key: cord-265779-p2bro1ai authors: Hussein, Nawfal R.; Musa, Dildar H.; Ibrahim, Nashwan; Naqid, Ibrahim A.; Saleem, Zana Sidiq M.; Jacksi, Karwan title: Impact Of Covid-19 Pandemic On Surgical Practice In Kurdistan, Iraq: An Online Cross-Sectional Survey date: 2020-11-04 journal: nan DOI: 10.1016/j.ijso.2020.10.014 sha: doc_id: 265779 cord_uid: p2bro1ai Introduction The COVID-19 pandemic is a major challenge to healthcare services in the world. It has negatively impacted surgical practice, and health workers. We aimed to assess the impact of the COVID-19 pandemic on surgical practice in the Kurdistan Region, Iraq. Methods An online cross-sectional study using an online survey was performed between 13 April to 29 April, 2020 in the Kurdistan Region, Iraq. An online cross-sectional study using an online survey was performed between 13 April to 29 April, 2020 in the Kurdistan Region, Iraq. A total of 241 surgeons, aged 28–70 years (mean range 22.2 ± 7.9 SD), were recruited to this study. The questionnaire was designed to evaluate the impact of the COVID-19 pandemic on surgeons’ practices. Participants completed a self-developed online questionnaire. Results The majority of participants (44.39%) were general surgeons, followed by urologists (17.01%). Approximately 82.57% of surgeons performed surgeries during the COVID-19 pandemic and 60.31% undertook emergency surgeries only. There was no significant difference between men and women (P=0.41) and different age groups (P=0.08). Only 28.22% of surgeons had access to full personal protective equipment (PPE), and 41.18% believed that wearing PPEs severely affected their skills. Results also found that surgeons aged between 28–34 years were more pledged to the use of PPEs, than other age groups (P=0.001). The use of PPEs during surgeries was significantly higher in the Sulaymaniyah province (P=0.001). The surgical services were also severely impacted in the Sulaymaniyah province than in the other provinces (p=0.001). Conclusion The COVID-19 pandemic severely affected surgical practice in the Kurdistan Region, particularly in the Sulaymaniyah province. Males, and young surgeons showed a higher commitment level for using PPE. Additional training and precautions are needed to increase awareness about COVID-19 among surgeons, and the importance of using PPE during surgery. COVID-19 pandemic is considered one of the most important healthcare crises in the world. It is an emerging respiratory disease that initially started in Wuhan, China in December 2019 and rapidly spread worldwide [1] . The World Health Organization declared COVID-19 as a global pandemic on 11 March, 2020 [2] . Fever, dry cough, dyspnoea, fatigue, and myalgia are the most significant clinical manifestations of the disease [3] . In Iraq, the first COVID-19 case was diagnosed on the 22 nd of February 2020. With the occurrence of the first COVID-19 case in the country, the Kurdistan Regional Government, in the northern Region of Iraq, enforced strict control measures for the infection. These measures involved the cancellation of gatherings and religious ceremonies, closing schools and education institutes, and closing airports, borders and nonemergency services in hospitals [4, 5] . In addition, local authorities in the Kurdistan region of Iraq diverted the city's limited staff and resources to cater to COVID-19 patients [6, 7] . To confront this worldwide health emergency that overpowered health systems around the world, health authorities had to improvise their working to manage with COVID-19, while guaranteeing continuity of care, and protecting medical staff and patients. At first appearance, surgeons' practices were not considered front-line services within the battle against the COVID-19 pandemic in Kurdistan Region, Iraq, when compared with other specialties including internal medicine, infectious diseases, intensive care physicians. On the other hand, as parts of the larger healthcare system, they play a vital role in reversing this pandemic [8] . In addition, the presence of a large number of people in operating theatres, the close contact of surgeons with patients, and urgent management and treatments have been placed on hold during this critical time because the virus is quickly transmitted and may potentially infect surgical care workers [9] . During the COVID-19 pandemic, there are a huge shortage of personal protective equipment (PPE) supplies, including disposable gloves, gowns, surgical masks, and alcohol-based hand sanitizers in the Kurdistan Region, Iraq. Most of these are due to travel and import restrictions from countries like China, one of the major exporters of PPE supplies to the world. These shortages changed the methods of surgical operation in Kurdistan, Iraq, which resulted in cancelling of all scheduled and elective surgeries. This pandemic disease poses a huge challenge to health care systems around the world, including in the Kurdistan Region [10] . Therefore, the aim of the present study was to assess the impact of the COVID-19 pandemic on surgical practice in the Kurdistan Region, Iraq. J o u r n a l P r e -p r o o f 1.2 Materials and Methods: This study was conducted in the Kurdistan Region, Iraq, from April 13, 2020 to April 29, 2020, with a total of 241 surgeons being recruited from Duhok, Erbil and Sulaymaniyah provinces. The ages of the participants ranged from 28 to 70 years old (mean range 22.2 ± 7.9 SD). This project was developed using an online self-administered web-based survey generator. The questionnaires were designed to evaluate the impact of the COVID-19 pandemic on surgeons' practices. The questionnaires were distributed to group of surgeons in Kurdistan region, Iraq via specific email or viber, because it was difficult to conduct a public-based national sampling study during the lockdown of the country. The questionnaires about the impact of COVID-19 on surgical practice were as designed by [11] with minor modifications. The survey involved various questions. The first part focused on personal demographic characteristics including age, gender, and province, and the second part was about the speciality and years of experience (Table 1) . Participants were then asked for specific questions about the use of personal protection, number of surgeries performed during COVID-19, and motivation of the surgeon to work in the management and treatment of COVID-19 patients. They were also asked to report the type of personal protection equipment, such as PPE, available at work for use during surgical operations. For statistical analysis, data retrieved from the online survey were introduced into Microsoft Excel and then imported into the GraphPad Prism Version 8. The results were expressed as frequencies and percentages. Statistical analysis was performed using the Chi-Square and Fisher Exact Test. The results were considered positive if p ≤0.05. In total, 241 surgeons representing the Kurdistan Region, Iraq, were recruited to the study ( Table 1 ). The mean age of the participants was 22.2 ± 7.9 years. Among the participants, 198 (82.16%) were male and 43 (17.84%) were female (Table 1 ). The highest number of responders were general surgeons (107/241; 44.39%), followed by urologists (41/241; 17.01%) and orthopaedic surgeons (22/241; 9.13%). Additionally, 31.95% and 22.82% of participants had 5-10 years and 10-15 years J o u r n a l P r e -p r o o f of surgical experience, respectively, and about 16.6 % had more than 20 years of experience (Table 1) . between 28-34 years, were more predisposed to using PPE than other age groups (P=0.001) ( Table 3 ). Ninety-five surgeons (39.42%) reported having operated on confirmed COVID-19 positive cases (Table 2) , with statistically significant differences between men and women (P=0.002) and age groups (P=0.01) ( Table 3) . It was also found that 48 (19.92%) participants were actively involved in the management teams of COVID-19 in the Ministry of Health in Kurdistan, Iraq (Table 2) . Age groups between 35-44 years old was more significantly involved in the management of COVID-19 than other age groups (P=0.006) (Table 3) . Surprisingly, 214 (88.79%) surgeons were ready to become more actively involved in the treatment of COVID-19 patients ( Table 2) , but there were no significant differences between gender (P=0.24), provinces (P=0.207), and age groups (P=0.89) ( Table 3 ). J o u r n a l P r e -p r o o f [14] . They reported that 86% of emergency surgery cases was decreased compared to the month before the quarantine [14] . Only about 20% of participants were involved in the management team of COVID19 positive patients in their institution. This may be due to their concern of getting the infection and transmitted the virus rapidly to their family member. This may also explain that the COVID-19 has a higher infectivity and fatality rate than other epidemic virus [15] . During the COVID-19 pandemic, there has been a shortage of PPE supplies [13] . This was reflected in our study, as only 28% of our surgeons had access to full PPE. This put surgeons in danger of acquiring the infection. Immediate international co-operation is needed to improve resource allocation and production capacity within and across patients. We found that surgical services were severely impacted in the city of Sulaymaniyah. This is probably due to the large number of cases registered in this city, as the city had the highest number of Covid-19 patients at the time. The use of PPE during surgeries was significantly higher in the city of Sulaymaniyah. This may be due to the higher rate of infection in this city. More training is needed to train surgeons about the importance of the use of PPE in surgeries. Although the older age group is at a higher risk of COVID-19 complications, our study showed that younger doctors had more commitment to the use of PPE. More training is needed to create awareness regarding the complications of COVID-19 among vulnerable groups. In this study, female doctors showed more readiness to perform operations on COVID-19 patients. This is difficult to explain, and more studies are needed to explore this. In this study, we showed that most of the surgeons involved in the care of COVID-19 patients were in the age group of 35-44 years. This is probably due to the experience of these doctors and the ability to protect themselves. To conclude, the surgical services in Sulaymaniyah city were severely impacted by the COVID-19 pandemic. There was a shortage of PPE supplies in the region. Surgical services were severely affected in Sulaymaniyah city due to the high number of patients diagnosed in the city. Young surgeons showed a higher commitment level for the use of PPE. More training and awareness sessions are required to make surgeons aware of COVID-19 transmission and the importance of PPE. The following information is required for submission. Please note that failure to respond to these questions/statements will mean your submission will be returned. 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We further confirm that the order of authors listed in the manuscript has been approved by all of us. J o u r n a l P r e -p r o o f A Novel Coronavirus from Patients with Pneumonia in China Rolling updates on coronavirus disease (COVID-19) Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study The Impact of COVID-19 Pandemic on the Elimination of Viral Hepatitis in Duhok City, Kurdistan Region of Iraq. Hepat Mon The Impact of Breaching Lockdown on the Spread of COVID-19 in Kurdistan Region A sharp increase in the number of COVID-19 cases and case fatality rates after lifting the lockdown in Kurdistan region of Iraq. Annals of medicine and surgery Impact of COVID-19 on the Medical Education: Experience from Kurdistan Region of Iraq Annotation: The COVID-19 Pandemic and Clinical Orthopaedic and Trauma Surgery Surgical practice and operative surgical strategies during the COVID-19 pandemic: A commentary The impact of COVID-19 pandemic on the care of patients with kidney diseases in Duhok City, Kurdistan Region of Iraq Impact of the COVID-19 pandemic on orthopedic surgical practice: international study Working through the COVID-19 outbreak: Rapid review and recommendations for MSK and allied heath personnel Global shortage of personal protective equipment. The Lancet. Infectious diseases COVID-19 and surgery: Running on good will or guilt? Annals of medicine and surgery Knowledge and attitudes of medical staff in Chinese psychiatric hospitals regarding COVID-19. Brain, Behavior, & Immunity -Health, 2020. 4: p. 100064. 1. COVID19 pandemic has severely affected surgical in Kurdistan region, Iraq 2. 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