|Year : 2021 | Volume
| Issue : 2 | Page : 103-108
The impact of COVID-19 pandemic on orthopedic practice in Nigeria
Udo Ego Anyaehie1, Obiora Nonso Muoghalu1, Gabriel Okey Eyichukwu1, Edwin Omon Edomwonyi2, John Enekele Onuminya2
1 Department of Orthopaedics and Traumatology, National Orthopaedic Hospital Enugu, Enugu State, Nigeria
2 Department of Orthopaedics and Traumatology, Faculty of Clinical Sciences, College of Medicine, Ambrose Alli University Ekpoma, Nigeria
|Date of Submission||21-Jul-2020|
|Date of Decision||28-Aug-2020|
|Date of Acceptance||18-Sep-2020|
|Date of Web Publication||29-Jan-2021|
Udo Ego Anyaehie
Department of Orthopaedics and Traumatology, National Orthopaedic Hospital Enugu, Enugu State.
Source of Support: None, Conflict of Interest: None
Background: COVID-19 pandemic is a global emerging viral disease caused by SARS- COV-2, 2019. It is a respiratory disease first reported in China in December 2019. It impacts on global health, economic, and social life with tremendous challenges. This study evaluates the impact of COVID-19 pandemic on orthopedic practice in Nigeria. Materials and Methods: A cross-sectional electronic survey of the impact of COVID-19 pandemic on orthopedic practice among orthopedic surgeons in Nigeria was done. The demographic characteristics, attitudes of orthopedic surgeons, available infrastructures, equipment, and the impact of COVID-19 pandemic on their practices were assessed. Results: A total of 87 respondents participated. The age of respondents ranged between 30 and 70 years with most involved being between 41 and 50 years age group (51.72%). Males constituted 96.5%. Majority, 47 (54%), of the respondents were not satisfied with the level of preparedness of their hospitals for COVID-19 pandemic. There was inadequate laboratory testing for COVID-19, personal protective equipment (PPE), and water supply. Elective surgical services were suspended and only emergency surgical interventions were allowed in many of their hospitals. Though the outpatient clinics were open, services were scaled down in the majority of hospitals to reduce workloads and maximize the use of scarce hospital consumables and resources. Conclusion: The impact of COVID-19 on orthopedic practice in Nigeria is huge with many unresolved challenges, absence of laid down protocols, basic equipment, testing materials, and PPE required for the management of COVID-19 pandemic. We recommend that the government provides adequate facilities and resources in hospitals to ensure optimal care during this pandemic.
Keywords: COVID-19 pandemic, impact, Nigeria, orthopedic practice
|How to cite this article:|
Anyaehie UE, Muoghalu ON, Eyichukwu GO, Edomwonyi EO, Onuminya JE. The impact of COVID-19 pandemic on orthopedic practice in Nigeria. Int J Med Health Dev 2021;26:103-8
|How to cite this URL:|
Anyaehie UE, Muoghalu ON, Eyichukwu GO, Edomwonyi EO, Onuminya JE. The impact of COVID-19 pandemic on orthopedic practice in Nigeria. Int J Med Health Dev [serial online] 2021 [cited 2022 Aug 12];26:103-8. Available from: https://www.ijmhdev.com/text.asp?2021/26/2/103/308252
| Introduction|| |
In December 2019, a novel coronavirus was identified as the cause of a cluster of pneumonia cases in Wuhan, a city in the Hubei Province of China. It rapidly spread, resulting in an epidemic in China, followed by an increasing number of cases in other countries throughout the world. In February 2020, the WHO designated the disease COVID-19, which stands for coronavirus disease in 2019. The virus that causes COVID-19 is designated severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).
The first case of COVID-19 in Nigeria was reported on February 27, 2020, and since then it has been slowly rising until late April 2020 when the daily rise in new cases became rapid; with increasing number of reported deaths. COVID-19 had spread to almost all the states and the federal capital territory of Nigeria. The country has also recorded increasing number of infected health workers and death of a number of them. There is a paucity of personal protective equipment (PPE) and testing kits with inadequate testing done for a country of a population of about 200 million. The pandemic requires that we have standardized isolation centers, level 3 and 4 laboratories with testing kits, trained manpower, and necessary equipment to handle the disease. As is expected, World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) had published recommendations for the prevention and control of COVID-19 for healthcare workers (HCWs). The lives and practices of many orthopedic surgeons and other HCWs we believe have been influenced by the pandemic. Hence, we decided to assess the impact of COVID-19 on the practice of orthopedic surgeons in Nigeria. Responses would be very vital in drawing operational guidelines, national planning and invariably boost our emergency preparedness for the containment and control of the present and future pandemics, hence the study.
| Materials and Methods|| |
Study design and dissemination
This is a cross-sectional study where electronic copies of self-administered questionnaires were sent to orthopedic doctors practicing in Nigeria via electronic survey (e-survey) Google Forms. A pilot study was done to assess easy readability, adequacy, acceptability, and relevance of the study. Information retrieved from the pilot study of the questionnaire was used to refine the questions before dissemination. The e-survey form was then shared with orthopedic surgeons via WhatsApp social media which we found to be the fastest and easiest way to communicate with them. This was disseminated from April 24, 2020 and daily reminders of the e-survey were sent out.
Our questionnaire was designed to evaluate the practice of orthopedic surgeons during this COVID-19 pandemic and what needs to be put in place to help contain the pandemic. It had 28 questions with respect to COVID-19 pandemic, comprising the demographics and attitude of the surgeons, hospital set up, preparedness, availability of PPE, protocols for dealing with COVID-19 suspects or positive patients and emergencies cases, and things needed to be put in place in their respective hospitals. The design of the questionnaire was anonymous and participants were made to understand that time to fill the form well under 10 min.
Data collection and analysis
The form was in circulation for about 11 days after which the form was inactivated when responses were no longer forthcoming. The responses collected were transferred to a spreadsheet and analyzed with Microsoft excel.
| Results|| |
A total of 87 respondents participated. The age range of respondents is 30–70 years with most involved being 41–50 years (51.72%, 45 respondents) as shown in age distribution [Figure 1].
Majority, 84 (96.5%), of the respondents were males while three (3.4%) were females. Those working in the public sector were 73 (83.9%) while those working in the private sector were 14 (16.1%).
Consultants constituted 68 (78.2%) of the respondents while senior residents constituted 19 (21.8%). We observed that 50 (57.5%) of the respondents go to work five times or more a week [Figure 2]. Majority, 59 (67.8%), of the respondents were not provided with PPE while 28 (32.2%) were provided.
Regular water supply was present in the facilities of 63 (72.4%) surgeons while 24 (27.6%) had irregular supply.
The surgeons that responded in the affirmative on the availability of hand washing spots at their gates were 57 (65.5%) and 30 (34.5%) responded negatively while 47 (54%) of them reported that their hospitals did not enforce hand washing at the gate by stationing security to guide them.
Mandatory wearing of facemasks by all staff, patients, and patient relations within the hospital premises were being enforced by the hospital authorities of 44 respondents (50.6%) whereas 43 (49.4%) did not enforce it. The masks are self-procured in 33 (37.9%) of the institutions while 16 (18.4%) of the surgeons reported that their hospitals provided the masks; the remaining 38 (43.7%) were unresponsive.
Majority of the surgeons 47 (54%) were not satisfied with the level of preparedness of their hospitals to handle COVID-19 pandemic, only 11 (12.6%) were satisfied while the remaining 29 (33.3%) were partially satisfied.
Majority, 65 (74.7%), of the surgeons' institutional outpatient departments (OPDs) were open and running while 22 (25.3%) were closed. The daily activities of 64 (73.6%) of the institutional OPD were reduced in terms of the number of cases seen while in 23 (26.4%) institutions there was no reduction in the number of cases seen. Only 22 (25.3%) of the surgeons reported that their hospitals hosted online consultations as against 65 (74.7%) who did not.
All respondents reported that their hospitals had their accident and emergency department open and running.
Majority, 66 (75.9%), of the surgeons suspended operating on elective cases; 21 (24.1%) that still operated on elective cases carried out an average of 3.5 cases a week. Most of them, 17 (81%) used PPE for the elective surgeries as a precautionary measure, 2 (9.5%) did not use any COVID-19 precautionary measure while 2 (9.5%) were silent on what they did.
A great number of the surgeons, 82 (94.3%), did not test their patients for COVID-19 before operating on them, 3 (3.5%) did, and 2 (2.3%) tested only suspected patients. The criteria for those who tested select cases were based on risk assessment where patients had a positive travel history or contact with one with positive travel history to epidemic states and the presence of respiratory symptoms.
On handling life-threatening orthopedic emergencies that would be better managed by the operative intervention [Figure 3], 35 (40.2%) will operate with PPE. All the surgeons reported not testing any of their emergency cases for COVID-19 and only 40 (46%) of the surgeons treated all emergency cases as being COVID-19 positive by attending to them with PPE. [Figure 4] depicts the choice of the respondents in non-life-threatening emergencies, and the choice if the same scenario plays out in a COVID-19 suspect is shown in [Figure 5].
|Figure 3: Attitudes of orthopedic surgeons toward patients with life -threatening orthopedic emergencies requiring operative interventions|
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|Figure 4: Attitude of orthopedic surgeons toward patients with unknown COVID-19 status who have non-life-threatening orthopedic emergencies requiring surgery|
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|Figure 5: Attitudes of orthopedic surgeons towards COVID-19 suspect who had non-life-threatening orthopedic emergency requiring surgery|
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The most reported hospital needs by the responders with respect to COVID-19 preparedness are listed in [Table 1] and [Table 2] in descending order. The least reported hospital needs were: The number of staff coming to work should be reduced to ensure social distancing; social distancing enforcement in clinics, theater, and wards with documented protocols; regular supply of running water; insurance for all health workers advocated. These accounted for 2.7% (two respondents each) and 1.3% (one respondent each) reported the following: Reduce the number of staff on emergency duties to allow better use of scarce resources; stop all elective cases; There should be testing of all patients going in for emergency surgery; restructure our hospital to right standards; placing of extraction fans in public spaces in the hospital; most of the things are in place.
| Discussions|| |
With the rising incidence of COVID-19 in Nigeria without projections on how soon the curve will flatten there is a need to study what pertains to orthopedic practice. The result showed that a number of resources and facilities were lacking in most of our hospitals with the most disturbing being the lack of PPEs which is a similar concern globally., It is alarming that 67.8% of the respondents reported that their frontline workers were not provided with PPEs to work with. We believe that this may be because these are orthopedic surgeons who are not regarded as direct frontline health workers. It is imperative that PPEs are made available to them as trauma patients may be asymptomatic spreaders. Thus, there is an urgent need for PPEs to be made available as a new normal in all hospitals and used based on risk assessment of cases as they present.
We observed that 27.6% of the respondents did not have a regular running water supply in their hospitals. This is a situation that should not be, as every health facility should have a constant, uninterrupted source of water supply to function, as availability of clean water in health facilities is critical to providing quality health care. Enforcing hand washing at the gate was not implemented in the hospitals of more than half of the respondents. We believe this might defeat the purpose of stationing handwashing gadgets at the gate as patients and visitors to the hospital might ignore that important practice if not reminded at the gates to do so.
Only a few (25.3%) had started an online consultation. We believe a lot more centers will commence the same teleconsultation as the incidence of COVID-19 rises. This will help reduce the load of patients streaming to the hospital for nonemergent cases. Telemedicine will allow mildly ill patients to get supportive care while minimizing their exposure to acutely ill patients and reduce the incidence of nosocomial COVID-19.
There appears to be no general consensus on certain aspects of the practice with different hospitals running their individual protocols. Majority had their OPD’s open and running but were limiting the numbers seen while almost all the hospitals had their accident and emergency department open. A good number were no more operating on elective cases. The reason for the above scenario we believe is so that the limited resources could be reserved for emergency cases especially as most of the centers did not test for COVID-19, particularly for their emergencies. Lack of testing kits in the country may well be the reason for the low rate of samples tested in the country. As of May 16, 2020, the Nigeria Center for Disease Control (NCDC) reported 32,942 samples tested with 5445 confirmed cases (288 new cases), 3,954 active cases, 1,320 discharged cases, and 171 deaths. A consensus report on how hospitals should know when to resume elective procedures have included some of the following: continuous decline in numbers of COVID-19 cases in the region, availability of testing kits and PPEs, ability to maintain social distancing perioperatively, among other points.
Considerations for the use of masks
The insistence that all inside the hospital premises must wear masks by half of the respondents is a good trend which we hope all the hospitals will adopt as carriers tend to contain their droplets within their masks. The community spread cloth masks should be worn by all outside their homes and when going to hospitals while surgical masks should be reserved for health workers to reduce the scarcity of masks. Other studies have reported the benefits of mass masking in preventing COVID-19 infection., A medical mask or respirator must be used when caring for patients. When supplies are limited, cloth face coverings may be reasonable for workers who do not engage in patient care and for providers when they are not involved in direct patient care activities. To minimize the risk that other people will be exposed to individuals who may have COVID-19, patients who report having symptoms should be asked to wear a surgical mask as soon as they are identified and directed to a separate area, if possible, with at least 6 feet (2 m) separation from other persons.
On handling life-threatening orthopedic emergencies it appears majority will operate as normal without recourse to use of PPE probably because the number of cases is fewer in their states along with concerns to save a life. We advise that precautions be taken to avoid HCW getting exposed to the virus from an asymptomatic spreader. In emergencies, patients should be routinely tested for COVID-19. If positive, full PPE must be provided and used. N95/tape sealed surgical mask with face shield and waterproof gowns and aprons must be used in all aerosol generating procedures irrespective of the patient’s COVID-19 status during the pandemic. This would avoid spread. Some studies have given a number of options including treating all as COVID-19 positive, managing conservatively where feasible as mortality is higher in positive patients with anesthesia, and early discharge of patients amongst other measures.
For non-life-threatening orthopedic emergencies that require surgery in patients whose COVID-19 status is unknown and in suspected COVID-19 carriers, there is no consensus as reported. It appears all surgeons carry on as deemed fit. There is thus a need to have a consensus meeting amongst orthopedic surgeons in Nigeria to discuss and agree on protocols of managing orthopedic patients during this pandemic. Such a meeting should also bare the internal deficiencies in our health system and seek ways to resolve them.
Provision of adequate PPE was the topmost need of majority of the respondents. Rapid depletion of PPE is a common report world over, particularly with respect to N95 masks. Studies have been done and reports made on reusability of N95 mask by individuals. Such reports include decontamination and reuse of the mask using hydrogen peroxide vapor, air drying for minimum of 72h which is the known maximum survival time for SARS-CoV2. Other measures like rescheduling elective cases and telemedicine will reduce the numbers presenting to the hospital and allow for proper utilization of limited PPE resources. Every other need as represented in [Table 1] is indirectly a plea to health institutions and the government to provide and attend to those deficiencies as a matter of urgency for health care services to be rendered appropriately and effectively.
Limitations of the study
The limited number of respondents and their spread may have affected the spectrum of information obtained.
| Conclusions|| |
Most of our facilities are not prepared for the COVID-19 pandemic challenges and we lack basic equipment and infrastructures for adequate healthcare in a time like this. Now that the pandemic is with us, it will be wise for us to respond to it the best we can in spite of our shortcomings.
- There is a need for orthopaedic surgeons in Nigeria to develop a uniform national protocol for orthopedic practice that will enable continuous services to all shades of orthopedic cases in a new normal clinical environment during and after COVID-19.
- The government should finance local production of adequate PPEs, COVID-19 test kits, and provide water supply which are all key to successful orthopedic practice in this pandemic.
- All orthopedic patients requiring surgery should be tested for COVID-19 and in the absence of testing every patient should be taken as COVID-19 positive and PPE should be a requirement for operative treatment.
- Frequent periodic checks and review of PPE stock are needful to avoid sudden depletion, and timely restocking is done as well as judicious use of available stock.
- The risk of operative treatment in COVID-19 positive patients is high and decision making for surgical intervention should be handled for now in centers with facilities for the treatment of severe COVID-19.
- It is anticipated that both government and private orthopedic facilities in Nigeria would upgrade the essential needs for orthopedic practice such that we would attain a new normal setting for an excellent orthopedic practice despite COVID-19 pandemic or endemic as the case may be. We must find a way to continue our practices despite any pandemic going forward and government must do the needful to provide the basic needs for the management of COVID-19 pandemic.
Financial support and sponsorship
Conflict of interest
The authors declare that there is no conflict of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2]