Discussion
The COVID-19 pandemic had a massive effect on the world. There was a change in the number and distribution of trauma seen during the pandemic. Patients visiting the outpatient department for routine ophthalmic care at a tertiary care hospital reduced from 9316 in prelockdown to 853 postlockdown. The unlock phase from August to December 2020 showed a rise to 5476, but it was still less than the regular numbers. This may be due to decreased occupational exposure and decreased vehicular traffic, which were few consequences of the lockdown imposed. This hypothesis is supported by the decrease in outdoor ocular trauma during lockdown when compared with prelockdown. Other supporting reasons are peoples’ preference to visit a nearby healthcare facility as there were stricter travel restrictions and there were no public transport facilities. Also, immense fear in people’s minds towards COVID-19 dedicated healthcare facilities (study area was one among them) may be another supporting reason. An important point to note is that many hospitals and clinics remained shut due to the lockdown, reducing the accessibility of healthcare.
A large proportion of patients visiting a tertiary healthcare institute belong to the lower-middle socio-economic class and the class of migrant workers, who migrate to the cities from other states in search of livelihood. They stay away from their homes and families to earn money, and they constitute almost 90% of India’s workforce. The lockdown stranded lakhs of such workers in a place foreign to them and many lost their jobs. After the initial 58-day lockdown, large scale camps were conducted to help such workers return to their homes. This resulted in an egress of almost 43% of the population from urban back to the rural areas.10 This reduction in the urban population could be a factor for the decrease in incidence of ocular trauma during the lockdown period.
With reduction in outdoor activities and traffic on the roads, the trauma occurring outdoors saw a steep decline. When compared with prelockdown levels road traffic accidents decreased by 22% in the lockdown and outdoor assaults decreased by 45.1%. However, there was an increase in home-based assaults by 150% during the lockdown than the prelockdown levels. Suicidal ocular trauma, which was not seen in the prelockdown period was present in the lockdown and unlock phases. An increase in suicidal tendencies during the pandemic has been supported by many other studies,11 12 and the increase seen in the present study could be indicative of the same.
The trauma sustained under the influence of alcohol reduced by 56% during the lockdown and during the unlock, it was comparable to the prelockdown period which may be due to government’s complete ban on sale of alcohol during the lockdown. However, there was an increase in home-based trauma on females, amounting to domestic violence and sexual assaults.13 Sexual assaults increased from 0.2% in prelockdown to 1.7% during the lockdown. The percentage of females involved in trauma increased by 18% in the lockdown. The unlock phase saw a similar trend as seen above but number were higher as compared with lockdown. This may be due to persistent fear towards COVID-19 dedicated healthcare facilities or inadequate monetary resources as a consequence of the unemployment even during the unlock period. This may be due to reflection of mental stress of husbands/other household members onto household women because of unavailability of alcohol to chronic alcoholics, financial strain, the mandate to stay at home and absence of various types of entertainment people used to enjoy in the prelockdown period. This could be a representation of the deterioration of mental well-being in the population. The mental health situation in India was complicated by the high burden of pre-existing mental health issues, stigma associated with getting necessary psychological therapy, a large at-risk population and illiteracy and ignorance coupled with vast false information being portrayed in the media.14
The importance of adding hospital-based trauma in the study was to bring out the assaults against doctors that faced a historic high during the pandemic and lockdown. Violence against doctors is not a new occurrence. However, the increase in hospital-based trauma against doctors has been exemplified in the study. Three doctors who faced assaults in the hospital sustained ocular trauma during the lockdown, which was a small fragment of what was really happening in the world.15
The trends seen in the study are not localised to one area, but have been seen to corroborate with studies carried out in other parts of the country and the world. A thorough review of literature showed few similar studies done in India and other parts of the world. An Indian study carried out in Chhattisgarh, India, published results that corroborated the findings of the present study.16 68.6% of the presenting patients were from a rural background and home-based injuries (78.8%) were the predominant cases. A similar study carried out in the USA showed that the patients also had delayed presentation to the hospital owing to financial and transport difficulties.17 A study in Italy showed a decrease in child and adolescent trauma, which could be due to the closure of schools and a reduction in children playing outdoors.18
The above findings are in contrast with a study carried out in the UK showing that ocular trauma during the lockdown increased by almost three times compared with the prelockdown average. Injuries sustained due to falls and home improvement projects were a major cause for this increase.19
The drastic changes that were seen in the society due to the lockdown threw light on various lacunae in the healthcare service delivery that were required to be filled. The need to improve the literacy rate so that people can understand and opinionate themselves on the happenings in the world, is of utmost importance. The biggest challenges that were faced was the weakness of the peripheral healthcare system, lack of transport facilities, financial strain and stressors worsening the psychological well-being. Strengthening the healthcare system, both hospital-based, remote mobile vehicle based and telemedicine is an aspect that needs attention. Healthcare can be made more accessible to people by establishing more and strengthening the existing mobile units. This can help ensure a better distribution of essentials and basic drugs. Telecommunication has improved leaps and bounds in the last few years and advantage has to be taken to provide medical and psychological support to remote areas, seeing that the majority of patients of trauma were from rural backgrounds.
The limitation to the study was that it was conducted based on the hospital records. Also, the study was based in a single tertiary care hospital which could have caused sampling bias.