Adjustment for international surgical outreach missions due to COVID-19.

Dear Editor,

Today we are in midst of an extraordinary time when our lives have become disrupted and we are forced to adjust to a new reality. On March 11, 2019 the World Health Organization (WHO) declared a viral global pandemic [1]. The COVID-19 pandemic is burdening medical systems across the globe, with the number of confirmed cases reaching over 14.5 million with over 600,000 deaths, as of July 20, 2020 [2]. This worldwide spread of the novel coronavirus poses incredible public health challenges domestically, as well as abroad. Often, LMIC (low and middle-income countries) are more vulnerable due to a number of factors, including socio-economic and geographic factors [3]. With a paucity of resources and personnel available to provide treatment, many health systems, at the local, state, and national level, were forced to take drastic measures to minimize spread of the virus, as well as optimize resource and personnel distribution. With patient and provider safety in mind, the majority of elective surgical procedures were temporarily halted globally. In addition, strict limitations to regional and international travel have been implemented, effectively disabling international surgical outreach missions.

Doctors Collaborating to help Children is one such non-profit organization which started a global health campaign to improve burn care in Ukraine [4]. As many other organizations dedicated to providing medical care abroad in underserved areas, we are now faced with the difficult decision to cancel scheduled outreach programs. The incidence of burn injury, and other surgically treated diseases is unlikely to acutely change in the setting of the COVID-19 pandemic, undoubtably creating an increase in patients seeking care [5]. However, discontinuing international surgical missions is critical in preventing regional viral spread, preserving PPE, and protecting ourselves and our patients.

Protection of medical personnel from risk of COVID-19 infection is paramount given the high mortality rate and high disease duration. The protective strategy is two-fold; reduction of exposure, and proper use of personal protective equipment (PPE) and sterilization techniques. During induction of anesthesia or any airway manipulation there is potential for aerosolization of droplets, significantly increasing risk to providers and OR staff. With this elevated risk there is a greater need for the use of PPE. For these reasons the CDC has recommended discontinuing elective surgical procedures in many places based on perceived risk of population exposure as well as to preserve PPE as necessary [6]. Internationally this risk may be difficult to assess given the implicit limitations of current testing techniques, and limited availability of tests. Due to the global shortage of PPE, care must be taken to preserve supplies [7].

In line with CDC recommendations to increase telemedicine care, we encourage providers involved in surgical outreach to do the same. However, telemedicine as an outreach tool presents certain challenges, namely; poor or absent infrastructure, language and social barriers, legal issues, and inability to perform a physical exams or procedures [8]. If possible, continuing or increasing telemedicine efforts at this time may help to offset the inevitable increase in patients requiring surgical care within our outreach target populations. Assisting with triage, telemedicine rounds, case discussion and formal education can be conducted remotely provided that barriers can be overcome.

Unfortunately, no one can predict the duration and full impact of the COVID-19 pandemic on global health and economy. Due to the novelty of the virus, there are still many unknows surrounding transmission, treatment, and long-term sequalae of infection. Limitations in testing and ventilators, PPE requirements, and a call for reducing global spread necessitate a stop in international travel for providers involved in surgical outreach missions. We continuing to work with doctors and health care ministers abroad remotely through increasing telemedicine efforts. As testing becomes more available with increasingly rapid results, and the development of a vaccine inches forward, we may begin to plan for resuming outreach activity [9]. Ultimately, resuming our missions must wait until it is safe and international travel is permitted, and should be in line with local regulations.

Funding

This work was not funded by any outside entities.

Conflict of interest

The authors report no conflicts of interest associated with this work.