Original article

Frequency of surgery and hospital admissions for

communicable diseases in a high- and middle-income setting
A. Jarnheimer1 , G. Kantor2 , S. Bickler3 , P. Farmer4 and L. Hagander1
1 Department of Clinical Sciences in Lund, Paediatric Surgery and Global Paediatrics, Faculty of Medicine, Lund University, Lund, Sweden, 2 Discovery
Health, Sandton, and Department of Anaesthesiology, University of Cape Town, Cape Town, South Africa, and Department of Anesthesiology and
Perioperative Medicine, University Hospitals Case Medical Center, Cleveland, Ohio, USA, 3 Division of Paediatric Surgery, Rady Children’s
Hospital–University of California, San Diego, California, USA, and 4 Department of Global Health and Social Medicine, Harvard Medical School,
Division of Global Health Equity, Brigham and Women’s Hospital, and Partners In Health, Boston, Massachusetts, USA
Correspondence to: Dr L. Hagander, Department of Clinical Sciences in Lund, Paediatric Surgery and Global Paediatrics, Faculty of Medicine, Lund
University, Children’s Hospital, 22185 Lund, Sweden (e-mail: lars.hagander@med.lu.se)

Background: In high-income countries, non-communicable diseases drive the demand for surgi-
cal healthcare. Middle-income countries face a double disease burden, of both communicable and
non-communicable disease. The aim of this study was to describe the role of surgery for the in-hospital
care of infectious conditions in the high-income country Sweden and the middle-income country South
Africa.
Methods: A retrospective cohort study was performed of 1⋅4 million infectious disease admissions. The
study populations were the entire population of Sweden, and a cohort of 3⋅5 million South Africans with
private healthcare insurance, during a 7-year interval. The outcome measures were frequency of surgical
procedures across a spectrum of diseases, and sex and age during the medical care event.
Results: Some 8⋅1 per cent of Swedish and 15⋅7 per cent of South African hospital admissions were
because of infectious disease. The proportion of infectious disease admissions that were associated with
surgery was constant over time: 8⋅0 (95 per cent c.i. 7⋅9 to 8⋅1) per cent in Sweden and 21⋅1 (21⋅0 to 21⋅2)
per cent in South Africa. The frequency of surgery was 2⋅6 (2⋅6 to 2⋅7) times greater in South Africa, and
2⋅2 (2⋅2 to 2⋅3) times higher after standardization for age, sex and disease category.
Conclusion: The study suggests that surgical care is required to manage patients with communicable
diseases, even in high-income settings with efficient prevention and functional primary care. These results
further stress the importance of scaling up functional surgical health systems in low- and middle-income
countries, where the disease burden is distinguished by infectious disease.

Paper accepted 7 April 2015

Published online 8 June 2015 in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.9845

Introduction to non-communicable diseases. In high-income countries

Access to surgical care is a prerequisite for the health
of all populations, yet surgical services are remarkably
absent in large parts of the world. Today a majority of
the world’s population lacks access to safe, affordable
surgical and anaesthesia care when needed1 . In 2006 it
was estimated that surgical conditions accounted for at
least 11 per cent of all global mortality and morbid-
ity, and in 2015 it was estimated that essential surgical
procedures could avert 6–7 per cent of all preventable
deaths in low- and middle-income countries2,3 . In 2012,
Murray and colleagues4 presented an updated Global
Burden of Disease (GBD) Study and found an ongoing
epidemiological shift from predominantly communicable
non-communicable diseases drive the demand for health-
care, whereas in low-income countries communicable dis-
eases still remain a leading cause of premature mortality
and disability4 . Middle-income countries are currently fac-
ing a double disease burden, of both communicable and
non-communicable disease, particularly in countries such
as South Africa where there are large differences between
the rich and the poor5,6 . Owing to the substantial contribu-
tion of infectious conditions to the disease burden in low-
and middle-income countries, together with the increasing
recognition of the importance of surgical interventions in
these settings, there is a need to understand the relationship
between surgery and infectious disease.

© 2015 BJS Society Ltd BJS 2015; 102: 1142–1149

Published by John Wiley & Sons Ltd
Surgery and hospital admissions for communicable diseases in a high- and middle-income setting 1143

Surgical procedures have an indispensable role in treating Table 1Total number of admissions owing to infectious disease
infectious diseases (such as pleural empyema, echinococ- and proportion of admissions by sex, age and infectious disease
cosis, osteomyelitis and necrotizing fasciitis)7 – 9 , but also category in Sweden (2006–2012) and South Africa (2008–2013)
in preventing infectious disease (for instance male circum- Sweden South Africa
cision to prevent human immunodeficiency virus (HIV)
Total admissions 10 093 532 (100) 3 544 330 (100)
infection and vesicoureteral reflux surgery to prevent pae- Admissions for infectious disease 820 357 (8⋅1) 555 958 (15⋅7)
diatric pyelonephritis)10,11 . Recently published data9 on Age (years)
inpatients in the USA show that surgical treatment is car- <5 121 082 (14⋅8) 212 610 (38⋅3)
5–14 28 630 (3⋅5) 57 083 (10⋅3)
ried out in all disease subcategories of the GBD Study,
15–34 86 532 (10⋅5) 103 824 (18⋅7)
including infectious diseases. Functional surgical health 35–64 182 970 (22⋅3) 135 433 (24⋅4)
systems are likely to avert considerable mortality and mor- > 65 401 099 (48⋅9) 45 810 (8⋅3)
bidity from infectious disease; however, there are to date Sex
M 424 031 (51⋅7) 272 602 (49⋅1)
no comprehensive population-based epidemiological stud-
F 396 282 (48⋅3) 282 158 (50⋅9)
ies on the surgical burden caused by infectious diseases. Infectious diseases
The purpose of this study was to address the need for HIV/AIDS and tuberculosis 5291 (0⋅6) 6419 (1⋅2)
surgical care as a component of the treatment of commu- Lower respiratory infections 316 152 (38⋅5) 191 652 (34⋅5)
Upper respiratory infections 77 089 (9⋅4) 125 859 (22⋅6)
nicable diseases by assessing the comparative frequency of
Gastrointestinal infections 109 702 (13⋅4) 99 321 (17⋅9)
surgical treatment for infectious diseases. It was hypoth- Urinary tract infections 17 425 (2⋅1) 18 506 (3⋅3)
esized that there was a considerable need for surgery to CNS infections 12 213 (1⋅5) 18 015 (3⋅2)
treat infectious diseases, and that this need was greater Sepsis 81 311 (9⋅9) 12 351 (2⋅2)
in a middle-income compared with a high-income coun- Hepatitis 3165 (0⋅4) 1752 (0⋅3)
Bone and joint infections 18 369 (2⋅2) 4769 (0⋅9)
try. The specific aims were to describe the frequency of Skin and soft tissue infections 74 771 (9⋅1) 45 504 (8⋅2)
surgical care for infectious conditions in a high- versus a STDs (excluding HIV) 1132 (0⋅1) 2086 (0⋅4)
middle-income country, among the Swedish population Herpes virus infection 7795 (1⋅0) 2560 (0⋅5)
and South Africans with a private healthcare insurance Exanthematous infections 6789 (0⋅8) 3952 (0⋅7)
Invasive mycosis 3220 (0⋅4) 1455 (0⋅3)
respectively, and to standardize by diagnosis, sex and age Tropical infectious diseases 2569 (0⋅3) 3547 (0⋅6)
group. The study was part of the Lancet Commission on Other 83 364 (10⋅2) 18 210 (3⋅3)
Global Surgery1 .
Values in parentheses are percentages. HIV, human immunodeficiency
virus; AIDS, acquired immune deficiency syndrome; CNS, central
nervous system; STD, sexually transmitted disease.
Methods

A retrospective cohort study was carried out by analy-
sis of admission registers in Sweden and South Africa.
The Swedish patient data were retrieved from the
National Patient Register (Nationella Patientregistret,
Solna, Sweden) covering the entire Swedish population
of approximately 9⋅6 million people12 ; the register con-
tains information on every completed medical care event in
Sweden, along with associated diagnoses and procedures13 .
The South African patient data were collected from the
country’s largest health insurance company (Discovery
Health, Sandton, South Africa), which covered on average
2⋅5 million people nationwide between 2008 and 201314 .
The South African study population is representative of
the approximately 8 million South Africans (16 per cent)
who have private health insurance plans15 – 17 . Private
insurance covers hospital care as well as a standard package
of outpatient care in relation to common and chronic
diseases. The insured population is mostly high-income,
working in the formal sector15 . This population experi-
ences relatively high annual rates of hospital admission,
and is more affluent and more urban than the uninsured
majority who receive care in the public system.
Inclusion and exclusion criteria
All patient admissions with a three-digit primary diagnostic
ICD-10 code pertaining to infectious disease were included
in the study (Table S1, supporting information). To avoid
including iatrogenic infectious disease, codes for postoper-
ative infections and other complications of surgical treat-
ment were excluded (ICD-10 codes T80–88). The Swedish
data set also included outpatient surgical procedures, which
were analysed separately.
Definitions
Surgical procedures for the Swedish data were defined
according to the Nordic Medico-Statistical Committee
(NOMESCO) Classification of Surgical Procedures18 ,
chapters A–Q, excluding minor surgical procedures,

© 2015 BJS Society Ltd www.bjs.co.uk BJS 2015; 102: 1142–1149

Published by John Wiley & Sons Ltd
1144 A. Jarnheimer, G. Kantor, S. Bickler, P. Farmer and L. Hagander

25 Men conditions requiring surgery was considered as multiple

Women admissions. The main reason for surgery was defined by
the primary ICD-10 diagnosis for the medical event.
20 Infectious diseases were defined according to the
Frequency of surgery (%)

diagnoses within the three subcategories of infectious

diseases in the GBD Study from 2010 (GBD 2010), and
15
corresponding ICD-10 codes were extracted from the sup-
plement of Lozano and colleagues4,20 . Infectious diseases
included in other GBD 2010 subcategories and infectious
10
diseases not captured by the GBD 2010 framework were
subsequently added and categorized (Table S1, supporting
5 information).

0 Outcome variables
Sweden South Africa
The primary outcome was occurrence of surgical proce-
Fig. 1Frequency of surgery among admissions for infectious dures during a hospital admission for infectious disease.
diseases in Sweden (2006–2012) and South Africa (2008–2013) Information on type of infection diagnosis (3-digit ICD-10
by sex. Error bars represent 95 per cent c.i.
code), sex and age group was collected.

transluminal endoscopy and diagnostic procedures con-

nected with surgery. For the South African data set, a
publicly available, similar list of operating room procedure
codes from the US Agency for Healthcare Research and
Quality website was used19 .
Frequency of surgery was defined as the proportion of
admissions associated with at least one surgical procedure
during the medical care event. Patients undergoing sev-
eral surgical procedures during a single admission were
considered as one admission associated with surgery, and
one patient presenting multiple times with infectious
Statistical analysis
Descriptive statistics were computed for each study vari-
able. The frequency of surgery was calculated for each
country and diagnosis, and presented with 95 per cent c.i.
using the Wilson score interval. The incidence of admis-
sions per 100 000 population was calculated using the mean
population between 2006 and 2012 (9 335 362) for Sweden,
and the mean number of people insured between 2008 and
2013 (2 428 451) for South Africa. For comparative analysis
the data were standardized for age, sex and disease category

35 Sweden
South Africa

30
Frequency of surgery (%)

25

20

15

10

0
0–4 5–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 80–84 85–89 90–94 95–99 ≥100
Age (years)

Frequency of surgery among admissions for infectious diseases in Sweden (2006–2012) and South Africa (2008–2013) by age.
Fig. 2
Error bars represent 95 per cent c.i.

© 2015 BJS Society Ltd www.bjs.co.uk BJS 2015; 102: 1142–1149

Published by John Wiley & Sons Ltd
Surgery and hospital admissions for communicable diseases in a high- and middle-income setting
using Stata® version 13 (StataCorp LP, College Station,
Texas, USA). Significance was set at an α error of 0⋅05.
Results
Incidence of surgery related to communicable
disease
There were 820 357 Swedish admissions for infectious dis-
ease during 2006–2012 and 555 958 South African admis-
sions for infectious disease during 2008–2013 (Table 1).
This corresponded to 8⋅1 and 15⋅7 per cent of all admis-
sions in Sweden and South Africa respectively, and to an
annual incidence of 1255 admissions per 100 000 people
among the Swedish population and 3816 admissions per
100 000 people among insured South Africans. The annual
rate of all hospital admissions was 15 446 per 100 000 peo-
ple in Sweden and 24 330 per 100 000 people in the South
African study population.
The proportion of infectious disease admissions that
were associated with surgery was 8⋅0 (95 per cent c.i. 7⋅9 to
8⋅1) per cent in Sweden and 21⋅1 (21⋅0 to 21⋅2) per cent in
South Africa. The frequency of surgery was constant over
time; when standardized for age, sex and disease category
the frequency of surgery decreased from being 2⋅6 (95 per
cent c.i. 2⋅6 to 2⋅7) times higher in South Africa, to 2⋅2 (2⋅2
to 2⋅3) times higher.
Frequency of surgery in relation to sex and age
There was little difference in infectious disease admis-
sions between men and women (Table 1), and men had a
higher frequency of surgery in both countries (Fig. 1). The
frequency of surgery varied with age, and was consider-
ably higher in late childhood and during reproductive age
(Fig. 2). In the Swedish population, 10⋅2 per cent of all
admissions requiring surgery involved patients aged less
than 15 years, compared with 33⋅9 per cent in the South
African cohort. The frequency of surgery in the paediatric
population (under 15 years old) was 4⋅5 per cent in Swe-
den and 14⋅7 per cent in South Africa, compared with 8⋅7
and 27⋅1 per cent respectively in the adult population (older
than 15 years).
Frequency of surgery in relation to disease
category
The frequency of surgery varied considerably with disease
category (Fig. 3) and with diagnosis (Tables S2 and S3), in
both Sweden and South Africa. For example, the frequency
of surgery for HIV/acquired immune deficiency syndrome
and tuberculosis was 8⋅2 (95 per cent c.i. 7⋅5 to 8⋅9) per
© 2015 BJS Society Ltd
Published by John Wiley & Sons Ltd
1145
cent in Sweden compared with 23⋅9 (22⋅9 to 24⋅9) per cent
in South Africa. For the large category of lower respiratory
infections, the frequency of surgery was 1⋅7 (1⋅6 to 1⋅7) per
cent in Sweden and 4⋅0 (3⋅9 to 4⋅1) per cent in South Africa,
much lower than for upper respiratory infections: 17⋅4
(17⋅2 to 17⋅7) and 43⋅8 (43⋅5 to 44⋅0) per cent respectively.
The highest frequencies of surgery were for South African
admissions for bone and joint infections (71⋅9 (70⋅6 to
73⋅2) per cent) and sexually transmitted diseases, excluding
HIV (72⋅2 (70⋅3 to 74⋅1) per cent). Specific information on
all categories and specific diagnoses is shown in Table S2
(supporting information). In both countries, most of the
surgical need was for upper respiratory (20⋅6 per cent in
Sweden, 47⋅0 per cent in South Africa), skin and soft tissue
(17⋅8 and 21⋅5 per cent) and gastrointestinal (18⋅3 and 9⋅4
per cent) infections. Lower respiratory and bone and joint
infections also generated many surgical events.
The GBD 2010 framework captured 86⋅6 and 96⋅4 per
cent of all admissions for infectious diseases in the Swedish
and South African cohorts respectively in this study. Infor-
mation on frequency of surgery for each GBD subcate-
gory, as well as included diagnoses can be found in Table S3
(supporting information). For every Swedish admission for
infectious disease associated with surgery, there were an
additional 2⋅7 outpatient events associated with surgery.
Discussion
This large cohort study provides a comprehensive descrip-
tion of the frequency of surgical procedures among admis-
sions for infectious disease, and includes a comparison
between a high-income country (Sweden) and an affluent
stratum of a middle-income country (South Africa). The
frequency of surgical treatment for communicable diseases
was remarkable in both these settings, and most infectious
disease diagnoses were at least occasionally associated with
surgical operations.
These results imply that surgical care plays an impor-
tant role in the treatment of infectious disease, and that
the need for surgery is not eliminated, even with well
established preventive measures or primary medical treat-
ment in high-income health systems, or among afflu-
ent middle-income populations with health insurance21 .
Hence, surgical care is cross-cutting and integral to most
aspects of the healthcare delivery. It should therefore not
be perceived only as a treatment for non-communicable
diseases, such as obstetric and gynaecological problems,
neonatal malformations, neoplasms and injuries.
Several studies3,7 – 9,22 have investigated surgical treat-
ment for various infectious diseases, but the actual propor-
tion of diseases that end up requiring surgical management
www.bjs.co.uk BJS 2015; 102: 1142–1149
1146 A. Jarnheimer, G. Kantor, S. Bickler, P. Farmer and L. Hagander

Lower respiratory infections 1·7% Other 8·0% Sepsis 4·6% Upper respiratory
infections 17·4%

Skin and soft tissue Bone and joint

infections 15·5% infections 45·4%

Exanthematous
infections 2·8%

infections 1·3%
Herpes virus
GI tract infections 10·9%
Urinary tract
infections 8·2% HIV and
TB 8·2%

Mycosis
7.8%
CNS infections

STDs 22·3%
Hepatitis 12·2%
8·8%
Tropical 4·1%

a Sweden

Lower respiratory infections 4·0% GI tract infections 11·0% Skin and soft
tissue
infections
55·4%

Urinary tract CNS infections HIV and TB

Upper respiratory infections 43·8%
infections 71·9%

23·9%
Bone and joint

infections 26·7% 3·0%

Exanthe- Tropical
matous 4·7%
Other 17·8% infections
2·3%
Sepsis 18·1%
Herpes virus
Mycosis 19·1%
Hepatitis 5·6%

infections
3·4%

STDs 72·2%

b South Africa

Fig. 3Proportion of admissions (box size) and frequency of surgery (colour intensity and percentages) for infectious disease in a Sweden
(2006–2012) and b South Africa (2008–2013). GI, gastrointestinal; HIV, human immunodeficiency virus; TB, tuberculosis; CNS,
central nervous system; STD, sexually transmitted disease. Diagnosis-level data are available in Table S2 (supporting information)

© 2015 BJS Society Ltd www.bjs.co.uk BJS 2015; 102: 1142–1149

Published by John Wiley & Sons Ltd
Surgery and hospital admissions for communicable diseases in a high- and middle-income setting
was rarely outlined. For example, although the GBD Study
by Murray and colleagues4 described the disease burden
of 291 diseases and injuries, it fell short of describing the
probability that any of the diseases would require surgery.
In a study22 of paediatric surgical admissions to a refer-
ral hospital in the Gambia, infectious disease accounted
for 14⋅5 per cent of all surgical admissions, indicating that
infectious disease was a major entity among surgical admis-
sions. US estimates of frequency of surgery presented by
Rose and co-workers9 are in concordance with the Swedish
data, suggesting uniform surgical needs for infectious dis-
ease in these two high-income countries. However, Rose
et al. did not investigate which infectious diseases required
surgery, or provide information on infectious diseases out-
side the GBD 2010 framework.
The lower frequency of surgery in Sweden, compared
with South Africa, could reflect the preventive qualities of
Swedish primary care, different health-seeking behaviour,
unknown biological factors, or Sweden’s extensive shift
towards outpatient surgical care. Indeed, when the Swedish
outpatient surgical care for infectious disease was included
in the analysis, the frequency of surgery was very similar in
the two countries. The high rates of admission in the South
African population may reflect a certain supply-induced
demand and an insurance structure that favours inpatient
care. Difference in disease spectrum, as shown by the
different numbers of patients within each disease category,
could also explain some of the crude differences in surgical
need between Sweden and South Africa. However, most of
the differences between the two countries remained after
standardizing for age, sex and disease spectrum.
The relatively high prevalence of communicable disease
globally, especially in low- and middle-income countries,
leads to a high absolute need for surgery for infections.
This is compounded by increased drug resistance to
traditional antibiotics, and limited access to second-line
antibiotics23 . There may, for example, be a considerable
unmet need for surgery for tuberculosis, considering
the increasing frequency of antibiotic resistance and
co-infection with HIV24 – 26 . The results also highlight the
importance of surgery in limiting long-term morbidity and
possibly mortality among young and uninsured patients in
low- and middle-income countries. In the South African
cohort in the present study, 33⋅9 per cent of all of the
admissions requiring surgery were of patients aged less
than 15 years.
The results of this study must be interpreted with certain
limitations in mind. Most importantly, because the studied
populations have low barriers to effective medical treat-
ment for infectious diseases, the need for surgical therapy
in less affluent contexts may have been underestimated.
© 2015 BJS Society Ltd
Published by John Wiley & Sons Ltd
1147
Therefore, the importance of surgery for treating infec-
tious disease may be considerably greater in settings where
access to healthcare is more limited26 , in which medically
manageable infectious diseases such as pneumococcal
pneumonia and superficial Staphylococcus aureus infections
more often risk progressing to empyema and osteomyelitis.
The present results may therefore underestimate the role
of surgery in low-income countries where the disease spec-
trum, health-seeking behaviour and accessibility to health-
care for infectious disease differ from those of the present
study population6,27 . Similarly, because the data presented
here describe the surgical need in a South African popula-
tion that more often has access to primary prevention and
primary care, the authors hesitate to generalize the results
to the majority of the South African population, which
lacks comprehensive insurance plans15 – 17 . Unfortunately,
population-based registers that would enable these types of
study in low-income settings are often not available; mea-
surements of healthcare delivery from facility-based regis-
ters do not necessarily reflect actual societal medical needs,
as many people do not have adequate access to care28 .
It is important to point out that indications for surgery
might differ between countries and healthcare systems,
even when the definition of surgery is the same. To adhere
to the definition of major surgery used in South Africa,
some minor surgical procedures were excluded from the
Swedish set of procedure codes. Furthermore, the study
design could not discriminate occasions when surgical pro-
cedures were unrelated to the primary diagnosis, such as
when appendicitis occurred during an admission for a com-
municable disease.
Finally, because admission was the primary unit of analy-
sis, the incidence of surgery for infectious disease per per-
son could not be calculated. In the same way, multiple pro-
cedures during one admission were not taken into account,
nor were minor surgical procedures, leaving a potentially
large amount of surgery unaccounted for in this study. It is
notable that, for every admission for infectious disease lead-
ing to inpatient surgery in Sweden, there were an additional
2⋅7 outpatient events associated with surgery. These proce-
dures were not included in the present analysis and conse-
quently the results are likely underestimate the amount of
surgery performed for infectious diseases.
This study provides background material for the Lancet
Commission on Global Surgery, a global effort to incorpo-
rate surgery as a fundamental component of healthcare in
resource-poor settings1 . The present study confirms that
surgery is performed for most infectious disease diagnoses.
Nevertheless, many important questions remain, the fore-
most being what types of surgical procedures are being
performed and for what indications? This knowledge
www.bjs.co.uk BJS 2015; 102: 1142–1149
1148
could allow decision-makers to more effectively address
the types of surgery most needed. Are the procedures
mostly advanced, requiring sophisticated operating facil-
ities, or are they more basic in nature and could they be
undertaken at a primary referral hospital?
A globally accepted list of surgical procedures, and a well
established list of infectious diseases with corresponding
ICD codes, as in the present study, would facilitate fur-
ther comparison of surgery in a standardized fashion. The
general lack of population-based health service data for
surgery in less affluent countries is a barrier to this type
of research. The main purpose of the present study was
not to draw conclusions regarding the South African sce-
nario but rather to emphasize the importance of surgical
care in treating communicable diseases. The results sug-
gest that communicable diseases depend on surgery for
their management even in high-income settings with access
to prevention and good primary care. This illustrates the
importance of scaling up functional surgical health systems
in low- and middle-income countries, where the disease
spectrum is still distinguished by infectious disease.
Acknowledgements
The authors thank S. Naidoo and T. Ncube at Discovery
Health for helping with extraction of the South African
data. They also acknowledge the invaluable statistical sup-
port of L. Werner (Department of Clinical Sciences, Lund
University) and important input during the writing process
from H. Holmer (Lund University).
Disclosure: The authors declare no conflict of interest.
References
1 Meara JG, Leather AJ, Hagander L, Alkire BC, Alonso N,
Ameh E et al. Global Surgery 2030: evidence and solutions
for achieving health, welfare and economic development.
Lancet 2015; [Epub ahead of print].
2 Mock CN, Donkor P, Gawande A, Jamison DT, Kruk ME,
Debas HT; DCP3 Essential Surgery Author Group.
Essential surgery: key messages from Disease Control
Priorities, 3rd edition. Lancet 2015 [Epub ahead of print].
3 Debas HT, Gosselin R, McCord C, Thind A. Surgery. In
Disease Control Priorities in Developing Countries, Jamison DT,
Breman JG, Measham AR, Alleyne G, Claeson M, Evans
DB et al. (eds). International Bank for Reconstruction and
Development/World Bank Group: Washington DC, 2006;
1245–1259.
4 Murray CJ, Vos T, Lozano R, Naghavi M, Flaxman AD,
Michaud C et al. Disability-adjusted life years (DALYs) for
291 diseases and injuries in 21 regions, 1990–2010: a
systematic analysis for the Global Burden of Disease Study
2010. Lancet 2012; 380: 2197–2223.
© 2015 BJS Society Ltd
Published by John Wiley & Sons Ltd
A. Jarnheimer, G. Kantor, S. Bickler, P. Farmer and L. Hagander
5 World Bank. Country and Lending Groups; 2015.
http://data.worldbank.org/about/country-classifications
[accessed 8 February 2015].
6 Institute for Health Metrics and Evaluation (IHME). GBD
Compare; 2013. http://vizhub.healthdata.org/gbd-compare
[accessed 8 February 2015].
7 Ameh EA, Abantanga FA, Birabwa-Male D. Surgical aspects
of bacterial infection in African children. Semin Pediatr Surg
2012; 21: 116–124.
8 King M, Bewes PC, Cairns J, Thornton J. Primary Surgery:
Vol 1, Non-Trauma: the Surgery of Sepsis. Oxford University
Press: Oxford, 1990.
9 Rose J, Chang DC, Weiser TG, Kassebaum NJ, Bickler
SW. The role of surgery in global health: analysis of United
States inpatient procedure frequency by condition using the
global burden of disease 2010 framework. PloS One 2014; 9:
e89693.
10 World Health Organization (WHO). Guideline on the Use of
Devices for Adult Male Circumcision for HIV Prevention.
WHO: Geneva, 2013.
11 Nagler EV, Williams G, Hodson EM, Craig JC.
Interventions for primary vesicoureteric reflux. Cochrane
Database Syst Rev 2011; (6)CD001532.
12 Statistics Sweden. Population and Population Changes
1749–2014. http://www.scb.se/en_/Finding-statistics/
Statistics-by-subject-area/Population/Population-
composition/Population-statistics/Aktuell-Pong/25795/
Yearly-statistics--The-whole-country/26046/ [accessed 8
February 2015].
13 National Board of Health and Welfare. In English – the
National Patient Register. http://www.socialstyrelsen.se/
register/halsodataregister/patientregistret/inenglish
[accessed 9 February 2015].
14 Discovery. Discovery Health Medical Scheme.
https://www.discovery.co.za/portal/individual/medical-aid
[accessed 14 February 2015].
15 Mills A, Ataguba JE, Akazili J, Borghi J, Garshong B,
Makawia S et al. Equity in financing and use of health care in
Ghana, South Africa, and Tanzania: implications for paths to
universal coverage. Lancet 2012; 380: 126–133.
16 Coovadia H, Jewkes R, Barron P, Sanders D, McIntyre D.
The health and health system of South Africa: historical
roots of current public health challenges. Lancet 2009; 374:
817–834.
17 Naidoo S. The South African national health insurance: a
revolution in health-care delivery! J Public Health (Oxf)
2012; 34: 149–150.
18 Nordic Centre for Classifications in Health Care.
NOMESCO Classification of Surgical Procedures (NCSP),
Version 1.14. Nordic Centre for Classifications in Health
Care: Oslo, 2009.
19 Agency for Healthcare Research and Quality. Appendix
A – Operating Room Procedure Codes. http://www.quality
indicators.ahrq.gov/Downloads/Modules/PSI/V42/
TechSpecs/PSI Appendices.pdf [accessed 8 February 2015].
www.bjs.co.uk BJS 2015; 102: 1142–1149
Surgery and hospital admissions for communicable diseases in a high- and middle-income setting 1149

20 Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K,
Aboyans V et al. Global and regional mortality from 235
causes of death for 20 age groups in 1990 and 2010: a
systematic analysis for the Global Burden of Disease Study
2010. Lancet 2012; 380: 2095–2128.
21 Organization for Economic Co-operation and Development
(OECD). OECD Reviews of Health Care Quality: Sweden
2013. OECD Publishing: Paris, 2013.
22 Bickler SW, Sanno-Duanda B. Epidemiology of paediatric
surgical admissions to a government referral hospital in the
Gambia. Bull World Health Organ 2000; 78: 1330–1336.
23 Van Boeckel TP, Gandra S, Ashok A, Caudron Q, Grenfell
BT, Levin SA et al. Global antibiotic consumption 2000 to
2010: an analysis of national pharmaceutical sales data.
Lancet Infect Dis 2014; 14: 742–750.
24 World Health Organization (WHO). Global Tuberculosis
Report 2013. WHO: Geneva, 2013.
25 Somocurcio JG, Sotomayor A, Shin S, Portilla S, Valcarcel
M, Guerra D et al. Surgery for patients with drug-resistant
tuberculosis: report of 121 cases receiving community-based
treatment in Lima, Peru. Thorax 2007; 62: 416–421.
26 Mukherjee JS, Rich ML, Socci AR, Joseph JK, Viru FA, Shin
SS et al. Programmes and principles in treatment of
multidrug-resistant tuberculosis. Lancet 2004; 363:
474–481.
27 Grimes CE, Bowman KG, Dodgion CM, Lavy CB.
Systematic review of barriers to surgical care in low-income
and middle-income countries. World J Surg 2011; 35:
941–950.
28 Groen RS, Samai M, Stewart KA, Cassidy LD, Kamara TB,
Yambasu SE et al. Untreated surgical conditions in Sierra
Leone: a cluster randomised, cross-sectional, countrywide
survey. Lancet 2012; 380: 1082–1087.

Supporting information

Additional supporting information may be found in the online version of this article:
Table S1 Included ICD-10 codes (Word document)
Table S2 Total number of admissions owing to infectious disease, number of admissions associated with surgery,
number of admissions per 100 000 population and year, and frequency of surgery in Sweden and South Africa (Word
document)
Table S3 Total number of admissions owing to infectious disease, number of admissions associated with surgery,
number of admissions per 100 000 population and year, and frequency of surgery for Global Burden of Disease 2010
infectious diseases in Sweden and South Africa (Word document)

Editor’s comments

This study is a part of the Lancet Commission on Global Surgery, supported by the BJS. The need for surgical care
for communicable diseases is analysed in a high- versus middle-income country setting. Clearly the need is greater in
the middle-income setting, although there remains a surprisingly constant demand for such services in a high-income
setting, despite availability of antibiotics, efficient prevention and functional primary care. The increasing antibiotic
resistance globally may redefine the role of surgery for communicable diseases in the coming years.

M. Sund
Editor, BJS

© 2015 BJS Society Ltd www.bjs.co.uk BJS 2015; 102: 1142–1149

Published by John Wiley & Sons Ltd