R, Zhang Y, Huang L, Cheng B heng, Xia Z yuan, Meng Q tao. Safety and efficacy of different anesthetic regimens for parturients with COVID-19 undergoing Cesarean delivery: a case series of 17 patients. Can J Anesth. 2020. doi:10.1007/s12630-020-01630-7
16. American College of Surgeons. COVID 19: Considerations for Optimum Surgeon Protection Before, During, and After Operation. 2020. https://www.facs.org/covid-19/ppe.
17. Wong J, Goh QY, Tan Z, et al. Preparing for a COVID-19 pandemic: a review of operating room outbreak response measures in a large tertiary hospital in Singapore. Can J Anesth. 2020. doi:10.1007/s12630-020-01620-9
18. Givi B, Schiff BA, Chinn SB, et al. Safety Recommendations for Evaluation and Surgery of the Head and Neck during the COVID-19 Pandemic. JAMA Otolaryngol – Head Neck Surg. 2020;1:1-6. doi:10.1001/jamaoto.2020.0780
19. Dexter F, Parra MC, Brown JR, Loftus RW. Perioperative COVID-19 Defense. Anesth Analg. 2020:1. doi:10.1213/ane.0000000000004829
20. Ti LK, Ang LS, Foong TW, Ng BSW. What we do when a COVID-19 patient needs an operation: operating room preparation and guidance. Can J Anesth. 2020:19-21. doi:10.1007/s12630-020-01617-4
21. Spinelli A, Pellino G. COVID-19 pandemic: perspectives on an unfolding crisis. Br J Surg. 2020:3-5. doi:10.1002/bjs.11627
22. Institute of Medicine. The Use and Effectiveness ofPowered Air Purifying Respirators in Health Care: Workshop Summary. National Academies Press; 2015.
23. Lui R, Wong S, Sánchez-Luna SA, et al. Overview of guidance for endoscopy during the coronavirus disease 2019 (COVID-19) pandemic. J Gastroenterol Hepatol. 2020;2019(852):0-3. doi:10.1111/jgh.15053
24. Choi SH, Kwon TG, Chung SK, Kim TH. Surgical smoke may be a biohazard to surgeons performing laparoscopic surgery. Surg Endosc. 2014, 28 (8): 2374-80.
25. Kwak HD, Kim SH, Seo YS, et al. Detecting hepatitis B virus in surgical smoke emitted during laparoscopic surgery. Occup Environ Med. 2016, 73:857––863.
26. Johnson GK, Robinson WS. Human immunodeficiency virus-1 (HIV-1) in the vapors of surgical power instruments. Journal of Medical Virology. 1991;33(1):47-50.
31. Kim DK, Kang DH. UVC LED irradiation effectively inactivates aerosolized viruses, bacteria, and fungi in a chamber-type air disinfection system. Appl Environ Microbiol 2018; DOI: https:// doi.org/10.1128/AEM.00944-18.
32. Bauchner H, Fontanarosa B, Livingston EH. Conserving supply of personal protective equipment: a call for ideas. JAMA. Published online March 20, 2020.
34. Schwartz A, Stiegel M, Greeson N, et al. Decontamination and Reuse of N95 Respirators with Hydrogen Peroxide Vapor to Address Worldwide Personal Protective Equipment Shortages During the SARS-CoV-2 (COVID-19) Pandemic. Appl Biosaf. 2020;2:1535676020919932. doi:10.1177/1535676020919932
Joshua S. Ng-Kamstra, Fellow in Adult Critical Care Medicine – Department of Critical Care Medicine, University of Calgary,
Dhruvin H. Hirpara, Resident in General Surgery – Department of Surgery, University of Toronto,
John Meara, Professor of Global Surgery and Social Medicine – Program in Global Surgery and Social Change, Harvard Medical School, Boston & Department of Plastic and Oral Surgery, Boston Children’s Hospital, Boston, &
Julie Hallet, Assistant Professor – Department of Surgery, Sunnybrook Health Sciences Centre & Department of Surgery, University of Toronto
The COVID-19 pandemic poses an acute threat to human health that is unprecedented in our lifetimes. Many health systems still continue to grapple with the volume of critically ill patients suffering from the virus.. The impacts of this crisis on surgical systems are being felt worldwide by patients and surgical providers. The estimated 30% of the global burden of disease caused by surgical conditions does not pause during a pandemic.1 Each year, 16.9 million people die due to surgically treatable conditions,2 and 15.2 million new cancers are diagnosed, 80% of which will require surgery.3 The magnitude and immediacy of the threat from COVID-19 has led many jurisdictions to cancel elective surgery to preserve precious hospital and critical care beds and limit nosocomial spread of the virus. As local trajectories of the pandemic become clear, surgeons and policymakers need to determine an optimal approach to meet population-level surgical needs to avoid additional pandemic-related morbidity and mortality.
Surgical systems are logistically demanding and interconnected networks of services: adaptation to the realities of limited operating theater availability is therefore complex. Human resources will also be threatened;4 safeguarding healthcare workers despite finite availability of personal protective equipment further adds to service delivery challenges. High-volume surgical systems must have the flexibility to systematically scale back provision of surgical care in a way that makes optimal use of resources while minimizing impacts on patients, providers, and systems. Looking at structured ways to operationalize sudden reductions in resources quickly, all countries can learn from existing principles and frameworks in the global surgery literature. Indeed, in addition to advocating for the health and economic benefits of investment in surgical systems,2 the global surgery literature recognizes and addresses the challenge of working under constraint.
Prioritization of Surgical Services
Surgical societies have provided guidance to surgeons as to which procedures are essential during this crisis.5,6 Such determinations are based on acuity, complexity, and population burden of disease. In a “must do, should do, can do” procedural framework,2 most surgeons have found themselves limited to providing only the first category: high value procedures (i.e. some cancer surgery) where long-term outcomes may hinge on timely surgical intervention, and urgent life- or limb-saving procedures. Should-do procedures are important but not vital procedures that may be amenable to a temporary workaround and still add value in the long run. Finally, can-do procedures are ones that are often desirable but not necessary—they could be deprioritized first with a relatively smaller impact on patient outcomes. These categories ought to be reassessed as resources change, but this framework can support discussions at the system, institution, and service levels. Non-operative management of traditionally surgical conditions (eg. antibiotics for uncomplicated appendicitis or endoscopic management of an early-stage esophageal cancer) may also aid in resource conservation. Finally, trauma prevention campaigns can be implemented or scaled up to minimize the need for emergency surgery.7
Mitigating Harm from Delays to Care
Globally, increased delays in access to surgical care are likely. Breaking these delays down into their three constituent components may help to mitigate them.2,8 First, is the delay in seeking care. With travel restrictions or residential lockdowns, the threshold to seek answers to concerns unrelated to the pandemic will increase. Creating easy access to primary care and surgical expertise, via telehealth for example, will give populations a venue to triage health concerns. Barriers to telehealth including finance, technical considerations, and confidentiality should be addressed collectively by providers, payers, government, and regulatory colleges. Second, the delay in reaching care at an appropriate center where diagnostics and therapeutics can be applied is less amenable to a technological solution. Maintaining separate health facilities as designated non-COVID-19 centers is one strategy to allow surgical work to continue or resume shortly after the pandemic peaks. As the pandemic progresses, the number of non-COVID-19 centres are reduced proportional to need as more patients present with viral illness, expanding again once the pandemic’s initial peak has passed. Finally, mitigating the delay in receiving surgical care requires adaptive waitlist management at the hospital level when progressively narrower bottlenecks in operating room time are encountered. Managing staffing constraints and pandemic-related supply chain disruptions will be critical to ensure that the appropriate personnel and disposables are available to use operating theaters as efficiently as possible.
Stuff, staff, space, and systems and the perils of reopening
Governments are struggling to balance the devastating economic consequences of ongoing stay-at-home orders with the risk of an overwhelming second wave of infections.9 While the optimal timing and strategy for reopening the economy remain unclear, strategies to mitigate the hazard of disease resurgence include widespread testing, serological surveys to better understand community-level exposure, staged relaxation of distancing measures, and bolstering hospital capacity to manage potential new cases. What these strategies all require are staff, stuff, space, and systems, an alliterative list of necessities for global health delivery coined by Dr. Paul Farmer.10
When public health officials deem it safe to resume some elective surgery, surgical leaders can also use this model to ensure that surgery again becomes available. Staff may need to be remarshaled from deployments to other acute care services; ensuring their mental and physical health during a period of significant stress will be critical. Stuff includes not only robust supplies of the necessary personal protective equipment to safely assess, operate on, and provide postoperative care for patients, but also medications and other operating room disposables that may become scarce due to supply chain disruptions. Space implies not only physical operating room space, but also appropriate spacing between postoperative patients, ideally in individual rooms, to prevent outbreaks of COVID-19 on wards. Finally, systems are required to ensure that care pathways for infected and uninfected patients are developed, staff are trained in their implementation, and their logistics are feasible.
Integrating surgery and other acute care services into global health security
Global health security (GHS) implies global collaboration to ensure that all health systems are prepared to manage public health threats and emergencies. Historically, the GHS discourse has been focused on infectious diseases as the primary public health threat born of globalization.11 The Global Health Security Agenda is a growing community of nations and organizations formed in 2014 to respond to infectious disease threats.12 By strengthening public health systems and stopping outbreaks at their point of origin, the GHSA aimed to decrease the risk of global pandemic disease. When it comes to a pandemic, the aphorism that prevention is better than cure is true. But it is an aphorism that historically excluded surgery from the global health discourse—why invest in surgery when some surgical disease is preventable?
The Lancet Commission on Global Surgery demonstrated the scale of human suffering that results when prevention is preached to the exclusion of treatment, with five billion individuals unable to access safe, affordable surgical care when needed.2 Not all surgical disease is preventable, and not every pandemic is stopped. GHS must evolve to include health services like critical care and surgery to plan for effective treatment of patients after a pandemic has emerged. If plans to address global critical care needs were in place before COVID-19, would countries have better mobilized to support beleaguered hospitals in China, Italy, or New York? If countries had anticipated the impacts of a pandemic on surgical care, would the cancellation of all elective surgery have been necessary? While these counterfactuals are unknowable, what is clear is that health services leaders must sit at the global health security table alongside infectious disease epidemiologists and public health professionals.
COVID-19 has reached almost every country on earth, and many surgical systems have already responded to the challenges it poses. The choices made in surgical system design, both historically and recently, will determine patient outcomes in the coming weeks and months. The shock to surgical systems will not be a short one—until the majority of the population has been exposed to the virus via vaccine or illness,13 the virus will pose a unique barrier to accessing safe surgical care.
Now more than ever, we must emphasize interdisciplinary collaboration, knowledge exchange, and health equity in order to maximize the efficiency of surgical access in all jurisdictions.14 Global surgery frameworks can support adaptation to rapid shifts in resource availability. More importantly, they can be used to plan the post-pandemic delivery of surgical services, serve to reconceive routine surgical care delivery systems, and plan resource scaling strategies to build more flexibility into surgical delivery in the future.
National surgical crisis planning must become part of the health systems lexicon. Mitigating acute threats to surgical systems including natural disasters, economic downturns, workforce declines, supply chain disruptions, military conflicts, and pandemic disease is not optional: our patients’ lives depend on it.
1. Shrime MG, Bickler SW, Alkire BC, Mock C. Global burden of surgical disease: an estimation from the provider perspective. The Lancet Global health 2015; 3 Suppl 2: S8-9.
2. Meara JG, Leather AJ, Hagander L, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet 2015.
3. Sullivan R, Alatise OI, Anderson BO, et al. Global cancer surgery: delivering safe, affordable, and timely cancer surgery. Lancet Oncol 2015; 16(11): 1193-224.
4. Bundu I, Patel A, Mansaray A, Kamara TB, Hunt LM. Surgery in the time of Ebola: how events impacted on a single surgical institution in Sierra Leone. J R Army Med Corps 2016; 162(3): 212-6.
5. Mock CN, Donkor P, Gawande A, et al. Essential surgery: key messages from Disease Control Priorities, 3rd edition. Lancet 2015; 385(9983): 2209-19.
Policies and public health efforts have not addressed the impact of pandemics on the provision of surgical services and the effects on health-related outcomes on surgical patients. This also applies to the response to Coronavirus disease 2019 (COVID-19). There hasn’t been any related research or analysis despite the impact of the pandemic so far. Understanding the effects of COVID-19 on patients undergoing surgery along with the effects of this pandemic on the provision of surgical services is a fundamental step to understanding the various different effects of a healthcare emergency of that magnitude and to implement policies from the lessons learned.
Impact on surgical patients
Undoubtedly despite the global focus to encounter the pandemic itself and the need to improve provision of services and treatments related to the immediate effects of COVID-19, with intensive care playing a major role, there are still millions of patients who will need surgical treatment. Major focus should be the provision of emergency surgical care, cancer surgery and transplant surgery. There is little or no knowledge on the outcomes of surgical patients with COVID-19 related disease.
Low quality data from a case series of patients who underwent cardiac surgery and acquired Middle East Respiratory Syndrome-Coronavirus (MERS-CoV) did show very high mortality of 83.33% (1). This has major direct implications on the management of emergency surgical patients during the pandemic as well as on the ongoing provision of organ transplantation and cancer related operations. Whether major cancer surgery and organ transplantation should be delayed and for how long, in view of the possible worse outcomes during the pandemic is one of the issues that should be investigated.
Impact on surgical services
We also need to address the effects of the current pandemic on surgical services provision. It is an unprecedented situation that has already changed the way surgeons and health systems worldwide are offering surgical services. There is also very low quality evidence available from the 2003 Hong Kong Severe Acute Respiratory Syndrome (SARS) epidemic that showed significant reduction in the colorectal surgical caseload that had a major negative impact on waiting times and training (2). Although it’s certain that the impact of the current COVID-19 pandemic will be of unprecedented severity, it’s actual consequences and the implications on resources, staff allocation and training are still uncertain. Understanding the effect of the pandemic would also inform future global policy around cancer and transplantation surgery during pandemics, and the provision of surgical services in general.
A new project
There is an urgent need to understand the outcomes of COVID-19 infected patients who undergo surgery. To address the above issues we designed CovidSurg, an international group of surgeons and anaesthetists, with representation from Canada, China, Germany, Hong Kong, Italy, Korea, Singapore, Spain, United Kingdom, and the United States. Our aim is to capture real-world data and share international experience that will inform the management of this complex group of patients who undergo surgery throughout the COVID-19 pandemic, improving their clinical care and to understand the effects of the pandemic on the provision of surgical services.
Outbreak of Middle East Respiratory Syndrome-Coronavirus Causes High Fatality After Cardiac Operations. Nazer RI, Ann Thorac Surg. 2017 Aug;104(2):e127-e129. doi: 10.1016/j.athoracsur.2017.02.072.
Tales from the frontline: the colorectal battle against SARS. Bradford IM Colorectal Dis. 2004 Mar;6(2):121-3. doi: 10.1111/j.1462-8910.2004.00600.x
In light of the need to assess priorities of surgical treatment in a resource-limited environment, NHS England have set out clinical priorities for cancer surgery. However, these priorities do not take into account the vulnerability of the patient to excess morbidity and mortality in the event of Covid-19 infection. It seems evident that, particularly when undertaking elective surgery, the vulnerability of a patient to Covid-19 related morbidity and mortality might be equally important to considerations of the timing of surgery as the underlying disease for which surgery is proposed.
The resource allocation system currently in use at Salford Royal NHS Foundation Trust (which has since been adopted throughout other hospitals at Northern care Alliance) takes both of these factors into account, by producing a score based upon the need to prioritise treatment on purely disease related grounds and also the vulnerability of the patient to Covid-19. The aim is to generate a score which can be used to determine the overall surgical treatment priority of a group of patients, possibly from different surgical subspecialties, when surgical resources have become limited as a result of the Covid-19 pandemic. The score allows different groups of surgeons and hospital management to objectively determine how temporarily limited resources might be allocated. It is meant to help guide collective discussions, not to be a rigid indicator of those patients for whom surgical treatment should be deferred, and it should be used to support, not to replace MDT discussions.
Cancer Surgery Priority
The NHS England Suggested Priority for Cancer surgery is summarised in table 1 below.
Priority level 1a
• Emergency: operation needed within 24 hours to save life
Priority level 1b
• Urgent:operation needed with 72 hours Based on: urgent/emergency surgery for life threatening conditions such as obstruction, bleeding and regional and/or localised infection permanent injury/clinical harm from progression of conditions such as spinal cord compression
Priority level 2
Elective surgery with the expectation of cure, prioritised according to: • Surgery within 4 weeks to save life/progression of disease beyond operability. Based on:urgency of symptoms, complications such as local compressive symptoms, biological priority (expected growth rate) of individual cancers
NB. Local complications may be temporarily controlled, for example with stents if surgery is deferred and /or interventional radiology.
Priority level 3
Elective surgery can be delayed for 10-12weeks with no predicted negative outcome.
Table 1: NHS England Suggested Priority for Cancer surgery
However we could make resource allocation easier if we devised a simple, objective and consistent way of summarising the two variables which influence decision making – clinical treatment priority and risk of COVID-related adverse outcome, into one numerical score;
The “Salford Score” simplifies this to:
Priority 1a = score (P)1
Priority 1b = score (P)2
Priority 2 = score (P)3
Priority 3 = score (P)4
A second component of this relates to vulnerability of the patient in case of a COVID infection (see table 2).
Outcome in case of COVID infection
Vulnerability level 1
• Unlikely to have excess mortality (compared to a completely fit individual < 70 years old) in the event of Covid infection
Vulnerability level 2
• Likely to have significant excess mortality compared to a completely fit individual < 70 years old in the event of Covid-19 infection, but would ordinarily receive invasive ventilation in that eventuality
Vulnerability level 3
• Extremely likely to succumb to Covid-19 infection and would not ordinarily receive invasive ventilation in that eventuality
Table 2: Vulnerability score
A resource allocation score of PxV, is then calculated so that a fit patient at high risk of imminent death of underlying disease (P1or 2) and unlikely to have excess Covid mortality (V1) would score 1 or 2 (and get urgent surgical treatment), whereas a patient with a non-immediately life threatening condition (P4) for which surgical treatment could be safely be delayed for 12 weeks and who would not, as a result of severe pre-existing medical comorbidity, be intubated etc. should they develop Covid and respiratory failure (V3) would score 12 and we would not proceed to offer surgery until the current resource position changes.
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
On 11th March 2020, World Health Organization declared the coronavirus disease (COVID-19) outbreak a pandemic.  Over 509,164 people have been infected worldwide with 23,335 deaths . (case fatality-rate 4.6%)
The first imported case of COVID-19 in Singapore occurred on 23rd January 2020.  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.  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.  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 Phasebegan before the first case was reported in Singapore. Cases were initially limited to China . 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].
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.  A seven-day cycle was appropriate in view of the reported mean incubation period of 5 days. 
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).
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. 
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:
Reducing OR workload to allow anesthetists to support ICU
Reducing outpatient clinic and endoscopy workload to free staff for deployment
The course for the COVID-19 pandemic is likely to be protracted.  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 . 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.  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.
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.
12. Chow KY, Lee CE, Ling 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.
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).
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.
There are five prerequisites for this intervention to be effective:
It is essential that all members of one household are in the same group.
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).
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.
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).
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.
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.
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.
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.
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.
None other than a close bond to Italy, #tuttoandrabene! Funding: none.
Johannes Kurt Schultz is a surgeon at the Akershus university Hospital in Norway.