Outcomes of Ambulatory Pediatric Surgical Care Provision in a Conflict Affected Population in Kakuma Refugee Camp During a Measles Outbreak

Abstract

Introduction and objectives

In 2023, Kakuma refugee camp experienced measles outbreaks leading to delayed provision of pediatric surgical care. Our objective was to assess postoperative outcomes following the implementation of a new protocol to minimize pediatric surgical patient exposure to measles.

Methods

We retrospectively reviewed ambulatory pediatric surgical care in Kakuma refugee camp to determine demographic information, diagnoses and procedures done, and postoperative outcomes following implementation of the new protocol.

Results

We conducted a total of 28 ambulatory pediatric procedures. All 25 patients had received their measles vaccine preoperatively (100%); 35.7% of the procedures were inguinal hernia repairs, 50 % were hydrocele repairs, and 10.71% were umbilical hernia repairs. There were no postoperative deaths, cases of measles, and no surgical site infections (0%).

Conclusion

Ambulatory pediatric surgical care provision is feasible in the refugee context during a measles outbreak, and the outcomes were comparable to other settings.

Keywords

refugee context measles outbreak elective ambulatory pediatric surgical care

Introduction

Globally, two billion children lack access to life saving pediatric surgical services, including children in rural and refugee contexts.¹ Concurrently, up to 20 million people including children are susceptible to measles and rubella partly due to reduced measles, mumps and rubella (MMR) vaccination coverage rates and the displacement of populations; none of the six World Health Organization (WHO) regions have achieved the 95% MMR coverage rate needed to provide broad herd immunity in regions.² By 2019, there was a 300% increase in the number of measles outbreaks including in 11 low and middle income countries (LMICs).² Displaced populations are particularly vulnerable to measles outbreaks. In 2021, there were more than 100 million displaced people globally (1). Women and children are most affected by displacement.¹

Refugee contexts are particularly vulnerable to measles outbreaks.³ In 2017, there was a large measles outbreak with more than 1700 cases among Rohingya refugees in Cox’s Bazar Bangladesh.³ Moreover, recent United Nations High Commissioner for Refugees (UNHCR) data published in 2019 demonstrated a total of 364 outbreaks in 21 countries affecting 108 refugee camps.⁴ Seventy five percent of the outbreaks were due to measles, cholera, and meningitis.⁴ Furthermore, 70% of the outbreaks occurred in 3 countries, namely, Kenya, Chad, and Thailand.⁴

In Kenya, more than 500′000 refugees are hosted in Kakuma refugee camp, Dadaab refugee camp, and urban areas⁵ (Figure 1). Children represent 52% of the refugee population in Kenya, and they often present with surgical conditions as a result of injuries and birth defects.⁵ Refugee children often present with more complex surgical conditions because of the trauma experienced and the delay in accessing care.⁶ Delays in accessing care are frequently due to being located in fragile health systems with inadequate infrastructure, equipment, supplies, and a specialist workforce. In Kakuma refugee camp, there have been recent efforts to build pediatric surgical capacity with pediatric surgical equipment, infrastructure, and training.¹ However, outbreaks including measles outbreaks burden the health system significantly; and medical and surgical teams are forced to make difficult decisions on whether pediatric surgical services and other routine clinical services should be deferred until outbreaks end.

Figure 1.

Map of Kenya with the geographic distribution, demographic characteristics of refugees, and their countries of origin 5.

A review of the current evidence on the provision of routine and elective pediatric surgical services during measles outbreaks demonstrated evidence gaps in protocols to be adopted for elective surgical service provision during measles outbreaks. Our objective therefore was to examine the feasibility and the safety of implementing a protocol for conducting safe ambulatory elective pediatric surgical procedures during a measles outbreak in a rural and refugee context.

Our hypothesis was that with a clear protocol embedding safety checks that maximized the protection of the pediatric surgical patient and minimized the exposure of a pediatric surgical patient to the inpatient ward, it would be feasible and safe to conduct elective pediatric surgical procedures during a measles outbreak.

Methods

Setting: The intervention took place in Kakuma refugee camp in Turkana, northwestern Kenya (Figure 1).

Study design: This study was an observational study that retrospectively examined patient charts to determine demographic information, diagnoses and procedures done, and postoperative outcomes.

Participants: Participants in the intervention were refugee children in need of surgical care, parents of the children in need of surgical care, surgeons (a pediatric surgeon and a general surgeon), anesthesia providers, medical officers, nurses, and policy makers.

Inclusion criteria: Children in need of elective surgery in Kakuma Refugee Camp.

Exclusion criteria: children presenting with emergency surgical conditions or other surgical conditions requiring hospitalization in Kakuma refugee camp.

Outcome measures: our primary outcome measures were MMR coverage, surgical volume, and post-operative complications (including bleeding, surgical site infection, and longer term complications including recurrence). Our secondary outcome measures were types of surgical cases performed and the length of hospital stay.

Data Analysis/Statistical Analysis

We calculated means for continuous variables. For categorical variables, we calculated proportions, and confidence intervals to determine statistical significance.

Standard Patient Pathway

Below is a description of the standard pediatric surgical patient pathway: Home → clinic → admission to the ward the night before surgery → surgical procedure on the day of surgery → return to the ward after surgery → discharge on postoperative day (POD) number 1 → follow up in clinic on POD number 7.

Below is a description of the revised pediatric surgical patient pathway implemented during the measles outbreak:

Home → clinic → preoperative area → operating room for surgical procedure → recovery area → discharge home on POD day 0 → follow up in clinic on POD number 7.

The standard protocol for elective pediatric surgical procedures before the measles outbreak was to admit patients the day before surgery into the pediatric ward; complete the final assessment; draw preoperative laboratory tests as needed; start intravenous fluids and keep them nil by mouth before surgery. The procedure would be done and postoperatively the patients would be admitted to the pediatric ward for observation and discharge on postoperative day number 1. With this standard protocol, there is significant contact between the elective pediatric surgical patients and inpatients admitted with medical conditions. With the new protocol that was implemented, there was minimal contact between elective pediatric surgical patients and pediatric inpatients, and we transitioned to conducting elective procedures as ambulatory procedures without hospitalizing patients. Consequently, we chose patients with surgical pathologies that allow for same day discharge and do not require admission to the inpatient unit.

Thus, with the revised protocol, we created a separate patient pathway for pediatric surgical patients to minimize their exposure to inpatient pediatric patients. In summary, before the day of surgery, patients were seen in the clinic for clinical assessments which included standard histories and physical exams (including weight checks). A hemoglobin level was checked to rule out any leukocytosis or anemia (including anemia due to sickle cell disease). If indicated, preoperative ultrasounds were performed.

Instructions were given to parents to keep the patient NPO after midnight and to arrive in the preoperative area at the hospital by 6:30AM. We reviewed vaccination records, and when there was a question on whether the patient had been vaccinated with MMR or tetanus vaccines, we proceeded with administering any potentially missing vaccine doses based on prior evidence demonstrating the safety of administering vaccinations before elective surgery in otherwise healthy children.⁷ All 38 patients were vaccinated for measles preoperatively. Furthermore, all members of the surgical and anesthesia staff were vaccinated against measles resulting in a 100% MMR vaccination coverage rate among patients and the surgical and anesthesia teams.

In the preoperative area on the day of the surgery, we confirmed NPO status. The surgical site was marked. The consent was reviewed; any additional questions the parents had were answered; and the nursing and anesthesia teams started intravenous (IV) fluids (D5NS). Please see the Ambulatory Pediatric Surgical Patient Pathway Checklist in the appendix.

In the operating room, the World Health Organization (WHO) surgical safety checklist was completed, and a dose of intravenous cefazolin was given.⁸ Surgical procedures were performed under general anesthesia. Local anesthetic (1% lidocaine) was administered at the beginning and at the end of the case. Wounds were closed with absorbable sutures (vicryl); steri strips were placed; and an occlusive tegaderm dressing was also placed as previously described.⁸

In the recovery room, the nursing and anesthesia teams worked together to check vital signs every 30 minutes. When the patient was awake enough, they were started on clear liquids and a light snack. In addition, as previously described, parents were instructed to keep the occlusive dressing in place until the follow up visit in clinic on POD number7.⁸ Parents were also instructed to give 15 mg/kg of paracetamol three times a day x 48 hours to adequately manage pain, and as needed after 48 hours. Parents were instructed to call the nurse if there were any concerns of fever, bleeding, or if the dressing had come down.

During the postoperative visit on POD number 7, the occlusive tegaderm dressing was taken down, and the wound was assessed for any presence of infection. Digital pictures were taken to document wound status.

Results

We conducted a total of 28 ambulatory pediatric procedures in 25 patients. Patients came primarily from South Sudan, Burundi, Somalia, and the Democratic Republic of Congo. All patients were boys and the average age was 5 years old (range 1 - 13 years old). All patients were up to date with their MMR vaccines preoperatively (100%); 35.7% of the procedures were inguinal hernia repairs (95% CI 0.18-0.53); 50 % were hydrocele repairs (95% CI 0.31-0.69), 10.71% were umbilical hernia repairs, and 3.57% orchiopexies. All patients were discharged home within 12 hours of admission. There were no cases of significant bleeding or perioperative deaths. At POD 7, there were no surgical site infections (0%) nor recurrences (0%) (Table 1). None of our pediatric surgical patients contracted measles, and all patients returned for their postoperative visit.

Table 1.

Demographic Characteristics, Diagnoses, and Postoperative Outcomes of Patients Undergoing Ambulatory Pediatric Surgical Care During a Measles Outbreak in Kakuma Refugee Camp

	Age (years)	Diagnosis	Sex	Procedure	POD #7 follow up
1	2	Right hydrocele & right undescended testicle	M	Right hydrocele repair and right orchiopexy	Wound clean, dry and intact with no signs of infection.
2	4	Right hydrocele	M	Right hydrocele repair	Wound clean, dry and intact with no signs of infection.
3	2	Right hydrocele & large umbilical hernia	M	Right hydrocele repair & umbilical hernia repair	Wounds clean dry and intact with no signs of infection.
4	7	Right inguinal hernia	M	Right inguinal hernia repair	Wound clean, dry and intact with no signs of infection.
5	5	Right hydrocele	M	Right hydrocele repair	Wound clean, dry and intact with no signs of infection.
6	10	Right hydrocele	M	Right hydrocele repair	Wound clean, dry and intact with no signs of infection.
7	11	Left hydrocele	M	Left hydrocele repair	Wound clean, dry and intact with no signs of infection.
8	2	Right hydrocele	M	Right hydrocele repair	Wound clean, dry and intact with no signs of infection.
9	3	Right hydrocele	M	Right hydrocele repair	Wound clean, dry and intact with no signs of infection.
10	7	Left hydrocele	M	Left hydrocele repair	Wound clean, dry and intact with no signs of infection.
11	3	Right inguinal hernia	M	Right inguinal hernia repair	Wound clean, dry and intact with no signs of infection.
12	9	Right inguinal hernia	M	Right inguinal hernia repair	Wound clean, dry and intact with no signs of infection.
13	2	Left inguinal hernia	M	Left inguinal hernia repair	Wound clean, dry and intact with no signs of infection.
14	2	Large umbilical hernia	M	Umbilical hernia repair	Wound clean, dry and intact with no signs of infection.
15	13	Recurrent left hydrocele s/p pediatric repair 8/2022	M	Left hydrocele repair with excisional biopsy of granulomatous lesions of the tunica vaginalis (Lord’s procedure)	Wound clean, dry and intact with no signs of infection.
16	13	Right inguinal hernia	M	Right inguinal hernia repair	Wound clean, dry and intact with no signs of infection.
17	5	Right inguinal hernia	M	Right inguinal hernia repair	Wound clean, dry and intact with no signs of infection.
18	1	Right inguinal hernia	M	Right inguinal hernia repair	Wound clean, dry and intact with no signs of infection.
19	1	Right inguinal hernia	M	Right inguinal repair	Wound clean, dry and intact with no signs of infection.
20	7	Left hydrocele	M	Left hydrocele repair	Wound clean, dry and intact with no signs of infection.
21	3	Right hydrocele	M	Right hydrocele repair	Wound clean, dry and intact with no signs of infection.
22	2	Large umbilical hernia and right inguinal hernia	M	Right inguinal hernia repair and umbilical hernia repair	Wound clean, dry and intact with no signs of infection.
23	4	Right hydrocele	M	Right hydrocele repair	Wound clean, dry and intact with no signs of infection.
24	Missing data	Right hydrocele	M	Right hydrocele repair	Wound clean, dry and intact with no signs of infection.
25	2	Right inguinal hernia	M	Right inguinal hernia repair	Wound clean, dry and intact with no signs of infection.

We had a missing data point for 1 out of the 25 participants.

Discussion

Feasibility

With this intervention, we were able to show that it is feasible to develop and implement a protocol for conducting safe elective ambulatory pediatric surgical care during a measles outbreak in a refugee setting. There are often multiple parallel health crises in refugee contexts - and the usual approach is to focus on one health crisis at a time often at the expense of other health interventions. In this case, our initial approach was to wait until the measles outbreak had ended before resuming elective pediatric surgical procedures. However, when the outbreak was prolonged, we also needed to consider possible disadvantages of delayed access to pediatric surgical care (especially for inguinal hernias which can incarcerate or strangulate). The protocol we developed and implemented emphasized minimizing any contact between pediatric surgical patients and inpatient pediatric patients. We also ensured adequate immunization coverage of all children for both MMR and tetanus vaccines. To our knowledge this is the first reported protocol for conducting safe elective ambulatory pediatric surgical care during a measles outbreak in a refugee setting.

Safety

In terms of peri-operative and postoperative outcomes, we were able to conduct surgeries safely from both a surgical standpoint and anesthesia standpoint. There were no immediate complications noted. All patients were transferred safely to the recovery room with adequate monitoring. We had no cases of significant bleeding, and no adverse reactions to anesthetic agents. Furthermore, we had no respiratory complications. All patients were discharged within 12 hours of coming to the hospital as soon as they were able to tolerate liquids and a light snack, and they had adequate pain control. Our figures compare favorably with other published data; Gonzalez et al documented a <1 death per 10 ‘000 anesthetics in developed countries, and 10.7-15.9 per 10′ 000 anesthetic in developing countries. Major risk factors for anesthesia related mortality are being a newborn or less than 1 year old, ASA III, and undergoing emergency surgery or cardiac surgery.⁹ In this systematic review, the main cause of pediatric anesthesia related death were problems with airway management and cardiocirculatory events.⁹ In our cohort, none of the patients had any of the major risk factors for anesthesia related mortality, which resulted in optimal perioperative and postoperative outcomes.

Postoperative Outcomes

At the postoperative visit on POD#7, all patients were seen, and the occlusive dressings and steri strips were taken down. There were no signs of surgical site infections (SSIs), which gave us a SSI rate of 0%. This was lower than the previously reported rate of 1% with the same protocol in rural Haiti.⁸ The 0% SSI rate was also lower compared to the 6.8% SSI quoted by Wood et al in another study conducted in rural Kenya in a non refugee context.¹⁰

Measles Outcomes

Preoperatively, we ensured all patients had received an MMR vaccine. If parents had no records from their home country or they were uncertain of the number of doses received, then we proceeded with providing the MMR vaccine preoperatively for an MMR vaccine coverage rate of 100%. Postoperatively, there were no cases of measles. The current evidence shows that the MMR vaccine is highly protective; 1 dose provides 93% protection.¹¹ Furthermore, there are no known contraindications to providing MMR vaccines preoperatively for otherwise healthy pediatric surgical patients.⁷ In reviewing the current literature, we did not find data documenting cases of measles in surgical patients including pediatric surgical patients during measles outbreaks.

Demographics

Male patients were overrepresented in our cohort. In reviewing the literature on barriers to accessing surgical care in low and middle income countries (LMICs), key barriers that emerge include transportation challenges, lack of local resources, poverty, and fear of undergoing surgery and anesthesia.¹² With regards to gender differences in access to surgical care in LMICs, Gyedu et al found that women in Ghana feared anesthesia, they lacked social support, and found it difficult to navigate the health care system.¹³ We found no articles addressing barriers to access for female pediatric surgical patients. This is an area for future research as we work towards ensuring equitable access to pediatric surgical care for both female and male pediatric surgical patients.

Strengths

Our study has several strengths. First, results from our study contribute to the current body of literature. To our knowledge, this is the first study to document the feasibility and the safety of creating a separate patient pathway for ambulatory elective pediatric surgical cases during a measles outbreak in a rural and refugee context. Several studies mention the deferment of elective pediatric surgical services during outbreak and pandemic contexts.^14-16 However, when an outbreak is prolonged, deferment of surgical care can lead to life threatening complications; for instance, in the case of hernias potential incarcerations and strangulations are risks during the deferment period. As a result, we explored innovative ways of safely maintaining access to elective pediatric surgical care during a measles outbreak in Kakuma refugee camp to minimize the risks of not having elective surgical care.

Second, our study builds evidence for a more comprehensive approach when there are multiple ongoing health crises. Rather than deferring pediatric surgical services, we developed and implemented a safe protocol for continuing with pediatric surgical services; using the opportunity to also optimize MMR vaccine coverage rates preoperatively. This approach shows that a comprehensive essential health package including surgical services for children is feasible in a refugee setting; and more importantly, it provides entry points for optimizing MMR and tetanus immunization coverage rates.

Limitations

This was a retrospective study with potential sources of bias including misclassification bias. Moreover, there could have been selection bias at play considering that in this cohort, male patients were over-represented. Future efforts should explore reasons for this and if needed implement interventions to reduce potential barriers for female pediatric surgical patients. Our findings may not be applicable in other settings including other refugee contexts. Our sample size was small, and future studies should include larger sample sizes to further build the evidence on the feasibility and the safety of the protocol.

Policy Implications

From a policy perspective, efforts should be made to continue providing routine health services including pediatric surgical services during measles outbreaks. Pediatric essential health packages in refugee settings should include pediatric surgical services to further optimize the health outcomes of refugee children.

Conclusions

In conclusion, with this study, we were able to show that it is feasible to develop and implement a protocol for conducting safe elective ambulatory pediatric surgical care during a measles outbreak in a refugee setting. More studies are needed to further examine the effectiveness and applicability of the intervention in multiple settings including in high income countries.

Footnotes

Ethical Considerations

We received ethical approval from the TICH ethical review committee; reference number 07221433509

Author Contributions

Kaseje, Neema: Contributed to conception or design, contributed to acquisition, analysis, or interpretation of data, Drafted the manuscript, critically revised the manuscript, gave final approval, Agrees to be accountable for all aspects of work ensuring integrity and accuracy. Otieno, Kefa: Contributed to conception or design, contributed to acquisition, analysis, or interpretation of data, critically revised the manuscript, gave final approval. Randa, Ida: contributed to acquisition, analysis, or interpretation of data, critically revised the manuscript, gave final approval. Hassan, Khalid: Contributed to conception or design, contributed to acquisition, analysis, or interpretation of data, critically revised the manuscript, gave final approval. Etenya, Brendan: Contributed to conception or design, contributed to acquisition, analysis, or interpretation of data, critically revised the manuscript, gave final approval. Patrick Oguti: Contributed to conception or design, contributed to acquisition, analysis, or interpretation of data, critically revised the manuscript, gave final approval.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Patient and Public Involvement

Patients or the public were not involved in the design, or conduct, or reporting, or dissemination plans of our research.

Appendix

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