key: cord-0764839-nynri6my
authors: Lu, Jiade J.
title: Experience of a Radiation Oncology Center Operating During the COVID-19 Outbreak
date: 2020-04-10
journal: Adv Radiat Oncol
DOI: 10.1016/j.adro.2020.04.003
sha: c174e0986c2f9af27612f27600836b329ff46e05
doc_id: 764839
cord_uid: nynri6my

nan

The novel coronavirus (officially designated as the COVID-19) has seen a rapid increase in the number of cases in the United States, causing a lot of concern, if not panic, to the public. Cancer treatment under such circumstances is tremendously challenging because patients undergoing radiation or chemotherapy may be more susceptible to infection, especially because cancer treatments usually require extended and continuous courses.

As the executive vice president of the Shanghai Proton and Heavy Ion Center (SPHIC), a tertiary cancer treatment facility on the front line against the COVID-19 epidemic responsible for patient care and infection control, our experience and opinions might be helpful for colleagues in the United States as a reference. Equipped with the Siemens particle therapy system and 2 Varian TrumBeam, SPHIC provides both photonand particle beamebased radiation therapy to patients with cancer. Since the inception of our clinical service, all patients treated at SPHIC have been required to be admitted for close monitoring and professional care during particle therapy. Unfortunately, the structure of our inpatient facility makes infection prevention difficult: the central air conditioning has ventilation connected across all rooms on the same floor, and thus all patients and staff on the same floor may be susceptible if 1 is infected, and the hospital has 150 beds, but there is only 1 isolation room (ie, 1 bed). Such a setting has made it extremely crucial to identify potential patients with COVID-19 before their admission to the hospital, after which they are referred for proper medical care under isolation. However, it is not practical to screen all patients on the spot at the hospital entrance for testing by reverse transcription polymerase chain reaction (for qualitative detection of severe acute respiratory syndrome corona virus-2 [SARS-CoV-2] RNA). The false negative rate could be high, influenced by the specimen collection technique. Thus, 2 tests (24 hours apart) are required to confirm a diagnosis.

To ensure the safety of our patients and staff while preventing cluster infection, a number of measures were implemented as soon as the outbreak was announced. The hospital closed all but 1 entrance, with a newly established triage area to take body temperatures in addition to recording the travel and contact histories for all people entering the hospital. Fortunately, as our mail room is near the main gate, all deliveries can be easily unloaded without entering the hospital. Anyone with a body temperature over 37.3 o C and pertinent contact/travel history is transferred to a fever clinic at a designated hospital (special clinics of major general hospitals established during the 2003 SARS epidemic to triage and treat patients with fever) to rule out COVID-19 infection.

In addition, a "buffer zone" inpatient floor was created for all newly admitted patients. They are admitted on to the same floor for the first 7-14 days (depending on the availability of the rooms) of their treatment so that contact is avoided between patients undergoing treatment and those who have been newly admitted. Frankly, I am not sure whether this practice is truly useful because patients are not admitted together in batches. Those relocated to another floor after 14 days may have had contact with an infected but asymptomatic patient newly admitted to the same floor. However, psychologically, the "buffer zone" worked very well for our patients.

All inpatients and their companions are required to have a low-dose computed tomography (CT) of the thorax taken to screen for pneumonia at the cost of the hospital on the day of hospital admission. Since the outbreak, the hospital allows only 1 companion to stay with their respective patient during the treatment course while barring the entry of other visitors. Although our choice to screen all patients and visitors using CT could be considered an overreaction, it can still at least identify patients with symptomatic pneumonia for further management when testing for COVID-19 is not available.

After admission, all patients and their companions are required to use masks if they need to leave their room and are discouraged to leave the floor unless necessary during their stay. CT of the thorax and complete blood count with differential are immediately ordered to rule out pneumonia for anyone who has developed a fever. We also repeat a complete blood count with differential, as patients with COVID-19 may have a decrease in lymph counts. Anyone who has clinical manifestation(s) of novel coronavirus pneumonia would be referred to a designated hospital for further investigation, including a qualitative detection of SARS-CoV-2 RNA by reverse transcription polymerase chain reaction.

Since the onset of the COVID-19 epidemic, the number of patients in our hospital has dropped substantially owing to the government-implemented travel restrictions and quarantine policies. However, most cancer care services to the local and foreign patients managed to come to Shanghai and have continued without interruption. The government requires anyone from a high-risk region to be quarantined for 14 days after arrival. Such a restriction has been vastly helpful in reducing the pressure of triaging potential patients with COVID-19 at our hospital because we lack a clinical division for infectious disease.

From a professional point of view, I do not think it is necessary to delay chemotherapy or radiation treatment for patients with cancer because of COVID-19, unless an infection is confirmed or highly suspected or there are other medical reasons. Nevertheless, we postponed a number of nonurgent services to reduce patient contact and unnecessary traveling. For example, posttreatment follow-ups at SPHIC were postponed for all patients without active symptoms, whereas follow-up in a nearby cancer center is highly encouraged for patients from other cities. Our physicians will communicate with the patients or their local physicians if disease progression is suspected. For patients with benign or indolent conditions (eg, asymptomatic meningioma or chordoma), patients are given the choice to postpone their treatment to avoid traveling and the crowds at the hospital, both considered high-risk during the epidemic. These practices were implemented at our hospital for approximately 6 weeks and all clinical services were recently resumed.

Most hospitals in Shanghai and other major cities postponed elective and nonurgent surgeries for approximately 6 weeks because of the epidemic but also partly because of insufficient blood donation. In addition, several other specialties such as dental, ophthalmology, and otolaryngology stopped clinical service owing to a higher risk of COVID-19 infection. Such practice has substantially reduced patient referral of patients with head and neck cancer to radiation oncology, indirectly reducing the risk of transmission of the infection.

Clinicians certainly possess a higher risk of encountering COVID-19 than the public. Although radiation oncology is considered a low-risk specialty compared with intensive care, pulmonology, and infectious disease, just to name a few, one cannot over emphasize self-protection during this outbreak. It has been confirmed that COVID-19 is mainly transmitted by droplet spread, and possibly by airborne transmission as well. Therefore, transmission-based precautions for all patients were implemented at SPHIC during the outbreak, especially for transmission by droplet. Hand hygiene using alcohol-based hand sanitizer is emphasized and mask use was made mandatory for all people at all times (unless they are in a single-person room like a private office). Except for head and neck cancer treatments, all patients are required to wear a surgical mask during transportation and radiation therapy. Physicians and nurses at SPHIC are required to wear surgical or N95 masks and gowns for all interactions that may involve contact with a patient. Safety goggles are recommended for high-risk procedures because transmission via mucous membranes (eg, eyelids) is possible. Personally, I prefer surgical masks over N95 respirators for easy breathing and communication with my patients. However, the results of a randomized trial recently published in JAMA that compared N95 versus surgical masks for preventing flu among health care personnel revealed no significant difference between the two. 1 The Shanghai municipal government did not issue an order to shelter in place but requires everyone to wear a mask in public. Although it is debatable whether mask use by healthy people can effectively prevent the spread of COVID-19, I support such measures considering the density of the population of any metropolitan area in China. The person next to you can well be a passive or convalescent carrier of this highly contagious disease.

When I was checking the statistics today for this writeup, I was relieved to find that no physician has been infected with the virus in the greater Shanghai area in the past 3 months despite the 350 confirmed cases. In addition, all 1649 physicians and nurses dispatched from Shanghai to support the city of Wuhan, the epicenter of the epidemic in this country, returned safely. The epidemic of COVID-19 in mainland China appears to be dissipating sooner than predicted. The United States not only has the most advanced healthcare infrastructure in the world, but also the most developed medical principles and strategies to fight against such adversity, so stay vigilant and be confident!

N95 respirators vs medical masks for preventing influenza among health care personnel: A randomized clinical trial