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. 2024 Jul 11;19(7):e0306836. doi: 10.1371/journal.pone.0306836

Impact of the Soweto football derby on the trauma emergency department at Chris Hani Baragwanath Academic Hospital, a tertiary level hospital in South Africa

Charles Baggott 1,*, Deirdré Kruger 1, Riaan Pretorius 1,2
Editor: Uday Bhaskar Manda3
PMCID: PMC11239021  PMID: 38990814

Abstract

Introduction

The Soweto Derby is one of Africa’s largest football derbies. The two rival teams, Kaizer Chiefs and Orlando Pirates, both originate in Soweto, a sprawling township 20km outside Johannesburg. Soweto is infamous for the high levels of violent crime and trauma, but also for Chris Hani Baragwanath Academic Hospital (CHBAH), with one of the world’s largest trauma emergency departments (ED). Research globally, describing the impact of sports events on public health care systems is conflicting, with evidence showing both increases and decreases in spectator related trauma. This paper seeks to describe the trauma burden during the Soweto Derby and add to the research concerning trauma relating to sporting derbies in low to middle income countries.

Objectives

To analyze the impact of the Soweto Derby on the trauma ED at CHBAH over a 24-hour period.

Methods

A retrospective comparative study at the CHBAH Trauma ED of 13 Soweto Derbies played over a 5 year period between 2015–2019, compared to the corresponding non-Soweto Derby days of the preceding year. Patients were triaged according to the South African Triage Scale and Advanced Trauma Life Support (ATLS) principles. Data was organized into 3 time frames where the triage score and mechanism of injuries were compared: 1) 4 hours pre-match, 2) 2 hours during the match, and 3) 18 hours post-match.

Results

Thirteen Soweto Derbies and 2552 patients were included. The median age was 29 with males accounting for 73.4% of all trauma cases. Significantly more P1 patients presented during the Soweto Derby. Pre-match there were 3x less P1 patients presenting to the ED (4.7% vs 12%, p = 0.044). During the match, there was a 40% drop in males presenting to ED (5.95% vs 9.45%, p = 0.015). Post-match there was a significant increase in P1 patients treated (17.4% vs 13.5%, p = 0.021)), with the majority being young males. There was no increase in either female or paediatric visits to the ED.

Conclusion

The Soweto Derby has a direct effect on the trauma burden at CHBAH, with more P1 patients presenting post-match. Young African males are disproportionally affected by severe trauma requiring increased health care resources in an already overburdened hospital.

Introduction

South Africa is notorious for its high levels of violent crime and regularly cited as one of the most dangerous societies in the world. Exposure to trauma is commonplace and has negative implications on the quality of life for all South Africans, especially those living in poor socio-economic conditions [1,2]. Soweto, situated south of Johannesburg, was designed as a township for Black people under the Apartheid system. Chris Hani Baragwanath Academic Hospital (CHBAH) is the only tertiary level hospital that services Soweto’s nearly 1.3 million residents. Some of the most violent areas of Soweto are located within a 10 km radius of CHBAH [3].

South Africa’s largest football derby, known locally as the ‘Soweto Derby’, is one of the most recognized football derbies in Africa and draws avid fans from Soweto and neighbouring Johannesburg, as well as the rest of South Africa and abroad. The two football teams involved, Orlando Pirates and Kaizer Chiefs, are both Soweto based and combined attract the largest fan base in the country. CHBAH is situated less than 6.5 km from both home stadiums and is ideally placed to serve trauma patients impacted by the Derby either at the stadium or on television. No Soweto Derbies were played at the traditional home ground of Orlando Pirates, the Orlando Stadium during the research period, which is a much smaller stadium with a capacity of roughly 40000 spectators. By comparison, the FNB stadium accommodates 90000 spectators and is the stadium of choice for both teams due to the scope and magnitude of the event, with its increased capacity, modern facilities, and improved safety options.

Sporting events may have implications for Emergency Departments (EDs). Popular sporting events attract large numbers of people together, creating a sense of community. Conversely, sport can generate heightened emotions, often fueled by increased alcohol consumption, which may result in irresponsible and aggressive behaviour. The pervading culture of toxic masculinity coupled with the intergenerational legacy of oppression and political violence during Apartheid further contributes to Soweto’s trauma burden [1,4]. CHBAH ED is already overwhelmed and may be under resourced to cope with increased trauma admissions related to the Soweto Derby.

Available international literature describing the relationship between trauma and prominent sporting events has been inconclusive, with conflicting evidence demonstrating both an increase and a decrease in sport-supporter related trauma [5–12]. Apart from one study which investigated the impact of trauma and mortality on the Cape Town pediatric population during the 2010 FIFA World Cup, there has been no published literature showing the relationship between the trauma burden and large sporting events in low- to middle-income countries [12].

Therefore, the aim of this study was to determine the impact of the Soweto Derby on trauma patient admissions at CHBAH.

Specifically, we measured the overall burden of trauma during the Soweto Derby over three time periods: before, during and after the Soweto Derby. These time intervals were compared to trauma visits on corresponding non-derby weekends. Drawing on previous research and anecdotal opinions, we hypothesized that there would be an increase in trauma seen post-match.

Methods

This retrospective comparative study was conducted at the Trauma ED of CHBAH.

The dates and times of the Soweto Derby from the years 2015–2019 were recorded. The first records from CHBAH ED were from the 2nd of August 2014 and the last date was on the 9th of November 2019.

The study population data was accessed between 01/08/2022 and 30/09/2022 from the Trauma ED register, recorded manually by triage nurses.

Demographics, triage score, vital signs, mechanism of injury and clinical diagnosis were collected for all trauma patients over a 24-hour period.

This was further divided into 3 intervals:

  1. 4 hours pre-match

  2. hours during the match, comprising two 45-minute halves and an additional 30 minutes consisting of a half-time break and extra-time

  3. 18 hours post-match, commencing from the end of the match

Both adult and paediatric populations were included. Patients younger than 14 years of age were regarded as paediatric patients.

All medical and non-trauma related surgical patients were excluded.

The non-matchday control group was established by accessing data from the corresponding day of the week, during the same time, over the same month of the previous year. For example, the match played on the 1st Saturday of November 2019 (02/11/2019), was compared to the non-match day period during the first Saturday of November 2018 (03/11/2018). This 24-hour period factored in the same time frames; 4 hours pre-match, 2 hours during the match and 18 hours post-match.

The kickoff for all Soweto Derby matches is between 15h00 and 16h00 and concludes approximately 2 hours later. The objective of the control group was to accurately account for similar conditions including seasonal weather changes and other major events that may have occurred during the same period.

Patients were triaged according to ATLS principles and the South African Triage scale, which has been validated in both resource limited settings, as well as high income countries [13,14]. For the purposes of this study, patients were simplified as either P1 or non-P1. P1-patients required immediate emergency management in a resuscitation bay, while non-P1 patients, described traditionally as either P2 and P3, required urgent and non-urgent intervention respectively. Formal triage scores in the trauma setting often under-triage patients if too much emphasis is put on vital signs, as these are often late signs in an evolving pathology. Often the mechanism of injury is more important, and at CHBAH the mechanism of injury is weighted stronger than vital signs, irrespective of how stable the vital signs are.

Patients were occasionally triaged incorrectly. These were amended when reviewed by the doctor, who would upstage or downstage the patients accordingly. This is reflected in the nursing triage records.

The match day continuous data and the corresponding non-match day controls were compared using the Two-sample Wilcoxon rank-sum (Mann-Whitney), with medians and interquartile ranges (IQRs) reported. The Pearson’s Chi-squared test and Fishers’ exact test, where appropriate, were conducted for analyses of categorical data with absolute and relative frequencies reported. Statistical significance was considered for p-values below 0.05.

Permission to access all adult and paediatric data was approved by the CEO of CHBAH. Ethics approval was provided by the Human Research Ethics Committee of the Faculty of Health Sciences at the University of the Witwatersrand. No private information was gathered from the participants. All the participants details have been anonymized and therefore impossible for participants to be identified.

Results

A total of 16 Soweto Derby matches were played during the study period of 2015–2019. Patient information was available for 13 of these matches, of which 11 matches were played at the FNB stadium. All these matches were broadcast live on television. A total of 26 days were assessed, comprising 13 Soweto Derby match days and 13 days of non-match day controls.

Demographic and patient characteristics are shown in Table 1 for the 2552 trauma ED patients included in the study according to whether their admission was during a Soweto Derby match day (n = 1432) or over a control weekend (n = 1120). In total, 312 more trauma patients were admitted on Soweto Derby match days, averaging 24 additional patients per match day, although this difference did not reach statistical significance.

Table 1. Demographic and clinical characteristics of the study population.

Parameter All patients Match day group Control day group P value
n = 2552 n = 1432 n = 1120
Age (years), median (IQR) 29.0 (21.0–36.0) 29 (22.0–36.0) 28.5 (21.0–36.0) 0.65
Adults, n (%) 2171 (85.1) 1226 (85.6) 945 (84.4) 0.38
Paediatrics, n (%) 381 (14.9) 206 (14.4) 175 (15.6)
Sex, n (%)
Male 1895 (74.3) 1059 (74.0) 836 (74.6) 0.69
Female 657 (25.7) 373 (26.0) 284 (25.4)
Mechanism of injury, n (%)
Blunt 1787 (70.0) 1000 (69.8) 787 (70.3) 0.21
Burns 105 (4.1) 51 (3.5) 54 (4.8)
Penetrating 660 (25.9) 381 (26.6) 279 (24.9)
Triage, n (%)
P1 343 (13.4) 210 (14.7) 133 (11.9) 0.04
Non-P1 2209 (86.6) 1222 (85.3) 987 (88.1)
Intubated, n (%) 46 (1.8) 23 (1.6) 23 (2.0) 0.45
Mortality, n (%) 13 (0.51) 6 (0.42) 7 (0.62) 0.58
Road traffic accidents 569 (22.3) 323 (22.6) 246 (22.0) 0.72
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The median (IQR) age was 29 (21.0–36.0) years and did not differ on match vs control day groups. The majority of patients were adults (85.1%) with a median (IQR) age of 30.0 (25.0–38.0) years, while the median (IQR) paediatric age was 6.0 (3.0–9.0) years, with no significant differences found in match vs control day groups (see also Fig 1).74.3% of all patients were male, similar to the control and Soweto Derby groups (p = 0.69; Table 1).

Fig 1. Age distribution of all triaged patients during the Soweto Derby and those in the control group.

Fig 1

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Blunt injuries accounted for the majority of injuries (70.0%) followed by penetrating injuries (25.9%) and burns (4.1%) which did not deviate from the controls, demonstrating no statistical differences in mechanism of injury between Soweto Derby and controls.

From Table 1, there were more P1 patients treated on match days compared to control days (14.7% versus 11.9%, respectively; p = 0.04). However, this did not lead to an increase of intubated and ventilated patients in the resuscitation bays. Moreover, mortality rates in the ED were low (0.51%) and did not increase during Soweto Derby match days.

When analyzing the three time periods covering the 24 hours of Soweto Derby match days, there was no statistical difference in the overall number of patients treated during the time periods on Soweto Derby match days vs control days (p = 0.34). However, during the 4 hours pre-match, there was a statistical decrease in P1 patients treated on Soweto Derby days, with almost three times fewer P1 patients treated before the Soweto Derby (4.76% vs 12.03%, p = 0.044; Fig 2).

Fig 2. Percentage of P1 admissions distributed over a 24-hour period during the Soweto Derby compared to the control group.

Fig 2

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Similarly, during the match time period there was an almost 40% decrease in male patients presenting to CHBAH’s Trauma ED during the Soweto Derby compared to control (5.95 vs 9.45%, p = 0.015; Fig 3), while there was no significant change recorded for either female or paediatric patients.

Fig 3. Percentage of male patients distributed over a 24-hour period during the Soweto Derby days compared to the control group.

Fig 3

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In the period 18 hours post-match, there was a significant increase in P1 patients on Soweto Derby days compared to the control group at 17.4% and 13.5%, respectively (p = 0.021).

There was no significant difference in the frequency of road accidents, either pedestrian vehicle collisions or motor-vehicle collisions between the two study groups, with 22.6% of trauma patients presenting with traffic-related accidents on match days compared to 22.0% in the control group (p = 0.72). However, an unexpected finding showed a significant decrease in traffic accidents when the result of the Soweto Derby ended in a draw, with 16.8% of trauma patients involved in a traffic-related accident, versus 23.4% and 25.4% when Kaizer Chiefs or Orlando Pirates won, respectively (p = 0.009).

Discussion

There have been varied opinions amongst health care workers globally as to whether large-scale sporting events have a modulating effect on healthcare systems [5,7,8,15–17]. Our study is the first to assess the relationship between the trauma burden and large sporting events in a South African setting.

The literature indicates that the nature and frequency of ED visits are influenced by the timing of major football matches. Research internationally has shown a decrease in trauma-related casualties before and during matches, with a rebound increase of trauma-related incidents after a match [12,16,17]. This supports our findings.

By dividing the Soweto Derby day into three specific time periods, the nature and pattern of trauma visits to the ED at CHBAH was differentiated.

Pre-match

There is limited research worldwide describing spectators’ behaviour before major football matches. A Northern Irish study showed a significant decrease in adult ED attendances pre-match while a French paper and results from a Cape Town study showed significantly decreased paediatric visits to ED preceding major football matches [7,8,12].

Our results demonstrated no significant difference in paediatric visits preceding Soweto Derbies, supporting findings by Hughes et al which show a significant decrease in P1 patients treated at CHBAH before the Soweto Derby.

It is postulated that patient and parenteral behaviors change before major sporting events making them less inclined to seek urgent medical attention, fearing missing the match, which would result in fewer ED visits. Patients may also become distracted in the buildup to the match or avoid hospitals, concerned about hospital overcrowding [7,12].

During the match

Our research showed a 40% decrease in men presenting to the Trauma ED during Soweto Derbies. International studies show that more than 65% of spectators are men. It is presumed in Soweto, more men watch the Soweto Derby, and hypothesized that male spectators shift their attention from their own ailments to the Soweto Derby, delaying hospital visits until after the match.

Intoxicated fans may only register the severity of their injuries after sobering up post-match [6,9]. In a retrospective study from Portugal examining Lisbon’s largest football Derby, 20% less patients were treated during the match. Alesandrini et al reported that paediatric visits to French hospitals, including children accompanied by their fathers, decreased significantly when the French national team played [15].

18 hours post-match

There was a significant increase in P1 patients treated at CHBAH in the post-match period compared to the control group. A local study by Bhana et al showed Saturdays and Sundays accounted for 48% of trauma visits to CHBAH with the majority of patients treated between 18h00 and 06h00. This is consistent with this paper’s findings where the18 hours post-match period were the busiest time for ED visits to CHBAH [3].

The Soweto Derby exacerbates problems seen every weekend which highlights the disproportionate levels of violence evident in this community, experienced mainly by young disadvantaged men, against the background of irresponsible alcohol use.

Role of alcohol

Retrospective data on alcohol use was not available for this study, but there is a strong association worldwide between spectator binge drinking and sporting events [18,19]. This may be exacerbated in South African context, which has some of the highest per capita drinking rates globally. Two studies have shown that 45–59% of men treated in South African ED’s are under the influence of alcohol [2,20,21]. Furthermore, disadvantaged communities like Soweto, suffer disproportionately from alcohol attributable morbidity and mortality rates [18,22]. The increased number of P1 patients treated after the Soweto Derby may be attributable to alcohol abuse and may account for the rebound effect of increased ED visits post-match [9,12,16,17]. Worldwide ED admissions during the COVID-19 pandemic dropped dramatically worldwide following national alcohol restrictions, emphasizing the dangerous role alcohol plays and the consequent impact on trauma visits [23].

P1 admissions

International literature shows that the number of patients requiring hospitalization increases significantly during large sporting events, despite the total number of ED visits not being affected, which is also reflected in our findings [9]. The total number of patients seen in the CHBAH ED during the Soweto Derby was not statistically different to the control group, but there were significantly more severely affected P1 patients requiring increased hospital resources and interventions.

There are only 12 ventilators in the resuscitation bay at CHBAH ED which are all in use most Saturday nights. The increased P1 burden of Soweto Derbies may result in compromised patient care, as no further ventilators are available.

Impact of gender and age on ED visits

The overwhelming majority of trauma patients in our research are men (74.3%). There was no significant change to paediatric or female ED visits during Soweto Derbies, contrary to international research, which shows an increase in domestic violence, primarily directed towards women and children during major sporting events [11,22].

Match outcome and violence

Research has shown that match outcomes effects spectators’ levels of aggression. Winning and upset losses result in more testosterone-related aggression and this leads to higher rates of drinking [18,22,24,25]. resulting in aggressive driving practices after winning and after upsets. Both Kaizer Chiefs and Orlando Pirates fans affected by trauma in Soweto would be seen at CHBAH, irrespective of the score line. A win for either team may lead to increased aggression and negligence on the road.

Our results point to a significant decrease in motor vehicle-related accidents when the match result was drawn, potentially due to a decrease in aggressive driving.

Limitations

Patients were not followed up post-admission, consequently this paper is unable to establish whether there were increased mortality rates resulting from injuries relating to the Soweto Derby.

Ambulance services at CHBH are regularly overwhelmed on weekends [3]. Patients who were injured during the football match, may have called for an ambulance timeously, but constrained emergency resources may have resulted in patients receiving emergency services only after the match, thereby increasing patient load post-match.

Blood alcohol levels were not routinely tested. This information would have strengthened the research.

Strengths

A total of 2552 trauma patient’s records over six years were gathered. This large population strengthened the validity of the results.

The method of deriving the control group was an advantage.

Weekends account for 48% of all trauma presentations at CHBAH. Most ED visits at CHBAH occur on Saturdays between 18h00 and 06h00. The Soweto Derby is always played on a Saturday at the same starting time at 16h00 with the match ending around 18h00. This correlates to the busiest period of the week at CHBAH ED [3]. The control accounts for this.

The most violent areas in Soweto are located within a 10km radius of CHBAH [3]. As there aren’t any other trauma facilities nearby, all serious trauma is directed to CHBAH. Therefore, the number of trauma cases seen at CHBAH reflects the actual trauma burden, which are exacerbated by the Soweto Derby.

Conclusion

The Soweto Derby has a direct effect on the trauma burden at CHBAH. The rate and the type of trauma treated at CHBAH ED are statistically different before, during and after the Soweto Derby. There are less P1 patients treated before the derby, while during the derby, fewer males present to the ED. Conversely, there is a significant increase in the amount of P1 trauma at CHBAH post-match. Disadvantaged African males bear the brunt of violent trauma in Soweto. Neither women nor children’s rates of trauma increased as a result of the Soweto Derby.

Further prospective studies are necessary to direct policy changes and improve collaboration between civil society and local government to more effectively address Soweto Derby spectator aggression. This information may also strengthen the planning and implementation of trauma responses at CHBAH, to make the Soweto Derby safer.

Supporting information

S1 Table. Types of injuries seen during the Soweto Derby and the control.

(DOCX)

pone.0306836.s001.docx (16.1KB, docx)

Data Availability

All relevant data are within the manuscript and its Supporting information files. Data cannot be shared publicly because patient confidentiality has to be maintained. Data are available from the University of the Witwatersrand Human Research Ethics Committee (contact www.witsethics.co.za/) for researchers who meet the criteria for access to confidential data.

Funding Statement

The author(s) received no specific funding for this work.

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Decision Letter 0

Donovan Anthony McGrowder

12 Mar 2024

PONE-D-24-00705Impact of the Soweto Football Derby on the trauma emergency department at Chris Hani Baragwanath Academic Hospital, a tertiary level hospital in South AfricaPLOS ONE

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Dear Dr. Baddott,

 Your manuscript “Impact of the Soweto Football Derby on the trauma emergency department at Chris Hani Baragwanath Academic Hospital, a tertiary level hospital in South Africa” has been assessed by our reviewers. They have raised a number of points which we believe would improve the manuscript and may allow a revised version to be published in PLOS ONE. Their reports, together with any other comments given are below.

 If you are able to fully address these points, we would encourage you to submit a revised manuscript to PLOS ONE by the date given below.

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Dr. Donovan McGrowder

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Reviewers' comments:

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Comments to the Author

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Reviewer #1: Yes

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

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Reviewer #2: Yes

**********

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Reviewer #1: Dear colleagues,

thank you very much for allowing me to review your important wor. You have worked on an very interesting topic both LMIC and high income countries, but maybe has a higher burden on heath care systems with restricted resources.

In your results, please elaborate more in detail on the respective injuries and on outcome of the patients in both groups. Currently, no details on injuries and patients condition, as well as interventions were reported. Secondly, please consider to perform a matched pairs analyses between your intervention and your standard group with e.g. mortality in the ED as your common endpoint. By doing so, you would give the reader a better and broader picture of what happend in your department.

Furthermore I have some more minor comments. First, please re-write the methods section in your abstract since currently it is not easy to understand. Secondly, figure 2 is not easy to understand as well. Please make sure that all figures are exactly showing what you want to demonstrate to the reader. Thirdly, in the results section you have described one of the two stadiums. Please give more details tio the second one.

I am very much looking forward to see the revised version of the manucript.

Kind regards

Reviewer #2: Dear authors,

I have read your manuscript with great interest. I think it nicely adds to existing literature. However, there are a few points I recommend to consider before publication:

-) Abstract, general: Many of your sentences are either too vague or contain information which must be confusing to someone reading this for the first time. For example: "Determining the impact" of something hardly describes your methodology. "P1" patients is not defined. Why do you speak of a derby as one event on the one hand and then several matches on the other?

-) Abstract, specific: "No research exists in low-to-middle income countries and this research hopes to bridge this gap." - Please rephrase. I'm sure you don't mean there is no research at all in such countries.

-) Comparing patients by their triage category can be tricky. From own experience, your nursing staff doing the triage is not always doing this accurately or thoroughly, leaving a high risk of bias here. Maybe try re-categorizing your patients by using their vital signs etc.? Or at least do a sample cross check if triaing was correct?

-) Figures 1-3: There is far too little information in the figure legends. Please explain all abbreviations and give some context.

-) The discussion section is rather long; maybe try steamlining it and introduce subheadings to group trains of thought.

-) The conclusion should be shorter and more concise.

**********

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PLoS One. 2024 Jul 11;19(7):e0306836. doi: 10.1371/journal.pone.0306836.r002

Author response to Decision Letter 0

23 Apr 2024

Rebuttal Letter

Manuscript reference number: PONE-D-24-00705

Title: Impact of the Soweto Football Derby on the trauma emergency department at Chris Hani Baragwanath Academic Hospital, a tertiary level hospital in South Africa

Dear Reviewers,

Thank you for the valuable and constructive comments and suggestions which we believe have led to an improved revised manuscript.

We hope that this Rebuttal Letter will be able to address all the questions that were raised.

All changes are in relation to the document with track changes, set on “All Markup” with “Show Revisions in Balloons”.

In response to the comments on the general journal requirements:

1) When submitting your revision, we need you to address these additional requirements.

Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

Response: We have gone through the PLOS ONE’s style requirements and have edited the body of work which needed to be in line with the journal’s required style.

2) We note that your Data Availability Statement is currently as follows: All relevant data are within the manuscript and its Supporting Information files. Please confirm at this time whether or not your submission contains all raw data required to replicate the results of your study. Authors must share the “minimal data set” for their submission. PLOS defines the minimal data set to consist of the data required to replicate all study findings reported in the article, as well as related metadata and methods.

Response: All our data is available. However, our national ethics approval certificates do not allow us to share any raw data without a legal data transfer agreement in place. Data cannot be shared publicly because patient confidentiality must be maintained. Data are available from the University of the Witwatersrand Human Research Ethics committee (contact www.witsethics.co.za/) for researchers who meet the criteria for access to confidential data.

3) We note that you have included the phrase “data not shown” in your manuscript. Unfortunately, this does not meet our data sharing requirements. PLOS does not permit references to inaccessible data. We require that authors provide all relevant data within the paper, Supporting Information files, or in an acceptable, public repository. Please add a citation to support this phrase or upload the data that corresponds with these findings to a stable repository (such as Figshare or Dryad) and provide and URLs, DOIs, or accession numbers that may be used to access these data. Or, if the data are not a core part of the research being presented in your study, we ask that you remove the phrase that refers to these data.

Response: Thank you for bringing this to our attention. In the process of cleaning up our results and discussion we felt that knowing that there were differences in sex according to age did not add to our research and has been deemed not a core part of the research, especially because most patients seen were young males. The relevant information regarding gender and age has already been added and discussed in the text.

Response to Reviewer #1

Comments:

1) In your results, please elaborate more in detail on the respective injuries and on outcome of the patients in both groups. Currently, no details on injuries and patients condition, as well as interventions were reported.

Response: In our work, we have categorized the trauma injuries as either blunt, penetrating or burns, which is a way of differentiating the patients succinctly in the trauma environment. In retrospect, detailing the specific types of injuries is very interesting. We have added a supplementary table (S1 Table 1) which has broken down the injuries into the main types, while at the same time keeping the injuries categorized into the three main categories (namely blunt, penetrating and burns). Please see the Supporting information S1 Table 1 on page 17 line 1533.

Additionally, patients were categorized according to their triage score, which gives an indication of the patient’s condition. This is reflected in Table 1 on page 9 line 282.

One of the limitations to this retrospective study is that patients were not followed up after the 24-hour period, and so we could not account for patients interventions outside of the ED, nor could we account for the patients who subsequently died while either admitted in the ward or in theatre. See limitations on page 14 line 1085-1094.

2) Please consider to perform a matched pairs analyses between your intervention and your standard group with e.g. mortality in the ED as your common endpoint. By doing so, you would give the reader a better and broader picture of what happened in your department. Response: Thank you for this comment. As part of our preliminary data analysis we had done an age dependent matched paired analysis between the Soweto Derby and the control. This did not change any of our significant findings, especially with no change in P1 patients seen overall or when divided into before the match, during the match, or after the match. Mortality was also assessed as an end point in the ED was and has been commented on page 8 line 259-262 and is represented in Table 1 page 9 line 282.

However, there was no significant difference in mortality and intubated patients between the Soweto Derby and the control, even with match paired analysis. Additionally, the data showed that the number of trauma patients intubated in the ED also did not increase. This was a surprising result for us as we had assumed that with a significant increase in P1 patients we would expect to see more intubations. However, on busy Saturday nights, in both the Soweto Derby and the controls, the 12 ventilators used in casualty were mostly in use, and there wasn’t any capacity to use any more, and this could possibly be the reason why there wasn’t a significant increase in intubations, even though it could have potentially led to impaired patient care. This has been elaborated on page 13 line 766-768.

3) Please re-write the methods section in your abstract since currently it is not easy to understand.

Response: The methods section in the abstract has been rewritten as requested. We hope this removes all ambiguity in both the abstract as well as in the methodology section. See page 2 line 32-37.

4) Figure 2 is not easy to understand as well. Please make sure that all figures are exactly showing what you want to demonstrate to the reader.

Response: Figure 2 has been replaced with a Bar Graph which we feel is easier to understand. The legend as well as the X and Y axis have been updated and better describe our findings. The figures have been removed from the manuscript as per PLOS 1 guidelines. Please see the figures in the attached TIFF image.

5) The results section you have described one of the two stadiums. Please give more details of the second one.

Response: The home stadium of Orlando Pirates is called Orlando Stadium. It is also situated in Soweto, also less than 10km from Chris Hani Baragwanath Academic Hospital.

The home stadium for Kaizer Chiefs is FNB stadium, which is also less than 10km from Chris Hani Baragwanath Academic Hospital. In the research period, Orlando Stadium wasn’t used during the Soweto Derby. This is because it is a much smaller stadium, which accommodates roughly 40000 spectators. FNB stadium has a capacity of more than 90000 and is one of the largest football stadiums in the world. Both teams treat this fixture as a home game as the spectators are coming from the same areas of Soweto and surrounds. Economically for both clubs mean that Orlando Stadium during the Soweto Derby is obsolete. This has been reflected in the revised results section. This has been discussed on page 4 line 125-129.

Reviewer #2

1) Abstract, general: Many of your sentences are either too vague or contain information which must be confusing to someone reading this for the first time. For example: "Determining the impact" of something hardly describes your methodology.

Response: The abstract has been rewritten, taking into account the comments of reviewer #1 and #2. See page 2 and 3

2) "P1" patients is not defined.

Response: P1 patients are patients that require immediate emergency care and are relatively uniform in most trauma triage systems. Chris Hani Baragwanath Academic Hospital has one of the busiest Trauma ED in the world, and makes use of triage scores based on ATLS principles and a modified version of the South African Triage Scale to help triage P1 patients correctly. This particular triage system has been validated in both LMIC and 1st world countries. This has been amended in the revised document. See page 2 lines32-37 and page 7 lines 210-221.

3) Why do you speak of a derby as one event on the one hand and then several matches on the other.

Response: Thank you brining this to our attention. All matches described in the text relate to the Soweto Derby. The Soweto Derby is a specific football match played between Kaizer Chiefs and Orlando Pirates, and in the context of that, all matches discussed in this paper refer to this particular football derby. We have removed ‘matches’, and replaced it with ‘Soweto Derby’ throughout to minimize any ambiguity.

4) Abstract, specific: "No research exists in low-to-middle income countries and this research hopes to bridge this gap." - Please rephrase. I'm sure you don't mean there is no research at all in such countries.

Response: The abstract has been rewritten to better describe our research. You are correct, this particular research is not the only research in LMIC, however it is the first one that we have seen that directly compares a domestic football derby and trauma in a LMIC. The only other research to our knowledge that was similar to this were done in Spain and Portugal, both of which are not LMIC. See abstract on page 2-3 lines 21-103.

5) Comparing patients by their triage category can be tricky. From own experience, your nursing staff doing the triage is not always doing this accurately or thoroughly, leaving a high risk of bias here. Maybe try re-categorizing your patients by using their vital signs etc.? Or at least do a sample cross check if triaing was correct?

Response: Comparing patients by their triage score helps compare like vs like. Patients are triaged by both nurses and doctors, and when there is a discrepancy then this is reflected in the triage files when patients are stepped up to the resuscitation bays or stepped down to the general trauma pit. All patients have to be accounted for in the triage file, whether admitted to hospital, discharged or sent to the mortuary. This cross checking of all patients decreases the chance of patients falling through the cracks. There is a very large sample size of 2552 patients in this study, and this would also decrease the potential bias of poorly triaged patients. Using vital signs alone cannot accurately account for all P1 patients in the trauma setting, as often vital sign changes are late signs. Often more importantly, patients are declared P1 by the mechanism of injury. For example, all gunshot wounds to the abdomen or chest are P1 patients irrespective of how stable the vital signs are. This has been further elaborated on and reflects in the methodology on page 5 lines 162-231.

6) Figures 1-3: There is far too little information in the figure legends. Please explain all abbreviations and give some context.

Response: All figures have been redone to better depict the relevant statistics. All figures are removed and added separately as per PLOS 1 protocol. Please see the attached TIFF image files.

7) The discussion section is rather long; maybe try steamlining it and introduce subheadings to group trains of thought.

Response: Thank you for bringing this to our attention. Upon reflection it is far too long. The discussion has been edited and is more concise. Subheadings have also been used to help with the general flow. Please see the discussion on pages 10-14 lines 323-1084.

8) The conclusion should be shorter and more concise.

Response: The conclusion has also been edited, and has become shorter and more concise. Please see page 15 lines 1299-1309.

Thank you for the valuable feedback in improving our manuscript and the opportunity to resubmit.

Yours sincerely,

Dr Baggott, Prof Kruger and Dr Pretorius

Attachment

Submitted filename: Rebuttal Letter 23.04.24.docx

pone.0306836.s002.docx (26KB, docx)

Decision Letter 1

Uday Bhaskar Manda

25 Jun 2024

Impact of the Soweto Football Derby on the trauma emergency department at Chris Hani Baragwanath Academic Hospital, a tertiary level hospital in South Africa

PONE-D-24-00705R1

Dear Dr. Baggott,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Uday Bhaskar Manda

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Dear Dr. Baggott,

Upon reviewing the comments from the reviewers I am pleased to inform that your manuscript has been accepted.

Thanks,

Uday Manda

Academic Editor.

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

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Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Dear colleagues,

thanks a lot for adressing all my questions and concerns. I have no further questions.

Kind regards,

Reviewer #2: (No Response)

**********

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Reviewer #1: No

Reviewer #2: No

**********

Acceptance letter

Uday Bhaskar Manda

2 Jul 2024

PONE-D-24-00705R1

PLOS ONE

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Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 Table. Types of injuries seen during the Soweto Derby and the control.

    (DOCX)

    pone.0306836.s001.docx (16.1KB, docx)
    Attachment

    Submitted filename: Rebuttal Letter 23.04.24.docx

    pone.0306836.s002.docx (26KB, docx)

    Data Availability Statement

    All relevant data are within the manuscript and its Supporting information files. Data cannot be shared publicly because patient confidentiality has to be maintained. Data are available from the University of the Witwatersrand Human Research Ethics Committee (contact www.witsethics.co.za/) for researchers who meet the criteria for access to confidential data.

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