Results
One hundred orthopaedic surgeons of various subspecialties participated in the study
from 50 countries ([Fig. 1 ]). Three surgeons wanted the identity as anonymous. The response was rapid in 45%
of the participating surgeons with a mean of 45 minutes (range: 10 minutes to 23 hours)
and remaining responded in a mean 3.5 days. All other surgeons who accepted the survey
but could not submit the forms in time due to work schedule and technical issues were
excluded from the study. The mean case of the study as on May 27, 2020 was 39,820
(range: 70–336,000). Lockdown was started as early as January 24, 2020 in China, followed
by many other countries ([Table 1 ]). Few countries such as Taiwan, South Korea, and Sweden which participated in this
study had no official lockdown but followed strict social distancing, avoidance of
using public transports and nonessential services, aggressive testing, contact tracing,
isolation, and hygienic measures to contain the COVID-19. United Arab Emirates had
lockdown between 8 pm and 6 am; Turkey had irregular lockdown periods with strict
home stay for persons older than 65 years and younger than 20 years ([Fig. 2 ]).
Table 1
Current status of lockdown in 50 countries (as of May 31, 2020)
Complete lift of lockdown
Partial
Phased release/stage manner lockdown countries
Japan, Sweden
South Korea, Taiwan
Argentina, Spain, Egypt, Romania, Republic of Kosovo, Costa Rica, Croatia, Germany
Unites States, Portugal, Belgium, Greece, Iran, Nigeria, Bulgaria, Jordan, Switzerland,
France, Italy, Norway, India, United Kingdom
Qatar, Singapore, Malaysia, Colombia, Canada, Indonesia, Saudi Arabia, Australia,
Algeria, Thailand, Nepal, Colombia, Hong Kong, Pakistan, Libya, Mexico, Bolivia, Poland,
Brazil, Bangladesh, and Peru
Fig. 1 100 orthopaedic surgeons from 50 countries dealing with one COVID-19. A pneumonia
of unknown cause detected in Wuhan, China was first reported to the WHO Country Office
in China on December 31, 2019.The outbreak was declared a Public Health Emergency
of International Concern on January 30, 2020.On February 11, 2020, WHO announced a
name for the new coronavirus disease: COVID-19.
Fig. 2 Practice types of the orthopaedic surgeons.
Orthopaedic surgeons working in national health care systems (National Health Service
[NHS] trust, etc.) and governmental colleges/hospitals accounted for 44% of the study.
Of which, 50% were posted in the pneumonia ward. This decision was taken as a government/national
health care policy to ameliorate the physician stress and to manage the overloaded
asymptomatic but positive COVID-19 patients in the wards. They were also included
in the pneumonia wards’ rosters to look after the sick patients and monitor the staff
nurses and paramedical staffs. They were trained for intubation, but none of the surgeons
had any chance to perform or did the study.
Rationale
Orthopaedic surgeons are at high risk of infection (1.5–20.7%)[2 ] because of contaminations from colleagues, outpatients’ clinics, wards, operating
rooms (ORs), and intensive care units (ICUs).
Recommendations
If they are working in pneumonia wards and other COVID-19 duties, the risk of infections
may be exponentially high. Besides, they face the pressure from inadequate protection
from contamination, frustration, isolation, exhaustion, and unable to practice the
orthopaedic surgery or its allied subspecialty. It is prudent and necessary to relocate
orthopaedic surgeons and utilize their services at the department concerned.
Level of evidence : V
Participant vote : 94% agree; 3% disagree; 3% abstain (super majority, strong consensus) (95% CI 88
to 97).
Private/semiprivate practitioners and orthopaedic surgeons as nursing homeowners accounted
for 54% in the study. They had shut down their practices (27%) immediate to lockdown
and had the option to tailor the clinics and surgeries depending upon the crisis and
the need. The missionary hospital (1%), nongovernment organizations (3%), and semiprivate
hospitals (5%) were working with poor supply of PPE kits, masks, and other protective
accessories. They had worst time in coping up and meeting the daily expenses and working
costs. The surgeons working in the private medical college hospitals (21%) had stopped
the nonemergency clinics/cases and continued operating the emergencies and emergency
clinics.
Immediate Lockdown Status
There were many factors involved in the decision making for the orthopaedic surgeons
to continue their normal schedule or to stop the clinics or surgeries or both. Countries
like United States, United Kingdom (NHS trust), and other public health care systems
were operating upon emergent cases, postponing/deferring surgery for nonemergency
cases, and consulting selective patients in the clinics (44%) during the entire lockdown.
Of the 54% private practitioners and self-employed orthopaedic surgeons, 27% stopped
surgery and clinics.
Subsequent to the lockdown, and gradual resumption of work in their country, 35% surgeons
prefer to operate and consult their clinics partly in a phased manner, which consisted
of working for 2 weeks and self-quarantining for 2 weeks. Despite some relief and
restricted lockdown lift in their countries, private practitioners/nursing homeowners
chose the clinics (30%) and surgery (25%) to remain shut. A total of 9% surgeons had
completely stopped their orthopaedics practice because of their fear, comorbid conditions,
and the age >60 years.
More than 55% of the countries were experiencing some kind of lockdown during the
entire study. Japan declared lockdown lift on May 25, 2020 and subsequently many countries
such as United Kingdom and India lifted lockdown in a phased/complete manner during
the writing of this article. Many countries (54%) still continue to have lockdown
and hope to lift partially or in a staged phase. India had demarcated the infected
zones as Green—infections free, Orange—sufficiently infected, and Red—severely affected.
This demarcation helped them to lift the ban on services such as local transport,
supermarkets and grocery and vegetable supply, and promoted gradual return of life
activities: Green zone with free movement within the districts, Orange zone with limited
access to food supply, and Red zone remained totally contained and put under strict
vigilance. All emergencies were attended in time and referred hassle-free ([Fig. 3 ]).
Fig. 3 Lockdown status among orthopaedic surgeons.
Specialty Surgeons Participated in the Study
The orthopaedic and subspecialty surgeons involved in the study are compiled in [Fig. 4 ].
Fig. 4 Orthopaedic and subspecialty surgeons involved in the study.
COVID-19 Protocols for Admission
Surgeons (84%) working in private/government hospitals had trained paramedical/emergency
room (ER) teams which asked for patient’s symptoms (fever > 38.5°C, cough, fatigue,
breathlessness, anorexia, malaise/myalgia, loss of taste or smell, sore throat, nasal
congestion, headache, diarrhea, nausea, vomiting), travel history, contact history,
locality (containment zones) in the hospital reception. If found negative they were
registered and allowed to enter inside the hospital premises. Suspected cases, symptomatic
patients (44%), and positive travel history patients were isolated, separated, and
referred to fever clinic/tertiary government medical college hospitals for COVID-19
tests and further management. Orthopaedics teams (73%) monitored temperature, oxygen
saturation, pulse rates, and blood pressure before sending them to clinical consultation
rooms or ERs. Strict adherence of 2 meter distancing, frequent hand wash with 70%
alcohol-based sanitizers, and no visitor for ambulant/single visitor for nonambulant
patients (53–60%) were mandatorily followed in 100% of surgeons’ working places. As
a precautionary measure, 44% of patients were contacted through telephone and enquired
about the symptoms and travel history. If suspicious symptoms elicited, they were
counseled for postponing surgery and treat them conservatively with medicines and
splints (22%). In total, 44% surgeons preferred day care surgery. A total of 42% of
hospitals had separate COVID-19 rooms for admitting suspected COVID-19 cases (40%)
and protocols for checking bed availability at any given point in time ([Fig. 5 ]).
Fig. 5 COVID-19 protocols for admission.
Rationale
WHO has published a recommendation for health care workers based on the current knowledge
of the situation in China and other countries.[3 ] It has laid strategies to prevent or limit transmission. WHO and Center for Disease
Control and Prevention (CDC) have both laid guidelines for prehospital survey[3 ] and work-up.[4 ]
[5 ]
[6 ]
Recommendations for Preoperative Work-Up
COVID-19 risk profile, travel history, and contact history should be collected and
scrutinized. Temperature and oxygen saturation should be checked on the day of surgery
([Fig. 6 ]). If positive findings (fever > 38.5°C, SpO2 < 90% on room air) are found, the patients should be evaluated with diagnostic work-up
before surgery (reverse transcription polymerase chain reaction [RT-PCR] and computed
tomography [CT] scan chest).
Fig. 6 Recommendations for preoperative work-up (flow chart).
Level of evidence : V
Participants vote : agree: 94%, disagree: 3%, should be done before surgery: 3% (super majority, strong
consensus) (95% CI 88 to 97).
Management of Nonemergency Cases
Considering the national emergency and critical lockdown, 55% of surgeons deferred
surgery and adopted alternative/conservative methods of treatment. Local steroid injections,
splints, cast, and oral analgesics were given to patients during the pandemic. Among
the nonemergency cases, 37% surgeons found that they had one or more symptomatic patients
who were referred to government/private tertiary medical colleges for further evaluation
and management. Only 3% surgeons operated on nonemergency cases such as radial tunnel
syndrome where working women presented with severe pain restricting their daily activities.
Immediate to the surgery, they returned to normal work and were pain-free and happy
([Fig. 7 ]).
Fig. 7 Management of nonemergency cases.
Rationale
The Centre for Medicare and Medicaid Services (CMS) has given preferential recommendation
for surgery and conservative management.[7 ] We had modified the questionnaire to suit the orthopaedics practices. They are as
follows:
Low acuity treatment: carpal tunnel syndrome, trigger finger, tennis elbow, etc.
Intermediate: joint replacement, spine surgery, arthroscopy.
High acuity: open fractures, severe trauma—fractures and dislocations, cauda equina
syndrome, compartment syndrome, cancer, highly symptomatic, acute infections, necrotizing
fasciitis, and vascular injuries ([Fig. 8 ]).
Fig. 8 Suggested flow-chart recommendation for selection and management of cases.
Recommendations from Surgeons
Level of evidence : V
Participants vote : 97% agree, 3% disagree (super majority, strong consensus) (95% CI 92 to 99).
Patients’ Consent and Information
Patients received information about COVID-19, hand hygiene, and the safe hygienic
practices prior to surgery. In addition, surgeons also obtained prior informed consent
(87%) and special consent (49%) in bilingual version (English + native language) about
the risk of contamination and spread to them during the stay. As a mandatory practice,
patients wore surgical mask and protective kits during the stay in the hospital. All
elective patients received adequate counseling before surgery (66%) and chances for
postponement and counseling for nonemergency case delaying were rendered.
Surgeries Performed during the Lockdown
Distal radius fractures (53%), hand and carpal bone fractures/dislocations (57%),
forearm fractures (39%), elbow fractures/dislocations (40%), shoulder (24%), spine
fractures, paraplegia and dislocations (17%), pelvis and acetabulum (15%), hip fractures/dislocations
(46%), femur fractures (32%), knee (27%), leg, ankle, and foot fractures (28%), microsurgeries
(29%), fingertip injuries (45%), soft tissue injuries (37%), amputations (39%), replants
and revascularizations (30%), septic arthritis/infections (38%), tendon, nerve, and
muscle injuries (50%), open fractures (57%), and emergency surgeries (57%) happened
during the COVID-19 crisis in 50 countries. In total, 75% surgeons did all these surgeries
in their normal OR; 15% had COVID-19 makeshift ORs where the cases were done; <10%
had the surgery done in minor ORs or day-care units or adjacent to ORs ([Fig. 9 ]).
Fig. 9 List of surgeries done (total: 637 cases).
Orthopaedic Surgery for Elderly and Comorbid Conditions
Orthopaedic surgeons had many challenging tasks in operating on elderly patients invariably
associated with comorbid conditions (diabetes, hypertension, coronary artery disease,
cancer, immunosuppression, and moribund obesity). Domestic falls at home were the
main reason for fractures in the elderly population. Distal radius fractures (20%),
trochanteric fracture (35%), fractured neck of femur (25%), supracondylar femur fractures
(12%), surgical neck humerus fractures (10%), ankle fractures/dislocations (7%), lumbar
fractures (5%), acetabular fractures (3%), and other fractures involving the hand
and foot were treated by the surgeons involved in the study. Hip fractures and hip
and knee surgeries in elderly patients had 15% mortality in this study because of
worsened varied existing reasons such as chronic renal failure, urosepsis, and coronary
artery diseases. Most of the surgeons (90%) treated distal radius fractures, surgical
neck humerus fractures, and hand fractures conservatively with cast/splints and early
mobilization.
Both in adults and elderly patients, these 100 surgeons had followed certain protocols
before and after the surgery. Based on their suggestions, we propose directions for
the presurgical work-up including for emergency and elective cases and the rationale
behind.
Rationale
Due to their increased susceptibility to pulmonary infection and increased morbidity[8 ]
[9 ] because of being bed-ridden and associated comorbid conditions such as hypertension,
heart disease, or diabetes,[10 ]
[11 ] orthopaedic surgeons operate on the elderly population to enhance early mobilization
and prevent risk of deep vein thrombosis (DVT),[12 ] thereby reducing the morbidity and mortality. Given the COVID-19 scenario, elderly
patients are vulnerable to developing pneumonia after fractures. So high suspicion
with a definite treatment guideline for elderly patients is required.[13 ]
[14 ] Open fractures and severe injuries require emergency surgery.[15 ]
[16 ]
Recommendations
Conservative for distal radius, surgical neck humerus, and clavicle fractures.
Operative for hip and knee fractures to have early mobilization and prevent morbidity
and mortality, DVT, and pulmonary complications.
Strict infection control measures, anticoagulation, and intensive supportive care.
Level of evidence : V
Participants vote : agree: 78%, disagree: 13%, abstain: 9% (super majority, strong consensus) [95% CI
69 to 85].
Orthopaedics Cases and Percentage of Reduction during the Lockdown
When analyzing the number of surgeries in different countries during the lockdown,
marked reductions were noted uniformly. Surgeons (18%) performed less than five surgical
cases per month; <5–15 cases in 24%; 16–25 cases in 22%; 26–50 cases in 18%; 51–100
cases in 8%, and >100 cases in 8%. Ten percent of surgeons did not operate during
the entire lockdown period. More than half of the surgeons had 50 to 75% reduction
in patients’ turn-up for regular clinics.
Again, countries with public health care systems modeled with the government, general
taxations, ministry of health control, or insurances, such as United States, United
Kingdom, United Arab Emirates, Saudi Arabia, South Korea, Taiwan, and New Zealand
had been continuing to operate more than 100 cases per month. Countries with huge
populations such as China, India, and Pakistan which depend on partly private and
government support had marked reduction in the number of cases (5–25 cases per month).
Overall, 63% of surgeons felt three-fourths reduction in their surgical cases compared
with their routine schedule ([Fig. 10 ]).
Fig. 10 Surgery reduction during the lockdown.
Orthopaedics Case Postponement and Catch-Up Procedures
The surgical case reduction automated to backlogs increases their future surgical
loads. Worryingly, surgeons expected 27% (n = 25) of patients will not come back for surgery again because of partial relief
from conservative management or very long reappointment schedule. On the other hand,
if the backlogs kept increasing over a period of time, the surgeons feared burden
on the health care systems and catch-up procedures could be hectic and clogged. In
total, 50 to 75% of surgeons estimated catch-up procedures could happen in 3 to 6
months or even longer. They firmly believed that mandatory structural reorganization
in the entire health care system to deal backlogs of waiting patients must be done
diligently and prudently.
Rationale
There have been various discussions in the past on how to address backlogs of surgical
cases, whether to increase or extend the operating time into the weekends.[17 ] The immediate concern from the operating team is physical and mental fatigue because
of sudden increase in work burden. Because of this fatigue there is 22% increased
risk of medical error.[18 ] Janhofer et al[18 ] came up with the solution of intraoperative “microbreaks” for fatigue mitigations
and enhanced safety. Besides the authors strategized, surgeons have reduced responsibility,
optimized sleep, nutrition, and hydration to maximize surgeon endurance.[19 ]
Recommendations for Catch-Up Procedures in Orthopaedic Surgery
Semi-elective cases and intermediate/high acuity should be given preference for surgical
work-up in the catch-up surgical list.
Considerations should be given to surgeons and the team for mitigating physical and
mental fatigues.
A transparent model should be followed.
Level of evidence : V
Participants vote : agree: 97%, disagree: 3% (super majority, strong consensus) (95% CI 92 to 99) ([Fig. 11 ]).
Fig. 11 Postponement of orthopaedic surgery.
Operating Room Dress Code
The orthopaedic surgeries were performed in their normal ORs in 73% and COVID-19 makeshift
ORs with negative pressure control and filters in 18%. Minor ORs and emergency ORs
were used in 8%. More than one-third of the surgeons (40%) did surgery with full PPE
kits, N95 masks, face shields, shoe covers, and protective glass, with proper donning
and doffing techniques before and after procedures. Surgeons (25%) performed surgeries
with normal surgical masks, operating gowns, shoes, and usual accessories during and
after the procedures, partly attributing to nonavailability, poor supply, and increased
demand for the PPE kits and the accessories. More cautiously 5% wore both surgical
and N95 masks together during the procedures. Surgeons had perspirations, heat, fogs,
and occasional breathlessness wearing the PPE kits and the accessories. Surgeons (2%)
preferred (filtering face piece level 1, 2, and 3) FFP3 masks over N95 masks, which
are slightly better and advantageous than N95 masks.
Rationale
PPE kits include surgical gloves, water-resistant gowns with long sleeves, a surgical
mask, and full-face protection with a face shield. This reduces intraoperative wound
contaminations from blood and body fluids, which get sprayed in an area of 2 to 8
meters around the operating table.[20 ] There are four levels of safety in gowns: level 1(use in minimal risk environment),
level 2 (low risk procedures), level 3 (moderate risk), and level 4 (high-risk procedures/infectious
diseases). There are three types of face masks protecting the mouth and the nose.
Single-use face mask: it filters large particles of 3 μm, prevents droplet transfer,
and is used by the health care workers[21 ] to protect and patients to limit COVID-19 transmission.[22 ]
Respirators mask[23 ]: it filters small particles of 0.3 μm and protects against airborne transmission.
The European Standard (EN 149:2001) classifies respirator masks into three types:
FFP1, FFP2, and FFP3. The N95 mask is FFP2 type which has 95% filtering capacity and
provides good protection. FFP3 is an N99 mask, which gives 99% filtration against
airborne contamination of 0.3 μm particles.
Power air-purifying respirator[24 ]: it was used mainly during the severe acute respiratory syndrome (SARS) outbreaks
by the health care workers and persons with high risk of transmission (surgeons).
Recommendations
Respirators (FFP1, FFP2, and FFP3) are designed to protect against droplets and aerosols
(percentage of filtered particles ≥300 nm). N95 masks filter 95% of ≥300 nm particles.
Both have high protective potential. WHO recommends all heath care workers should
wear a respirator (FFP3/N95).
Surgical masks are reasonably safe for patients with COVID-19 and health care providers.
Level of evidence : V
Participants vote : 76% agree, 20% disagree, 4% abstain (super majority, strong consensus) (95% CI 69
to 86).
Operating Team
Surgeons, OR staff, technicians, radiograph and anesthetist technicians, assistants,
ICU staff, and paramedical staff play a crucial role in a successful surgery. Operating
orthopaedic surgeon, staff, technicians, and ICU staff worked on roster (28%) and
were quarantined for 14 days. In countries (45%) with huge cases of orthopaedics trauma
cases, COVID-19 cases, and lack of adequate doctor/staff ratios, the entire team worked
on regular schedule without quarantine or break. The operating team worked with PPE
kits, N95 masks, and protective accessories (25%) and with normal surgical masks and
gowns (45%).
Rationale
The Systems Engineering Initiative for Patient Safety (SEIPS) model[25 ] provides a good framework for a health care system to critically evaluate the armamentarium
of measures to minimize the risk of intrahospital spread and protect its frontline
health care workers against occupational COVID-19 infection. It suggested health care
workers including doctors to be segregated into two dimensions and the need to get
quarantine themselves at regular intervals.[26 ]
Recommendations
Doctors, staff, and paramedical staff should be divided into teams working on duty
rosters with full PPE kits and N95 masks or equivalent. Medical students should be
withdrawn from surgical postings. Daily temperature and SpO2 check should be done. Self-quarantine for 2 weeks is mandated. If symptomatic they
need to visit fever clinics for further management.
Level of evidence : V.
Participants vote : 86% agree, 11% disagree, 3% partly (super majority, strong consensus) (95% CI 78
to 91).
Operating Room
Majority of the surgeons (80%) recommended limited staff and associates inside the
OR. They preferred negative pressure ventilation (32%), high-efficiency particulate
air (HEPA) filters (41%), and centralized (32%) and split air-conditioning (16%).
They also insisted for single-use disposable gowns, masks, and accessories (38%),
and strict adherence to autoclaving and implant handling (32%). Poor supply of disposable
gowns and PPE kits, shortage of implant supply, obligatory use of HEPA filters with
frequent air changes, and unenduring change of OR infrastructure such as centralized
air-conditioning and positive pressure ventilation to negative pressure ventilation
were some of the challenging tasks of the surgeons involved in this study to render
safe orthopedics surgical practice during this COVID-19 pandemic ([Fig. 12 ]).
Fig. 12 Operating room recommendations.
Rationale
ORs are designed with positive pressure and changing it to negative pressure ORs is
not easy and cumbersome.[25 ]
[27 ] Addition of HEPA filters will filter coronavirus (0.125 µm) efficiently and reduces
viral load and risk of viral disseminations. ORs have air-conditioning and humidification
units with individual atmospheric air inlet and exhaust systems. In positive pressure
ventilation, fresh air is supplied to the OR without recycling, and the outflow to
the atmosphere occurs via overhead exhaust vents. Improvisation of the existing ORs
to produce negative pressure ventilation can help reduce viral dissemination.[28 ] Nonessential materials are kept away and the operative personal should be reduced
to minimum. The rationale behind strict adherence was to prevent the risk of contamination
and spread of corona virus.[28 ]
[29 ] High-speed cutters in cervical spine surgeries and hip replacement surgeries produce
aerosol <5 µm and contaminate OR personals.[30 ] The blood aerosols can reach the upper respiratory tract.[31 ] Pulsatile lavage will splatter blood and body fluids which are highly infectious.[32 ] Electrocautery used in surgery which produces smokes (aerosols)[16 ] is found to have Corynebacterium , papillomavirus, human immunodeficiency virus, and hepatitis B.[33 ] Although limited data are available regarding the corona virus spread while performing
such aerosol-generating procedures (AGPs) in orthopaedic surgeries, they should not
be any exception.
The indication for surgical fixation during this pandemic should be simple, rational,
definitive, and expeditious.[34 ] Joint replacement allows early mobilization. Minimally invasive external fixation
should be tried for closed and open fractures.[35 ] Uncemented[36 ] and unreamed nails have shorter operative time and potential advantage in reducing
respiratory complications and fat embolism.[37 ]
Recommendations
HEPA filter, dedicating space for nonessential materials inside the OR complex, separate
entry and exit rooms with hand washing, stern donning and doffing methods, meticulous
and judicious use of high-speed drills, electrocautery, suction devices, definite
surgical procedures (early mobilization), less aggressive external fixators for complex
injuries, implant choices (uncemented implants, unreamed nails), and wound wash techniques
(pulsatile lavage) are imperative protocols in the OR complex.
Cleansing should be done using detergent and water followed by use of 1,000 ppm bleach
solution for all hard surfaces in the operating theater. The disinfection time should
be longer than 30 minutes. The operating theater should be closed for at least 2 hours,
and the next operation should be performed after laminar flow and ventilation being
turned on.
The surgeon should remove the gowns, discard used PPE, adhere to hand hygiene, and
shower before leaving the OR complex.
If possible reverse engineer for negative pressure ventilation ORs.
Level of evidence : V
Participants vote : agree: 91%, disagree: 6%, abstain: 3% (super majority, strong consensus) (95% CI
84 to 95).
Anesthesia
Surgeons (60%) preferred regional anesthesia (spinal/epidural/supraclavicular block,
axillary block) over general anesthesia for lower limb and upper limb cases with minimal
or no sedation. Surgeons (25%) did surgeries of the fingertip injuries and finger
fractures under local anesthesia and preferred WALANT anesthesia for hand and wrist
injuries (tendon repairs/transfers). Surgeons (15%) opted for general anesthesia when
operating head injuries, spine injuries, polytrauma multiple fractures with special
precautions during and after intubation. Given that COVID-19 appears to be transmitted
via aerosolized droplets with closest person to person contact, all surgeons felt
universal precautions and droplet cautions must be followed. The choice of anesthesia
technique generally depends on the procedure and patient. All the patients were given
surgical masks during the procedure. Surgeons avoided general anesthesia, airway instrumentation,
and attendant aerosol generation to prevent risk of airborne transmission ([Fig. 13 ]).
Fig. 13 Methods of anesthesia used in the study.
Rationale
The major routes of SARS-CoV-2 transmission are through respiratory droplets and contact
with contaminated surfaces.[38 ] The AGPs are tracheal intubation, noninvasive ventilation, tracheostomy, manual
ventilation before intubation, and bronchoscopy.[39 ] The risk of infection is 6.6 times higher with general anesthesia.[40 ] Nausea and vomiting associated with the general anesthesia produce high virulent
airborne particles which have serious deleterious effects compromising the respiratory
system. Although symptomatic patients are the primary source of infection, asymptomatic
subjects may also spread the disease and should not be neglected.[41 ] Regional anesthesia is recommended over general anesthesia; nasal prongs are used
for oxygen supply. Aeration of closed environments, appropriate use of PPE kits, frequent
hand hygiene, masks for patients, and surface decontamination are mandatory.[42 ]
Recommendations
Local/regional anesthesia with minimal or no sedation is preferred for upper and lower
limb procedures.
General anesthesia should be reserved for individuals who need the most. If performed,
follow strict and efficient protocols to minimize aerosol droplet transmission. (PPE,
N95 masks, 6-feet distancing from the patient’s head, and postanesthesia care units
are mandatory.)
Patients should wear surgical masks throughout the procedure and if oxygen is required,
it should be supplemented by nasal prongs.
Minimize aerosolization, coughing, and circuit leaks.
Level of evidence : V
Participants vote : agree: 91%, disagree: 6%, abstain: 3% (super majority, strong consensus) (95% CI
84 to 95).
Postoperative Care and Follow-Up
Despite the current situations, 29% of the surgeons still preferred to see the patients
as usual on their working day with modifications in their OR and clinics, such as
recovering in isolation rooms (disinfected with 70% ethanol, sodium hypochlorite,
or 0.5% hydrogen peroxide), restricting visitors’ entry, discharge as day care if
possible, shifting to the ICU if needed, and using protective therapy protocols. Our
analysis had day-care surgery and discharge by 20% surgeons and patients with extended
stay were discharged in less than 3 days by 60% of the surgeons and 7 days by 9% of
the surgeons.
Surgeons (9–31%) restricted the postoperative follow-up to a particular day in a week
or few days in a week. Fifteen percent of the surgeons preferred teleconsultation
(video + telephone calls). Very limited procedures such as suture removal, Kirschner
wire removal, and splint and cast applications were done (22%) on selected days on
appointment basis. Subsequent follow-up consultations and regular patients’ clinic
visits strictly followed safe hygienic measures and social distancing measures such
as outpatient/clinic patients (46%) less than five patients per hour, seating arrangements
of 2 meter distancing (75%), 50:50 physical–digital consultations (13%), restricting
of nonessential materials (26%; books, bags, etc.), and minimal contact and accompanying
persons’ entry (39%). Some surgeons (31–34%) preferred normal business schedule as
usual like before ([Fig. 14 ]).
Fig. 14 Post-operative care and follow up.
Rationale
The human coronaviruses (e.g., SARS-CoV-2) can persist on inanimate surfaces in the
OR which can be effectively inactivated by surface disinfection procedures, such as
using 70% ethanol or 0.5% hydrogen peroxide.[43 ]
[44 ]
[45 ] Besides, the OR can be cleaned with sodium hypochlorite followed by hydrogen peroxide
vaporization as an added precautionary measure.[46 ]
Symptomatic patients or asymptomatic patients with COVID-19 test positive after the
surgery should be kept isolated in the intensive ward of COVID with surgical masks.[30 ] Theoretically, nonsteroidal anti-inflammatory drugs can potentially worsen symptoms
in patients with COVID-19[47 ] because of their increased expression of angiotensin-converting enzyme 2 (ACE-2)
which enables SARS-CoV-2 (the coronavirus responsible for COVID-19) to bind to its
target cells in the lung. It is prudent to avoid this class of drugs and choose other
classes of safe analgesics. A minimum of 1 hour should be planned between the cases
to allow the OR to be properly decontaminated with all its equipment.
The face-to-face visits should be limited to urgent cases and selected postoperative
care, which include postoperative COVID-19 symptoms, suture removal, evaluation of
fracture reduction, and wound dressings.[48 ] All patients should perform frequent and accurate hand hygiene and wear surgical
masks inside the hospital premises, and health care providers should wear PPE kits,
nonsterile gloves, face shields, N95/FFP3 respirators or surgical masks if unavailable,
and protective glass face shields for droplet precautions.[49 ] Telemedicine (videoconferencing) is a useful adjunct to conduct nonurgent follow-up
and it provides rapid direct visualization of the patients.[50 ] Besides it enhances telerehabilitation[51 ] by teaching them exercises periodically, analyzing the range of movements, and further
therapy as per the need.
Recommendations
Day care surgery and early discharge.
Teleconsultations (video and audio calls) and telerehabilitation.
In every follow-up visit, patients must wear a mask and be screened for fever/cough/breathlessness.
Surgeons must wear appropriate PPE kits (a disposable gown, nonsterile gloves, a face
shield or goggles, an FFP2/FFP3/N95 respirator, or a surgical mask).
Level of evidence : V
Participants vote : agree: 91%, disagree: 6%, abstain: 3% (super majority, strong consensus) (95% CI
84 to 95).
COVID-19 Test Positive after Surgery
For all emergency surgeries, the surgeons did COVID-19 test of the patients in the
postoperative period and found negative in 87%, and positive in 13% (range 5–15 cases).
COVID-19-positive cases were intimated to the local authority, shifted to tertiary
care/government medical college hospitals for further follow-up and management.
Recommendations
RT-PCR tests for all elective cases and emergency patients in the postoperative ward.
If positive, shift to tertiary care/governmental hospitals for ICU care.
Level of evidence : V
Participants vote : agree: 86%, disagree: 14% (super majority, strong consensus) (95% CI 78 to 91).
CT-Scan Chest
Seventy-seven percent of the surgeons did not recommend CT-scan chest for their patients
irrespective of emergency and elective nature. Thirteen percent of surgeons did CT
scan chest to find for COVID-19 lung features before surgery in all of their patients.
Some surgeons (7–10%) preferred it when the radiographs or RT-PCR results were inconclusive
([Fig. 15 ]).
Fig. 15 Surgeons’ recommendations for CT-scan chest.
Rationale
So far, the pattern of ground-glass and consolidative pulmonary opacities, often with
bilateral and peripheral lung distributions, has remained the chest CT hallmark of
COVID-19 infection.[52 ] Considering the possibility of false-negative PCR results, surgeons recommend diagnosis
based on clinical and chest CT findings (ground glass opacities and consolidation).
It is also agreed that COVID-19 has, in addition, different lung features and presentations
similar to outbreaks such as SARS and Middle East respiratory syndrome ([Table 2 ]). For symptomatic patients, CT scan is reliable when it is done 0 to 2 days after
symptom onset and a delayed CT scan has limited sensitivity and negative predictive
value.
Table 2
CT scan chest finding in COVID-19.
CT scan chest findings[52 ]
Presence of ground-glass opacities
Presence of consolidation
Laterality of ground-glass opacities and consolidation
Number of lobes affected where either ground-glass or consolidative opacities were
present
Degree of involvement of each lung lobe in addition to overall extent of lung involvement
measured by means of a “total severity score” as detailed below
Presence of nodules
Presence of a pleural effusion
Presence of thoracic lymphadenopathy (defined as lymph node size of ≥10 mm in short-axis
dimension)
Airway abnormalities (including airway-wall thickening, bronchiectasis, and endoluminal
secretions
Axial distribution of disease (categorized as no axial distribution of disease, central
“peribronchovascular” predominant disease, or peripheral predominant disease)
Presence of underlying lung disease such as emphysema or fibrosis
Recommendation
CT scan findings such as consolidation, bilateral disease, greater total lung involvement,
linear opacities, “reverse halo” sign, “crazy-paving” pattern, and peripheral lung
distribution are found after confirmed COVID-19 infection. A routine scan may be required
for specific cases.
Level of evidence : V
Participants vote : agree: 49%, disagree: 49%, abstain: 2% (no majority, no consensus) (95% CI 39 to
59).
COVID-19 Tests
All emergency surgeries included in the entire study were done without COVID-19 test
and for all elective cases, surgeons kept COVID-19 test (RT-PCR) as mandatory. Still
for emergency cases, 40% of the surgeons preferred the COVID-19 test at the time of
surgery or sooner in the postoperative period, which could help them to isolate asymptomatic
but COVID-19-positive patients for further quarantine, treatment, and official reporting
to the government agencies. For all elective cases and nonemergency cases, though
RT-PCR testing was mandatory, only 77% of the surgeons did it in their cases and 14%
preferred immunoglobulin M (IgM) and immunoglobulin G (IgG) antibody testing. Lack
of testing kits and initial hospital norms to compensate could be the reason. Some
surgeons (10%) relied on blood parameters (serum ferritin, interleukins, complete
blood counts, C-reactive protein, liver functions test, leukocyte:neutrophil ratios,
lymphocyte:neutrophil ratio) for their patients ([Fig. 16 ]).
Fig. 16 Surgeons’ recommendations for COVID-19 tests.
Rationale
Serological assays (IgG, IgM) for SARS-CoV-2 are done for identifying groups at high
risk for COVID-19 infections.
Real-time RT-PCR assay is a molecular diagnostic test. The samples from the nasopharyngeal
swab have been widely used to detect SARS-CoV-2. This nucleic acid amplification test
(NAAT) identifies genes specific for screening and confirming the disease. PCR amplification
of the viral E gene is a screening test and amplification of the RdRp region of the
orf1b gene is a confirmatory test of RT-PCR for COVID-19.
There are several RT-PCR protocols[53 ] for the detection of SARS-CoV-2 RNA posted by the WHO at https://www.cdc.gov/coronavirus/2019-ncov/lab/resources/antibody-tests-guidelines.html (updated May 25, 2020 and accessed on May 28, 2020). Testing for IgG and IgM antibodies
confirmed the persons’ infection. In general, IgM is one of the first types of antibodies
produced after infection and is most useful for determining recent infection, while
IgG generally develops after IgM and may remain detectable for months or years.[53 ]
Recommendations
Specimens should be collected from nasopharyngeal swab (preferred) and oropharyngeal
swab. If not possible then collect from nasopharyngeal aspirates and sputum (if produced)
and/or endotracheal aspirate or bronchoalveolar lavage in patients with more severe
respiratory disease.
Nucleic acid testing (NAAT) is the primary method of diagnosing COVID-19, which is
based on the detection of unique sequences of virus RNA. Real-time RT-PCR detects
SARS-CoV-2 genetically.
PCR testing of asymptomatic or mildly symptomatic contacts can be considered in the
assessment of individuals who have had contact with a COVID-19 case.
Screening protocols should be adapted to the local situation. Even the transmission
electron microscopy can identify the morphology of the virus (corona-shaped).
No identified advantage of IgG and IgM antibody assays. Antibodies detected in the
patient suggest that infection has occurred and some degree of immunity from infection
has developed.
Surgeons are also aware of false negatives from test reports and hope that advancement
in NAAT techniques (e.g., CB NAAT [cartridge-based NAAT]) could possibly reduce the
false negativity and open a window for clarity and focus.
Level of evidence : V
Participants vote : agree: 100%, disagree: 0 (super majority, strong consensus).
Emergency Room and Pneumonia Ward Management
Junior residents and registrars (21%), junior consultants (38%), and senior consultants
(43%) first received the orthopaedics emergencies in the ER, assessed, and operated
them. Several countries (43%) have COVID-19 triage protocols and separated the cases
from normal health care services to prevent the risk of contamination. Involvement
of junior residents in COVID-19 wards and removing them from their routine orthopaedics
duties inevitably interrupt the learning and put them more prone to risk of infection.
Countries with national public health care systems and government medical colleges
have their orthopaedics surgeons and allied specialists (30%) posted in the pneumonia
ward. By this, the patient load (asymptomatic and minimally affected patients) of
the physicians and pulmonologists is reduced. Absence of active teaching of the trainees
and orthopaedics surgical training for residents has become a reality. Specialists
such as hand and microsurgeons were unavailable when really required for their emergencies
and technically demanding surgeries.
Rationale
The overall goal during the fight against COVID-19 is to create a system model that
allows for appropriate resource allocation (surgeons, specialists, staff, technicians,
ICU staff, paramedics, and other health care workers) to provide optimal patient care,
while minimizing viral spread to the patients and other members of the treatment team.[54 ] Health care workers involved in the COVID-19 ward or ICU treatments may remain asymptomatic
for up to 14 days.[55 ] It is prudent and rational to have different teams of surgeons, staffs, and paramedical
technicians to work on rosters so that each team can be 14 days away from the work.
Recommendations
Cyclical quarantine among the health care workers and COVID-19 test for suspected
team members.
Level of evidence : V
Participants vote : agree: 94%, disagree: 6% (super majority, strong consensus) (95% CI 88 to 97).
Shortage of Staff and Hospital Supplies
Immediately after the lockdown, hospitals across the globe faced acute shortage of
staff (25%), nurses for the ward, ORs, and ICUs because of the transport restriction
and initial fear among people about the dreadful virus. In order to meet the initial
increasing demands, PPEs, surgical masks/N95/FFP3, and gowns (41%) and medicines (7%)
fell short of supply. No free availability of surgical masks concerned 10% of surgeons
involved in the study. Mostly, all national health care systems/government medical
college hospitals in developed and developing countries jolted during the initial
phase, came to stand still in 11% countries, and recuperated gradually with strict
lockdown rules and procurement of PPE kits, masks, and ICU instruments (ventilators,
monitors, and COVID-19 test kits; [Fig. 17 ]).
Fig. 17 Shortage of staff and hospital supplies.
Apart from government medical college hospitals and national public health care systems,
70% of private hospitals/nursing homes had suffered a major setback financially; the
shortage of manpower forced them to shut down the essential services. Many such hospitals
have to furlough their staffs to 25 to 50% and paramedics to 50% of their normal strength
and incurred financial constrains varying from 25 to 100% during the lockdown. Doctors
and staff employed in the private health sectors faced 50 to 100% salary loss.
Expectation to Normalcy Soon after the Lifting of Lockdown
The suspension of elective surgeries put severe financial strains on the patients,
physicians, and the entire health care system in all countries. One-third of the surgeons
expected the current situation to improve in 15 days and 24% in 2 months’ time. Surgeons
(8.5%) who were maintaining their operating schedule and clinic visits as usual during
the lockdown continued the same after the official lockdown lift, and found no difference
in the normalcy. Very few surgeons (5%) worried about the future, kept fingers crossed,
and waited for changes to happen soon. There are several factors which determine the
return to normalcy, which include government policy of lifting lockdown, containment
of the virus, flattening the curve, comprehensive protocol analysis based on countries’
local need, and the infrastructure to bring back to normalcy if not fast but slowly
and steadily ([Fig. 18 ]).
Fig. 18 Expectation to normalcy soon after the lift of lockdown.
Rationale
Ceasing elective procedures and other services (master health check-up, etc.) in many
hospitals has decreased their revenue and increased their expenses and daily working
costs. The cash source was depleted, and the hospital operations were halted.[56 ] The surgeons would prefer “cherry-picking” and “lemon dropping” surgical procedures
avoiding the complex and less revenue surgeries.[57 ] Since there is a negative economy and financial loss in the private sectors, the
compensatory way would be to increase the cost for all surgical procedures and services
rendered to the patients. As the medical systems look ahead to resume their elective
cases, they require abundant support from the local government and insurance providers,
and ways of quick settlements to the hospital. While writing this article, many challenging
logistic issues came to the fore that one needs to answer, such as how much and how
long to retain employees and staffs, cuts in salary and regular benefits, loan repayments,
and hospital maintenance charges. These are crucial in getting private health care
providers back to normalcy.[57 ] Over the past decade, considerations were moving forward to ambulatory surgery centers[58 ] and outpatient sitting arthroplasties.[59 ] Multiple systemic reviews have reported these methods as safe and effective.[60 ]
Recommendations
As both hospitals and patients are struggling to recuperate in this COVID-19 crisis,
mutually benefitting strategic cost-effective and efficient surgical protocols supported
by insurance providers and governments could make a big difference for normalcy to
return.
Proposing ambulatory surgery centers and outpatients’ surgeries will disencumber the
corona strain placed on hospital systems managing patients with COVID-19.
Level of evidence : V
Participants vote :agree: 94%, disagree: 6% (super majority, strong consensus) (95% CI 88 to 97).
Orthopaedic Surgeons Are No More Surgeons
Focusing their attention toward administrative works (26%), writing, reviewing manuscripts
(69%), attending their household works, sharing their views and knowledge through
online webinars (65%), and making shifts in working made surgeons no more a surgeon
in the lockdown period ([Fig. 19 ]).
Fig. 19 Pattern of non-orthopeadics works during the lockdown.
Orthopaedic Surgeon Is No More Special
Despite the fact that disclosure can be voluntary, 8% orthopaedic surgeons of different
countries got infected (positive COVID-19 test) and 5% tested were found negative
during the lockdown. Out of fear, 15% stopped operating and visiting clinics and remained
confined in the home. Altruistically, 30% felt the noble service should be extended
for emergency cases only and stop nonemergent clinics and surgeries.
PPE Kits and Real Safety Concerns
Fifteen percent surgeons believed the rationality behind the use of PPE kits during
the crisis and felt 100% safe, whereas 24% surgeons felt half protected and 25% felt
75% of protection from the risk of viral transmission; 23% surgeons felt unsafe with
PPE/N95/FFP3 kits despite the scientific claim and proven facts ([Fig. 20 ]).
Fig. 20 How safe is PPE kits?
Rationale
Respirator masks (N95/FFP3) show protection factors 11.5 to 15.9 times greater than
those of surgical masks.[23 ] Moreover, a perfect-size and well-fitted mask leads to efficient sealing of the
respiratory tract. Intact masks can be worn up to 8 hours continuously.[23 ] European and U.S. standards for masks used for PPE showed that FFP1 has 80% filtration
efficiency for particles of 0.3 μm, N95 (FFP2) has 95%, and N99 (FFP3) has 99%, offering
good protection against airborne transmission.[34 ] The European FFP3, equivalent to the U.S. N99, is recommended for aerosol protection
against COVID-19. PPE is essential to prevent risk of transmission and cross-infections.
A surgical gown which comprises the front area of the gown from chest to knees and
the sleeves from the cuff to above the elbow has safety levels 1 to 4.[21 ]
Recommendations
Respiratory AGPs, surgeries with high-speed devices (drill, saw, irrigations, etc.),
extubating, and ending of anesthesia in the OR require FFP3 masks or powered air-purifying
respirators, and face shields or surgical hoods, whereas surgical AGPs only require
FFP2 masks.
Level 4 surgical gowns, face shields or goggles, and double gloves should be used.
In case of proven or suspected COVID-19 infection, orthopaedic surgeons should use
FFP2–3 or N95–99 respirator masks.
Cleaning of ORs should be done wearing FFP2/N95 or FFP3 masks.
Caution for reuse and methods needed for reuse of N95 masks: 15 minute exposure to
ultraviolet radiation, fumigation with hydrogen peroxide, hot water heating (>56°C
[typically 60–80°C] for 30 minutes followed by drying with a hair dryer), steaming
(30 minutes of pressurized steam at 121°C), and baking (75°C for 30 minutes).
Level of evidence : V
Participants vote : agree: 94%, disagree: 6% (super majority, strong consensus) (95% CI 88 to 97).
Surgeons Are Men of Fear
Fifty-nine percent of the surgeons feared of getting infected and 28% considered them
vulnerable to get infected. One surgeon (1%) was getting treatment for their pneumonia
associated with COVID-19 while writing this article. At this juncture, we all wish
them a speedy recovery and safe return to work soon ([Fig. 21 ]).
Fig. 21 Fear of infections/self infections
Instantly, 80% of the surgeons feared of their near and dear ones getting infected
from them. For which, they had self-quarantined in a separate room/part of the home,
facing all odds and obstacles and sacrificing for their love ones.
Rationale
Transmission of COVID-19 can happen in 25% of the orthopaedic surgeons.[2 ] There were confirmed (20.8%) transmissions of COVID-19 to family members, which
always make orthopaedic surgeons feel panicked, depressed, and worried.
Recommendations
In the case of COVID-19 positive, isolation of orthopaedic surgeons needs self-quarantine
and avoid close contact with family members for 2 weeks.
They can be released when there are complete resolutions of symptoms (temperature
returns to normal for more than 3 days, respiratory symptoms are significantly relieved)
RT PCR and antibody test is negative on two consecutive occasions (sampling interval
≥ 24 hours).
Level of evidence : IV
Participants vote : agree: 94%, disagree: 6% (super majority, strong consensus).
Orthopaedic Surgeons Are Good Chefs and Readers
Spending lots of time with the wife and kids (44%), helping them in the kitchen (42%),
and cleaning and home making (56%) proved that orthopaedic surgeons were the best
for their better half. Reading books and journals (70%), watching movies and entertainment
channels (48%), yoga (8%), going to gyms and bodybuilding (9%), playing golf, gardening,
and playing with the kids were the activities they did to spend their quality time
during the lockdown ([Fig. 22 ]).
Fig. 22 Utilization of time apart from normal schedule during the lock down.
Surgeons Are Not Sprinters
Treadmills (22%), cross trainers (8%), Zumba (3%), You tube exercises (15%), workouts,
jogging, bike riding, limited outdoor running, and meditations were performed during
the lockdown as their cardiac and physical fitness measures. More than 50% stayed
within the home, fearing not to get injured while running/jogging, but utilized the
best available time in their interests.
Orthopaedics Surgery and Allied Subspecialty Meetings
Fifty-nine percent of the surgeons favored virtual webinars and limited meetings,
and 12% favored webinars only. Interestingly, 23% of the surgeons prefer normal meetings
at the conference venues because they take pleasure in face-to-face meet and like
the real-time happenings. Zoom Tm (66%), webinars (40%), Facetime (16%), Skype Tm
(20%), Google Chat/Duo Tm (17%), WhatsApp videos Tm, Microsoft Teams Tm, Hospital
software, and Halo app were the preferred tools for their virtual meetings during
the lockdown ([Fig. 23 ]).
Fig. 23 Orthopedics surgery and allied subspecialty meetings.
Rationale
Virtual learning through webinars, meetings, and online lectures helps participants
in various ways; they can record and reproduce the events, can access and share images,
and feel at ease in attending during the work and other schedules.[54 ] It has no personal face-to-face contact, economically productive, and more viable
than the real conferences.[61 ] Video-based education promotes surgical training by providing audiovisual contents
on indications, preoperative work-up, OR settings, operative techniques, and postoperative
care.[62 ]
Recommendations
Limited meetings and online webinars are useful resources to implement surgical education
in the COVID-19 era.
Level of evidence : V
Participants vote :agree: 94%, disagree: 6% (super majority, strong consensus) (95% CI 88 to 97).
Ethical Considerations
Although teleconsultation and virtual meetings have been much improvised to provide
better health care, the physician–patient relationship which has been the existing
norm for millennia, such as meet and greet, gentle and tender examinations, and shared
decision-making, seems to have vanished in the COVID-19 era.
Surgeons who were saviors in eradicating pain and disability have now become warriors
against the pandemic disease. He may not be allowed to do his best for his patients
and at times he may be compelled to say no to many things in his practice and incontrovertibly
treat few of them conservatively. COVID-19 has put the orthopaedic surgeons in a censorious
and interpretive position where they have to protect themselves and their family members
from viral transmissions and at the same time have to actively indulge in his profession.
Few of the surgeons have been terminated from the job and their positions, which imposed
significant psychological and financial burdens.
Mandatory Check in for Orthopaedic Surgeons
Awareness of the current and projected COVID-19 cases in the local community and country.
Regular and frequent reporting to the concern local authority.
Making an adequate supply of PPE, medical gases, drugs, and essential stocks available
at the practice location and in the country.
Staffing and paramedical technicians’ availability. Duty roster and shifts.
Medical officers/ambulatory service location capacity.
Testing centers in the local community/region.
Health and age of each individual patient and their risk for severe disease.
Level of evidence : V
Participants vote :agree: 97%, disagree: 3% (super majority, strong consensus) (95% CI 92 to 99).
Protecting Yourself and Others from the Spread of COVID-19
Regularly and thoroughly clean your hands with an alcohol-based hand rub or wash them
with soap and water.
Maintain at least 1 meter (3 feet) distance between yourself and others. Avoid going
to crowded places.
Avoid touching eyes, nose, and mouth. Make sure you and the people around you follow
good respiratory hygiene. This means covering your mouth and nose with your bent elbow
or tissue when you cough or sneeze. Then dispose of the used tissue immediately and
wash your hands.
Stay home and self-isolate even with minor symptoms such as cough, headache, and mild
fever, until you recover. Have someone bring you supplies. If you need to leave your
house, wear a mask to avoid infecting others.
If you have fever, cough, and difficulty breathing, seek medical attention, but call
by telephone in advance if possible and follow the directions of your local health
authority.
Stay up to date on the latest information from trusted sources, such as WHO or your
local and national health authorities.
Level of evidence : V
Participants vote : agree: 97%, disagree: 3% (super majority, strong consensus) (95% CI 92 to 99).
