key: cord-0712810-etjuldnq authors: Stoehr, Jenna Rose; Jahromi, Alireza Hamidian; Chu, Quyen D.; Zibari, Gazi B.; Gosain, Arun K. title: Considerations for Resuming Global Surgery Outreach Programs During and After the COVID-19 Pandemic date: 2021-05-25 journal: Surgery DOI: 10.1016/j.surg.2021.05.029 sha: f54d2e9e5f988a0af229b152ec5b62136688075c doc_id: 712810 cord_uid: etjuldnq BACKGROUND: The Coronavirus Disease 2019 (COVID-19) pandemic has disrupted the delivery of safe surgical care worldwide. One specific aspect of global surgical care that has been severely limited is the ability for physicians and trainees to participate in global surgical outreach programs (GSOPs) in low- and middle-income countries (LMICs). METHODS: A narrative review of the literature regarding GSOPs during the COVID-19 pandemic was performed. Factors that must be considered in the reinstatement of GSOPs were identified and suggestions to address them were provided based on the available literature and the experiences of the senior authors. RESULTS: As GSOPs were cancelled at the start of the pandemic, many academic surgeons turned to digital solutions in order to continue to engage with LMIC partners. With the advent of COVID-19 vaccines and improved access to testing and treatment worldwide, the recommencement of GSOPs may begin to be considered. Important considerations prior to initiation include vaccine and testing availability for visiting providers, local staff, and patients, local hospital capacity, staff and equipment shortages, and the characteristics of the patient population and visiting providers. Region- and country-specific factors, including local infection rates and concomitant health crises, must also be taken into account. Expansion of digital collaborative efforts may further deepen international connections and promote sustainable models of care. CONCLUSIONS: With careful consideration, GSOPs may begin to be safely restarted in the near future. The current paper evaluates individual factors that must be considered to safely restart GSOPs as the COVID-19 pandemic is better controlled. Background: The Coronavirus Disease 2019 pandemic has disrupted the delivery of safe 27 surgical care worldwide. One specific aspect of global surgical care that has been severely limited is the 28 ability for physicians and trainees to participate in global surgical outreach programs (GSOPs) in low-29 and middle-income countries (LMICs). 30 31 Methods: A narrative review of the literature regarding GSOPs during the COVID-19 pandemic was 32 performed. Factors that must be considered in the reinstatement of GSOPs were identified and 33 suggestions to address them were provided based on the available literature and the experiences of the 34 senior authors. 35 36 Results: As GSOPs were cancelled at the start of the pandemic, many academic surgeons turned to digital 37 solutions in order to continue to engage with LMIC partners. With the advent of COVID-19 vaccines and 38 improved access to testing and treatment worldwide, the recommencement of GSOPs may begin to be 39 considered. Important considerations prior to initiation include vaccine and testing availability for visiting 40 providers, local staff, and patients, local hospital capacity, staff and equipment shortages, and the 41 characteristics of the patient population and visiting providers. Region-and country-specific factors, 42 including local infection rates and concomitant health crises, must also be taken into account. Expansion 43 of digital collaborative efforts may further deepen international connections and promote sustainable 44 models of care. 45 46 Conclusions: With careful consideration, GSOPs may begin to be safely restarted in the near future. The 47 Introduction 51 52 The Coronavirus Disease 2019 pandemic has caused significant collateral damage 53 to public health worldwide. 1 From the global surgeon's perspective, the pandemic has not only disrupted 54 local surgical care, but it has also interrupted the ability for surgeons and other healthcare providers from 55 high-income countries (HICs) to provide surgical services to international patients through global surgical 56 outreach programs (GSOPs). 2 It is estimated that millions of surgical procedures have been cancelled or 57 delayed, and the backlog continues to grow. Low-and middle-income countries (LMICs) are at 58 particularly high risk of facing untold burden due to the strain of the pandemic atop healthcare systems 59 that are already under-resourced with limited surgical capacity. 3 In addition to scant pre-pandemic 60 infrastructure and resources, LMICs additionally face new barriers related to COVID-19 testing, 61 treatment, vaccine access, and personal protective equipment (PPE). 4,5 62 While the early effect of the COVID-19 pandemic on GSOPs has been previously discussed, 63 there has been little discussion on how the changing landscape of the pandemic will affect the ability for 64 GSOPs to restart. 6 The aim of this narrative review is to discuss considerations for resuming GSOPs in 65 the COVID-19 era. In the first part of the review, the effect of the pandemic on GSOPs from its onset 66 until the present day will be reviewed. In the second part, the factors that must be considered as we enter 67 the next phase of the pandemic (where GSOPs may be resumed) will be discussed. In the third part, a case 68 study using a GSOP site familiar to the senior author will illustrate how these considerations may be 69 Instagram, and Facebook to share information and contribute to conversation. While these opportunities 125 do not provide the same experience to providers or benefits to patients as a GSOP, they allow for the 126 cultivation of ongoing interest in and commitment to global surgery, which can be further acted upon 127 once travel restrictions are lifted and GSOPs resume. After many dismal months, there is cause for tentative hope. Two COVID-19 vaccines (Pfizer, 131 Moderna) have been given Emergency Use Authorization (EUA) by the US Food and Drug 132 Administration (FDA) and are being distributed worldwide, and others are undergoing clinical testing. 12 133 Multiple pharmacologic therapies for COVID-19 are being evaluated, and one (remdesivir) has been 134 approved under EUA. 13 With these advances, we can begin to consider taking slow steps towards return 135 to pre-pandemic activities. For academic surgeons and trainees with an interest in global surgery, this 136 means planning to reinstate GSOPs. However, in order to do so, there are multiple important 137 considerations to address in order to ensure the safety of both the visiting team and the patients in need 138 (summarized in Table 1 ). These include a) vaccination availability, b) testing availability, c) local 139 resources (including PPE, surgical equipment, local hospital capacity and local staff), d) surgical specialty 140 considerations, and e) other region-specific considerations. We will discuss these individual factors in 141 detail below. 142 Multiple vaccine options are in development, have been tested with preliminary trials, and/or are 145 temporarily approved for administration to the public in different countries. While access to COVID-19 146 vaccination is improving, it is lacking in many locations around the world. Vaccine availability is limited 147 to certain group of individuals (i.e., healthcare providers, high risk individuals, essential workers, and the 148 elderly) in most countries and subject to local policy. Current vaccine production rates and distribution 149 strategies implicate that it will be months, if not years, before vaccine will become available to the 150 general public, even in HICs. The majority of destinations for GSOPs are in LMICs, yet LMICs are at 151 risk of being left behind in the race to acquire vaccine doses. HICs have been able to purchase vaccines 152 directly from manufacturers, while LMICs are reliant on programs such as the COVID-19 Vaccines for Vaccines and Immunization (GAVI). COVAX aims to provide equitable vaccine access across 155 countries, but it is underfunded. 14 HICs representing 14% of the world population have purchased 53% of 156 the available vaccine supply, and LMICs relying on COVAX may only be able to vaccinate 10-20% of 157 their populations in 2021. 15, 16 Although the Biden administration is committing significant funds to 158 COVAX, 17 it may be quite some time until visiting GSOP teams can expect their patients and partners in 159 LMICs to be vaccinated. 160 Undoubtedly, all members of the visiting healthcare team must be fully vaccinated with one or 161 two doses of vaccine (depending on the vaccine type) to achieve full immunity prior to traveling. Further, 162 it will behoove all household members of the visiting team members to be vaccinated if they are eligible, 163 as returning providers are at risk of exposing them. Visiting team members will need to be tested and 164 quarantine before and after travel, as it is possible that a vaccinated person may still become infected. In 165 addition, with the development of new variants of the virus, the efficacy of current vaccines may be 166 limited. Thus, ongoing testing and stringent use of PPE will likely be necessary for the local health care 167 providers and the visiting team for the foreseeable future. 168 Testing availability is likely to be higher than vaccine availability in LMICs in the upcoming 171 months. However, testing is still unlikely to be available to the extent that it is in HICs, and modified 172 testing protocols may need to be instituted. 18, 19 Whereas many hospitals in HICs have mandated COVID-173 19 testing for all patients undergoing surgery, regardless of symptoms, hospitals in LMICs may need to 174 reserve COVID-19 testing for symptomatic patients or patients undergoing procedures that are at higher 175 risk of producing aerosol droplets. There is promise for the development and use of rapid diagnostic tests 176 in LMICs, which may further hasten the withdrawal of travel restrictions and increase the likelihood of 177 need to assume that all patients and caregivers are potentially infectious, and therefore take all necessary 181 precautions during their interactions. 182 Due to the limited time that GSOPs have abroad, it is advisable to incorporate telemedicine into 183 the pre-and post-visit evaluations. An advantage of the pandemic is that the use of telemedicine has been 184 expanded, and it provides an excellent tool for virtual patient visits before and after the surgical trip. In 185 addition, facilitating COVID testing within one week of arrival of the outreach team would expedite the 186 workflow and make the GSOP more effective. interventions, and resource requirements. Teams may consider stratifying procedures by urgency: 220 performing procedures with the highest risk of morbidity and delaying procedures that can wait for future 221 trips. Teams may also consider instituting operative changes that promote the safety of the surgical team, 222 such as the increased use of regional and/or local anesthesia to avoid intubation. 30 While using regional or 223 local anesthesia may not be appropriate in certain patient populations (i.e. pediatrics) or procedures (i.e. 224 America rely on an underfunded public health system, complex surgical care is often inaccessible to the 233 general population. 22 Healthcare workers in Latin America have struggled during the COVID-19 234 pandemic to receive adequate PPE and support from government entities, and hospitals lack infrastructure 235 to keep providers protected from COVID-19 transmission during surgery. 33,34 A particular challenge in 236 Central and South America during the COVID-19 era is the concurrent dengue fever epidemic, in addition 237 to the ongoing struggle to address chronic conditions, i.e. HIV, tuberculosis, and tropical infectious 238 diseases. [35] [36] [37] There is also a risk for worse COVID-19 outcomes due to both the high obesity and 239 malnutrition rates of the population in many Latin American countries. 38, 39 In Mexico, as hospitals began 240 to reach the maximum capacity, private hospitals entered into a unique agreement with the federal 241 government in order to expand the capacity for treating 242 there are many challenges to overcome prior to the resumption of elective surgery through GSOPs in the 243 current overburdened state of the healthcare system in these countries. Its robust testing and contract tracing policies allowed for early curbing of confirmed cases, a low burden 296 index (calculated with confirmed cases in comparison to ICU beds), and the lowest number of confirmed 297 deaths compared to 7 other South American countries. 50 However, case numbers rose in August 2020 as 298 quarantine restrictions were lifted, plateaued for much of the fall and winter, and increased considerably 299 in the spring, putting significant strain on the healthcare system. As of April 2021, there are 300 approximately 300 new confirmed cases per day and a test positivity rate of 35%. 51 For reference, a 301 positivity rate of less than 5% is an indicator of relative control of the pandemic in a given country. The 302 aforementioned considerations (vaccines, testing, local resources, and surgical specialty) will be applied 303 to discuss potential reinstatement of the GSOP in Paraguay. 304 It is highly unlikely that Paraguay will have widespread vaccination in the upcoming months. The 305 country only recently received its first shipments of vaccine. 52 Through April 2021, 0.6% of the 306 population have been vaccinated, and low rates of vaccine acceptance have been reported. 51, 53 The 307 situation in Paraguay illustrates how LMICs with the greatest need for care through GSOPs may also 308 have the lowest vaccination rates, and thus will have many challenges to overcome for reinstatement. As vaccination availability in Paraguay cannot be ensured, testing availability then becomes the 310 driving factor to ensure safe reinstatement. During a typical medical mission in Asunción, the first day 311 consists of screening patients for surgical eligibility. Over the next week, 100 to 125 surgeries are 312 performed by visiting surgeons. The high volume attainable is due to the operating room structure, where 313 4-5 patients are operated on simultaneously. This allows for optimization of the number of patients treated 314 and collaboration between surgeons. However, this model is only sustainable if all patients have access to 315 a reliable, rapid test for COVID-19. Patients would need to be tested by local partners 1-3 days prior to 316 the visiting teams' arrival. Patients would then need to quarantine until their surgery date, so local 317 housing would need to be provided. 318 If patients cannot be tested, they would need to be managed as if they are presumed positive. This 319 would mean that full PPE would be worn for all procedures. Due to the nature of cleft and craniofacial 320 surgery, general anesthesia and intubation could not be avoided. Intubation would need to be done with 321 the surgical team out of the room and with a waiting period of 20 minutes for respiratory droplets to 322 settle. Most significantly, the operative capacity would slow to one-fifth of its prior volume, which would 323 likely make the trip unsustainable. 324 Thus, to plan the reinstatement of the Operation Smile craniofacial GSOP in Asunción, the 325 visiting team would need to communicate with local partners to get an accurate assessment of testing and 326 resource availability. According to government resources, COVID-19 testing is currently available for 327 symptomatic and potentially exposed individuals at public hospitals, and rapid testing is available for a 328 fee through private laboratories. 54 As such, additional financial support for testing may need to be 329 included in trip costs. If local facilities and providers are available for surgery and post-operative 330 monitoring, and if rapid testing is feasible, then the reinstatement of the GSOP in Asunción may be 331 considered. 332 The COVID-19 pandemic has altered the global community in numerous ways. While it is far 335 from over, improved testing, treatment, and vaccination all may contribute to a new era where the virus -336 if not vanquishedis mitigated. As we approach this time, it behooves us to consider reinstating GSOPs 337 for the benefit of patients worldwide. Consideration of multiple factors, including the availability of 338 vaccines, testing, PPE, equipment, and staff, in addition to region-and country-specific policies, 339 resources, and needs, will be critical for the safe recommencement of GSOPs in the COVID-19 and post-340 COVID-19 era. 341 No funding or financial support was received for this manuscript. 346 J o u r n a l P r e -p r o o f Table 1 . Summary of factors to be considered in resuming global surgical outreach programs (GSOPs) 487 and suggestions to address them. 488 Vaccines  All visiting providers (and household members, if possible) vaccinated.  Assess vaccine availability for local providers and patients.  Monitor local infection rates and presence of virus variants. Testing  Pre-trip and post-trip testing and quarantine periods for visiting providers.  Assess local testing availability.  Institute testing protocols for patients (subject to local policy).  Communicate with LMIC partners about local hospital capacity in advance.  Delay trip if there is concern for inadequate OR, ICU, or hospital bed space.  Communicate with LMIC partners about surgical equipment availability.  Bring or ship surgical equipment that can be sterilized on site.  Acquire donated surgical equipment from manufacturers that can remain in the LMIC.  Communicate with LMIC partners about PPE availability.  Bring or ship enough PPE for entire visiting team for entire duration of trip, plus extra for local staff.  Assume all patients and staff are potentially infectious and take precautions accordingly.  Communicate with LMIC partners about staff shortages in advance.  Consider bringing additional visiting team members if local staff are occupied. 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Consideration of multiple factors, including the availability of vaccines, testing, PPE, equipment, and staff, in addition to region-and country-specific policies, resources, and needs, will be critical for the safe recommencement of global surgical outreach programs in the near future.