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Assessment of the Effects of the COVID-19 Lockdown on Trauma at AaBET Hospital in Addis Ababa, Ethiopia

Introduction A novel coronavirus disease (COVID-19) broke out in Wuhan, Hubei Province, China, in December 2019 that continues to pose major challenges to trauma care around the world. The objective of this study was to assess the effects of COVID-19 on the pattern of traumatic injuries and outcomes. Methodology This retrospective, descriptive study was conducted over a three-month period at Addis Ababa Burn Emergency and Trauma (AaBET) Hospital, Addis Ababa, Ethiopia. It compared pre- and post-COVID-19 data from the hospital registry and reports. Specifically, data from March through May, 2019 (pre-COVID-19) were compared to data from March through May, 2020 (during COVID-19). The data were analyzed using SPSS 20.0. Descriptive analyses of the variables are reported as numbers and percentages. Results There were a total of 5179 emergency visits during the study period, of which 2763 were trauma cases (53.4%). Among trauma cases, 1441 (52.1%) were attributable to road traffic injuries. During the COVID-19 period, 1901 patients were admitted, of which 1412 (74.3%) were trauma cases. Of the trauma cases during the COVID-19 period, 476 (33.7%) were attributable to road traffic injuries. There was a 42% decrease in emergency visits during the COVID-19 period. Although there was a 4.5% rise in trauma cases during the COVID-19, traffic injury-related trauma cases decreased by 50.7% during the same period. A significant increase in non-road traffic injury was noted during the lockdown period. These include interpersonal and domestic violence, and significant decreases were noted in multiple site injuries. Further, admissions were significantly decreased. Conclusion During the period of lockdown, there was a significant decrease in road traffic injuries in AaBET hospital and an increase in non-road traffic injuries. Implementation of preventive measures will decrease road-traffic injury burden.

converted public universities' dormitories to increase the capacity of quarantine centers to over 50,000 beds, established additional isolation centers with a total of 15,000 beds, and set up treatment centers with a 5000-bed capacity. 5 As of July 17, 2020, Ethiopia, which has a population of 109 million, reported 9503 cases with 167 deaths and 4941 recoveries. 6 COVID-19 is a major challenge to the provision of trauma care around the world. The Addis Ababa Burn, Emergency and Trauma center (AABET) is located in the capital of the second most populous country in Africa. This opportunity allows researchers to effectively study the effects of COVID-19 on road-traffic injuries, particularly those related to traffic accidents, falls, and interpersonal violence. 7 The goal of this study was to assess the effects of the lockdown on the presentation of patients to AABET's Emergency Department (ED) because of injuries from road traffic and non-road traffic injuries during the pandemic.

Study Area
AaBET Hospital was established in 2015 as a part of St. Paul's Hospital Millennium Medical College (SPHMMC). The hospital's ED has approximately 15-20,000 annual emergency visits. The hospital also provides inpatient/outpatient services, elective and emergency surgeries, orthopedics, and plastic/reconstructive surgery. AaBET hospital was providing routine care and accepting trauma referrals from all over the country while tending to additional needs related to COVID-19.

Study Design and Period
A retrospective, descriptive study design was used. The study period began with the government's implementation of social distancing measures in March, 2020 until the end of May, 2020. The data were compared with the same 3-month period in March-May 2019 before any COVID-19 related measures were implemented to assess its effects during the two years.

Inclusion Criteria
• All trauma patients who presented to the AaBET hospital's Emergency Department during the study period.

Data Collection
A structured data collection sheet was used to collect data from AaBET hospital registries and reports. Demographic data, mode of referral and referral source, triage code, mechanism and type of injury, and patients' outcomes were assessed. The modified South African color triaging system was used which includes red, orange, yellow, and green. Mechanism of injury was assessed as RTI or non-road traffic injuries. Trauma patients' outcomes were assessed as death, discharge, admission, or transfer.

Data Analysis
The data collected were entered into Excel and analyzed with SPSS v. 20.0. Descriptive analyses of variables are reported as numbers and percentages.

Ethical Clearance
A written legal ethical clearance for the study was obtained from St. Paul's Hospital Millennium Medical College IRB.

Results
During the six-month study period (pre-and post-COVID months), 5179 patients were seen in the ED, of which 2763 (53.4%) had sustained trauma.
During the selected three-months period in 2019 and 2020, there was a decrease of 1377 patients (42.0%). The number of trauma patients has increased by 61 (4.5% In 2020, there were more injuries attributable to non-road traffic injuries (142%) than road traffic injury. Furthermore, a 50.2% decrease in road traffic injury (RTI) was noted.
Over the three-month period in 2019, 49 (3.6%) patients triaged to red. In 2020, 116 (8.2%) patients triaged to red. The most common pattern of injuries in 2019 and 2020 were extremity and pelvis injuries at 33.8% and 35.5%, respectively ( Table 2).
The number of patients, both trauma and non-trauma cases, seen in the Emergency Department in 2020 also drastically decreased from 2019. The monthly differences in total patients, trauma patients, road traffic injury, and nonroad traffic injury traumas each year during the lockdown are shown in Figure 1.

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Over the total study period, 923 (33.4%) patients were admitted to the hospital, 1665 (60.3%) were discharged, and 77 (2.8%) patients were referred. The overall mortality rate during the study period was 3.5%.

Discussion
During the lockdown period, the total number of total patients decreased significantly along with road traffic injuries. However, there was an increase in non-traffic injuries. Other reports showed a significant decline in the number of acute trauma patients and admissions after social distancing and lockdowns were implemented. [8][9][10] The number of patients who sustained road traffic injuries decreased by 50.2% in 2020. This could be attributable to the various policies the Ministry of Transport implemented. Effective April 2020, the Ministry of Transport limited the use of private cars. This reduced the number of passengers in cars and readjusted service fees for cross-country public buses. Private cars were used through a rotation system based on the last number of the registration plate. Specifically, odd and even numbers were allowed on the road on alternate days. Further, various initiatives that allowed private and public employees to work remotely may have reduced the number of road traffic injuries in the city. The closure of primary and secondary schools may have played a role in the reduction in the number of cars on the road in the country as well. [11][12][13][14][15][16] This finding suggests the importance of the implementing preventive policies to decrease the burden of road traffic injuries.
In this study, non-road traffic injuries were significantly higher, which corroborates other studies. 10 The decrement in poly-trauma could be attributable to decreases in road traffic injuries. Also, the increase in specific site injuries (head, extremity) could be attributed to an increase in non-road traffic injuries. Studies show that violence and falls lead to injuries to the extremities, pelvic and face. 17 The increase in interpersonal violence during the COVID-19 pandemic has been witnessed globally because of intrafamilial and domestic violence during home confinement. [18][19][20][21] This study also reveals an increase in injuries to the extremities and pelvis, which are common in falls and interpersonal violence. 22,23 The number of trauma patients in our hospital who were admitted decreased significantly during the lockdown period, while discharges and referrals to another healthcare facility increased during the same period. Even though mortality remained relatively the same, the decline in the admission rate and increase in discharge shows that many patients had minor injuries during the lockdown period. As AaBET hospital was not a designated COVID hospital at the time of the study, admission rate was not affected by COVID patients or resources.

Limitations
The study had several limitations. First, there was no detailed analysis of the mechanism of the injury. Hence, further analysis of non-RTI specific injuries is required. Second, the study assessed trauma patients in only one hospital. Therefore, the results cannot be generalized to other hospitals. Our study was limited to a three-month period of two years because of a lack of resources to analyze data from a full year. The most effective intervention occurred during the first three months of the lockdown, which decreased individuals' mobility during the study period. Therefore, we selected these three months (March-May 2020) for the comparative analysis.

Conclusion
This study shows that there was a significant decrease in road traffic injuries during the COVID-19 lockdown period, while there was an increase in injuries attributable to interpersonal violence and falls. The implementation of preventive measures will have a positive effect on decreasing road traffic injury burden.

Abbreviations
AaBET Hospital, Addis Ababa Burn Emergency and Trauma Hospital; ED, emergency department; RTI, road traffic injury; SPHMMC, St. Paul's Hospital Millennium Medical College.

Data Sharing Statement
The data used to support the findings of this study are available from the first author upon request.

Ethical Clearance
A written legal ethical clearance for the study was obtained from St. Paul's Hospital Millennium Medical College IRB. St. Paul's Hospital Millennium Medical College IRB does not require patient consent to review medical records as it does not impose harm on the patients. Patient's data were kept confidential and compliant with the principles of Declaration of Helsinki.

Author Contributions
All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Funding
There was no funding for this study.

Disclosure
The authors declare no conflicts of interest in relation to this work.