We Asked the Experts: The Tropical Surgeon: Everywhere in Chains But Not Imprisoned

Surgical practice in the tropics very much reminds one of the famous quote attributed to Jean-Jacques Rousseau: “Man is born free, but he is everywhere in chains”. The numerous and onerous challenges of tropical surgical practice are the metaphorical chains that bog down the tropical surgeon.

Poor government funding of health care and very low health insurance coverage in the tropics make surgery materials rarely available in operating theatres, necessitating patients having to buy these materials out-of-pocket (OOP), even in emergencies. The majority of patients cannot afford surgery materials OOP, owing to widespread poverty. This prolongs decision-to-incision time, consequently increasing perioperative morbidity and mortality.

Most hospitals depend on fuel-powered generators for electricity, due to epileptic power supply in the tropics. Cost of fuel is high, and most underfunded public hospitals cannot afford this expense sustainably. It is common for patients’ relatives to provide fuel to power generators for surgeries, especially in emergencies [1]. Surgeries are performed using lamps, phone torchlights or even sunlight. Even when power is available, operating theatres are poorly lit and lack basic supplies like running water, oxygen, functional anaesthesia machines, and even pulse oximeters [1]. It is common for surgeries to be postponed or cancelled because there is no oxygen or power supply in the operating theatre.

Unavailability of blood/blood products remains a significant cause of delayed decision-to-operating room time in the tropics. The bulk of blood donations are by replacement donors, who are usually patients’ relatives and friends. A patient may not have blood if his/her relative/friend has not donated, even for emergency procedures. These relatives often cannot afford the cross-match test, or are unable to donate due to blood incompatibility, or ineligibility, for various reasons.

Poor staffing is a perennial problem, resulting in surgical residents working for prolonged hours. Cumulative work hours of up to 123 h/week have been reported [2]. It is normal to have one house officer, one surgery registrar, and one specialist registrar on-call every day of the week in many surgical units in the tropics. These long work hours correlate with high rates of burnout, reduced quality of life, morbidity, and, in extreme cases, mortality, amongst surgical residents [2].

Even fewer than surgeons in the tropics, are anaesthetists. The anaesthetist-to-patient ratio is as low as 1:300,000, compared to 1;10,000 in developed countries [3]. Most of the available anaesthetists are employed in tertiary hospitals, leaving surgeons in secondary and private hospitals without much anaesthetist support [3]. This contributes to third-phase delay in the provision of surgical care in the tropics, whilst “waiting for the anaesthetist”, who may be unavailable. Surgeon-administered spinal anaesthesia and ketamine for emergency operations are commonplace, with an assistant monitoring the patient with a stethoscope attached to the patient’s chest and manually checking the vital signs at intervals, owing to non-functional or unavailable monitors [1, 3]. The surgeon in the tropics improvises many unavailable surgery equipment pieces, from using face towels as abdominal mops, to Foley’s catheter as chest tube.

Few functional operating theatres complement staff shortages in the tropics. In many hospitals, it is normal to find only one functional operating theatre, where all surgical cases, irrespective of specialty, are performed. Emergency surgeries are thus delayed, and elective procedures, often postponed or cancelled. These factors contribute significantly to high-case fatality rates (even from common, treatable surgical conditions) and reduced operative volumes in the tropics. Only 6% of the estimated 313 million surgical procedures undertaken globally each year occur in the tropics [4].

Aside from the challenges of practice, tropical surgeons lack motivation to undertake research due to a combination of lack of resources, poor funding, and other systemic factors. These factors force the tropical surgeon to do the researches that he can do, and not necessarily the researches that he should do. The outputs are mostly low-impact research works, which are at best published in local journals that are constrained by poor funding/subscription, infrequent publishing, long review times, and even longer times between acceptance and publication. Overtime, the tropical surgeon preferentially drops the pen for the scalpel.

Despite these challenges, the tropical surgeon has refused to be bogged down and has continued pushing the frontiers of surgical practice across different surgical specialties. Tropical surgeons are performing open heart surgeries, renal transplantations, minimal access general surgery, gynaecology and oncology operations, separation of conjoined twins, many major and complex hepatic, pancreatic, paediatric, plastic, and neurosurgeries, amongst several others, even with improvisations and local adaptations.

Outside of the theatre, many tropical surgeons have distinguished themselves as heads and members of different local, regional, and international health and surgical bodies/organisations, advancing the development of surgical care in their areas of influence. In the area of research, the recently published pragmatic multicentre factorial randomised controlled trial (RCT) testing measures to reduce surgical site infection in low- and middle-income countries (FALCON) is the largest RCT ever conducted across LMICs in the field of surgery. It was funded by the United Kingdom National Institute for Health Research (NIHR) and undertaken in 54 hospitals in seven countries, across three continents [5]. FALCON is an excellent example of how global collaboration can significantly address the challenges of, and improve surgical practice in the tropics.

There is an urgent need for concerted local and global efforts at finding solutions to the myriad of challenges bedevilling tropical surgical practice, if universal access to safe and affordable surgical care is to be improved. Public economic policies that engender economic growth and development would benefit health care delivery in the tropics. Government funding of health care should increase. This would guarantee availability of surgical supplies and equipment and improve infrastructural support in hospitals. Health insurance coverage should be optimised, and health-related savings encouraged amongst those not covered by health insurance. Public–private partnerships in public health care and funding of researches that impact tropical surgical practice are beneficial. These much and more were recommended by the Lancet Commission on Global Surgery, launched in 2014 to address the crucial gaps in access to surgical care in resource-poor countries [4]. Six years after the Commission published her Report, there is still a lot to be desired. It is time for a global re-awakening.

A qualitative study of barriers and facilitators to adequate environmental health conditions and infection control for healthcare workers in Malawi

The burden of healthcare-associated infections (HAIs) is greater in low- and middle-income countries than in high-income countries. Inadequate environmental health (EH) conditions and work systems contribute to HAIs in countries like Malawi. We collected qualitative data from 48 semi-structured interviews with healthcare workers (HCWs) from 45 healthcare facilities (HCFs) across Malawi and conducted a thematic analysis. The facilitators of infection prevention and control (IPC) practices in HCFs included disinfection practices, patient education, and waste management procedures. HCWs reported barriers such as lack of IPC training, bottlenecks in maintenance and repair, hand hygiene infrastructure, water provision, and personal protective equipment. This is one of the most comprehensive assessments to date of IPC practices and environmental conditions in Malawian HCFs in relation to HCWs. A comprehensive understanding of barriers and facilitators to IPC practices will help decision-makers craft better interventions and policies to support HCWs to protect themselves and their patients.

Cost Evaluation of Minimally Invasive Tissue Sampling (MITS) Implementation in Low- and Middle-Income Countries

Background
Low- and middle-income countries (LMICs) face disproportionately high mortality rates, yet the causes of death in LMICs are not robustly understood, limiting the effectiveness of interventions to reduce mortality. Minimally invasive tissue sampling (MITS) is a standardized postmortem examination method that holds promise for use in LMICs, where other approaches for determining cause of death are too costly or unacceptable. This study documents the costs associated with implementing the MITS procedure in LMICs from the healthcare provider perspective and aims to inform resource allocation decisions by public health decisionmakers.

Methods
We surveyed 4 sites in LMICs across Sub-Saharan Africa and South Asia with experience conducting MITS. Using a bottom-up costing approach, we collected direct costs of resources (labor and materials) to conduct MITS and the pre-implementation costs required to initiate MITS.

Results
Initial investments range widely yet represent a substantial cost to implement MITS and are determined by the existing infrastructure and needs of a site. The costs to conduct a single case range between $609 and $1028 per case and are driven by labor, sample testing, and MITS supplies costs.

Conclusions
Variation in each site’s use of staff roles and testing protocols suggests sites conducting MITS may adapt use of resources based on available expertise, equipment, and surveillance objectives. This study is a first step toward necessary examinations of cost-effectiveness, which may provide insight into cost optimization and economic justification for the expansion of MITS.

Challenges of implementing the Paediatric Surviving Sepsis Campaign International Guidelines 2020 in resource-limited settings: A real-world view beyond the academia

The Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-associated Organ Dysfunction in Children was released in 2020 and is intended for use in all global settings that care for children with sepsis. However, practitioners managing children with sep- sis in resource-limited settings (RLS) face several challenges and disease patterns not experienced by those in resource-rich settings. Based upon our collective experience from RLS, we aimed to reflect on the difficulties of implementing the international guidelines. We believe there is an urgent need for more evidence from RLS on feasible, efficacious approaches to the management of sepsis and septic shock that could be included in future context-specific guidelines.

Building Capacity and Infrastructure at Hospitals Implementing Minimally Invasive Tissue Sampling: Experience and Lessons Learned From Nepal, Rwanda, and Tanzania

Background
Minimally invasive tissue sampling (MITS) is a useful tool to determine cause of death in low- and middle-income countries (LMICs). In 2019 the MITS Surveillance Alliance supported the implementation of small-scale postmortem studies using MITS in several LMICs.

Methods
In this article we describe the preparations, challenges, and lessons learned as part of implementing MITS across 4 study sites in 3 countries: Nepal, Rwanda, and Tanzania. We describe the process for building capacity to conduct MITS, which consisted of training in MITS sample collection, individual site assessment to determine readiness and gaps prior to implementation, site visits as sites began implementation of MITS, and feedback based on remote evaluation of histology slides via an online portal.

Results
The 4 study sites each conducted 100 MITS, for a total of 400. All 4 sites lacked sufficient infrastructure and facilities to conduct MITS, and upgrades were required. Common challenges faced by sites included that clinical autopsies were neither routinely conducted nor widely accepted. Limited clinical records made cause of death determination more difficult. Lessons learned included the importance of sensitization of the community and medical staff to MITS to enhance understanding and increase consent.

Conclusions
The study sites accomplished MITS and utilized the available support systems to overcome the challenges. The quality of the procedures was satisfactory and was facilitated through the organized capacity-building programs

Menace of antimicrobial resistance in LMICs: Current surveillance practices and control measures to tackle hostility

Antimicrobial Resistance (AMR) is significant challenge humanity faces today, with many patients losing their lives every year due to AMR. It is more widespread and has shown a higher prevalence in low- and middle-income countries (LMICs) due to lack of awareness and other associated reasons. WHO has suggested some crucial guidelines and specific strategies such as antimicrobial stewardship programs taken at the institutional level to combat AMR. Creating awareness at the grassroots level can help to reduce the AMR and promote safe and effective use of antimicrobials. Control strategies in curbing AMR also comprise hygiene and sanitation as microbes travel from contaminated surroundings to the human body surface. As resistance to multiple drugs increases, vaccines can play a significant role in curbing the menace of AMR. This article summarizes the current surveillance practices and applied control measures to tackle the hostility in these countries with particular reference to the role of antimicrobial stewardship programs and the responsibilities of regulatory authorities in managing the situation.

Diaspora engagement: a scoping review of diaspora involvement with strengthening health systems of their origin country

Background
Diaspora communities are a growing source of external aid and resources to address unmet needs of health systems of their homelands. Although numerous articles have been published, these endeavors as a whole have not been systematically assessed.

Objective
Examine the available literature to assess activities through which diasporas engage with the health system in their origin country and what barriers they face in their interventions.

Methods
This is a scoping review from 1990–2018 using the PRISMA-Scr framework to examine both peer-reviewed and gray literature on (1) specific activities through which diasporas contribute to the health system in their origin country; (2) major health needs diasporas have tried to address; and (3) barriers faced by diaspora healthcare efforts.

Results
The initial search identified 119 articles, of which 45 were eligible after excluding non-relevant studies. These were case studies of diaspora contributions to health systems in their origin country (13), interviews (13), literature reviews (9), general articles on the topic (4), and correspondences or presentations (6). The healthcare needs diasporas have sought to address include health workforce emigration (‘brain drain’) (10), capacity building for research and training (10), inadequate infrastructure (5), and finances (4). Specific activities included short-term missions (11), establishing partnerships (9), emigration back to country of origin (8), specific research and training programs (8), and financial remittances (5). Specific barriers identified were most commonly financial need within the origin country (8), lack of sustainability (6), communication issues (6), lack of intention to return to the origin country (5), infrastructure (4), and political concerns (3).

Conclusion
Further research on how to expand the scope of and reduce barriers to diaspora engagement is needed to optimize the effectiveness of diaspora contributions to their origin countries. Metrics and standards should be developed for assessing impact of diaspora engagement and interventions.

Snakebite envenoming in humanitarian crises and migration: A scoping review and the Médecins Sans Frontières experience

Snakebite envenoming is a public health concern in many countries affected by humanitarian crises. Its magnitude was recognized internationally but associations between snakebite peaks and humanitarian crises were never clearly established or analysed. This scoping review searched any available evidence of this hypothesized association between snakebite types of crises, through PubMed/Medline by two researchers. The search also included hand searching, and reports from humanitarian organizations working in this area.

The scoping review yielded 41 results. None described a robust epidemiological link or evidence of causality. There is an evidence gap regarding our research question. Several publications however point or hint towards the occurrence of snakebite outbreaks during conflict, displacement, floods, and migration of impoverished agricultural workers. Non-systematic screening yielded another 11 publications (52 in total). We found Médecins Sans Frontières routine reports showing that 6469 patients were admitted in 2019 throughout its projects in 17 countries. The impact of snakebite was the highest in four countries particularly affected by humanitarian crises, South Sudan, Ethiopia, Central African Republic, and Yemen, with some hospitals receiving more than 1000 annual admissions. Time correlations with conflict and events are shown in Figures. We found no published epidemiological data formally showing any associations between humanitarian crises and snakebite incidence. However, the search publications showing peaks during crises, and monitoring curves in four countries point towards an increased risk during humanitarian crises.

We call for urgent population-based studies and surveillance. Stakeholders should consider upgrading snakebite care and antivenom supply during humanitarian crises in snakebite-endemic countries.

Point-prevalence surveys of antimicrobial consumption and resistance at a paediatric and an adult tertiary referral hospital in Yangon, Myanmar

Background
Antimicrobial resistance is increasingly prevalent worldwide. The inappropriate use of antimicrobials, including in the hospital setting, is considered a major driver of antimicrobial resistance.

Aim
To inform improvements in antimicrobial stewardship, we undertook point prevalence surveys of antimicrobial prescribing at Yangon Children’s Hospital and Yangon General Hospital in Yangon, Myanmar.

Methods
We conducted our surveys using the Global Point-Prevalence Survey of Antimicrobial Consumption and Resistance (Global-PPS) method. All inpatients who were prescribed an antimicrobial on the day of the survey were included in the analysis.

Findings
We evaluated a total of 1,980 patients admitted to two hospitals during December 2019. Of these, 1,255 (63.4%) patients were prescribed a total of 2,108 antimicrobials. Among antimicrobials prescribed, 722 (34.3%) were third-generation cephalosporins, the most commonly prescribed antimicrobial class. A total of 940 (44.6%) antimicrobials were prescribed for community-acquired infection, and 724 (34.3%) for surgical prophylaxis. Of 2,108 antimicrobials, 317 (15.0%) were prescribed for gastrointestinal tract prophylaxis, 305 (14.5%) for skin, soft tissue, bone and joint prophylaxis, and 303 (14.4%) for pneumonia treatment. A stop or review date was documented for 350 (16.6%) antimicrobial prescriptions, 673 (31.9%) antimicrobial prescriptions were guideline compliant, and 1,335 (63.3%) antimicrobials were administered via the parenteral route. Of 1,083 antimicrobials prescribed for a therapeutic use, 221 (20.4%) were targeted therapy.

Conclusion
Our findings underscore the need to update and expand evidence-based guidelines for antimicrobial use, promote the benefits of targeted antimicrobial therapy, and support the implementation of hospital-based antimicrobial stewardship programmes at the hospitals surveyed.

A national, multicentre web-based point prevalence survey of antimicrobial use and quality indices among hospitalised paediatric patients across South Africa

Objectives
Data on antimicrobial consumption among the paediatric population in public hospitals in South Africa is limited. These needs to be addressed to improve future use and reduce antimicrobial resistance rates. Consequently, the objective is to quantify antimicrobial usage;and identify and classify which antimicrobials are used in the peadiatric population in public sector hospitals in South Africa according to World Health Organiosation (WHO) AWaRe list of antimicrobials

Methods
Conduct a point prevalence survey among 18 public sector hospitals from nine provinces using a newly developed web-based application. The data will be analysed according to the WHO AwaRe list to guide future quality improvement programmes.

Results
1261 paediatric patient files were reviewed with 49.7% (627/1261) receiving at least one antimicrobial, with 1013 antimicrobials prescribed overall. The top five antimicrobials included ampicillin (16.4%), gentamycin (10.0%), amoxicillin and enzyme inhibitor (9.6%), ceftriaxone (7.4%), and amikacin (6.3%). Antimicrobials from the Access classification were the most used (55.9%) with 3.1% being from the Reserve classification. The most common infectious conditions were pneumonia (21.3%; 148/1013) and clinical sepsis (16.0%; 111/1013). Parenteral administration (75.6%) and prolonged surgical prophylaxis (66.7%; 10/15) were common and concerns. 28% of the paediatric patients had cultures requested for them before antimicrobial treatment (284/1013) however only 38.7% (110/284) of culture results were available in the files.

Conclusion
Overall, antimicrobial prescribing is common among paediatric patients in South Africa. Interventions should be targeted at improving antimicrobial prescribing, including surgical prophylaxis, and encouraging greater use of oral antibiotics.