Introduction The objective of this study was to examine the relationship between trauma volume and alcohol prohibition during the COVID‐19 lockdown in South Africa. Methods This was a retrospective analysis of trauma volume from Worcester Regional Hospital in South Africa from 1 January to 28 December 2020. We compared total volume and incidence rates during five calendar periods; one when alcohol sales were allowed as per normal and four when alcohol sales were completely or partially banned. Poisson regression was used to model differences between alcohol ban and non‐ban periods. Results During the first period (pre‐COVID‐19, no ban), the trauma admission rate was 95 per 100 days, compared to 39 during the second period (complete ban 1), 74 during the third period (partial ban 1), 40 during the fourth period (complete ban 2) and 105 during the fifth period (partial ban 2). There was a 59–69% decrease in trauma volume between the no ban and complete ban 1 periods. When alcohol sales were partially reinstated, trauma volume significantly increased by 83–90% then dropped again by 39–46% with complete ban 2. By the second half of 2020, when alcohol sales were partially allowed again (partial ban 2), trauma volume increased by 163–250%, thus returning to pre‐COVID‐19 levels. Discussion and Conclusions Our study demonstrates a clear trend of decreased trauma volume during periods of complete alcohol prohibition compared to non‐ and partial alcohol bans. This finding suggests that temporary alcohol bans can be used to decrease health facility traffic during national emergencies.

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In March 2020, the World Health Organization declared a pandemic due to the rapid spread of COVID-19, a disease resulting from a novel coronavirus, SARS-CoV-2. South Africa (SA) has had more than 1 million cases, more than half of the COVID-19 infection on the African continent. [1] The first COVID-19 case in SA was on 5 March 2020. In preparation for the anticipated upsurge in cases, a national lockdown began on 27 March, which closed all borders, schools and large gatherings. All persons were required to stay at home if not involved in essential activities. Because COVID-19 is an acute respiratory syndrome, some patients with severe disease have required ventilator support and intensive care unit support. In order to prepare hospitals for the COVID-19 surge, health facilities reduced non-essential activity, such as elective surgical care. [2] A 2020 national survey of SA surgeons reported that >90% of hospitals cancelled or reduced elective procedures in April. [3] Modelling studies have estimated a national backlog of ~150 000 surgical procedures, but studies reporting primary data on operative volume are lacking. [3,4] ObjectivesThe primary objective of this study was to estimate the surgical backlog due to the COVID-19 pandemic in Western Cape Province, SA, by comparing 2019 and 2020 elective general surgery operative volume at six district and regional hospitals. The secondary objective was to compare the operative volume of appendicectomy, laparoscopic cholecystectomy, cancer and trauma between the 2 years. Methods Design and settingThis was a retrospective study of general surgery operations from six SA government hospitals in the Western Cape. Data were obtained This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

Strengthening and defining the role of rural hospitals within a surgical ecosystem is essential to improving quality and timely surgical access for rural people in low and middle-income countries (LMICs). Regional hospitals are the cornerstone of LMIC rural surgical care but have insufficient human resources and infrastructure that limit the surgical care they can provide. District hospitals are most accessible for many rural patients but also have limited surgical capacity. In order to surgical access for rural people, both regional and district hospital surgical services must be strengthened. A strong relationship between regional and district hospitals through a hub and spoke model is needed. Regional hospital surgeons can support training and supervision for and referrals from district hospitals. Telemedicine can play a key role to leapfrog physical barriers and surgical specialist shortages. The changing demographics of surgical disease will continue to worsen the strain on tertiary hospitals where most subspecialists in LMICs work. The fewer rural patients who need to travel to urban referral and tertiary facilities for problems that can be managed at lower-level facilities, the better access to timely surgical care for all.

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Background. There are limited published data describing surgical admissions at a regional hospital level in the South African (SA) context. Objectives. To retrospectively review data from an electronic discharge summary database at a regional SA hospital from 2012 to 2016 to describe the burden of surgical disease by analysing characteristics of the patients admitted. Methods. All discharge summary records for the 4-year period were reviewed after extraction from a database created for the surgery department. Admissions were classified into 5 types: (i) elective surgery or investigations (ESI); (ii) trauma; (iii) burns; (iv) non-traumatic surgical emergencies (NTSE); and (v) unplanned readmission within 30 days. Other variables reviewed were demographic data, the International Statistical Classification of Diseases and Related Health Problems -Version 10 (ICD-10) diagnosis; area of origin; and outcome (death, tertiary referral, discharge). Data were subgrouped into 12-month periods to facilitate trend analysis. Results. Discharge summaries (N=9 805) over the 4-year study period were assessed and 9 799 were included in the analysis. All data were entered by the attending medical personnel. A total of 5 647 male patients (57.6%) and 4 152 female patients (42.4%) were admitted, with a mean age of 43.3 years (95% confidence interval (CI) 43.0 -43.8) and a mean length of stay of 4.9 days (95% CI 4.7 -5.1). Male patients comprised a larger proportion of trauma (83.7%) and burn (63.9%) admissions. The mean length of stay ranged from 3.5 days for elective patients to 9.1 days for burn patients. The most common diagnoses for emergency admissions were appendicitis, peripheral vascular disease and peptic ulcer disease. Common diagnoses for elective admissions were gallstone disease, inguinal hernia, anal fistulas/fissures, and ventral and incisional hernia. The most common cancer diagnoses were of the colorectum, oesophagus, breast and stomach. The overall mortality rate was 2.2%, and highest by subtype was burn patients (6.3%). Trend analysis showed a statistically significant increase in admission for NTSE (p=0.019), trauma (p<0.001) and 30-day readmission rates (p<0.001), with a decrease in admissions for ESI (p=0.001) over the 4 years. Conclusions.A precise understanding of the burden of disease profile is essential for national, provincial and district budgeting and resource allocation. Ongoing surveillance such as that performed in the study provides this critical information.

To the Editor: Specialist outreach is a strongly promoted strategy for improving the access of rural populations to specialist care. However, the provision of outreach diverts specialist services from their base hospitals, and places services at those base hospitals in jeopardy. In the under-resourced South African context, it is necessary to monitor and evaluate outreach services to see whether they add value to the health service.

This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.