Research Article: Epidemiology of pediatric surgical needs in low-income countries

Date Published: March 3, 2017

Publisher: Public Library of Science

Author(s): Elissa K. Butler, Tu M. Tran, Neeraja Nagarajan, Joseph Canner, Anthony T. Fuller, Adam Kushner, Michael M. Haglund, Emily R. Smith, Ana Paula Arez.


According to recent estimates, at least 11% of the total global burden of disease is attributable to surgically-treatable diseases. In children, the burden is even more striking with up to 85% of children in low-income and middle-income countries (LMIC) having a surgically-treatable condition by age 15. Using population data from four countries, we estimated pediatric surgical needs amongst children residing in LMICs.

A cluster randomized cross-sectional countrywide household survey (Surgeons OverSeas Assessment of Surgical Need) was done in four countries (Rwanda, Sierra Leone, Nepal and Uganda) and included demographics, a verbal head to toe examination, and questions on access to care. Global estimates regarding surgical need among children were derived from combined data, accounting for country-level clustering.

A total of 13,806 participants were surveyed and 6,361 (46.1%) were children (0–18 years of age) with median age of 8 (Interquartile range [IQR]: 4–13) years. Overall, 19% (1,181/6,361) of children had a surgical need and 62% (738/1,181) of these children had at least one unmet need. Based on these estimates, the number of children living with a surgical need in these four LMICs is estimated at 3.7 million (95% CI: 3.4, 4.0 million). The highest percentage of unmet surgical conditions included head, face, and neck conditions, followed by conditions in the extremities. Over a third of the untreated conditions were masses while the overwhelming majority of treated conditions in all countries were wounds or burns.

Surgery has been elevated as an “indivisible, indispensable part of health care” in LMICs and the newly formed 2015 Sustainable Development Goals are noted as unachievable without the provision of surgical care. Given the large burden of pediatric surgical conditions in LMICs, scale-up of services for children is an essential component to improve pediatric health in LMICs.

Partial Text

The burden of surgical conditions in low-income and middle-income countries (LMICs) is striking with an estimated 5 billion people lacking access to surgical care when needed[1,2] and the burden among children similarly high[2–4]. Many pediatric conditions requiring surgery carry the risk of life-long disability or higher risk of mortality given that the conditions arise during the years of critical development[5]. Thus, children represent a population with unique surgical needs, including anesthetic, perioperative, and postoperative capacity requirements.

Data was collected by the SOSAS survey, a validated cross-sectional, cluster-based population survey in four countries: Nepal, Rwanda, Sierra Leone, and Uganda[8–11]. The survey was administered in Rwanda in 2011, Sierra Leone in 2012, Nepal in 2014, and Uganda in 2014. Nepal, Rwanda, Sierra Leone, and Uganda are low-income countries with vastly different child health indicators than the United States (Table 1). Life expectancy is lower than the United States by 29 years in Sierra Leone, 19 years in Uganda, 16 years in Rwanda, and 10 years in Nepal. The percentage of the population under the poverty line is much higher in all 4 countries, with the highest percentage in Sierra Leone (53%) followed by Rwanda (23%). Neonatal, infant, and under-5 mortality rates per 1,000 live births are 5 to 17 times higher than the US rates. Compared to the US population where 19% is under the age of 15, 34% to 48% of the 4 LMIC populations are under 15.

A total of 13,806 total respondents were surveyed in Nepal (96.8% of eligible household responded), Rwanda (99.9% of eligible households responded), Sierra Leone (98.3% of eligible household responded), and Uganda (96.4% of eligible households responded). Of these SOSAS survey respondents, 6,361 (46.1%) were children (Table 2). Children in Rwanda were slightly younger than the other countries with a median age of 7 years (interquartile range [IQR] 3–11) and children in Nepal were slightly older with a median age of 10 years (IQR 5–15) (p-value <0.0001). There were similar proportions of males to females in each country with 51.5% male and 48.5% female, overall (p-value 0.9). Over 75% of all survey respondents reported living in rural areas with the greatest percentages in Rwanda (90.6%) and Uganda (81.8%) followed by Nepal (71.0%) and Sierra Leone (62.9%) (p-value <0.0001). The median number of persons within each household ranged from 5 members in Nepal, Rwanda, and Uganda to 6 members in Sierra Leone (p-value <0.0001). This study combines data from four low-income countries to better elucidate the burden of surgical disease in pediatric populations in these LMICs. Overall, there is a high burden of unmet surgical need in the pediatric population of these countries. Nearly 20% of children had a surgical need, and 62% of those children had at least one unmet surgical need. Extrapolating these estimates to the current pediatric populations in the four countries equates to an estimated 3.7 million children in need of surgical care[12].   Source:


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