The Implementation of COVID-19 Social Distancing Measures Changed the Frequency and the Characteristics of Facial Injury: The Newcastle (Australia) Experience

Abstract

Study Design:

A retrospective study was undertaken of a cohort of facially injured patients using matched 8-week periods: non-COVID (2019) and COVID (2020).

Objective:

To determine whether there were any changes to the frequency and characteristics of facial injury due to the imposition of COVID-19 social distancing measures.

Methods:

The primary predictor variable was an 8-week period of COVID-19 social distancing. The primary outcome variable was the sustaining of a facial injury. Demographic (age/gender) and injury characteristics (mechanism, site, and treatment) were also studied. Descriptive statistical analysis was undertaken and comparison made using Pearson χ² and Fisher’s exact tests.

Results:

The number of facial injuries decreased from 103 (2019) to 73 (2020). There were statistically significant differences in changes over time for the 8-week periods. There were some clinically apparent differences seen in the characteristics of facial injuries.

Conclusions:

The imposition of COVID-19 social distancing changed the frequency and characteristics of facial injury.

Introduction

Seasonal influenza epidemics make a substantial contribution to annual national and international morbidity and mortality rates.¹

In December 2019, Wuhan City, Hubei Provence, China, reported the cluster of a group of residents who developed a primary pneumonia that was both highly infectious and virulent.² This outbreak became the epicenter of a rapidly progressive epidemic that unfortunately, by the 12th March 2020, was declared a pandemic by the World Health Organization.³

The causative agent held responsible for the pneumonia was a novel coronavirus which was subsequently identified as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a single-stranded positive-sense RNA virus.⁴ The corresponding disease was formally named Coronavirus Disease 2019 (i.e. COVID-19).⁵

The progressive development of an increasing number of cases combined with evidence of a widening geographic spread (predominantly due to the ease, frequency, and volume of regional, national, and international travel) on the back of the WHO pandemic declaration bore witness to the global implementation of unprecedented government-imposed public health measures in an attempt to reduce the infection and spread of virus.⁶ A variety of R₀ (effective rate of infection) rates have been reported in the early literature that ranges from 1 to 2.6.⁷

Australian Federal Government Response

A national health protection principal committee was established in Australia (Australian Health Protection Principal Committee [AHPPC]) to deal with the COVID-19 pandemic and the impact it would have on the population in general and the delivery of health care services specifically. The AHPPC was comprised of the Federal chief medical officer (and representatives) and the chief health officers of each state (n = 6) and territory (n = 2).⁸

The “COVID plan” thus devised was enacted as an initial action response which followed on the 15th March by a declarative targeted action response.⁹

International border surveillance refused entry to any Chinese national from Hubei province and health checks were imposed on all foreign travelers entering from or transiting through high-risk countries.¹⁰ This was subsequently extended to all overseas visitors including non-Australian nationals. Australian return travelers were subject to mandatory quarantine for 14 days on their return.¹¹

Federal and state governments also imposed a range of community measures under the broad term of “social distancing” (self-isolation—staying at home, social distancing, limits on nonessential public gathering, and intra- and interstate travel restrictions) as well as a number of public health measures to decrease community viral transmission.¹²

It is known that pubs, bars, registered and licensed clubs, and nightclubs act as places for socializing, the provision of entertainment and the sale and consumption of alcohol. It is accepted that these venues are high-risk settings for episodes of non-accidental interpersonal violence, injury, and assault.¹³

It is also known that contact sports, places of work, and motor vehicles are equally responsible for a variety of accidental injuries.¹⁴ The imposition of COVID-19 “social distancing” legislation in its broadest sense has impacted across the full spectrum of these personal and public interactions.

The purpose of the study was to determine whether there were any changes to the frequency and characteristics of facial injury following the “COVID-19 targeted action response” which was instituted in March 2020, by comparing this to a similar period of study in the preceding year (2019).

The hypothesis of the study was that social distancing caused a difference in the frequency and characteristics of facial injury with the null hypothesis being that there is no difference.

The aims of the study were to evaluate whether the imposition of COVID-19 pandemic social distancing restrictions (on a variety of social gatherings, activities and workplaces) altered the frequency and characteristics of facial injury sustained by:

1. Calculating the frequency of facial injury over a matched 8-week period in 2019 (no restrictions) and 2020 (COVID-19 restrictions);

2. Identifying variations in demographics and injury characteristics.

Materials and Methods

Study Design, Sample, and Setting

To address the research purpose, the authors designed and implemented a retrospective study (conducted over 2 comparable 8-week periods in 2019 and 2020, commencing on the 16th of March and ending on the 11th of May) of the clinical records of a cohort of patients who sustained a facial injury. The study was conducted in the Department of Maxillofacial Surgery at the John Hunter Hospital, Newcastle, Australia.

The study population was derived from all maxillofacial trauma patients who attended our level 1 tertiary referral regional trauma hospital and who were assessed or managed by the Department of Maxillofacial surgery. Exclusion criteria were imposed on patients who had insufficient clinical data.

Local health district population estimates were obtained for the study years 2019 (n = 942 374) and 2020 (n = 952 381).¹⁵

Variables

The primary predictor variable was an 8-week period of COVID-19 social distancing. The primary outcome variable was the sustaining of a facial injury. Other variables studied included demographic (age and gender) and injury characteristics (mechanism, site, and treatment).

Data Collection

The relevant data that were required to undertake the study was retrieved from the unit log books and cross-checked against the hospitals digital medical record system. The relevant data were entered onto a password protected spreadsheet by a single author.

Censorship

Censorship was within a matched 8-week period in each study year.

Statistical Methods

Descriptive statistics were presented as count percentages and compared between 2019 and 2020 using the Pearson χ² test (or Fisher’s exact test if small cell counts). The change in count of facial injuries per week over the 8-week period for 2019 and 2020 was analyzed using the Poisson regression (count outcome). Modeling included week (continuous), year, and the interaction term. Estimates presented include the estimated change per week for each year with 95% confidence interval. Statistical analyses were programmed using SAS v9.4 (SAS institute, Cary, North Carolina, USA). A priori, P < .05 (2-tailed) was used to indicate statistical significance.

Ethics

The study was designated as a retrospective review of patient records and was therefore granted an exemption of writing by the local institutional review board (IRB), authorized as negligible risk: AU 20205-07. The authors adhered to the privacy and confidentiality of all clinical information in the conduct of this research as espoused by the World Medical Association’s Helsinki Declaration.

Results

The frequency of facial injury presentations decreased from 103 (prevalence 0.11 per thousand) for the 2-month period in 2019 to 73 (prevalence 0.08 per thousand) for the equivalent 2-month period in 2020. Further to this, it was noted that operative managed cases decreased by 10%.

Table 1 outlines the demographics, injury type, and mechanisms of our cohort of patients. Clinically apparent differences were noted between the 2 years in the age-group of patients, with a decrease in the 11-20 and 21-30 age-group (17%-11% and 26%-18%, respectively) and an increase in the 71-80 age-group (3.9%-12%) between 2019 and 2020.

Table 1.

Demographics, Injury Type, and Mechanism of Injuries.

Characteristic	Class/statistic	2019 (n = 103)	2020 (n = 73)	P value
Age	0-10	10 (9.7%)	8 (11%)	.4039
	11-20	17 (17%)	8 (11%)
	21-30	27 (26%)	13 (18%)
	31-40	10 (9.7%)	11 (15%)
	41-50	11 (11%)	8 (11%)
	51-60	12 (12%)	6 (8.2%)
	61-70	7 (6.8%)	5 (6.8%)
	71-80	4 (3.9%)	9 (12%)
	81-90	5 (4.9%)	4 (5.5%)
	91-100	0	1 (1.4%)
Gender	Male	84 (82%)	52 (71%)	.1075
	Female	19 (18%)	21 (29%)
COVID-19 period	No	—	73 (100.0%)
Alcohol or drug use	No	94 (91%)	62 (85%)	.1923
	Yes	9 (8.7%)	11 (15%)
Mechanism	Animal injuries	6 (5.8%)	4 (5.5%)	.1099
	Domestic violence	0	3 (4.1%)
	Falls	22 (21%)	28 (38%)
	Interpersonal violence	39 (38%)	19 (26%)
	MVA	11 (11%)	6 (8.2%)
	Sports	19 (18%)	10 (14%)
	Work	3 (2.9%)	1 (1.4%)
	Unknown/other	3 (2.9%)	2 (2.7%)
Injury	Isolated maxillofacial bony injury	54 (52%)	43 (60%)	.6236
	Isolated soft tissue	26 (25%)	16 (22%)
	Polytrauma	23 (22%)	13 (18%)
Type of bony injury	Dentoalveolar	1 (1.0%)	0	.1186
	Frontal bone	4 (3.9%)	4 (5.5%)
	Mandible	7 (6.8%)	11 (15%)
	Maxilla/midface	0	3 (4.1%)
	Nasal bone/NOE	11 (11%)	4 (5.5%)
	Orbit	15 (15%)	14 (19%)
	Pan-facial	13 (13%)	9 (12%)
	Zygomatic-maxillary Complex	22 (21%)	8 (11%)
	N/A	30 (29%)	20 (27%)

There were also small changes evident in the gender presentation of patients between the 2 years with a decrease in male patients (82%-71%) and a corresponding increase in female patients (18%-29%).

The mechanism of injury also appeared to change with evidence of an increase in falls (21%-38%) and domestic violence (0%-4.1%), and a concurrent decrease in interpersonal violence (38%-26%). More subtly, there appeared to be a reduction in the motor vehicle accident (MVA) (11%-8.2%), sports (18%-14%), and work-related categories of injuries (2.9%-1.4%).

There were small but defined decreases in nasal bone/naso-orbital ethmoid (NOE) injuries (11%-5.5%) along with zygomatic-maxillary complex injuries (21%-11%) with a concurrent increase in mandible injuries (6.8%-15%).

Table 2 outlines the management of facial injuries showing an increase in nonoperative management (46%-56%) and a reduction (54%-44%) in operative management. Table 3 breaks down the prevalence into a week-by-week comparison between 2019 and 2020.

Table 2.

Management of Injuries.

Characteristic	Class/statistic	2019 (n = 103)	2020 (n = 73)	P value
Management	Nonoperative	47 (46%)	41 (56%)	.1685
	Operative	56 (54%)	32 (44%)

Table 3.

Facial Injuries and Prevalence (Per 1000 Persons) by Year.

	2019		2020
Week	Facial injuries	Prevalence per 1000 persons	Facial injuries	Prevalence per 1000 persons
1	5	0.0053	14	0.0147
2	15	0.0159	10	0.0105
3	7	0.0074	9	0.0094
4	10	0.0106	6	0.0063
5	19	0.0202	7	0.0073
6	14	0.0149	13	0.0136
7	13	0.0138	6	0.0063
8	20	0.0212	8	0.0084
Total	103	0.1093	73	0.0766

Discussion

It is our contention that the implementation of COVID-19 social distancing measures that were introduced primarily to reduce the community transmission of the virus serendipitously had a secondary “spin-off” public health effect by altering the demographics and characteristics of trauma that are normally associated with the sustaining of a facial injury.

The main finding of our study revealed that the frequency of presentations of facial injury decreased from 103 (prevalence of 0.11/1000) for the 8-week period in 2019 to 73 (prevalence of 0.08/1000) for the equivalent 8-week period in 2020.

Public Health Approaches to Reduce Injury

Injuries continue to remain a neglected epidemic in many countries. There is evidence however that the leading causes of disability and death following injury can be prevented through concerted public health measures.¹⁶

Several strategies have been proposed by public health officials in an attempt to develop a comprehensive community-based injury mitigation program. In the main, there have been 3 general approaches that have been adopted by professional bodies as injury prevention strategies¹⁷:

1. The provision of education and information to promote voluntary behavioral change in persons known to be at risk of specific injury.¹⁷

2. The legislation of regulations and laws in order to impose behavioral change.¹⁷

3. The adoption of automatic protection, by either improved product design or environmental modification, in order to protect the community at large.¹⁷

An example of how these strategies could work both individually or collectively can be seen by the reduction in morbidity and mortality from motor vehicle accidents that has been achieved by speed limit and seat belt legislation, air bags, high mounted brake lamps, and crumple zone design modifications to the construction of motor vehicles.^17–19

In a legislative sense, previous studies have shown that the regional implementation of prohibitive liquor legislation, introduced to limit the sale of and access to alcohol at pubs, bars, and nightclubs, can lead to a sustained reduction in the incidence of assault occasioning facial injury, as seen in patients presenting to level 1 trauma hospitals.¹³

COVID-19 Pandemic Implications of Social Distancing

In a 2-week period from the 13th March 2020, as the international coronavirus outbreak progressively established itself in Australia, a series of legislative changes were introduced by the Australian Federal and State governments.⁸ These were progressively introduced in a staged manner as follows: stage 1:13th March: social distancing and limitations of public gathering, stage 2:22nd March: discontinuation of all nonessential gathering, and stage 3:30th March: home isolation.⁸

These actions were primarily introduced to reduce community virus transmission and in turn flatten the national epidemic curve. As a result of these legislative changes, we noted, with almost immediate effect, a change in the demographic and characteristics of facial injury attendees to our level 1 tertiary referral trauma service.

We proposed that the coronavirus restrictions that were imposed on a variety of community, social and work gatherings (eg, temporary closure of licensed clubs, pubs, bars, hotels, gyms and indoor sport venues⁸) as well as the restraint of a number of community sporting and recreational activities in addition to its intended effect, might have had a serendipitous effect in reducing both the number and characteristics of facial injuries that routinely present to our Maxillofacial Service.

To date, there have been little published data that have documented the impact that COVID-19 social distancing has had on the epidemiology and management of facial injury.

Two small studies from China and Italy have alluded to an increase in falls and domestic accidents as being the main cause of facial injury presentations during lockdowns.^20,21

This was supported by a large five center collaborative UK study (of 225 patients) which found that the majority of facial injuries were sustained in the home (60%) with the primary mechanism of injury resulting from a slip, trip, or fall (70%).²² There was, however, no comparison to non-COVID-19 figures offered in this regard.

Our study revealed that 38% of facial injuries in the COVID-19 (2020) period were due to falls, which equated to a 17% increase when compared with the non-COVID-19 control period. We propose that this would be a direct result of the COVID-19 laws that were introduced to keep people safe, as most of the populace were confined to their homes.

Coronavirus has been identified within a variety of mucosal subsites that comprise the upper aerodigestive tract.²³ Interpersonal transmission is generally via nasal, conjunctival, or oral exposure and is facilitated in 1 of 2 ways. Firstly, via droplet exposure (salivary and pharyngeal secretions) expectorated through either cough, sneeze, speech, or off contaminated surfaces. Secondly, via aerosol-generating procedures (AGPs) during invasive examination, manipulation, or operative intervention.²³

While a range of personal protective equipment has been promoted to shield the health care workforce from viral exposure,^23,24 arguably the best way to mitigate the risk is, where possible, avoiding the undertaking of elective surgical procedures and being circumspect about the undertaking of emergent cases.

Our study found that 56% of our cohort was nonsurgically managed in the COVID-19 (2020) period, which was a modest 10% increase over the corresponding non-COVID-19 (2019) control period. Maxillofacial surgical service provision not surprisingly has changed since the declaration of the COVID-19 pandemic. However, some attempt has been made to reduce surgical exposure and AGPs by treating, for example, trauma cases either more conservatively or nonsurgically when appropriate.

It is also noted that a hidden epidemic that is yet to become evident is that financial and emotional stress and home isolation impositions may inadvertently leave known and potential victims of intimate partner-domestic violence more vulnerable and isolated and, as a result, subject to an increased likelihood of violence.²⁵

While the study only took place over an 8-week period, we gained a “snapshot” of how a variety of restrictions on social gatherings can in turn reduce the frequency and characteristics of facial injury.

Some of the conclusions that we have drawn could have been confounded by the widespread adoption of “phone apps” which, when combined with as much as 234% increase in online alcohol purchases, has resulted in an increase in alcohol consumption that has been facilitated by “contact-free home delivery.”²⁶ There has been a decrease consumption of alcohol at point of sale/bricks and mortar stores which may, on face value, lead to a decrease in assault and interpersonal violence.²⁷ However, an unexpected consequence is that “electronic sales” and contact-free home delivery has circumvented statutory proof of age and identification that is necessary for the purchase of alcohol, leading to a potential rise in home injury from falls and accidents due to intoxication.²⁸

In addition, independent research commissioned by major hardware retailers has shown that there has been a 65% increase in do-it yourself (DIY) tasks, especially painting and gardening.²⁹ The launch of “DIY project bundles” directed at the novice but aspiring home renovator or crafter could raise, for example, the frequency of falls in the home from trestle, ladders, and scaffolds. Interestingly, the caveat espoused by the retailer is, “when undertaking DIY stay safe and avoid unnecessary risks.”²⁹

The strengths of our study were that it was conducted in 1 institution which serves as a tertiary regional center managing all facial injury—and which captured a relatively great volume in a short space of time. As a baseline, we compared the same presentation and time period in the preceding year, which would account for any seasonal or temporal variations in trauma presentations.

The main weakness of our study was the relatively short investigative time span. Although in acknowledging this, the numbers that were recruited into the study were sufficiently robust to produce both observational and statistical conclusions.

In conclusion, it was our contention that the legislative imposition of a broad-based social distancing policy during the early part of the COVID-19 outbreak in Australia had a significant impact on the known etiology of facial injury. This in turn brought about a reduction in the frequency and a change in the characteristics of facial injuries that presented to our level 1 trauma hospital.

Further research will be undertaken following the progressive relaxation of these laws to ascertain whether facial injury presentation returns to its pre-COVID-19 level.