Impact of COVID-19 on surgical care in Rwanda

A: Background The COVID-19 pandemic has profoundly affected health care delivery. With the increasing number of cases, health care systems around the world have faced strains, with shortages of health care workers, personal protective equipment (PPE), ventilators and other resources. Surgical practice has faced dramatic changes in this pandemic. In certain parts, elective surgery and clinics have been cancelled to prioritize resources for the increasing COVID-19 patients and decrease risk to patients and health care worker. In Rwanda, access to surgical care is limited with insufficient surgical capacity and high unmet surgical needs, with most of the care provided in urban areas. In various surgical specialties, patient waiting lists are long with insufficient operating room space and hospital beds. Patients must wait for long periods to get the care they need. With the surge of COVID19, there is a need to study to what extent COVID19 pandemic has affected surgical care delivery in Rwanda. The impact will be assessed in terms of surgical volume, elective versus emergency cases by specialty, transfer patterns to referral hospitals and outcomes (mortality, morbidity and length of hospital stay). Knowing the impact of the pandemic on surgical care will enable developing measures to address the surgical burden and provide appropriate care to patients in need, as well eventually putting in place strong measures for possible future public health crises. B: Goals and Objectives: The project aims to assess the impact of COVID-19 on accessibility to surgical care in Rwanda. The project has the following specific objective: i) To determine the number of surgeries performed (Emergencies vs electives by specialty) over a 15 weeks period from March 22nd to June 30th, 2020 (During COVID-19 outbreak) ii) To determine the number of surgical outpatients by different surgical specialties received over a 15 weeks period from March 22nd to June 30th, 2019 (Before COVID-19 outbreak) iii) To determine type of surgical cases managed during Covid-19 pandemic lockdown across different surgical specialties iv) To compare both periods (before and during COVID-19 outbreak) as far as number of cases, inhospital mortality, morbidity, and length of hospital stay are concerned with respect to different surgical specialties v) To identify challenges encountered by surgical care providers to provision of surgical care over the 15 weeks period during COVID-19 pandemic lockdown vi) To develop a tool kit to be used by Rwandan Surgical community during next pandemic outbreaks C: Methods The project will be a mixed method study with concurrent explanatory design: • Study site: Multi-centric, nation-wide, including private and public hospitals that provide surgical care. Private hospitals will be stratified into hospitals and polyclinics whereas public institutions will be stratified into two categories: referral hospitals (university teaching hospitals, provincial and other referral hospitals) and district hospitals (DHs) • Sampling technique:  Stratified multi-stage cluster sampling will be used  Qualitative data will be collected through focus group discussions (FGDs) using a semi structured interview guide: A focus group discussion engaging 6 to 12 people made of 37 surgeons, anesthesiologists, gynecologists, and theatre nurses will be constituted to foster active participation and in-depth discussion  Quantitative data will be collected through cross-sectional survey using a preestablished questionnaire • Data collection, processing and analysis: Data on surgical cases will be summarized and cleaned in MS Excel spreadsheet. The questionnaire will be completed online using survey monkey, data will be extracted in excel format cleaned and coded, then analyzed using STATA. D: Expected outcomes The findings of the project will have the following clinical implications: • Screening the Covid-19 positive and suspected cases by both molecular and serological techniques would inform of the diagnostic ability of each of the tests and provide insight into the ability of each test to predict severe disease and guide into the triaging of patient • Determining the association between the viral load and disease severity would guide towards the evaluation of the management approaches and ensure that only very severe cases are managed by hospitalization while mild cases can be monitored at home or at outpatient facilities • Determining the SARs-Cov-2 recombination/mutation events by sequence analysis would inform of the disease transmission patterns and guide towards the adoption of management practices that are tailored as per the observed transmission patterns. • Assessing the ACE-2 levels in the Covid-19 samples in Kenya would inform of the role of this receptor in modulating viral infectivity and subsequently establish the susceptibility of the Kenyan population to Covid-19. Corelating the expression of this receptor with the patient clinical data would inform of the therapies to foster especially in patients with preexisting conditions. In addition, evaluating the role of this protein as a prognostic indicator would provide insight into the development of ideal point of care diagnostics to fast track disease detection. • Research outputs shall be communicated via scientific conferences and policy reports and subsequently published in open access peer reviewed international journals to inform a wider scientific community The key expected outcomes: • COVID19 transmission in Rwanda identified • New spots for vaccine and therapeutic development and hence contribute to the global efforts • Evidence on genetic diversity for COVID19 in African will be generated