Inequalities in screening policies and perioperative protection for patients with acute appendicitis during the pandemic: Subanalysis of the ACIE Appy study

Acute appendicitis remains a common reason for hospital admission. Reports have suggested a reduction in patients attending emergency departments during the acute phase of the SARSCoV- 2 pandemic. Moreover, a global surge in conservative management of acute appendicitis has recently been registered by the Appy Study of the Association of Italian Surgeons in Europe (ACIE)1. This is a treatment option that has been known for some years, although quite seldom used before the pandemic2–4. As most countries are experiencing new waves of the pandemic, the attitude of surgeons towards SARS-CoV-2 screening policies and personal protective equipment (PPE) used during the management of patients with acute appendicitis need to be established. According to a subanalysis of the ACIE Appy Study, half of surgeons globally were testing patients for SARS-CoV-2 only when symptomatic or there was suspicion of infection; approximately 12 per cent did not test patients at all (Fig. 1 and Table S1). There were regional differences. In Europe, respondents tested all patients (50.8 per cent) or those with suspected infection (43.9 per cent), with only 5.3 per cent not being tested at all. In the USA, the majority of participants only tested patients with a suspected infection (65.6 per cent). A similar picture of testing only those with a suspected infection was also reported from Latin America (57.2 per cent), Asia/Middle East (76.8 per cent), and Africa (41.7 per cent). Even more worrisome, 58.3 per cent of respondents from Africa and 27.6 per cent from Latin America were not testing patients at all before appendicectomy. Concerning the screening modality, most respondents used PCR alone or in combination with chest imaging. Serology was rarely used overall and never in Africa (Fig. 1 and Table S2 ). It is now accepted that chest imaging is not routinely required and that PCR is an accurate screening modality. Serology might, however, be useful to shed light on the disease course and previous exposure to the virus, but respondents from some countries still have restricted access to this test. In terms of PPE during appendicectomy, most African respondents did not use different PPE compared with the prepandemic period in patients who tested negative for COVID-19. More concerning is that 58.3 per cent did not use different PPE in untested patients. This differed from other regions where the rate of those not considering a change of PPE in untested patients did not exceed 22 per cent. One in 10 respondents from Latin America also reported that they were not using different PPE compared with the prepandemic phase in patients who tested positive for COVID-19. These data, and taking into account the high prevalence of acute appendicitis, leads to the conclusion that omission of routine patient screening may have contributed to local clusters among patients and threatened the safety of healthcare workers5. In this respect, it is likely that limited access to PPE explains the attitude of surgeons towards patients with unknown SARSCoV- 2 status or those infected, raising ethical concerns about the safety of surgical staff. It is of outmost importance that, even during challenging times and stress on economic stability, industrialized countries make efforts to sustain low-income countries and those with limited resources. This would ensure equal working conditions, safer treatment for patients with acute appendicitis, and better control of the pandemic