Will the high acceptance rate of coronavirus disease 2019 vaccine in Morocco accelerate the recovery of neurosurgical practice?
- Department of Neurosurgery, Ibn Tofail Hospital, Mohammed VI University Hospital, Marrakesh, Morocco.
Farid Zahrou, Department of Neurosurgery, Ibn Tofail Hospital, Mohammed VI University Hospital, Marrakesh, Morocco.
DOI:10.25259/SNI_690_2021Copyright: © 2021 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Farid Zahrou, Yassine Ait M’barek, Tarik Belokda, Badr Drai, Hasna Abdourafiq, Lamia Benantar, Khalid Aniba. Will the high acceptance rate of coronavirus disease 2019 vaccine in Morocco accelerate the recovery of neurosurgical practice?. 30-Sep-2021;12:486
How to cite this URL: Farid Zahrou, Yassine Ait M’barek, Tarik Belokda, Badr Drai, Hasna Abdourafiq, Lamia Benantar, Khalid Aniba. Will the high acceptance rate of coronavirus disease 2019 vaccine in Morocco accelerate the recovery of neurosurgical practice?. 30-Sep-2021;12:486. Available from: https://surgicalneurologyint.com/surgicalint-articles/11141/
Background: In developing countries, where there is a chronic shortage of neurosurgeons and medical infrastructures, the pandemic has taken a heavy toll on neurosurgical activities. In the absence of a curative treatment, reaching herd immunity through mass vaccination campaigns is the best hope we have of ending this pandemic. Therefore, the purpose of our study was first to assess the effect of coronavirus disease 2019 (COVID-19) outbreak on neurosurgical services of a Moroccan tertiary hospital. Secondarily, we aimed to describe current vaccination compliance rate in our country, and its impact on the recovery of neurosurgical practice.
Methods: To examine how COVID-19 challenged the neurosurgical delivery of care in our unit, we compared emergency and elective admissions during COVID-19 and pre-COVID-19 period using the registry of neurosurgery department. Second, after evaluating vaccine acceptance rates among 1463 healthcare workers and patients admitted to our hospital, we compared the number of surgeries performed in our department after implementation of a mass vaccination campaign.
Results: The overall number of procedures dropped from n = 197 (pre-COVID-19) to n = 150 during COVID-19. The number of elective surgeries declined from an average of 10.5 operations per week before COVID-19 to four surgeries per week during the COVID-19 pandemic. Conversely, an average of 3.5 emergency operations was performed each week before COVID-19 compared to 5.6 per week during the pandemic. On the other hand, our results showed that willingness to get the COVID-19 vaccine among the participants was high (81.7%) with significantly less hesitant individuals among healthcare workers (P = 0.001). This successful vaccine rollout helped resuming gradually elective surgeries in our department.
Conclusion: Our study found a high acceptance rate of COVID-19 vaccines among Moroccans, which gives a glimmer of hope of restoring all our neurosurgical services. However, despite the high acceptance rate, the authorities must address concerns among hesitant individuals and raise awareness on the importance of COVID-19 immunization.
Keywords: Acceptance, Coronavirus disease 2019, Impact, Neurosurgery, Vaccine
In December 2019, coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged in Wuhan, China.[
In Morocco, the first case of COVID-19 was reported on March 2 in Casablanca, 2020.[
To overcome this pandemic and recover from its devastating human, social and economic impact, all countries around the world try to get enough COVID-19 vaccines to immunize their communities. Morocco was no exception in this regard. Despite its limited resources, the North African kingdom has one of the most advanced vaccination programs. The country launched a nationwide vaccination campaign on January 28, aiming to vaccinate 80% of its citizens.[
However, utility of vaccine campaigns is not merely dependent on vaccine availability and affordability. In fact, vaccine hesitancy remains a global challenge even among healthcare workers and appears to have a decisive role in the successful control of the pandemic.[
Study design and data collection
To assess the impact of the COVID-19 pandemic on neurosurgical practice in Morocco, a single-center retrospective epidemiological study was conducted in our hospital, which is one of the major hospitals in our city, based in an urban area of 1.3 million inhabitants.
First of all, we described the global epidemiology of COVID-19 in our city based on the COVID-19 online database created by the Moroccan Ministry of Health.[
To examine how COVID-19 challenged the neurosurgical delivery of care in our unit, we compared emergency and elective admissions during COVID-19 and pre-COVID-19 period using the registry of neurosurgery department. All neurosurgical procedures performed in our department between March 2, 2020, and June 28, 2020, were enrolled in our study. Data collected were: the surgery date, the number, and the types of surgical procedures performed during the study period. We also classified patients according to surgical urgency. Urgent cases included:
Brain tumor with cerebral herniation on MRI or worsening symptoms or acute hydrocephalus Skull base tumors with worsening symptoms or visual disturbances Acute hydrocephalus, shunt malfunction, and ruptured spina bifida Aneurysm rupture or other acute vascular diseases Neurotrauma, vertebro-medullary trauma, cauda equina syndrome, acute spinal cord compression, and paralyzing disk herniation.
Brain tumor with cerebral herniation on MRI or worsening symptoms or acute hydrocephalus
Skull base tumors with worsening symptoms or visual disturbances
Acute hydrocephalus, shunt malfunction, and ruptured spina bifida
Aneurysm rupture or other acute vascular diseases
Neurotrauma, vertebro-medullary trauma, cauda equina syndrome, acute spinal cord compression, and paralyzing disk herniation.
Apart from these emergencies, the rest of the patients were included in elective surgery group. These data were then compared to those obtained in the “pre-COVID-19 period” (from March 2, 2019, to June 28, 2019), to assess the impact of the pandemic.
Second, to evaluate vaccine acceptance rates among Moroccan population, we distributed an anonymous questionnaire from January 1, 2021, to January 31, 2021, just before the beginning of the mass vaccination program in Morocco to healthcare workers and patients admitted to our hospital within the study period. The questions were related to socio-demographic characteristics (age, gender, area of residence, marital status, and parenthood status), education level, employment status, financial status, underlying diseases, perceptions, risk factors for COVID-19, and willingness to get COVID-19 vaccination. With reference to previous studies,[
Finally, to assess the early impact of the national vaccination program on neurosurgical activity in our hospital, we compared elective and urgent procedures performed in our department before (from March 2, 2020, to June 28, 2020) and after implementation of a mass vaccination campaign against COVID-19 in Morocco (from March 2, 2021, to June 28, 2021).
Statistical analysis was performed using the Statistical Package for the Social Sciences version 25. Mean and standard deviation was calculated to describe continuous variables while numbers and percentages were used for categorical variables. Descriptive analysis and Chi-square tests were used to evaluate the data and assess the statistical significance of observed differences between cohorts before and during the COVID-19 pandemic. P < 0.05 was considered significant.
COVID-19 in Morocco
Since the report of the first case on March 2, 2020, and until June 28, 2021, the cumulative number of confirmed cases reached 529,895 cases with 9,283 deaths and a cumulative incidence of 1456, 3 per 100,000 inhabitants.[
Marrakech is the fourth largest city in the Kingdom with 1329,850 inhabitants. The Red City was ranked 9th best global destination in 2019 by TripAdvisor.[
Hospital organization and the phases of the pandemic at our Hospital
After announcing the country’s first case of COVID-19 on March 2, a full reorganization of the health system was initiated countrywide to overcome the chronic weakness of medical infrastructure and the lack of resources. We divided our experience during this period into two phases: phase 1 (March 2-27, 2020) in which the activity remained almost normal and phase 2 (March 28 – June 28, 2020) during which Mohammed VI university hospital was completely devoted to COVID-19 admissions, while our hospital was d assigned to manage all non-COVID patients with urgent neurosurgical pathology. At the beginning of phase 2, our hospital, which became the only hospital in the region admitting neurosurgery patients, had to be on high alert to contain the influx of patients and to ensure safety of health-care providers and neurosurgical patients.
Emergency and elective neurosurgical operations performed before and during COVID-19 at our hospital
We divided our patients into two groups: those requiring immediate surgical procedure and those waiting for scheduled surgery before and during COVID-19 pandemic. The total number of procedures dropped from n = 197 (preCOVID-19) to n = 150 during COVID-19. Conversely, the number of emergency operations increased during COVID-19 (n = 95) compared to pre-COVID-19 period (n = 58). Before the pandemic, an average of 3.4 emergency operations was performed each week compared to 5.6 per week during COVID-19 [
Concerning elective surgery, the overall number of operations declined from an average of 10.5 elective operations per week before COVID-19 to 7, 25 per week during phase 1 and 2, 9 per week during phase 2 [
The analysis set consisted of 1463 participants. Among the participants, 98 (6.7%) were medical doctors, 145 (9.9%) were nurses or paramedics, and 1220 (83.4%) were patients admitted to our hospital during the study period. The main characteristics of the participants are summarized in [
Overall, willingness to get the COVID-19 vaccine was high, 45.9% of the participants were very likely and 35.8% were likely to be vaccinated, while 5.8% were undecided. Further analysis revealed that vaccine acceptance rates were significantly higher among healthcare workers (90.6%) than patients (80%; P = 0.001). Furthermore, the main reasons for vaccine hesitancy were fears of the vaccine’s safety and concerns over efficacy and future unknown effects of the vaccine [
The early impact of COVID-19 vaccination campaign on neurosurgical practice
Our findings showed that the total number of procedures increased from n = 150 (before vaccination) to n = 179 after starting a mass vaccination campaign in our country. However, the number of urgent operations decreased after implementation of the vaccination campaign to approach the average number found in the pre-COVID 19 period. Concerning elective surgery, the number of procedures increased from an average of 4 elective operations per week to 7.5 per week after starting the vaccination [
The analysis of the distribution of operations per neurosurgical subspecialty revealed a statistically significant increase after implementation of the national vaccination campaign in tumor surgery (P = 0.049) and endoscopic surgery (P = 0.019). In contrast, we noted a statistically significant decrease in trauma surgeries (P = 0.001) and spine surgery (P = 0.04) after starting COVID-19 vaccination (P = 0.001) [
COVID-19: A global health crisis
The coronavirus COVID-19 pandemic is the defining global health crisis of our time and the greatest challenge we have faced since World War Two. Since its emergence in Asia in December 2019, the virus has spread to every continent and nearly every country on earth. In the absence of effective treatments, many countries have responded by implementing several non-pharmaceutical interventions to halt the spread of the virus and limit the number of fatalities: social distancing, cancellation of public events, school closures, workplace closures, isolation and quarantine for infected people, and internal and international travel restrictions. The effectiveness of these containment measures remains unclear, but the number of reported cases in many countries increased rapidly after the release of lockdown measures. As of Monday May 31, 2021, over 170 million coronavirus cases have been reported and over 3.6 million people have died of COVID-19 worldwide. The USA, India, and Brazil have recorded the highest number of confirmed cases, followed by France, Turkey, Russia, and the United Kingdom (UK). Moreover, the number of cases and deaths in Africa has increased at a faster rate in the last weeks compared to the other waves. This is driven by several factors including public fatigue, social mixing, ineffective use of public health and social measures, vaccine inequity, and the spread of new variants.[
On the other hand, several coronavirus vaccines have been approved for use, either by individual countries or groups of countries, such as the European Union and the WHO.[
Neurosurgical impact of COVID-19 outbreak
The COVID-19 pandemic is a health crisis of unprecedented proportions that has taken a heavy toll on various aspects of the society. Health systems are facing the most serious global pandemic crisis in a century. To contain the spread of novel coronavirus COVID-19 and reduce the pressure on health systems, numerous guidelines were published by international surgical societies including neurosurgical societies.[
To manage vital health-care resources during this public health emergency, national and international societies suggested stopping all elective activity and maintaining only emergent and urgent procedures.[
On the other hand, our findings showed that the number of urgent surgeries performed in our department increased during the pandemic, compared to the preCOVID 19 period. This can be explained by the fact that our department became the only hospital in the region admitting neurosurgery patients, since the other hospitals were devoted to COVID-19 cases. We also noticed that during the pandemic the number of neurotrauma cases increased by approximately 10% compared to the pre-COVID-19 period, although road traffic accidents declined during lockdown. This can be explained by the significant increase of interpersonal violence documented by many reports, the increased unstructured time and the socioeconomic impact of the pandemic resulting in higher unemployment.[
Neurosurgical training and education have also been significantly affected by this pandemic. In fact, neurosurgery departments worldwide have been forced to restructure their training programs to handle this healthcare emergency. According to a continental survey on the impact of COVID-19 on neurosurgical training in Africa, only 41% of the respondents had received training in COVID-19, although many African countries do not have formal neurosurgery training schemes or fellowship opportunities.[
In light of the above, successful control of COVID-19 infections and deaths at the international level seems to be important in ensuring continuation of neurosurgical training and provision of neurosurgical services. This objective can only be achieved through mass vaccination campaigns to reach herd immunity. However, despite the huge efforts made by health authorities, a major hindrance can be related to vaccine hesitancy.
Based on the Strategic Advisory Group of Experts on Immunization, vaccine hesitancy is the term used to describe: “delay in acceptance or refusal of vaccination despite availability of vaccination services.”[
Our survey results found high vaccine acceptance rates among our healthcare workers and our patients. In fact, the vast majority of the participants (81.7%) are willing to take up a COVID-19 vaccine if offered. While only 18.3% are still hesitant or refusing to get vaccinated. The previous studies have also studied this global phenomenon and revealed the existence of regional variability in COVID-19 vaccine acceptance rates. According to a systematic review assessing the acceptances rates in different countries worldwide, the highest vaccine acceptance rates (>90%) among the general population were reported by four studies from Ecuador (97.0%), Malaysia (94.3%), Indonesia (93.3%), and China (91.3%). On the opposite, the lowest vaccine acceptance rates (<60%) among the general public were found in seven studies from Kuwait (23.6%), Jordan (28.4%), Italy (53.7), Russia (54.9%), Poland (56.3%), US (56.9%), and France (58.9%). However, this topic has not been explored to a large degree in Africa. Therefore, more studies are needed to address COVID-19 vaccine hesitancy in this continent.[
Finally, the main reasons for vaccine hesitancy in our study were fears of the vaccine’s safety and concerns over efficacy and future unknown effects of the vaccine. The same concerns were reported by Dror et al. in Israel[
The early impact of the COVID-19 vaccination campaign: Signals of hope
Morocco launched its ambitious COVID-19 vaccination campaign on January 28, 2021, seeking to vaccinate 80% of its adults. The king of Morocco, as the spiritual leader of the nation, was the first Moroccan to be vaccinated, giving an essential boost to the vaccination campaign. Despite monumental challenges, the African country is among the world’s pioneers in vaccinating its population against COVID-19. On June 28, 2021, the total number of people fully vaccinated against COVID-19 in Morocco reached 8954030 (about 25.6% of Moroccan population), while a total of 9908882 first doses of COVID-19 vaccines have been administered.[
In fact, it is too early to evaluate the real impact of the vaccination campaign. However, the ministry of health has carried out a comparative analysis on the epidemiological situation in Morocco and the UK based on the number of cases, the vaccination rate and the number of deaths. This study, which covered the period from January to August 2021, showed that, despite rising COVID-19 cases, the infection fatality rate of the disease is less than in the early stages of the pandemic thanks to vaccination. As of August 6, 2021, the case fatality rate was 0.6% in Morocco for a vaccination rate of 29.4% versus 0.2% in the UK for a vaccination rate of 57.9%.[
Concerning the early impact of the COVID-19 vaccination campaign on neurosurgical activities in our country, our findings showed that the number of elective surgeries performed in our department increased after the start of the vaccination campaign. This can be explained by several factors. First of all, the number of COVID-19 patients admitted to hospital ICUs decreased after the implementation of the vaccination campaign. Furthermore, the relative stability of the epidemiological situation in Morocco allowed surgeons to go back to their departments and to resume their professional activities. As mentioned above, to minimize the risk of acquiring COVID-19 infection while managing patients, we reorganized our surgical team into three groups. However, we resumed the traditional staff scheduling after all the team members got fully vaccinated. Therefore, our hospital was given the green light to gradually begin ramping-up elective surgeries and procedures. Nevertheless, vaccination alone is not enough to contain the pandemic. The healthcare workers should respect safety measures to avoid exposure to nosocomial infection for both patients and surgical teams.
Strengths and limitations of our study
Our study has several strengths. First, our study provided answers to two topics. On one hand, it revealed the neurosurgical impact of COVID-19 pandemic in Morocco. Moreover, on the other hand, it highlighted the high acceptance rate of COVID-19 vaccine among our participants, which can help controlling the pandemic, to restore all neurosurgical services. Second, to the best of our knowledge, this is the first study in Morocco to assess the acceptance regarding COVID-19 vaccines and the reasons why a COVID-19 vaccine would be refused. It also did so just before the launch of the vaccination campaign in Morocco on January 28, 2021. The country is now rolling out a successful vaccination program starting with the oldest and most vulnerable population groups. Finally, our survey covered healthcare workers as well as patients and compared responses to identify differences.
There are also limitations of our study which should be noted. First of all, concerning neurosurgical impact of the pandemic, the number of patients included was small due to the relatively short study period. A larger period could have been investigated but would not have been more relevant to evaluate the impact of the pandemic on neurosurgical activities. Moreover, the study was retrospectively performed in a single center and may therefore involve selection bias. We further did not analyze the impact of COVID-19 on patient outcomes because we could not exclude the possibility of unmeasured confounding factors. Another limitation is Morocco’s infection rates during the early phase of the COVID-19 pandemic which were low compared with those of other countries.
The whole world is experiencing an unprecedented health crisis that has profoundly impacted all aspects of society, including neurosurgical activities. Our results highlighted how difficult is managing neurosurgical services during this pandemic in developing countries which cannot support any additional pressure on their health care systems. However, our study also found a high rate of acceptance of COVID-19 vaccines among Moroccans, which gives a glimmer of hope. Despite the high acceptance rate, the Moroccan authorities must address concerns among hesitant individuals and raise awareness on the importance of COVID-19 immunization, so that we can return soon to our normal life.
The authors certify that they have obtained all appropriate patient consent.
Publication of this article was made possible by the James I. and Carolyn R. Ausman Educational Foundation.
There are no conflicts of interest.
The authors certify that they have obtained all appropriate patient consent.
Publication of this article was made possible by the James I. and Carolyn R. Ausman Educational Foundation.
There are no conflicts of interest.
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