Qualitative exploration of health system response to COVID-19 pandemic applying the WHO health systems framework: Case study of a Nigerian state

Pandemics can result in significantly high rates of morbidity and mortality with higher impact in Lower- and Middle-Income Countries like Nigeria. Health systems have an important role in a multi-sector response to pandemics, as there are already concerns that COVID-19 will significantly divert limited health care resources. This study appraised the readiness and resilience of the Nigerian health system to the COVID-19 pandemic, using Oyo State, southwest Nigeria, as a case study. This study was a cross-sectional qualitative study involving key informant and in-depth interviews. Purposive sampling was used in recruiting participants who were members of the Task Force on COVID-19 in the state and Emergency Operations Centre (EOC) members (physicians, nurses, laboratory scientists, “contact tracers”, logistic managers) and other partners. The state’s health system response to COVID 19 was assessed using the WHO health systems framework. Audio recordings of the interviews done in English were transcribed and thematic analysis of these transcripts was carried out using NVIVO software. Results show that the state government responded promptly by putting in place measures to address the COVID-19 pandemic. However, the response was not adequate owing to the fact that the health system has already been weakened by various challenges like poor funding of the health system, shortage of human resources and inadequate infrastructure. These contributed to the health system’s sub-optimal response to the pandemic. In order to arm the health system for adequate and appropriate response during major health disasters like pandemics, fundamental pillars of the health system-finance, human resources, information and technology, medical equipment and leadership – need to be addressed in order to have a resilient health system.

Association between government policy and delays in emergent and elective surgical care during the COVID-19 pandemic in Brazil: a modeling study

Background
The impact of public health policy to reduce the spread of COVID-19 on access to surgical care is poorly defined. We aim to quantify the surgical backlog during the COVID-19 pandemic in the Brazilian public health system and determine the relationship between state-level policy response and the degree of state-level delays in public surgical care.

Methods
Monthly estimates of surgical procedures performed per state from January 2016 to December 2020 were obtained from Brazil’s Unified Health System Informatics Department. Forecasting models using historical surgical volume data before March 2020 (first reported COVID-19 case) were constructed to predict expected monthly operations from March through December 2020. Total, emergency, and elective surgical monthly backlogs were calculated by comparing reported volume to forecasted volume. Linear mixed effects models were used to model the relationship between public surgical delivery and two measures of health policy response: the COVID-19 Stringency Index (SI) and the Containment & Health Index (CHI) by state.

Findings
Between March and December 2020, the total surgical backlog included 1,119,433 (95% Confidence Interval 762,663–1,523,995) total operations, 161,321 (95%CI 37,468–395,478) emergent operations, and 928,758 (95%CI 675,202–1,208,769) elective operations. Increased SI and CHI scores were associated with reductions in emergent surgical delays but increases in elective surgical backlogs. The maximum government stringency (score = 100) reduced emergency delays to nearly zero but tripled the elective surgical backlog.

Interpretation
Strong health policy efforts to contain COVID-19 ensure minimal reductions in delivery of emergent surgery, but dramatically increase elective backlogs. Additional coordinated government efforts will be necessary to specifically address the increased elective backlogs that accompany stringent responses.

Ethical Dilemmas in Surgical Mission Trips During the COVID-19 Pandemic

This case is hypothetical and does not involve real patients or actual entities.

A long-running otolaryngology surgical teaching mission to Haiti was postponed in 2020 due to a combination of Haitian travel restrictions and American-based university travel bans during the coronavirus disease 2019 (COVID-19) pandemic. Several months have passed since the postponement of this recurring trip, and the local Haitian ear, nose, and throat (ENT) team has reached out to the international surgical teaching team to express their desire for surgical mission trips to return. The backlog of patients that the local team feels could not be treated without assistance continues to grow.

The COVID-19 vaccine is now available in the United States, and most US-based health care practitioners have been vaccinated, including all medical volunteers involved in this trip. University-based travel bans have also been lifted. Few Haitian health care providers have been vaccinated. Local Haitian travel restrictions are no longer being enforced, and it is legally possible to travel to the island. The international team has obtained enough personal protective equipment (PPE) to run a self-sufficient trip, but local PPE resources remain scarce.

Should the international surgical team restart mission work at this time? If so, what criteria need to be met for humanitarian organizations to provide safe and ethical care in the COVID-19 era when global inequality remains regarding vaccine distribution?

Global head and neck surgery research during the COVID pandemic: A bibliometric analysis

Background
Before the COVID-19 pandemic, access to otolaryngology and head-and-neck surgery was limited in low- and middle-income countries (LMICs). The pandemic has increased the burden on LMIC health systems by causing unanticipated expenses, delayed care, and changes in research activity. We aimed to assess the landscape of global ENT research during the pandemic.

Materials and methods
The authors developed a search strategy composed of the following keywords: “otolaryngology,” “head and neck surgery,” and “low- and middle-income countries.” Then, they searched eleven citation databases via the Web of Science from January 01, 2020, to May 03, 2021. They imported the result as metadata into VosViewer and ran bibliometric analyses to identify the most influential institutions, countries, and themes.

Results
During the study period, 3077 articles were published. Two hundred eighty-nine articles (9%) mentioned COVID-19 explicitly. The second most common theme was pediatric ENT (223 articles, 7%). The United States had the most publications [1616 articles, 12,033 citations, and 2986 total link strength (TLS)], followed by China (336 articles, 10,981 citations, and 571 TLS). South Africa, the first African country, was fourth (302 articles, 699 citations, and 908 TLS), while Brazil, the first South American country, was seventh (158 articles, 582 citations, and 376 TLS). The most prolific institution was the National Institute of Allergy and Infectious Diseases (186 articles, 1110 citations, and 674 TLS).

Conclusion
COVID-19 was the most common research theme during the pandemic, surpassing pediatric ENT.

Lessons for Latin America from Mexico’s Experience With Patient Safety and Covid Response

Globally, more than 1 in 10 patients continue to be harmed due to safety lapses during their care.[1] Unsafe care results in over three million deaths each year. The health burden of harm is estimated at 64 million Disability-Adjusted Life Years (DALYs) per year similar to that of HIV/AIDS. Most of this burden is in low- and middle-income countries (LMICs). Recent estimates suggest that as many as 4 in 100 people die from unsafe care in the developing world [1]. The COVID-19 pandemic has clearly shown the risk of patient harm. The estimated proportion of hospital-acquired COVID-19 cases ranges from 12.5% to 44% [1]. As many as one third of these cases are reported to be among healthcare staff.
In Mexico, the Patient Safety journey started in 2002, with the National Crusade for Quality in Health Care,[2] the first Quality Policy in Latin America. The efforts to improve patient safety in Mexico can be divided into three distinct waves. A fourth wave has commenced with the pandemic. These lessons on patient safety are even more important now in the COVID era and can be applied in the region and elsewher

Severe impact of COVID-19 pandemic on non-COVID patient care and health delivery: An observational study from a large multispecialty hospital of India

OBJECTIVES:
The COVID-19 pandemic has severely impacted health-care delivery globally, especially for non-COVID diseases. These cases received suboptimal attention and care during the pandemic. In this observational cohort study, we have studied the impact of the COVID-19 pandemic on various aspects of medical and surgical practices.

MATERIAL AND METHODS:
This observational, cross-sectional cohort study was performed on the data of a 710 bedded, multispecialty, and tertiary care corporate hospital of the national capital of India. The data of the pandemic period (April 1, 2020–March 31, 2021) were divided into three main groups and were then compared with the patient data of the preceding non-pandemic year (April 1, 2019–March 31, 2020) of more than six hundred thousand cases.

RESULTS:
From the data of 677,237 cases in these 2 years, we found a significant effect of COVID-19 pandemic on most spheres of clinical practice (P < 0.05), including outpatient attendance and surgical work. The specialties providing critical and emergency care were less affected. Although the total hospital admissions reduced by 34.07%, these were not statistically significant (P = 0.506), as the number of COVID-19 admissions took place during this time and compensated for the drop. CONCLUSION: The COVID-19 pandemic has significantly impacted health-care delivery to non-COVID cases across all the major medical and surgical specialties. Still, major urgent surgical and interventional work for cases was undertaken with due precautions, without waiting for the ongoing pandemic to end, as the delay in their treatment could have been catastrophic.

Global survey on disruption and mitigation of neurological services during COVID-19: the perspective of global international neurological patients and scientific associations

Background
The COVID-19 pandemic outbreak has dramatically disrupted healthcare systems. Two rapid WHO pulse surveys studied disruptions in mental health services, but did not particularly focus on neurology. Here, a global survey was conducted and addresses the impact of the pandemic on neurology services.

Methods
A cross-sectional study was carried out in which 34 international neurological associations were asked to distribute the survey to national associations. The responses represented the national situation, in November–December 2020, with regard to the main disrupted neurological services, reasons and the mitigation strategies implemented as well as the disruption on training of residents and on neurological research. A comparison with the situation in February–April 2020, first pandemic wave, was also requested.

Findings
54 completed surveys came from 43 countries covering all the 6 WHO regions. Overall, neurological services disruption was reported as mild by 26%, moderate by 30%, complete by 13% of associations. The most affected services were cross-sectoral neurological services (57%) and neurorehabilitation (56%). The second wave of the pandemic, however, was associated with the improvement of service provision for diagnostics services (44%) and for neurorehabilitation (41%). Governmental directives were the major cause of services’ disruption (56%). Mitigation strategies were mostly established through telemedicine (48%). Almost half of respondents reported a significant impact on neurological research (48%) and educational activities (60%). Most associations (67%) were not involved in decision making for neurological patients’ issues by their national government.

Interpretation
The COVID-19 pandemic affects neurological services and raises the universal need for the development of neurological health care at the policy, systems and services levels. A global national plan on mitigation strategies for disruption of neurological services during pandemic situations should be established and neurological scientific and patients associations should get involved in decision making.

Disruptions of neurological services, its causes and mitigation strategies during COVID-19: a global review

Background
The COVID-19 pandemic leads to disruptions of health services worldwide. To evaluate the particular impact on neurological services a rapid review was conducted.

Methods
Studies reporting the provision of neurological services during the pandemic and/or adopted mitigation strategies were included in this review. PubMed and World Health Organization’s (WHO) COVID-19 database were searched. Data extraction followed categories used by WHO COVID-19 pulse surveys and operational guidelines on maintaining essential health services during COVID-19.

Findings
The search yielded 1101 articles, of which 369 fulfilled eligibility criteria, describing data from 210,419 participants, being adults (81%), children (11.4%) or both (7.3%). Included articles reported data from 105 countries and territories covering all WHO regions and World Bank income levels (low income: 1.9%, lower middle: 24.7%, upper middle: 29.5% and high income; 44.8%). Cross-sectoral services for neurological disorders were most frequently disrupted (62.9%), followed by emergency/acute care (47.1%). The degree of disruption was at least moderate for 75% of studies. Travel restrictions due to lockdowns (81.7%) and regulatory closure of services (65.4%) were the most commonly reported causes of disruption. Authors most frequently described telemedicine (82.1%) and novel dispensing approaches for medicines (51.8%) as mitigation strategies. Evidence for the effectiveness of these measures is largely missing.

Interpretation
The COVID-19 pandemic affects all aspects of neurological care. Given the worldwide prevalence of neurological disorders and the potential long-term neurological consequences of COVID-19, service disruptions are devastating. Different strategies such as telemedicine might mitigate the negative effects of the pandemic, but their efficacy and acceptability remain to be seen.

Impact of the COVID-19 Pandemic on Oncology Clinical Research in Latin America (LACOG 0420)

PURPOSE
COVID-19 has affected cancer care worldwide. Clinical trials are an important alternative for the treatment of oncologic patients, especially in Latin America, where trials can be the only opportunity for some of them to access novel and, sometimes, standard treatments.

METHODS
This was a cross-sectional study, in which a 22-question survey regarding the impact of the COVID-19 pandemic on oncology clinical trials was sent to 350 representatives of research programs in selected Latin American institutions, members of the Latin American Cooperative Oncology Group.

RESULTS
There were 90 research centers participating in the survey, with 70 of them from Brazil. The majority were partly private or fully private (n = 77; 85.6%) and had confirmed COVID-19 cases at the institution (n = 57; 63.3%). Accruals were suspended at least for some studies in 80% (n = 72) of the responses, mostly because of sponsors’ decision. Clinical trials’ routine was affected by medical visits cancelation, reduction of patients’ attendance, reduction of other specialties’ availability, and/or alterations on follow-up processes. Formal COVID-19 mitigation policies were adopted in 96.7% of the centers, including remote monitoring and remote site initiation visits, telemedicine visits, reduction of research team workdays or home office, special consent procedures, shipment of oral drugs directly to patients’ home, and increase in outpatient diagnostic studies. Importantly, some of these changes were suggested to be part of future oncology clinical trials’ routine, particularly the ones regarding remote methods, such as telemedicine.

CONCLUSION
To our knowledge, this was the first survey to evaluate the impact of COVID-19 on Latin American oncology clinical trials. The results are consistent with surveys from other world regions. These findings may endorse improvements in clinical trials’ processes and management in the postpandemic period.

Medical and Nursing Students’ Perception and Experience of Virtual Classrooms during the COVID-19 Pandemic in Nepal

Background: On March 9, 2020, the government of Nepal declared suspension of all academic activities in line with a nationwide lockdown following the COVID-19 outbreak. To keep pace with the academic calendar, medical universities resumed their teaching and learning activities through virtual means on account of nonfeasibility of holding physical classes. The present study sought to identify the perception and experiences of undergraduate medical and nursing students regarding the virtual classrooms.
Methods: We adopted a sequential explanatory mixed method design whereby data were collected in two phases. Quantitative data were gathered from a survey (n=737) and qualitative data from focused group discussion (n=14). The participants were recruited using a non-probability Peer Esteem Snowballing technique. Quantitative data were analyzed using descriptive and inferential statistics, whereas qualitative data was examined using a narrative thematic analytic approach.
Results: Mean age of participants was 22±2.01 with (81%) female participation. The quantitative findings revealed that the “synchrony” domain had the highest mean score (4.10±0.47) and “course interaction” had the lowest mean score (2.93±0.81) amongst the four domains. The domains were significantly correlated to each other (P=0.01) and (P=0.05). Results from focus group discussion indicated that interactions were lower in the virtual classes and there was a great variation between the learners’ perception and their experiences of virtual classrooms. Students preferred blended classes to be implemented in future sessions.
Conclusion: In spite of various challenges, the students perceived the transition from traditional to virtual classrooms in a positive and enthusiastic way. An effective virtual learning experience requires a modified instructional approach on the part of educators and a consistent attitude from learners.