key: cord-1029503-e3e6oasf
authors: Asghar, Syed; Zaid, Waleed; Ansari, Afreen; Chapple, Andrew; Callahan, Nicholas; Melville, James; Kim, Roderick; Boehm, Audra; Young, Simon
title: The Incidence of COVID-19 Patients in Oral and Maxillofacial Surgery
date: 2021-09-30
journal: J Oral Maxillofac Surg
DOI: 10.1016/j.joms.2021.09.016
sha: dd6cb50e867f1aba00ae63f21ad071ce55a8bd21
doc_id: 1029503
cord_uid: e3e6oasf

PURPOSE: The SARS-CoV-2 global pandemic has resulted in widespread changes to healthcare practices across the United States. The purpose of this study is to examine the incidence of COVID-19 patients in the oral-maxillofacial surgery setting in order to help guide perioperative protocols during the pandemic. METHODS: In this retrospective cohort study, predictor variables (presence of preoperative symptoms on presentation, patient age, patient gender, patient race, hospital location, and presence of statewide stay-at-home orders) were examined with outcome variables (SARS-CoV-2 test results) over 10 months between 03/2020 and 12/2020 for patients undergoing surgical procedures in the operating room by the following Oral-Maxillofacial Surgery Departments: - Louisiana State University Health Sciences Center (Baton Rouge, LA) - University of Illinois at Chicago (Chicago, IL) - University of Texas Health Science Center at Houston (Houston, TX) Data analysis included Fisher exact tests to compare categorical variables across COVID test groups and Wilcoxon rank sum tests to compare continuous covariates. Two-sample tests of proportions were used to compare observed COVID-19 positivity rates to other study results. RESULTS: Out of 684 patients in 3 institutions, 17 patients (2.5%, 95% CI = 1.5%-4.0%) tested positive for COVID-19 over a 10 month interval (03/01/2020- 12/31/2020). The majority of patients that tested positive were asymptomatic in the preoperative setting (p-value=.09). They were significantly more likely to be African-American (p-value=.015) and less likely to have a stay-at-home order present at the time of surgery (p-value=.033). Age, gender, and hospital location did not play a statistically significant role. CONCLUSION: Our results demonstrate a 2.5% incidence of COVID-19 infection in the total population of patients undergoing scheduled oral-maxillofacial surgeries in 3 major healthcare systems across the United States. This data may help inform perioperative protocols and infection control measures during the COVID-19 pandemic.

Out of 684 patients in 3 institutions, 17 patients (2.5%, 95% CI = 1.5%-4.0%) tested positive for COVID-19 over a 10 month interval (03/01/2020-12/31/2020).

The majority of patients that tested positive were asymptomatic in the preoperative setting (p-value=.09). They were significantly more likely to be African-American (p-value=.015) and less likely to have a stay-at-home order present at the time of surgery (p-value=.033). Age, gender, and hospital location did not play a statistically significant role.

Our results demonstrate a 2.5% incidence of COVID-19 infection in the total population of patients undergoing scheduled oral-maxillofacial surgeries in 3 major healthcare systems across the United States. This data may help inform perioperative protocols and infection control measures during the COVID-19 pandemic.

The COVID-19 pandemic has resulted in nearly 40 million positive cases and 640,000 deaths in the United States alone 1 Regarding dental and oral surgery procedures, CDC recommendations are based on the assertion that these procedures are high-risk due to detectable SARS-CoV-2 titers in nasal, oral, and pharyngeal secretions. Recommendations by the CDC include universal preoperative SARS-CoV-2 testing, postponement of elective procedures, implementation of teledentistry and triage protocols, respiratory and hand hygiene, exposure protocols, universal source control measures, physical distancing, and avoidance of aerosol generating procedures. 2 Per the CDC, the use of targeted nucleic acid or antigen detection of SARS-CoV-2 for patients without signs or symptoms may be used to identify those with asymptomatic or pre-symptomatic SARS-CoV-2 infection and reduce exposure risk in some healthcare settings. 2 Presently, there is limited data on the outcomes or utility of universal preoperative testing for asymptomatic or pre-symptomatic SARS-CoV-2 infection. Some studies suggest that anywhere from 5 to 75% of those with COVID-19 could be asymptomatic. 3 There are similarly limited evidence-based outcomes for many other infection control recommendations.

Due to this scarcity of data and policy variation across the United States, hospital leaders and private practitioners have been forced to interpret and balance CDC and professional society recommendations, state policies, and institutional resources and priorities in delivering care while limiting disease spread. Many large hospital centers across the United States (including those involved in this study) thus implemented universal preoperative SARS-CoV-2 screening tests.

The purpose of this study is to examine the results of these universal preprocedure SARS-CoV-2 screening tests with the specific aim of obtaining objective data by which we can inform our infection control measures. The authors hypothesize that universal testing will reveal a higher incidence of COVID-19 patients than that reported in the existing literature due to the epidemic spread of the virus and its variants.

To address the research purpose, investigators designed and implemented a retrospective cohort study. The study population was composed of all patients that were taken to the operating room for elective surgery from March 1st, 2020

to December 31st, 2020. Predictor variables were the presence of preoperative symptoms on presentation, patient race, patient gender, hospital location, and presence of statewide stay-at-home orders. The outcome variable was the SARS-CoV-2 testing result. The following institutions participated: 

Coronaviruses are a large group of viruses that derive their name from their distinctive microscopic appearance-each virion is surrounded by a halo, or 9 . It is difficult to attribute causation for these differences. Additionally, 88% (15/17) of patients who tested positive were asymptomatic. This number is remarkably higher than that found in the literature;

for example, a systematic meta-analysis by Jingjing et. al in 2020 found only 15.6% of confirmed COVID-19 patients to be asymptomatic. 10 Our study did identify a significantly higher incidence in the African American population, however, this is consistent with the disproportionate infection and death rates on those communities as identified in other studies. 11 The findings of our study support our hypothesis; however, it is unknown whether this proportion is due to a higher incidence in the general population, inherent demographic characteristics of the study population, or other unknown variables.

The strengths of this study were the large sample size and multicenter nature of data collection. The weaknesses of this study arise from the rapidly-evolving epidemiology of the SARS-CoV-2 virus. The study may represent an inherently higher or lower risk population as the study period encompassed time frames during which some healthcare systems postponed all elective surgery. It is unknown if healthcare facilities implemented additional pre-screening processes that occurred prior to pre-procedure testing. Vaccination rollout, virus mutation, and evolving herd immunity may have all played critical roles in the reliability of our findings. Finally, there may be inherent demographic differences in patient populations that required oral-maxillofacial surgery intervention at tertiary referral centers as per our selection criteria.

In conclusion, this study identified a 2.4% incidence of COVID-19 infection in oral-maxillofacial surgery patients at participating institutions. Interestingly, this incidence level is significantly higher than incidence rates mentioned in several comparative studies ( 

Guidance for Dental Settings Interim Infection Prevention and Control Guidance for Dental Settings During the Coronavirus Disease 2019 (COVID-19) Pandemic

COVID-19: What proportion are asymptomatic? The Centre for Evidence-Based Medicine

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Why is it called coronavirus? Medical News Today

Incidence of COVID-19 in pediatric surgical patients among 3 US children's hospitals

Preoperative COVID-19 testing and decolonization

Surgery and COVID-19

Low prevalence (0.13%) of COVID-19 infection in asymptomatic preoperative/pre-procedure patients at a large, academic medical center informs approaches to perioperative care

Proportion of asymptomatic coronavirus disease 2019: A systematic review and meta-analysis

Assessing differential impacts of COVID-19 on black communities

COVID-19 variants: What's the concern? Mayo Clinic

Figures: Figure 1: Positive Test Numbers by