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ORIGINAL ARTICLE
Year : 2021  |  Volume : 24  |  Issue : 9  |  Page : 1338-1342

Impact of COVID-19 on Ophthalmic Outpatient Services in An Eye Care Center in Southern Nigeria


Department of Ophthalmology, University of Benin, Benin City, Nigeria

Date of Submission03-Dec-2020
Date of Acceptance24-May-2021
Date of Web Publication16-Sep-2021

Correspondence Address:
Dr. V B Osaguona
Department of Ophthalmology, University of Benin, Benin City
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_668_20

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   Abstract 


Background: Coronavirus disease-2019 (COVID-19) is a communicable disease and a global pandemic affecting different parts of the world including Nigeria. Measures to curb the spread of the causative virus included a nationwide lockdown. Aim: The aim of this study was to assess the impact of COVID-19 on ophthalmic outpatient services in an eye care center in Nigeria. Method: The medical statistics for all persons attending the Ophthalmic Outpatient Clinic from January to August 2020 and January to August 2019 was obtained. The statistics for January to August 2020 was compared with that of the corresponding months in 2019 for outpatient clinic attendance, gender, and number of children and adults. Results: In the 2019 study period, the total number of patients attending the Ophthalmic Outpatient Clinic was 16,189. There were 6788 males, 9401 females, 2963 children, and 13,226 adults. In similar months in 2020, the total number of patients was 8,735, of which 3,934 were males, 4801 females, 1651 children, and 7084 adults. There was an overall decline of 46% in the number of outpatient attendance in 2020. The decline was 76.3% in April 2020 (peak of the lockdown). There was a rebound in outpatient visits in July 2020 (when the interstate travel ban was lifted) to 4.9 times that of April 2020; however, this was 56.9% that of July of the preceding year. Conclusion: COVID-19 pandemic impacted negatively on outpatient visits. A rebound in the number of visits was observed when the interstate travel ban was lifted, although far below the preceding year's value.

Keywords: COVID-19, Nigeria, outpatient visit, pandemic


How to cite this article:
Osaguona V B, Osahon A I, Uhumwangho O M. Impact of COVID-19 on Ophthalmic Outpatient Services in An Eye Care Center in Southern Nigeria. Niger J Clin Pract 2021;24:1338-42

How to cite this URL:
Osaguona V B, Osahon A I, Uhumwangho O M. Impact of COVID-19 on Ophthalmic Outpatient Services in An Eye Care Center in Southern Nigeria. Niger J Clin Pract [serial online] 2021 [cited 2022 Nov 29];24:1338-42. Available from: https://www.njcponline.com/text.asp?2021/24/9/1338/325924




   Introduction Top


Coronavirus disease-2019 (COVID-19) is a global pandemic affecting different parts of the world including Nigeria. COVID-19 is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).[1] The first outbreak of the disease was reported on the 31st of December 2019 in Wuhan, Hubei, China.[2] In Nigeria, the first case of COVID-19 was confirmed on February 27, 2020, when an Italian citizen tested positive in Lagos State.[3] In Edo State, the first case of COVID-19 was reported on March 23, 2020.[4] As of September 25, 2020, the total number of confirmed cases in Edo State was 2616 with 23 active cases, 2486 discharges, and 107 deaths while as a country, Nigeria had a total number of 57,724 confirmed cases made of 7,637 active cases, 48,985 discharges, and 1102 deaths.[5]

In order to prevent the spread of the disease, governments all over the world instituted various measures to contain the spread of the virus. These included massive public awareness and enlightenment on regular washing of hands with soap and water, wearing of face masks, physical distancing, lockdown, restriction of movements, and crowd gatherings. Businesses including health services were partially or completely disrupted in many countries due to the lockdown, and hospital consultations were not excluded. In a hospital in Italy, outpatient visits dropped by 75.2% among patients attending its Medical Retina and Imaging Unit during the Italian quarantine.[6] Furthermore, in Nigeria, the Federal Government imposed a nationwide lockdown on March 30, 2020.[3] Movement of people was restricted apart from basic needs, illness, and essential services. Thereafter, the ban on interstate movement was lifted by the Federal Government of Nigeria with effect from July 1, 2020.[7] Knowledge of the impact of COVID-19 pandemic on ophthalmic services in our facility will allow for better planning in the future. The aim of this study is to assess the impact of COVID-19 on ophthalmic outpatient services at the eye clinic of the University of Benin Teaching Hospital, Nigeria.


   Methods Top


This study was carried out at the Ophthalmology Department of the University of Benin Teaching Hospital, Benin City, Nigeria. The Hospital offers specialist care in different fields of Medicine to residents within its host city and neighboring states such as Delta, Ondo, and Kogi. Ethical approval for this study was obtained from the Ethics and Research Committee of the Hospital on November 12, 2020. The medical statistics for all persons attending the Ophthalmic Outpatient Clinic for the months of January to August 2020 and January to August 2019 was obtained. Children were defined as persons below 18 years of age while adults were persons 18 years and above. For each month, the number of patients (children and adults), gender, and clinical information were obtained. Departmental and institutional measures and protocols were instituted during the COVID-19 outbreak to curb the spread of SARS-CoV-2 among staff and patients. During the initial phase when the government instituted lockdown measures in the country, patients who presented to the Outpatient Eye Clinic were first interviewed to determine if their ocular conditions required emergent or urgent action for intervention or were routine, elective, or follow-up cases. Health workers were profiled in order to screen for those deemed to be more at risk of deleterious outcomes or more susceptible to the SARS-COV-2 virus such as those with diabetes mellitus, chronic obstructive pulmonary disease, pregnancy, immunosuppression, and elderly above 60 years. Those who fell in this category were withdrawn from frontline work and where possible allowed to work from home. All health workers were rostered to avoid overcrowding at the work place and undue exposure of all staff at the same time. Infrared thermometers were used to check the temperature of all persons prior to entrance into the waiting room in order to identify febrile patients with temperature above 37.5°C. Escorts and accompanying persons were discouraged unless absolutely needed in cases such as children, visually impaired patients and other persons with disabilities. All patients were asked to wear face mask and disinfect their hands with hand sanitizers containing at least 70% ethyl alcohol which was prepared by the Pharmacy Department of the institution or wash hands thoroughly with soap and water provided at the entrance of the building prior to entering the waiting room. Personnel were designated to obtain relevant information from the patients and clients that will help to screen and identify possible exposure to SARS-CoV-2. They were also asked about fever and symptoms of respiratory illness and whether they or a family member had come into contact with another person with confirmed COVID-19 in the past 2 to 14 days. Any patient whose answer was affirmative to either question was sent to the hospital's emergency room for further evaluation. A maximum of ten patients were allowed in the waiting room at a time and they were seated at least 2 feet from one another.

The health workers and doctors wore appropriate personal protective equipment. All instruments/equipment were frequently disinfected at the start of a clinic day, after every patient use and at the end of the clinic. The slit lamps were used with the breath shield barriers in place. The use of the direct ophthalmoscope was suspended and posterior segment examination of the eyes was done with fundus lenses and binocular indirect ophthalmoscopes. Appropriate care was also enforced in optical services rendered to patients such as sanitizing frames before patient try them on.

Data collected were analyzed with Microsoft Office Excel software (Microsoft Corporation, 2010, Louisville KY). The statistics for January to August 2020 was compared with those of the corresponding months in 2019 for outpatient clinic attendance, gender, and number of children and adults.


   Results Top


From January to August 2019, the total number of patients attending the Ophthalmic Outpatient Clinic was 16,189 [Figure 1]. There were 6,788 males with a male:female ratio of 1:1.38; 2,963 children and 13,226 adults [Table 1]. In similar months in 2020, the total number of patients attending the ophthalmic outpatient clinic decreased to 8,735 [Table 1]. This represented an overall decline of 46% in the number of outpatient attendance. There were more adults than children in both 2019 and 2020.
Figure 1: Number of outpatient visits in 2019 and 2020

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Table 1: Demographic distribution of patients attending the Ophthalmic Outpatient Clinic in 2019 and 2020

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After the first case of COVID-19 in Nigeria was confirmed in February 27, 2020, a sharp drop (44.3%) was observed in the number of outpatient in March 2020 (972 patients) from 1745 patients in the preceding month of February 2020 [Figure 2] and 49.6% decline from that of March 2019 [Figure 2]. Following the lockdown, the outpatient attendance dropped further by 76.3% in April 2020 [Figure 2]. The outpatient visits then gradually increased from May 2020 upwards. By July 2020, when the ban on interstate travel was lifted, the outpatient visits had increased to 4.9 times that of April 2020 [Figure 2] and 56.9% that in July of the preceding year; however, adult visits remained far below the preceding year's value while pediatric visits were approaching typical levels of the preceding year [Figure 3]. The most common presenting complaint in April 2020 (peak of the lockdown) was reduced vision 30% [Figure 4] and most of the cases were ocular emergencies such as blunt and penetrating trauma with ecchymosis, subconjunctival hemorrhage, corneoscleral laceration, panuveitis and keratitis.
Figure 2: Number of outpatient visits per month for 2019 and 2020

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Figure 3: Number of adult and pediatric visits in 2019 and 2020

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Figure 4: Presenting complaints of patients seen at the peak of the lockdown. Some patients presented with more than one symptom

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   Discussion Top


This study was done to assess the impact of COVID-19 pandemic on ophthalmic services in a tertiary care center. There was a substantial decline in the outpatient visits during this period when compared to similar months in 2019. A significant decline in outpatient visits for ophthalmology and other specialties during COVID 19 pandemic is also reported elsewhere.[6],[8],[9],[10],[11],[12],[13] In France, consultations dropped by 40% and 50% respectively among general practitioners and specialist during the pandemic.[8] In Harvard University, there was a reduction in outpatient volume in all specialties but ophthalmology was the most affected with a 79% decrease in outpatient volume.[11]

In our center, there was a gradual decrease in outpatient visits in January through February 2020 when compared with the same months in 2019. It is not known if this may be related to increasing reports of COVID-19 spread from country to country. There was a steep decline in outpatient attendance in March 2010. This period correlates with the report of the first confirmed case of COVID-19 in Nigeria on February 27, 2020.[3] The decline in outpatient visits further worsened in April 2020 following the first confirmed case of COVID-19 in Edo State on March 23, 2020,[4] as well as the imposition of a nationwide lockdown on March 30, 2020 by the Federal Government of Nigeria[3] which limited the movement of people from neighboring states and within the cities. As part of measures to contain the spread, the public was advised to stay at home unless absolutely necessary to leave the house. Furthermore, to minimize risk to patients and healthcare personnel in this center, outpatient visits were limited to emergencies. Many patients also deferred visits to the hospital for fear of being exposed to SARS CoV-2 infection.

There was a steep rise in the number of outpatient consultations for both adults and children in July 2020; which correlates with the time when the ban on interstate travel was lifted.[7] However, the number of outpatient visits were far below those for similar months in 2019. Adult visit remained far below that of 2019 while the pediatric visit was close to levels recorded in 2019. This could be because caregivers are anxious when they observe ophthalmic problems in their children or wards while adults may defer visits to a more convenient time.

During the pandemic, the hospital embarked on staff training on the use of telemedicine, but this was a novel experience. Thus we recommend continued training of staff and patients on the use of telemedicine, and it should be together with outpatient visits. That way, both staff and patients will get familiar with telemedicine consultations which will give a better experience for future needs paving the way for a new normal in ophthalmic and other specialty health care service delivery. There is need for appropriate laws regulating the use of telemedicine in Nigeria to be put in place. A national guideline and standard operating procedure for eye care during the COVID-19 pandemic has been developed by the Federal Ministry of Health, Nigeria.[14] This will hopefully provide the needed information for occupational safety for eye care workers while providing the much-needed care to patients. These guidelines to curtail the spread of COVID-19 (likely to be relevant in other disease outbreaks) may require continuous evaluation and update to ensure optimal service delivery to patients while protecting health workers who are the frontliners in any disease outbreak and are thus susceptible as an occupational hazard.

This study has limitations in that it is a single eye center study which may not reflect the impact of COVID-19 pandemic in other eye centers in Nigeria. Thus, further studies to determine the impact of COVID-19 in other centers is advocated.

In conclusion, there was a significant decline in the number of outpatient visits during the COVID-19 pandemic in 2020 when compared to similar months in the pre-COVID-2019. The decline was worst in April 2020 which was the peak of the lockdown and a rebound was seen in July 2020 when the ban on interstate travel was lifted in Nigeria.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
World Health Organization. Naming the coronavirus disease (COVID-19) and the virus that causes it. www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/naming-the-coronavirus-disease-(covid-2019) and-the-virus-that-causes-it. [Last accessed 2020 Sep 25].  Back to cited text no. 1
    
2.
World Health Organization. Coronavirus disease 2019 (COVID-19): situation report, 94. World Health Organization.2020. https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200423-sitrep-94-covid-19.pdf?sfvrsn=b8304bf0_4 [Last accessed on 2020 Sep 25].  Back to cited text no. 2
    
3.
Nigeria Center for Disease Control. First case of corona virus disease confirmed in Nigeria. February 28, 2020. www. ncdc.gov.ng/news/227/first-case-of-corona-virus-disease-confirmed-in-nigeria. [Last accessed 2020 Sep 24].  Back to cited text no. 3
    
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Onyedika Ugoeze N. Nigeria's coronavirus cases now 40. The Guardian Newspaper. 2020. https://m.guardian.ng/news/nigerias-coronavirus-toll-cases-now-40/ [Last accessed on 2020 Sep 25].  Back to cited text no. 4
    
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Nigeria Center for Disease Control. Covid-19 Nigeria. https//covid19.ncdc.gov.ng. [Last accessed 2020 Sep 24].  Back to cited text no. 5
    
6.
Borelli E, Grosso D, Vella G, Sacconi R, Querques L, Zucchiatti I, et al. Impact of Covid-19 on outpatient visits and intravitreal treatments in a referral retina unit: Let's be ready for a plausible “rebound effect”. Graefes Arch Clin Exp Ophthalmol 2020;258:2655-60.  Back to cited text no. 6
    
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Olalekan A. FG lifts ban on interstate travels. The punch Newspaper. June 29, 2020. https://punchng.com/breaking-fg-lifts-ban-on-interstare-travels/. [Last accessed 2020 Sep 25].  Back to cited text no. 7
    
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Deloitte. What will be the impact of COVID19 pandemic on healthcare systems? June 2020. https://www2.deloitte.com/fr/fr/pages/covid-insights/articles/impact-covid19-healthcare-systems.html. [Last accessed 2020 Sep 28].  Back to cited text no. 8
    
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Gomes CM, Favorito LA, Henriques JVT, Canalini AF, Anzolch KMJ, Fernandes RC, et al. Impact of COVID-19 on clinical practice, income, health and lifestyle behavior of Brazilian urologists. Int Braz J Urol 2020;46:1042-71.  Back to cited text no. 9
    
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Etyang O. COVID-19 Pandemic and its Potential Impact on The Health Sector in the COMESA Region. https://www.comesa.int/wp-content/uploads/2020/06/COVID-19-Potential-Impact-on-the-Health-Sector.pdf. [Last accessed 2020 Sep 28].  Back to cited text no. 10
    
11.
Mehrotra A, Chernew M, Linetsky D, Cutler D. The impact of the COVID 19 pandemic on outpatient visits: A rebound emerges. 2020. https://www.commonwealthfund.org/ publications/2020/apr/impact covid 19 outpatient visits. [Last accessed 2020 Oct 21].  Back to cited text no. 11
    
12.
Massachusetts Health Policy Commission. Estimating the Impact of COVID-19 on the Health Care System. https://www.mass.gov/doc/estimating-the-Impact-of-COVID-19-presentation/download. [Last accessed 2020 Oct 25].  Back to cited text no. 12
    
13.
Wang W, Zheng Y, Jiang L. Impact of the COVID 19 epidemic on outpatient visits of common respiratory diseases. Research Square. 2020. https://doi.org/10.21203/rs. 3.rs 34656/v1. [Last accessed 2020 Sep 28].  Back to cited text no. 13
    
14.
Federal Ministry of Health, Nigeria. Eye on COVID: A National Guideline and Standard Operating Procedure for Eye Care during the COVID-19 pandemic. 2020. https://health.gov.ng/doc/Eye-on-Covid.pdf. [Last accessed 2020 Nov 9].  Back to cited text no. 14
    


    Figures

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