Impact of COVID-19 Related Lockdown on the Frequency of Acute and Oncological Surgeries—Lessons Learned From an Austrian University Hospital

Innsbruck Medical University Hospital, Austria, provides the highest level of care for a region of approximately 1.8 million people. During the early COVID-19 outbreak in spring 2020 surgical activity was drastically reduced with the prime goal of preserving hospital capacities, especially intensive care beds. We conducted a retrospective analysis of surgical activities performed at Innsbruck Medical University Hospital during the lockdown period from March 15 to April 14, 2020 and compared these activities to the same period during the previous 5 years. Total surgical activity was reduced by 65.4% compared to the same period during the previous 5 years (p < 0.001); elective surgeries were reduced by 88.7%, acute surgeries by 35.3% and oncological surgeries by 47.8% compared to the previous 5 years (all p < 0.001). This dramatic decrease in acute and oncological surgeries can most likely be ascribed to the fact that many patients avoided health care facilities because of the strict stay-at-home policy and/or the fear of contracting SARS-CoV-2 in the hospital. In view of future waves, the population should be encouraged to seek medical help for acute symptoms and to attend cancer screening programs.

Reasonable Limiting of 7-Day Incidence per Hundred Thousand and Herd Immunization in Germany and Other Countries

Based on hospital capacities, facts from past experience with the coronavirus disease 2019 (COVID-19) virus and the number of dark infections during the second wave (DII=2D2), a reasonable limiting value of 140/D2 for the 7-day incidence per 100,000 persons (MSDIHT) and a second wave herd immunization threshold fraction value of 0.26 in Germany were calculated. If the MSDIHT is held below this limiting value, the German hospital system can cope with the number of new seriously infected persons without any triage decisions. On the basis of the SIRV epidemics model, the classical threshold values for herd immunization were calculated for 18 countries. For these countries, the dates regarding when herd immunization against the second COVID-19 wave will be reached were estimated.

Hospital Capacities and Shortages of Healthcare Resources Among U.S. Hospitals During COVID-19 Pandemic, National Healthcare Safety Network, March 27–July 14, 2020

During March 27–July 14, 2020, the CDC’s National Healthcare Safety Network extended its surveillance to hospital capacities responding to COVID-19 pandemic. The data showed wide variations across hospitals in case burden, bed occupancies, ventilator usage, and healthcare personnel and supply status. These data were used to inform emergency responses.

Reasonable Limiting 7-day Incidence per Hundred Thousand Value in Germany

Based on the hospital capacities, facts from the past experience with the Covid-19 virus and the dark number of infections D=10D_{10} a reasonable limiting value of 170/D_{10} for the monitored 7-day incidence per 100000 persons value (MSDIHT) in Germany is calculated. If the MSDIHT is held below this limiting value the German hospital system can cope with the number of new seriously infected persons without any triage decisions. A significant improvement to an almost complete testing of the population would lead to dramatic reduction of the current dark numer value to D_{10}=0.1 so that ten times higher MSDIHT values of 1700 are acceptable. Such a high limiting value would spare Germany from its currently imposed strict lockdown. The costs for such extensive and complete testing campaigns are highly justified as they are orders of magnitudes below the estimated economical costs of more than 3.6 billion Euros for each lockdown day.

Geographical disparities in access to hospital care in Ontario, Canada: a spatial coverage modelling approach

ObjectivesPrevious studies on geographical disparities in healthcare access have been limited by not accounting for the healthcare provider’s capacity, a key determinant of supply and demand relationships.DesignThis study proposed a spatial coverage modelling approach to evaluate disparities in hospital care access using Canadian Institute for Health Information data in 2007.SettingThis study focusses on accessibility of inpatient and emergency cares at both levels of individual hospital and the administrative regions of Local Health Integration Network (LHIN) levels.MeasuresWe integrated a set of traffic and geographical data to precisely estimate travel time as a measure of the level of accessibility to the nearest hospital by three scenarios: walking, driving and a combination of the both. We estimated population coverage rates, using hospital capacities and population in the catchments, as a measure of the level of the healthcare availability. Hospital capacities were calculated based on numbers of medical staff and beds, occupation rates and annual working hours of healthcare providers.ResultsWe observed significant disparities in hospital capacity, travel time and population coverage rate across the LHINs. This study included 25 teaching and 148 community hospitals. The teaching hospitals had stronger capacities with 489 209 inpatient and 130 773 emergency patients served in the year, while the population served in community hospitals were 2.64 times higher. Compared with north Ontario, more locations in the south could reach to hospitals within 30 min irrespective of the travel mode. Additionally, Northern Ontario has higher population coverage rates, for example, with 42.6~46.9% for inpatient and 15.7~44% for emergency cares, compared with 2.4~34.7% and 0.35~14.6% in Southern Ontario, within a 30 min catchment by driving.ConclusionCreating a comprehensive, flexible and integrated healthcare system should be considered as an effective approach to improve equity in access to care.

A Stochastic Compartmental Model for COVID-19

We propose two stochastic models for the Coronavirus pandemic. The statistical properties of the models, in particular the correlation functions and the probability density function, have duly been computed. Our models, which generalises a model previously proposed and published in a specialised journal, take into account the adoption of the lockdown measures as well as the crucial role of the hospitals and Health Care Institutes. To accomplish this work we have analysed two scenarios: the SIS-model (Susceptible ⇒ Infectious ⇒ Susceptible) in presence of the lockdown measures and the SIS-model integrated with the action of the hospitals (always in presence of the lockdown measures). We show that in the case of the pure SIS-model, once the lockdown measures are removed, the Coronavirus will start growing again. However, in the second scenario, beyond a certain threshold of the hospital capacities, the Coronavirus is not only kept under control, but its capacity to spread tends to diminish in time. Therefore, the combined effect of the lockdown measures with the action of the hospitals and health Institutes is able to contain and dampen the spread of the SARS-CoV-2 epidemic. This result can be used during a period of time when the massive distribution of delivery of a limited number of vaccines in a given population is not yet feasible. By way of example, we analysed the data for USA and France where the intensities of the noise have been estimated by Statistical Mechanics. In particular, for USA we have analysed two possible hypotheses: USA is still subject to the first wave of infection by and USA is in the second (or third) wave of SARS-CoV-2 infection.The agreement between theoretical predictions and real data confirms the validity of our approach.

Pre-endoscopy SARS-CoV-2 testing strategy during COVID-19 pandemic: The care must go on

ABSTRACTBackgroundIn response to the COVID-19 pandemic, endoscopic societies have recommended reduction of endoscopic procedures. In particular non-urgent endoscopies should be postponed. However, this might lead to unnecessary delay in diagnosing gastrointestinal conditions.MethodsRetrospectively we analysed the gastrointestinal endoscopies performed at the Central Endoscopy Unit of Saarland University Medical Center during seven weeks from 23 March to 10 May 2020 and present our real-world single-center experience with an individualized rtPCR-based pre-endoscopy SARS-CoV-2 testing (“PECo”) strategy.ResultsAltogether 359 gastrointestinal endoscopies were performed. The PECo strategy enabled us to conservatively handle endoscopy program reduction (44% reduction as compared 2019). The results of COVID-19 rtPCR from nasopharyngeal swabs were available in 89% of patients prior to endoscopies. Apart from six patients with known COVID-19, all other tested patients were negative. The frequencies of endoscopic therapies and clinically significant findings did not differ between patients with or without SARS-CoV-2 tests.ConclusionA reasonable reduction of the endoscopy program in the setting of structured SARS-CoV-2 testing is feasible and safe. The PECo strategy allows continuation of endoscopic procedures in a region with intermediate frequency of COVID-19 when hospital capacities are not overwhelmed by the pandemic. Thus, the study might help to develop new strategies during future waves of COVID-19 or local outbreaks.

Effect of COVID-19 on Emergent Stroke Care

Background and Purpose: Anecdotal evidence suggests that the coronavirus disease 2019 (COVID-19) pandemic mitigation efforts may inadvertently discourage patients from seeking treatment for stroke with resultant increased morbidity and mortality. Analysis of regional data, while hospital capacities for acute stroke care remained fully available, offers an opportunity to assess this. We report regional Stroke Team acute activations and reperfusion treatments during COVID-19 mitigation activities. Methods: Using case log data prospectively collected by a Stroke Team exclusively serving ≈2 million inhabitants and 30 healthcare facilities, we retrospectively reviewed volumes of consultations and reperfusion treatments for acute ischemic stroke. We compared volumes before and after announcements of COVID-19 mitigation measures and the prior calendar year. Results: Compared with the 10 weeks prior, stroke consultations declined by 39% (95% CI, 32%–46%) in the 5 weeks after announcement of statewide school and restaurant closures in Ohio, Kentucky, and Indiana. Results compared with the prior year and time trend analyses were consistent. Reperfusion treatments also appeared to decline by 31% (95% CI, 3%–51%), and specifically thrombolysis by 33% (95% CI, 4%–55%), but this finding had less precision. Conclusions: Upon the announcement of measures to mitigate COVID-19, regional acute stroke consultations declined significantly. Reperfusion treatment rates, particularly thrombolysis, also appeared to decline qualitatively, and this finding requires further study. Urgent public education is necessary to mitigate a possible crisis of avoiding essential emergency care due to COVID-19.

Mobility traces and spreading of COVID-19

1Executive summaryWe use human mobility models, for which we are experts, and attach a virus infection dynamics to it, for which we are not experts but have taken it from the literature, including recent publications. This results in a virus spreading dynamics model. The results should be verified, but because of the current time pressure, we publish them in their current state. Recommendations for improvement are welcome. We come to the following conclusions:Complete lockdown works. About 10 days after lockdown, the infection dynamics dies down. This assumes that lockdown is complete, which can be guaranteed in the simulation, but not in reality. Still, it gives strong support to the argument that it is never too late for complete lockdown.As a rule of thumb, we would suggest complete lockdown no later than once 10% of hospital capacities available for COVID-19 are in use, and possibly much earlier. This is based on the following insights:Even after lockdown, the infection dynamics continues at home, leading to another tripling of the cases before the dynamics is slowed.There will be many critical cases coming from people who were infected before lockdown. Because of the exponential growth dynamics, their number will be large.Researchers with more detailed disease progression models should improve upon these statements.Our simulations say that complete removal of infections at child care, primary schools, workplaces and during leisure activities will not be enough to sufficiently slow down the infection dynamics. It would have been better, but still not sufficient, if initiated earlier.Infections in public transport play an important role. In the simulations shown later, removing infections in the public transport system reduces the infection speed and the height of the peak by approximately 20%. Evidently, this depends on the infection parameters, which are not well known. – This does not point to reducing public transport capacities as a reaction to the reduced demand, but rather use it for lower densities of passengers and thus reduced infection rates.In our simulations, removal of infections at child care, primary schools, workplaces, leisure activities, and in public transport may barely have been sufficient to control the infection dynamics if implemented early on. Now according to our simulations it is too late for this, and (even) harsher measures will have to be initiated until possibly a return to such a restrictive, but still somewhat functional regime will again be possible.Evidently, all of these results have to be taken with care. They are based on preliminary infection parameters taken from the literature, used inside a model that has more transport/movement details than all others that we are aware of but still not enough to describe all aspects of reality, and suffer from having to write computer code under time pressure. Optimally, they should be confirmed independently. Short of that, given current knowledge we believe that they provide justification for “complete lockdown” at the latest when about 10% of available hospital capacities for COVID-19 are in use (and possibly earlier; we are no experts of hospital capabilities).1What was not investigated in detail in our simulations was contact tracing, i.e. tracking down the infection chains and moving all people along infection chains into quarantine. The case of Singapore has so far shown that this may be successful. Preliminary simulation of that tactic shows that it is difficult to implement for COVID-19, since the incubation time is rather long, people are contagious before they feel sick, or maybe never feel sufficiently sick at all. We will investigate in future work if and how contact tracing can be used together with a restrictive, but not totally locked down regime.When opening up after lockdown, it would be important to know the true fraction of people who are already immune, since that would slow down the infection dynamics by itself. For Wuhan, the currently available numbers report that only about 0.1% of the population was infected, which would be very far away from “herd immunity”. However, there have been and still may be many unknown infections (Frankfurter Allgemeine Zeitung GmbH 2020).