COVID-19 is a defining global health crisis. Understanding how spine surgeons around the world prepared for, and responded to, COVID-19 will help guide response to future pandemics. Louie et al. [27] highlighted, in over 900 spine surgeons worldwide, that COVID-19 had a substantial impact upon their patient care, practice, and personal lives; however, such impact varied. As such, our goal was to outline whether previous experience with outbreaks/pandemics played a role in surgeons’ preparedness, response, and perceptions. Interestingly, based on survey results, surgeons felt generally underprepared for a pandemic of this magnitude. The WHO and other global health experts have prioritized learning from previous health crises, yet our study noted that regions with previous infectious disease outbreaks were no more prepared to respond to COVID-19. Our study further outlines that previous measures of global health security were not predictive of preparedness or minimized impact.
Impact of previous epidemics on preparedness
The COVID-19 pandemic is neither novel nor unexpected. During the twentieth century, there were three major pandemics that ravaged the globe: the H1N1 Spanish flu of 1918, the H2N2 Asian flu of 1957, and the H3N2 Hong Kong flu of 1968 [37]. Since 1968, only the HIV/AIDs outbreak spread across the globe and has had widespread impact on healthcare workers [38]. The more recent epidemic level outbreaks of SARS in 2002, H1N1 Swine flu in 2009, MERS in 2012, and Ebola in 2013 provided certain regions around the world with an early opportunity to prepare for deadly infectious disease outbreaks [11, 12, 17, 18, 39,40,41].
Our survey indicates that respondents who indicated prior experience with the SARS, MERS, H1N1, and Ebola outbreaks were no better prepared to take on the COVID-19 pandemic. This likely indicates that countries around the world have struggled to change government and hospital policy based upon prior experiences. Limitations in access and availability of testing have been cited as a major shortcoming in the media [42, 43]. Our results indicate that access to testing is no longer a major limitation for surgeons, with over 82% of surgeons reporting access to a COVID-19 test. However, only 6.7% of surgeons around the world reported actually being tested. Surprisingly, 5.5% of respondents with prior epidemic experience reported being tested compared to 7.2% of those without prior epidemic experience. This gap between testing availability and completed testing indicates that universal testing of healthcare workers is not occurring.
Numerous health departments across the world have outlined that formal local and institutional guidelines are critical for pandemic preparedness [44,45,46]. In 2009, the WHO reported that many countries around the world were in the process of forming a pandemic plan, but no standard pattern in content or timing was in place, and many countries were waiting for WHO to lead with their own plan. The WHO warned that without regional or global leadership on formal pandemic plans, preparedness could diverge even further across the world [46]. In our study, a surprisingly low 60.4% of respondents reported that formal hospital guidelines for pandemic response were in place. This number only marginally increased to 64.2% among respondents with prior epidemic exposure but did not reach statistical significance. Clearly, formal institutional guidelines should have been a priority among all hospitals prior to the outbreak reaching pandemic proportions.
Another preparedness deficiency was access to personal protective equipment and other critical hospital resources. The media in the USA and across the world highlighted the critical lack of PPE that frontline healthcare workers faced in the early days of the COVID-19 outbreak [7, 8, 47,48,49]. While many respondents felt the media was sensationalizing the outbreak, our study indicates that the critical shortage of PPE is real with only 49.6% of respondents reporting access to adequate PPE. Even in regions with prior health crises, the availability of PPE was not significantly improved. Another key resource limitation facing health systems during this pandemic is the ventilator shortage. Not only are physicians facing the possibility of difficult decisions surrounding allocation of ventilators [50, 51], but operating room anesthesia machines are being reallocated to intensive care units (ICUs) closing operating rooms (ORs) for surgeon use [52]. An alarmingly low 41% of respondents reported adequate ventilator supplies, and access to ventilators was not improved by experience with prior epidemics. Clearly, a need exists for larger stockpiles of these critical resources that can be mobilized during global pandemics.
Overall, respondents from countries with previous infectious disease outbreaks did not report improved government or hospital-level preparedness. This indicates that health systems and governments likely failed to learn from prior health crises or did not dedicate the time, resources, or manpower to strategic planning. Regardless of these prior oversights, there is now a major need to come together and prepare for future pandemics.
Impact of previous epidemics on COVID response
In the early days of COVID-19, there were a variety of responses to the growing threat spreading across the world. China instituted a swift government-mandated lockdown of Wuhan in the Hubei Province in an attempt to slow the spread [53,54,55]. South Korea quickly implemented a widespread testing initiative that helped to isolate cases and prevent a prolonged nationwide lockdown [56, 57]. Both of these nations had previous experience with SARS, MERS, and other infectious disease outbreaks and had instituted national policies allowing for rapid approval of testing in the face of new disease outbreaks [58]. Prior experiences likely guided the response to, and impact of, COVID-19.
Surprisingly, the government and hospital restrictions instituted around the world were fairly consistent. Respondents reported high rates of government-mandated cancellation of elective surgeries, mandatory stay-at-home orders, limitations on group gatherings, and closure of businesses and schools. A few subtle differences were noted. Respondents who indicated prior experience with infectious disease epidemics reported being placed into quarantine at a higher rate after exposure to COVID-19. This may be because these governments had prior experience with quarantines and were willing to swiftly institute mandatory isolation.
Hospital-based restrictions were also remarkably conserved across the world. There were high rates of travel bans, cancellations of academic activities, cancellations of hospital meetings, and work-from-home orders. Interestingly, prior epidemic experience was an independent predictor of still performing elective spine surgeries. The significance of this finding is unclear, given that epidemic experience was not predictive of preparedness.
Overall, surgeons appear to be somewhat dissatisfied with their governmental and hospital responses. A total of 58.5% of respondents reported their government’s response as “acceptable,” while 27.6% rate their government’s action as “not enough.” Satisfaction rates with hospital responses are similar with 61.4% of respondents rating their hospital’s response as “acceptable,” while 27.7% rate their hospital’s action as “not enough.” Respondents with prior infectious disease epidemic experience did not rate their government or hospital response any better. A moral and ethical obligation exists to improve our ability to respond to future crises.
COVID-19 and spine practice across the world
Government and hospital policies in response to COVID-19 are impacting spine practices across the world. Over 67% of respondents reported a greater than 75% decrease in their weekly case volume. This reduction in volume has led to significant economic concerns among surgeons [59]. Nearly 70% of surgeons reported a reduction in income from the current COVID-19 crisis. However, having prior experience with epidemics did lead to a significant decrease in rates of reported income loss. This may be confounded by the fact that most countries with prior epidemics utilize government run health systems.
Apart from economically impacting surgeons, the COVID-19 pandemic has financial implications for all healthcare staff. In this study, 40.5% of respondents reported having staff furlough at their institutions, with 8.8% reporting layoffs. Unfortunately, having prior experience with infectious disease epidemics did not protect against these financial effects. This point highlights the need for comprehensive government policies that prevent these economic impacts, rather than reacting to them.
Does the global health security index accurately predict impact of COVID-19?
The GHSI is the first comprehensive assessment of health security and pandemic preparedness across 195 countries [20]. The GHSI provides a ranking by overall pandemic preparedness, early detection capabilities, and ability to mitigate a health disaster. The goal of the GHSI project was to use data obtained from prior disease outbreaks to improve the international capability to address pandemics [21]. Our survey results indicate that the GHSI was poorly correlated with COVID-19 preparedness and surgeons’ perceptions on response. Countries such as the USA were rated as “most prepared” by the GHSI yet were not adequately prepared based on our survey. China, a country rated as “more prepared” with a low GHSI of 48.2, had similar access to PPE and critical resources as the USA.
The poor performance of the GHSI may indicate that traditional methods for assessing pandemic preparedness are faulty, or COVID-19 did not follow the patterns established by previous infectious disease outbreaks. Either way, we have an ethical and moral obligation to learn from the current situation to revamp the ways in which we prepare for pandemics and the way we assess pandemic preparedness. Improvements in global coordination and cooperation have the potential to lessen the impact of infectious disease outbreaks, not only on surgeons, but on all of humanity.
Limitations
As with many questionnaire-based studies, there are limitations to this study. The survey distribution was limited to the current AO Spine surgeon members network. The survey was sent out to 3805 spine surgeons worldwide; however, only 902 surgeons responded (23.7%). This may introduce a response bias because individuals with strong opinions may be more likely to respond. Previous studies have described that low response rate is a risk factor for low validity, but does not necessitate low validity [60]. Response rates are important to consider, but, independently, should not be considered a proxy for study validity.
Our study lacked the power to break down responses by individual country. Therefore, certain countries may have adequately learned from previous epidemics, but their response is diluted by the many others who did not. We attempted to control for this by using geographic region in our multivariate analysis. However, there may be questionable generalizability in regions in which there were few or no respondents. The timing of the survey may have also impacted our results as countries around the world were at different stages of the pandemic when they received the questionnaire. Given the limit of survey length due to fatigue, we were not able to explore all of the possible domains related to COVID-19.
Finally, our targeted demographic was AO spine surgeons. This is one group of subspecialty surgeons, and the results may not represent the view and concerns of other medical specialties. However, given that COVID-19 is impacting all healthcare providers around the world, we feel spine surgeons are reasonably representative of other surgical providers. We are unable to comment on COVID-19 preparedness or impact for the general public. Despite these limitations, this survey remains the largest, international effort to assess multiple domains of the impact of COVID-19 on spine surgeons.