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Ok, thank you. Thanks. Ok, good afternoon, everybody. Uh Today, uh our medical officer, Doctor Kita Sally is going to talk about COVID-19 and pediatric surgeon. It's a disease we only know for about a year and we pediatric surgeons have sketchy knowledge about this issue. So we thought it was better to just discuss it and to give her input and advice. We have uh our invited guest today is Doctor Hers Lot. She is a pediatric infectious disease specialist at Fre Hospital in East London. Uh She also runs the HIV and the TB Clinic for Children. She was trained in general pediatrics and in pediatric infectious diseases at a Red Cross Hospital in Cape Town. And she enjoys teaching undergraduates and postgraduate students. So I will request now doctor uh Corita Sally to give her presentation and then we will ask Doctor Lotion to give her advice. OK. Q go ahead. You can share your screen. OK. Two, sorry, I forgot to unmute myself. Uh just uh enlarge it. Yeah, that's great. You can start. OK, fine. OK, good afternoon everybody. I just have a um short presentation today on COVID-19 and the pediatric surgeon. Um We're going to have a quick introduction, going to look at the consequences of this pandemic and we'll um have a look at some data and outcomes as well. And then lastly just some take home points. Yes. So as we are all well aware by now, COVID-19 has changed the face of medical and surgical care as we know it. Um from the beginning of this pandemic, routine clinics have been closed and elective surgeries have also been suspended. Um All of these measures were basically put in place to mobilize funds for fighting COVID-19 and also to reduce the hospital transmission. Um So these efforts have resulted in a backlog of our elective procedures and of elective procedures across the globe. Um in resource constrained countries such as ours, this has led to an overwhelming compounded effect in an already overburdened health care system. So, data from 193 countries over a 12 week period during the pandemic has shown um an elective surgery cancellation rate of more than 72%. Needless to say the delay in surgical intervention may also result in increased morbidities and complications to outpatients. Um on the flip side to all of this um is that when patients do in fact need to seek medical care, um for example, when they have been discharged and given a followup date or just if they need to present into hospital um with an illness, the misinformation and clear pandemic and of the virus may also lead to apprehension about going to hospital and in doing so may hinder their health seeking behavior as is evident to all of us. Um Abdominal surgeries are still required during this pandemic. Uh Some centers have adopted a conservative approach to managing um acute appendicitis. For example, uh in certain centers in New York Barovsky et al reported that more than 45% of kids who were, in fact COVID-19 positive received conservative management for acute appendicitis. Um Jones et al has concluded positive results with conservative management of appendicitis in both adults and kids. Um Having said that part et al reported that treating acute appendicitis conservatively may actually lead to an increased number of complications. 1 may presume that in more developed countries um presentation of appendicitis happens much earlier compared to countries such as ours. And this could be why um they have managed the conservative management approach um as it may be a little bit more acceptable in certain centers when compared to South Africa, other health facilities have shown a substantial drop in appendicitis altogether during the lockdown period. In particular, the reason for this um remains unclear although one can postulate that it is a result of reduced exposure to pathogens due to the hand washing mask, weeding and everybody observing social distancing. Um It is important to note that the impact on pediatric surgical practice is significant even though the pediatric population is much less affected by COVID-19 when compared to the adult population. So in the States, it was found that asymptomatic COVID positive kidney had a low risk of postoperative, adverse complications. And one can therefore extrapolate that surgical procedures are safe within this demographic bearing in mind. Obviously that healthcare workers still need to take precautions when treating these kids. Um Evidence from adult data has shown that laparoscopic procedures are also safe for healthcare providers um when patients are COVID positive and also in PS provided that the necessary anesthetic and PPE precautions were taken into account. Symptomatic COVID positive adults who underwent surgical procedures did significantly worse than the asymptomatic counterparts. Um Evidence in the asymptomatic adult patients showed an increase in pulmonary complications and other morbidities within the 30 day POSTOP period. So it's not really completely understood why kids and adults who are COVID positive have different post-op outcomes and respond differently to the virus. There is a belief that it may be due to the reduced age. Um A lower A SA classification and the absence of symptoms or comorbidities. Um All of these factors may be working in favor of our kids like evidence of these speculations. Um The evidence is however lacking. Um Another kid hospital looked at deferring emergent operations, namely acute appendicitis due to a positive COVID-19 result. And here it was actually found that there was in fact, failure of medical management of appendicitis among more than 55% of study participants over a five week period. Um And these failures ultimately resulted in longer hospital stays, longer, antibiotic requirements and numerous interventional radiological procedures for infection control. So currently, there is insufficient data and way too few studies to provide comprehensive guidelines for surgical practice in the pediatric or adult population for that matter. Um During this COVID-19 pandemic, um most centers are deferring elective procedures, emerging conditions such as acute appendicitis, however, seem to warrant surgical intervention rather than conservative management. Another effect of this pandemic that often gets overlooked um is the emotional and behavioral responses that have resulted. Kids have displayed an array of signs and symptoms, displaying these stresses as a result of the pandemic. It is important to note that these displays will obviously be age and context dependent. So, infants and young kiddies may develop issues with feeding, sleeping incontinence. They may become irritable and display regression in their milestones. Older Children may develop anxiety, become fearful or ultimately withdraw or they may develop issues with aggression and get into trouble at school or with their peers. They may also present to us healthcare workers with um symptoms of vague abdominal pain or headaches. In most circumstances, sensitive and caring family members and friends may be all those needed to guide kids through these tumultuous times in more severe cases. However, where daily function is negatively impacted, they may need more specific and specialist intervention. It is important to note that kids are often an indication as to how things are at home. Often very stressed. Kids are reflecting the emotional state of the homes they are being raised in. One can imagine, for example, the financial stresses of a parent who has lost their income as a result of this pandemic may very well be the reason the kids in the home are showing emotional and behavioral changes. So this coupled with the vast number of personal changes within their lives such as homeschooling needing to deal with and adapt to online teaching, not getting to interact with their peers and friends. All of these factors may lead to overwhelming stress in a kid, resulting in um emotional and behavioral changes then becomes imperative that we remain on the lookout for warning signs in our kids and for us to then refer them appropriately for additional support. Ultimately, we need to identify potential issues early on and facilitate resilience to being present, empathic nurturing as parents and also as healthcare providers. So then just some um some reminders and take home points. I think it's important for all of us as healthcare providers to acknowledge the impact of COVID-19. Um Initially, when I said that line, I um obviously intended for us to be aware of the impact of the pandemic on our patients. But I think um it's also important for us to understand the implications of the effect of the the pandemic on our patients families and on ourselves and on our colleagues as well as the effect is um far reaching. And I think it's, it's more the impact of, of COVID-19 is more widespread than, than we are anticipating. Um as mentioned before, comprehensive guidelines for best practice are still pending. Um We need to identify and recognize that the kids we are seeing, they are actually a yardstick for their families and their family situations. So as healthcare providers for these kids, we need to be watchdogs for the stresses and or signs and symptoms of the stresses that they are experiencing. And we also need to counsel parents and enable them to help build resilience within these kids going forward. Thank you. So, as I said, it was short. Um but yeah, just gives us a overview. No, thank you. K I think uh uh we knew that our knowledge is limited and uh we just wanted uh like a pilot presentation uh to get more uh advice uh especially from Doctor Lotion. So it's a nice, very nice presentation short and concise. Thank you. If you can stop sharing your screen, then uh I will request Doctor Lotion to share her screen. Yeah. Ok. Harsha. You can share your screen now, please. Oh, um can I stop? You can start. Thank you. So we can see the topic is not very uh creative. Um but that's what I was asked to speak on is COVID-19 and pediatric surgery or the pediatric surgeon. Um Thank you uh Kita for your talk. I think it actually brought up quite a few points about the other other effects of COVID-19 on patients and families as well. I'm going to take a slightly more clinical approach to COVID-19 and pediatric surgery and um, yeah, hopefully it will just bring up or any questions at the end, we can go through at the end and there is very, as you know, appropriateness has mentioned, there's not a lot of literature at the moment regarding specifically surgery and COVID-19 and outcomes as well. Um But I'll go through a few medical related problem. Um Well, conditions with surgery. Ok. So by way of introduction, a almost a year ago, the world changed forever. Um It's the new norm at the moment. Um and we've also seen in the last year, an overall num decrease in the number of pediatric hospital admissions across the world, not just in South Africa with the heart lockdowns in all the countries. I think pediatric admissions, whether it was medical or surgical dropped by at least a third, sometimes even half. Um electrosurgery as you all know, was canceled. Um and we also had a reduced number of Children presenting with other respiratory viruses to the medical uh facility to on the medical side as well. And as a result because of lockdown, you've had delayed presentation of very ill Children. So by the time they actually got to us, they were extremely ill. Um when we could have picked them up a lot earlier, had they been seen at the clinics for their routine visits and um, immunization visits. So, COVID-19 in Children, um, I mean, lots of the reports are showing us that fewer Children are infected with the virus than adults. And there's lots of, lots of hypotheses why that is. So, they also tended to have milder disease. Um, and in South Africa and actually even across the world, Children less than a year of age were actually found to have a higher number of hospital admissions than the older Children. And I'll show you some graphs in the next few slides. Um Majority of some Children were also asymptomatic. So they were tested but actually had no symptoms that we know of and transmission was actually mostly through family members and obviously through gatherings now that schools, uh well, not really schools but through family gatherings as well. Ok. So this is South Africa. As of last week, we had nearly 1.5 million cases. Um And the incidence risk was about 2500 um per person. So mean age of infection was actually 40 at the um through this year. So this is through the whole pandemic starting last year, March. So each, each number is a epidemiological year which correlates to a calendar year and you can see it very nicely demonstrates the first and the second wave which well weeks 25 to about 33 would be our June, July peak. And then obviously, and now during the December, January peak and the eastern cape initially was quite high in the 1st 1st wave and we peaked very early. We peaked much earlier in the second wave than K ZN or the Western Cape did Children. Um I mean, even though, you know, this graph is probably taken into account the 1st and 2nd wave because in the first wave, we saw mostly older patients over sixties been been infected and hospitalized. And then with the second wave, it was actually the younger age group. So down to about the thirties to 40 year olds and Children still made up quite a small percentage of, of the overall number of um infections that, that um, that we found. Ok. So if we look at different age groups and um what it showed there's actually still Children were still very much lower in number than your adults and over 19 years of age. So the N ID actually extra um um breaks it down into under 19 and over 19 years of age when they're looking at their pediatric and adult population. Ok. So just in Children in general, we, if you look at the 1st and 2nd wave numbers were much higher and I don't know if that was because of increased testing, increased awareness or, and we just had more infections in the second wave as well. It hit us quite, quite hard come December so you can see almost 1.5 times the amount of kids infected in the second wave and that was across the age groups. Ok. So this was also a breakdown by age. So if we just ignore the orange line, which is a 15 to 19 year old, you'll see that the under ones which is a kind of lighter red really were the higher number of admissions, hospital admissions, um, that, that you can see. So, I mean, if we don't count pediatrics as 15 years, we actually the under one year olds were, were quite, were, were quite sick when they did come in. Um, the number that died was actually only about 3% of the total number of patients, um, that died in the country, which is not a lot, but it still is a fair number. So it was 100 and 52 as of the end of last year and quite a few of them actually had underlying conditions, although it isn't really been associated with the risk factor to have an underlying, um, um, illness and HIV definitely didn't come up in this in when they looked at the data. Ok. So in, um, frea I just very briefly looked at the numbers because I've been keeping some data from when we started, um, seeing kids last year and we've only had about 23 Children that were PCR or antigen positive. And of, and yeah, we've tested about 250 I think in the last year, 20 of those were admitted to the hospital. This is just very rough numbers. There's nothing. Um, yeah, I just quickly looked at whatever I had. Um, two Children were antibody positive and actually presented with other illnesses and three unfortunately did pass away and most of them actually had respiratory symptoms. And I think there was one pediatric surgery patient towards the end of last year, that was admitted with appendicitis. So the clinical presentation is really respiratory symptoms, um, gastrointestinal symptoms, neurological symptoms, we're not quite sure whether they're related or not. And then it's multisystem inflammatory syndrome in Children, which I'll talk a little bit more about in the time in the following slides. So Tygerberg Hospital did actually quite a good review of all their patients admitted. They had quite a large number because Cape Town was obviously the epicenter in the first wave. Um So they, the Western Cape saw a lot more Children admitted than the rest of the country did. And they actually looked mostly at the respiratory infections and a lot of them, you know, majority of the kids presented with cough fever, sore throat and you know, features of pneumonia as well. There were a few that had diarrhea and vomiting and I think they probably will be presenting more of the data on the other non respiratory aspect of COVID as well. So what happens in surgical patients? So the only study I could actually find really on looking at just ran, you know, universal testing preoperatively was a study from the US and it was just looking at three pediatric hospitals. Um and they, they did preoperative screening and universal testing for total of 1295 patients. And they found less than 1% of them were actually COVID positive. So there were 12 positive patients and half of those had symptoms um compared to 100 and 57 who had symptoms but actually tested negative. So it's also difficult to know, you know, the timing of the test and and also the quality of the test as well. But most of the symptoms were mainly fever, rhinorrhea and those that had a known exposure to somebody with COVID-19. So the incidence is low, but as I said, some patients may have actually been missed and Children probably only have mild symptoms. So they didn't actually give an outcome of what happened to these Children once they had their surgery or what was their, their surgical uh problem. So the multisystem inflammatory syndrome in Children was first identified in April 2020. And report is coming out from the UK Children presenting with the sepsis like syndrome looking like Kawasaki disease. Um The USA sh followed shortly after and if you remember those were when those two countries and also Italy and Spain also reported cases as well is when those Children, you know, when they were actually probably at their peak or kind of tailing off the first, the first wave. Um It was mostly older Children, so older than 78 years of age adolescents and they presented with fever hypertension, abdominal pain and some and cardiac dysfunction. Very few had respiratory symptoms and they all, almost all of them had a history of either current or past um SARS COV two infection. So there's some publications that have come out and South Africa also published from the Cape Town Group. They did publish a series of about 20 odd kids, but I think they've got quite a few more now that they will be hopefully publishing soon. So there is an overlap between bacterial sepsis and which mainly could be staphylococcus or streptococcus toxic shock syndrome and your Kawasaki disease. So we very rarely see Kawasaki and some of the clinical features are similar to the fever, the mucocutaneous manifestations. The they have edema of the hands and feet, the rash. Um they have cervical nodes and they, but the main, the whole, well, one of the main features of Kawasaki dis um disease is actually the cardiac manifestations. So they in they can have aneurysms of their coronary arteries. Um So with, yeah, with your M isc, your primary infection may not actually be the cause as patients are often presenting much later. Ok. And it's thought to be due to a host immune response against the virus. Ok. So this was from one of the journals that actually looked at a or a hypothesis as to why we're getting this sort of multi inflammatory syn syndrome. And it is, you know, as part of the whole SARS infection and with adults, as well as they, it's a cytokine release syndrome. So basically, you get infected, you have a viral load, your immune system gets mobilized, you start releasing cytokines, chemokines that drives the inflammation tries to actually clear the virus. Um if you have a low viral load or you're not, you know, you're not, you're not as severely affected, you can actually clear the virus quite easily. So there's less inflammation happening and you end up having mild disease. But in some, some patients and due to genetic factors as well, they have a high viral load. And so if you have the higher viral load, the more exaggerated your immune response actually is and therefore you have a better or you have a much, much greater ig antibody mediated response, interferon gamma and your and interleukin six as well. So that's why you can, that's then shows up a severe disease. And it's also thought that the virus may be replicating in the intestinal tract, which could then explain the abdominal symptoms that a lot of these Children are presenting with. Ok. So there's a few studies that have looked at surgical presentations and then subsequently been diagnosed with multisystem inflammatory syndrome. These are mostly case series. They, there's very, there's no randomized controlled study at the moment. But in New York they looked at so 44 patients who were diagnosed with M IC, they were all SARS COVID anti, well, almost all were CO COVID antibody positive and almost nine, well, 95% of them had gi symptoms on admission, mostly abdominal pain and then vomiting. Um They, this paper actually just described two of the cases where one present, one child presented with an appendicitis and the other, well, clinically thought it looked like an appendicitis and the other with probably of an ovarian cyst. And when they did further examinations, they actually found there was no surgical intervention necessary and it was just abdominal uh abdominal inflammation and sepsis. And both these kids responded to steroid therapy quite well. This was a Tygerberg study um where they had four Children, all, oh, sorry, all with acute appendicitis, all PCR positive. Um All four kids actually went to surgery and they did find clinical evidence of appendicitis. But because of the uh very high inflammatory markers and the sepsis like syndrome, they, they were actually labeled as M IC as well with appendicitis. And then a study probably but earlier on in the whole pandemic from Spain where they described five Children who presented with an acute abdomen or abdominal sepsis. And when they also did further imaging, they, it showed that there was inflammation of the intestine without any surgically treatable disease. Ok. So M IC has actually become a notifiable condition in South Africa. I'm not going to go through this whole slide. We look at all the, we look at some of the um criteria in the next slides. So you know, if we do diagnose it and there are some criteria to diagnose it, we need to notify them. So the wh O based on all the evidence from different countries and the CDC as well came up with six, well set out six criteria. So it's obviously the age. So we're looking at under nineteens, although there have been a few adults in their twenties which have been described as having similar presentation fever has to be present and definitely at least for about three days. And in terms of the multisystem involvement, you need two of any of the following. So either the rash or the conjunctivitis, it could be in shock. They may not actually have hypertension, they may not, they may or may not have cardiac dysfunction. Um they may or may not have coagulopathy and the acute gastrointestinal symptoms seem to be present in a lot in quite a few of the studies. And quite a few of the papers that have been written, there's also got to show evidence of elevated markers of inflammation, including your ES RP CT high ferritins. If we have access to interleukin six levels, we can do them, but we actually don't hear and I don't actually think many centers, it's probably just a research test that they're doing and there's gotta be no other reason why they're presenting looking like they're in, in, in shock or having septic shock. So, in other words, we've excluded a bacterial cause. They don't have, you know, your blood cultures have not flagged positive. And we've got to show evidence of SARS COVID two infections. So either serology antigen testing or PCR testing and, or they have a contact with an individual with COVID-19. So that's just pic, what they could look like. Um There's these are all available on the critical care website um under the pediatric section and there's actually quite a good guideline there on M IC. So I'm not gonna go through in detail treatment options, but this is what you actually need to look out for. So it is good to discuss these patients that you're not sure about. And po possibly we may have, you know, had a few Children with abdominal pain that don't actually present to the medical side and will present to the surgeons. So whether those were missed, missed uh pre um COVID infections or, you know, could have and COVID as well. Um we don't know, but you know, it's, they, they need anr support if they're hypertensive immunoglobulin has been shown to have good outcomes, although it's very expensive. So it's very, you know, you can't justify using it in everyone who we're thinking that it may be there. But sero therapy is a lot cheaper and it's difficult at the moment to look at a study comparing immunoglobulin and steroid therapy because we just don't have the numbers right now and maybe we'll see it now that the second wave is actually is, it's on its way when on its way out, we may actually see a few more Children presenting with these sort of symptoms and then antic regulation in the form of either heparin, low or low molecular weight heparin or aspirin. The biologic agents are also quite expensive and we tend not to use them unless it's been approved by either a rheumatologist or a sort of, you know, a high specialist. And we can prove that the other two agents are not actually working. So just very quickly on laboratory testing, just to decide which test you want to do when. And it depends on number one, the prevalence of the disease in the community which test you would choose and when you think you may have become infected. Ok. So we've got 22 tests available to us, which is the PCR and the antigen test. The antigen is obviously a quicker turnaround time. But if you the first line will demons is demonstrating the an the antigen test, you, you can really, it really has a good sensitivity and positive predictive value if you if you actually have a high viral load. So if you're at the tail end of your infection. Your antigen test may very well be negative but you may still have been infected with, with SARS COVID two. whereas your PCR can remain positive for quite a long way, quite a long way after you are infectious as well. So you may actually be asymptomatic and still have a positive PCR generally with the antigen test. You, you have some sort of symptoms, um because your viral load is high for you to have symptoms at that moment in time. Um It can't be used as a screening, should not be used as a pre you know, pre preinfective um test. Um whereas your PCR, you probably could use that although it may still be negative if you have not yet been infected. Ok. So just very quickly. So as I said, it's the sensitivity of the estrogen test is higher when the viral loads are higher. And that's usually in your first five days following symptom onset and definitely has to take into consideration prevalence of the disease. So if you have a positive result in a low prevalence setting, then you're actually not sure if this is a false positive. Ok. So you actually, you then need to test further, you need to then do a um repeat the te or repeat testing with the PCR. If you have a negative result in a high prevalence setting, and you've got a clinical suspicion that the patient has COVID, then you still also need to test, do a, do a follow up test as well. Ok. So just moving forward in terms of surgery and just staff in the hospital as well, we still need to keep protecting ourselves. So we need to prevent infections in ourselves. And that, you know, that includes social distancing or physical distancing when we're at home or in, in uh public spaces and continuing hand hygiene and the use of face mask. I put vaccines in in brackets cause it's a bit of a contentious issue at the moment. But yes, once that becomes available, we'll actually be, we should hopefully protect our staff as well. And then in, in the hospital itself and in theater is the appropriate use of your personal protective equipment, using our face masks, our visors gowns and gloves in theater and in the wards if needed as well when we're doing samples and nasopharyngeal samples and then symptom screening of all patients. So, you know, actually asking the question, yes, we know most Children will be asymptomatic but you know, if you have a suspicion that it could be or they've been in contact rather test them. OK. And remember the parents and caregivers are also there. So we're lucky, at least atreo we've been able to screen every patient and every caregiver that comes through the doors of the hospital. Um but that may not be around for, you know, for the rest of well going it. We don't know how long we're gonna be able to do all of that. So it's up to us as well to actually to actually screen our patients. Ok. Um And then also to reconsider the diagnosis in Children presenting with abdominal pain if there's no other convincing evidence of a surgical problem. So, you know, as I said, there is a temporal association between SARS COV two infection and M IC and we now are a month out of the peak, well out of out of wave two or getting out of wave two. And we may actually see Children presenting with abdominal pain that probably don't have a surgical, a surgical reason for it. Um Elective surgery is something I think that the pediatric surgery department has to decide when they would like to start. And it's is, you know, there's a lot of implications and a lot of planning as well around it. And, you know, I think most not currently, most things are happening as emerge emergency or semi semi emergent um cases and you don't want them to become emergencies if you can do them electively. Ok. So just in conclusion, so unfortunately, this infection will be with us for the near future. Um There are predictions of a third wave. We're not sure when that will come. I think it's probably gonna come sooner than they think it would. Children do have milder disease. Um But, you know, as the previous speaker mentioned, it's probably been disadvantaged the most during this pandemic as well. And just remember that COVID is not just a respiratory disease and we need to consider the M syndrome in older Children as well. Thank you. Aha. Thank you very much. I mean that is so excellent and I'm so glad that uh we invited you to uh to give this talk and and uh really you have told us uh all the clinical aspects uh including uh the relevant information from, from South Africa. So thank you very much. That was actually what was necessary for us. So I see there are uh we have our own consultants and I see, I think I saw Pro Lazarus was here. Um I don't know, uh is pro Lazarus still here? I saw him logging in but I don't see him in the, at 10 days. Um If not, then I'll just ask Doctor Moni to give her views, um, comments, ask questions. We will also ask other participants to ask question. But uh, yeah, sure them. Hi Prof. Yes, thanks. And uh thanks to Kita, that was a very concise and relevant um, talk for us and how we have experienced uh COVID with our patients. And thanks Tasha for letting us know about the medical aspects um that we don't actually see. Um Yeah, so my comment is just, um I think we uh in the pediatric surgery department are seeing um the, the, the side effects of the, the panic and anxiety more than uh the actual virus in the Children and how they, the health seeking behavior, them avoiding, uh, the family is avoiding hospitals. Us not being able to do elective work. So it's all those peripheral, um, you know, uh side effects of the COVID in the general collective and in the general population that has affected us. And, um, now I think we need to start thinking about opening that elective surgery because those like Harsha mentioned, those electives are becoming emergencies. And we know, I think we can all agree that the Children aren't affected um by the virus. It's more about staffing issues and, and the fear and anxiety like I said. So. Um yeah, I think for the children's sake, we're gonna have to start doing the electives. Um and yeah, prevent any further uh problems and issues with the Children who, who didn't need to be involved in, in all of this really. But um yeah, that's, that's, that's what I uh feel about the whole thing and it, it's important that we do realize the stress and anxiety that we put on Children as well like a very well. Um yeah, elucidated for us very concisely as well. But thanks. Yeah, that's thank you all. Thank you. Thank you. Uh our second consultant, Doctor Maaa. Uh sell uh any comments, uh any, anything about it. All right. Thanks Rob. Um Thanks Anita and Harsha for the talk. Um Yeah, I don't really have lots of comments except to say that um COVID has been um a problem for all of us. But at the same time, it's been a blessing for the oncology group because you've been continuing as normal for them and actually been prioritizing them. But as UR is stating, I think we have to start thinking um as a, as a unit and start realizing that um we can't postpone elective things forever. And we have to start thinking as to when you want to initiate electives as much as um certain things um can wait. But ultimately, the Children want to make, make sure that it's done as soon as possible when it's safe. Um And so that they don't have complications in the future. So, um that's something that we as a department definitely have to look into and start phasing in slowly. Um whether we say it's semielective so that it doesn't look like it's a pure elective thing which ultimately an elective will become uh semielective on emergency um with time. Um But it's something I think we definitely need to look at, but otherwise, um no other comments. Thank you. Thank you. Hello. And uh yeah, you pointed out correctly that actually oncology patients got benefited because our department participated in an international study which is being run from Oxford. And I think we um HLGA and Danel collected the data and uh maybe HCA can comment more about it. There were four or five uh things which we realized. So, so I will ask HGA to come in and uh as we have started discussing, I think we will have to consider doing semielective operations and we'll have to just phase them in slowly. Hlga. Can you just, uh tell us about our findings from participation in the pediatric oncology COVID study? Yes. Cross. We actually, um, had not many patients from oncology that were COVID positive, most were only screened syp for symptoms and then tested. But all the ones that had to go to Red Cross or Tygerberg for whatever reasons, all had to get COVID tests. And the few that we picked up were picked up during that screening, none of them died of COVID. The ones that did die in the period that we looked at during the study, died of oncology related problems, either sepsis or because of their malignancy. And in terms of our work, they certainly have benefited because they didn't have to wait for ports. They didn't have to wait for their surgeries whenever, um, the oncology team asked for any surgery. It was. Yes, sure. Tomorrow we can do it. So they certainly benefited from this because we were doing less work and could squeeze them in and through theater much easier. Ok, Elga, thank you. I'll now ask Doctor Majola our consultant, pediatric surgeon, uh, to give his thoughts, comments and observations. Uh, Doctor Majola. Hi, thanks, uh, for the opportunity. Thank you. And how of all giving us the information and just, yeah, enlightening us again about COVID. Yeah, it's, besides just the almost everything being shut down, it was just more of a frustration as well from us as surgeons or people who, who our work is mostly based with our hands. And also just that the frustration also was more on every, um, we were also being put under the same blankets as adults which as the stats have shown that our kids or the pediatric group never really suffered much um from COVID itself. And if they did, it wasn't really as complicated as how the adults were presenting. So, yeah, it's, it's about time that we really start uh isolating or basically separating ourselves in the sense of not getting our kids being grouped with um with the same grandkids and the same sort of protocols that adults are treated under and basically uh simulating us so that we can start uh continuing with our work per se. As we've seen, uh kids don't really suffer much from it. And yeah, so we need to get to work. Uh Thank you. II uh fully agree. I mean, all of us uh fully agree. Uh uh It happened at the beginning of the pandemic that we were being treated, Children were being treated uh same as adults and I think the same is happening about uh restarting of the routine work. Uh So we will certainly consider that um I think there is a, there is a question from Robert is what is your comment on COVID and intususception given the viral causes as we are well documented. Uh We certainly haven't seen any child with intususception who was diagnosed COVID positive, but I'll ask, uh, Doctor Lotion if she has any comment or any uh anything to say about this question. Um Thanks. Um I must say, I don't think it's come out too much that there's been an association between COVID and increased numbers of interception though. Not that I've come, you know, that, not that it's been flagged in the, hm, in the future. Um Yeah, so I don't know. I mean, maybe we, maybe we just not seen those Children. I don't know or, you know, they're presenting with more severe disease elsewhere. Um It's difficult to know because we've also, you know, when you look at the district numbers, there's been an even mostly with adults, but we haven't really, yeah, I don't think they've, they've kind of divided up into Children and adults, but there's been quite a number of excess debts and hm, well, that's all COVID related or other medical and surgical problems where patients are not actually presenting to healthcare facilities. It's very difficult to actually say at this stage. So yes, COVID'S had, you know, quite an impact not just on hospital care but also just what's happening out to the community because patients may actually be passing away or may have had severe, you know, severe, whatever, whatever problem and not actually are too scared to go to the healthcare facility to report it. So we actually don't know. But, I mean, I know. Yeah, I mean, I think you guys would be the best to know about intususception but I don't, I don't actually think any reports have come out from Cape Town even because they've had the highest number of positive Children, um this whole year and I don't, II can't see anything coming through about interception. They probably recognize more appendicitis and I don't know what, what, you know, what the reason for that is, but I think there have been more cases of appendicitis coming through than itself. Yeah. Yeah. Yeah, that's it. Uh No, I agree with you. I think there are those excess deaths and some of them at least are uh are due to COVID. So, so I'm sure the number of deaths due to COVID is much higher than about 50,000. What is being uh published right now? And um I think uh II would just like to sort of say again that our screening system at fair has been excellent. And I think we need to continue that for quite a while and it has uh not only saved our patients but also staff, doctors and nurses and other staff from getting unnecessarily exposed to COVID. So I think that is something which was achieved uh very nicely and just a bit of tongue in cheek. Um uh that you may remember that at the beginning of the pandemic, there was huge pressure on us put on us by the adult surgeons, but more so by the anesthetist for the use of uh Cart Blanche pediatric Theater as, as COVID Theater for Children. And um, it's, it's, we actually thank the, the trustees of the Carte Blanche Trust who vly uh refused to give permission. And uh it would have been so disastrous to, to just keep these two theaters for COVID, which would have had few operations and the Children would have really suffered uh from ge getting their operations delayed and, and uh further complications. So I think that was something uh it's almost like we had to fight for the rights of our patients and that fight continues. So anybody else who has any question, comment, please uh go ahead. You can either unmute yourself and ask or quickly write it in the chat box. Otherwise I'm going to just ask uh Doctor Lotion to just give her further comments befo before we say goodbye, any other comments, questions from any of our doctors, any other attendees from anywhere else, anybody? Yes. Uh Llama, please go ahead. Uh Thank you. Thank you so much, Ro and thank you to the speakers and uh just thank you for the opportunity to speak as well. I'm just thinking about what you were saying about the. So just to introduce yourself. Where do you work? And what? 00, sorry, sorry, Rob L uh, studying in Pretoria as a pediatric surgery, uh, registrar at Pretoria University. Thank you. Um, what I wanted to just add or maybe comment is, uh, what, uh, the, I think the group was saying about semielective and elective surgery. We also saw the same, I mean, the entire world did. Uh, but what we started doing to try and phase in doing some of the elective semielective cases is that we tried to just uh link to the hospitals where the the base hospitals where the patients were coming from and just spoke to a certain to certain pediatric doctors to do the COVID swabs there. And uh I think they were giving us almost uh our anesthetist or our teams, they were giving us all the, the, the, the theater sisters and the staff, they were giving us not to have a uh a result. That's more than five days, that's more than seven days old. So if we had a case that we saw that it needed to be done, even though it's not an emergency, we then just contact the doctor, it could be a referring doctor or try to contact the doctor from the base hospital to do the, the swab. So that by the time the patient comes to us, we would have followed up the result and it's definitely negative. So it was a bit of a tedious um or should I say it still is, but that's the way we've started doing some of the cases that we feel cannot wait forever. I just thought maybe I'll just add that comment here. Thank you, Llama. Uh Luckily what we have done is, uh we have not routinely tested Children for any operation uh at, at fair or Sicily Ma Hospital in East London. We have effective screening system and there was a phase for a month where adults were all tested for COVID. But then the swabs ran out. So we have been taking advice from Doctor Lotion and doctors who is an adult infectious disease specialist. And I'm actually happy to say that we haven't wasted unnecessary testing of, of Children and their parents if they were not screened positive, if they were screened positive, we have done them. So I think that's that swabbing is not a problem which is preventing us from doing routine work. I think it is just that we need to come out of that gear of not doing routine planned work and slowly start doing semi urgent semielective work. Ok. So thank you, Llama. Um If there's nobody else, I'll just uh request Harsha to give her final thoughts and then we will, we will end the meeting. Harsha. Sure, thanks pro um Yeah. So I think, you know, I mean, I think the decision for elective and semielective has gotta come from the department and I think we're still gonna move forward with not routinely swabbing all cases for pediatrics. Um, but obviously they're symptomatic then. Yes, they should be tested. And I think the one thing and, and Nhleko made the point is that we need to advocate for Children. He was quite right in that, you know, Children got lumped in with adults, adult services. And, you know, even though we had one, I mean, I showed you the numbers, we literally had 20 cases in the last year, but somehow their, their own services got disrupted and the more we fought for it, the more it was like, oh, well, but it's just one child, it's one child, but actually it's at one child's life that we can make a difference to. So I think we must still keep advocating for the care of Children and services and ensuring and you know, and also just making sure that we have equipment available for them or that we have because a lot of efforts have gone into the adult services and Children have been left by the wayside, unfortunately. Um but we must still keep um make the point of actually fighting for them because that's what we do and that's why we do what we do. So, yeah, so thank you for the opportunity. Um and for inviting me and yes, I hope um I think we all learned a little bit something different today as well. No, thank you. No. Thank you very much that was really excellent and I'm really that uh we had this uh talk and this discussion. So, thank you all. Thank you, Juanita. Thank you, Harsha and all the consultants and, and um uh everybody else contributing and your presence. So next week, it will be restricted to our department morbidity and mortality. But in two weeks time, uh Doctor Neha will present about uh gastrointestinal duplications. And we are hoping to get uh doctor uh uh Ellen Mauna consultant, pediatric surgeon and H OD at Charlotte Hospital Johannesburg as our invited guest. So you will receive that invitation um I in a week's time. So thank you all. Have a good evening. Bye-bye. Ok.