Changes in social activity in Japan during the COVID-19 pandemic based on the number of trauma surgeries

Since the first confirmed case of novel coronavirus (COVID-19) infection in Japan in February 2020, the number of annual COVID-19 patients exploded from 232,000 in 2020 to 1,495,000 in 2021 and 274,844,000 in 2022 (total statistics on the number of patients have been suspended since May 2023) (Figure 1) [1].

 Figure 1: Changes in newly infected COVID-19 patients in Japan in 2020-2023. 

During this period, national and local governments requested the public to restrict their activities (refrain from going out) eight times until mid-2022. In addition, based on the "Basic Policy for Countermeasures against COVID-19", medical institutions were requested to postpone non-urgent scheduled surgeries [2,3]. However, emergency surgeries such as trauma surgery were performed as usual during this period of restricted medical activities. In Japan, 36% of all trauma cases were due to traffic accidents and 20% were due to falls, many of which occurred during outdoor activities, so these can be used as indicators of people's social activity [4,5]. In this paper, I compiled data on changes in the number of trauma surgeries at 12 urban core hospitals that handled emergency surgeries over a four-year period from 2020 to 2023. Based on these results, factors behind changes in people's social activities during the COVID-19 pandemic were also considered.

I investigated changes in trends in emergency trauma surgery from 2015 to 2023. Of these, 2020-2023 was the COVID-19 pandemic period. The survey facilities were 12 regional core general hospitals with more than 350 beds that provide emergency medical care in their respective region (Fukuoka Tokushukai Hospital (Kasuga City), Ehime Prefectural Central Hospital (Matsuyama City), Nagasaki Minato Medical Center (Nagasaki City), Oita Tsurumi Hospital (Beppu City), Oita Nakamura Hospital (Oita City), Matsue Red Cross Hospital (Matsue City), Yamaguchi Prefectural General Medical Center (Hofu City), Sasebo City General Hospital (Sasebo City), Miyazaki Konan Hospital (Miyazaki City), Kitakyushu General Hospital (Kitakyushu City), Kitakyushu Municipal Yahata Hospital (Kitakyushu City) and National Nagasaki Medical Center (Omura City)). The number of emergency trauma surgeries per year was extracted from the trauma database of each facility on May 18, 2024. Furthermore, these surgical patients were divided into general anaesthesia, spinal anaesthesia/local anaesthesia by type of anaesthesia.

Changes in the total number of trauma surgeries (Figure 2, Table 1). The average number of emergency trauma patients per year at the 12 hospitals from 2015 to 2019 (before the COVID-19 pandemic) was 4279.4, with a 95% confidence interval (CI) of 3768.4 to 4790.4. During the COVID-19 pandemic, 3825, 4465, 4778 and 4536 patients underwent trauma surgery in 2020, 2021, 2022 and 2023, respectively. These results showed that the total number of trauma surgeries decreased by about 11% in 2020, the first year of the COVID-19 pandemic, but this was not a significant decrease compared with before the pandemic and returned to the same level as before the pandemic for the three years from the second year. 

Figure 2: Number of trauma surgeries and COVID-19 patients in 2015-2023. 

Table 1: Number of trauma surgeries before and during the COVID-19 epidemic.

Changes in the number of trauma surgeries by anaesthesia type (Figure 3, Table 1) The annual average number of patients who underwent emergency trauma surgery under general anaesthesia before the COVID-19 pandemic was 952.4, with a 95% CI of 419.2-1485.6, whereas in 2020, 2021, 2022 and 2023, it was 1005, 1128, 1180 and 1241, respectively. No significant difference was observed in the number of emergency trauma surgery patients under general anaesthesia on comparing before and after the COVID-19 pandemic. Conversely, the annual average number of patients who underwent surgery under spinal or local anaesthesia before the COVID-19 pandemic was 3374.8, with a 95% CI of 3215.5-3534.1, whereas in 2020, 2021, 2022 and 2023, it was 2820, 3347, 3598 and 3295, respectively. In 2020, the first year of the epidemic, the number of surgeries performed using spinal and local anaesthesia decreased significantly by 16% compared with pre-epidemic levels, but no significant differences were observed in subsequent years.

Figure 3: Number of trauma surgeries under general or local/spinal anaesthesia and COVID-19 patients in 2015-2023.

When the World Health Organization declared the COVID-19 pandemic on March 12, 2020, various surgical departments around the world were forced to cancel or postpone non-urgent surgeries to conserve medical resources for COVID-19 patients [6-8]. During the peak 12 weeks of disruptions caused by the COVID-19 pandemic in 2020, approximately 28.4 million surgeries were canceled worldwide and it was estimated that it would take 45 weeks to resolve delays in surgery [7]. 

However, for emergency patients with trauma, surgery is unavoidable and general anaesthesia may be required depending on the severity of the injury and age of the patient. Therefore, regardless of the medical restraints, governments and hospitals impose; surgery will be prioritized for emergency trauma patients. Nevertheless, this survey found that the number of trauma surgery patients in 2020, the first year of the epidemic, decreased, with the reason being that the number of relatively minor trauma patients who could be operated on with local or lumbar anesthesia decreased significantly. Moreover, despite the exponential increase in the number of COVID-19 infections in the second and third years, the number of emergency trauma patients dropped sharply in 2020, the first year of the epidemic, but since 2021, it has returned to the same number of trauma patients as before the epidemic. Emergency trauma surgeries are less affected by surgical restraint recommendations, even those during the COVID-19 pandemic, so the decrease in the number of these surgeries indicates a decrease in the incidence of disease. Regarding trauma, a significant change was observed in the incidence of traffic accidents in Japan. In the five years from 2015 to 2019 before the COVID-19 pandemic, the average number of injuries due to traffic accidents exceeded 570,000. However, this figure has been decreasing year by year and the average number of injuries over the three years from 2020 to 2022 was about 360,000, revealing a 37% decrease in the number of traffic accident injuries during the COVID-19 pandemic [9]. This is considered to reflect not only improvements in the safety performance of automobiles, but also a reduction in the need for transport due to the COVID-19 pandemic and people refraining from going out to prevent the spread of infection. 

There are few statistical reports on minor trauma, but Ito et al. analysed the onset mechanism of 500 cases of facial trauma, including minor injuries, over a three-year period, reporting that approximately half of the injuries were sustained at home or in the vicinity, 28% were due to traffic accidents, 7% involved fights or drinking and 5% were sport-related accidents. Of these, most of the injuries sustained at home or in the vicinity involved young children whose main living space was the home, while in adults, more injuries were sustained outdoors [10]. In Japan, local governments issued stay-at-home (SAH) orders three times in 2020, four times in 2021 and once in 2022, calling for people to refrain from activities until mid-2022. However, this survey estimated that these instructions were only followed for the first year and it is considered that since 2021, minor trauma has increased as people have become accustomed to the COVID-19 epidemic and have had more opportunities to pursue social activities as vaccinations have become more widespread.

The decrease in minor trauma surgeries in the first year of the pandemic was considered to be due to people complying with SAH and refraining from going out to in order contain the epidemic. However, from the following year onwards, as people became accustomed to COVID-19 and multiple vaccinations became widespread, SAH became less thorough, social activities increased and as a result, minor trauma increased. The COVID-19 pandemic to date can be seen as a large social experiment that has been ongoing for four years. In this report, I examined changes in people's behaviour based on the trends in the number of trauma surgery patients. On concerning the results, behavioural restrictions that rely on people's voluntary initiative without penalties, such as curfews, will be effective at first, but this effect will weaken after about one year.

We would like to express our deep gratitude to Drs. Gozo Nishimura, Katsuhiko Kamebuchi, Hiroki Yano, Hiroshi Nakagawa, Kuniaki Anraku, Motoi Nakano, Hiroyuki Tasaki, Takehiro Daian, Kouichiro Yoshimuta, Ritsuko Miyauchi and Shintari Ikenoya, for their kind cooperation in collecting and providing the clinical data.

This manuscript has not benefited from any source of funding support and grants and the authors have no conflicting financial interest.

Guarantor of integrity of the entire study, Study concepts and design, Literature research, Clinical studies, Experimental studies / data analysis, Statistical analysis, Manuscript preparation and Manuscript editing by Masaki Fujioka.

Author has not received conflicts of interest and sources of funding, including employment, grants, patent ownership and other interests.

The protocol for the research project has been approved by a suitably constituted Ethics Committee of National Hospital Organization Nagasaki Medical Centre. Approval number: 2021023.

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