key: cord-0994677-njo93g3h authors: Xie, Conghua; Wang, Xiaoyong; Liu, Hui; Bao, Zhirong; Yu, Jing; Zhong, Yahua; Chua, Melvin LK title: Infection Control of 2019 Novel Corona Virus Disease (COVID-19) in Cancer Patients undergoing Radiotherapy in Wuhan date: 2020-03-24 journal: nan DOI: 10.1101/2020.03.21.20037051 sha: abeef69684548150bb62ab5924dfcb2e0b99f88e doc_id: 994677 cord_uid: njo93g3h Background A pandemic of 2019 novel corona virus disease (COVID-19), which was first reported in Wuhan city, has affected more than 100,000 patients worldwide. Patients with cancer are at a higher risk of COVID-19, but currently, there is no guidance on the management of cancer patients during this outbreak. Here, we report the infection control measures and early outcomes of patients who received radiotherapy (RT) at a tertiary cancer centre in Wuhan. Methods We reviewed all patients who were treated at the Zhongnan Hospital of Wuhan University (ZHWU) from Jan 20 to Mar 6, 2020. This preceded the city lock-down date of Jan 23, 2020. Infection control measures were implemented, which included a clinical pathway for managing suspect COVID-19 cases, on-site screening, modifications to the RT facility, and protection of healthcare workers. Primary end-point was infection rate among patients and healthcare staff. Diagnosis of COVID-19 was based on the 5th edition criteria. Findings 209 patients completed RT during the study period. Median age was 55 y (IQR = 48-64). Thoracic, head and neck, and lower gastrointestinal and gynaecological cancer patients consisted the majority of patients. Treatment sites included thoracic (38.3%), head and neck (25.4%), and abdomen and pelvis (25.8%); 47.4%, 27.3%, and 25.4% of treatments were for adjuvant, radical, and palliative indications, respectively. 188 treatments/day were performed prior to the lock-down, in contrast to 12.4 treatments/day post-lock-down. Only one (0.48%) patient was diagnosed with COVID-19 during the study period. No healthcare worker was infected. Interpretation Herein, we show that in a susceptible population to COVID-19, strict infection control measures can curb human-to-human transmission, and ensure timely delivery of RT to cancer patients. A pandemic of 2019 novel corona virus disease , which was first reported in Wuhan city, has affected more than 100,000 patients worldwide. Patients with cancer are at a higher risk of COVID-19, but currently, there is no guidance on the management of cancer patients during this outbreak. Here, we report the infection control measures and early outcomes of patients who received radiotherapy (RT) at a tertiary cancer centre in Wuhan. We reviewed all patients who were treated at the Zhongnan Hospital of Wuhan University (ZHWU) from Jan 20 to Mar 6, 2020 . This preceded the city lock-down date of Jan 23, 2020. Infection control measures were implemented, which included a clinical pathway for managing suspect COVID-19 cases, on-site screening, modifications to the RT facility, and protection of healthcare workers. Primary end-point was infection rate among patients and healthcare staff. Diagnosis of COVID-19 was based on the 5 th edition criteria. during the study period. No healthcare worker was infected. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 24, 2020. 6 Often, it is used as a definitive or adjuvant modality, and in patients with disseminated systemic disease, RT is effective for palliating symptoms. It is therefore imperative that RT services are not affected during this outbreak. Here, we report our experience and preliminary outcomes of 209 RT patients, who were treated at the Zhongnan Hospital of Wuhan University (ZHWU) during the period when the city was locked down on Jan 23, 2020. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted March 24, 2020. . https://doi.org/10.1101/2020.03.21.20037051 doi: medRxiv preprint All patients who were treated at the Department of Medical and Radiation Oncology, ZHWU, from Jan 20 to Mar 6, 2020 were included in this study. The start-date of the study period preceded the commencement of the lock-down of Wuhan city on Jan 23, 2020. Patient's demographics, medical history, contact history, clinical symptoms and examination, haematological and biochemical investigations, and results of the computed tomography (CT) of the chest were obtained. Data cut-off date for the study was Mar 6, 2020. This study was approved by the institutional review board of ZHWU (2020039). As aggregated, anonymised patient data was used in this study, waiver of consent was approved by the ethics committee. The workflow for screening of both hospitalised and non-hospitalised patients is outlined in CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 24, 2020. . the characteristic CT change of COVID-19 pneumonia is the presence of ground-glass changes in the outer zone of one or both lungs. This method of diagnosis for COVID-19 is considered more reliable than the SARS-CoV-2 real-time reverse transcription polymerase chain reaction (RT-PCR) assay, since CT manifestations tend to appear earlier than nucleic acid detection. 7 If either the CT or laboratory results were abnormal, the suspect cases would then be sent to the outpatient fever clinic for further assessment. Throat swab samples would be collected and tested using the SARS-CoV-2 RT-PCR assay. While waiting for the outcome of the RT-PCR test, patients would be quarantined in a dedicated area within the hospital compound to mitigate the risk of nosocomial spread. Contact, droplet and airborne precautions were undertaken for the suspect cases. In the event of a positive RT-PCR result or highly suspicious CT findings, patients would be transported to a designated infectious disease hospital for isolation, observation, and treatment. For patients with normal results, they will be admitted to the hospital for RT or receive RT as an outpatient. We employed the following workflow to screen all patients and health-care workers (nurses, radiation therapists, physicists ,physicians and paramedics): 1) All people entering the treatment area must record a body temperature of less than 37.3℃ prior to entry; 2) they would be screened again for contact history; 3) they must don a three-ply surgical mask at all times; and 4) strict hand hygiene must be practised. Patient holding area should be well-ventilated. Central air conditioning in the treatment area was not permitted. The treatment devices in close contact with . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 24, 2020. . the patient were thoroughly disinfected after every patient, while patient-specific treatment gadgets (e.g. thermoplastic shells, VacLoks etc.) were returned to the respective position after each treatment to avoid contact contamination. Next, to avoid overcrowding, treatment timings were staggered such that Given the risk of COVID-19 pneumonia to frontline medical staff, the following measures were implemented to mitigate the risk of cross-infection from patients to healthcare workers: 1) a buddy system to expedite the notification of unwell team members who harboured symptoms of fever, fatigue and dry cough, or who had a positive contact history with a COVID-19 patient; 2) twice daily temperature monitoring of all staff; 3) all staff members who were involved in transfer and delivery of treatment for patients had to don protective gear comprising of disposable surgical caps, gowns, N95 masks, face screens, double-layered gloves, and shoe covers; 4) radiation therapists were split into two-man teams at any point in time, along with optimisation of processes for patient set-up and treatment delivery to reduce cross infection; 5) protective gear should be disposed of in a medical hazard waste bag; 6) strict hand hygiene before leaving the treatment area; 7) team gatherings during work were prohibited; and 8) finally, social distancing was encouraged to prevent transmission to family members. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 24, 2020. . . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 24, 2020. . https://doi.org/10.1101/2020.03.21.20037051 doi: medRxiv preprint From Jan 20, 2020 to Mar 6, 2020, 209 patients were treated at our RT facility. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 24, 2020. . https://doi.org/10.1101/2020.03.21.20037051 doi: medRxiv preprint and RT-PCR screening investigations were negative. Among them, 52 patients were not able to return for RT post-lock-down, while 18 patients continued to undergo RT without delay. Nonetheless, treatments for these patients were re-scheduled to the end of the day. Finally, no medical staff was infected during the study period. All patients, including the COVID-19 case, remained alive as of Mar 12, 2020. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 24, 2020. 9 it has also been shown that the latter subgroup, as well as patients with co-morbidities like chronic obstructive pulmonary disease and cardiac conditions are more likely to succumb to severe illness. 10 Hence, there is a real concern about the impact of COVID-19 in patients with cancer. To date, two case series have identified that patients with cancer habour an approximately two-fold increased risk of COVID-19, and reasons underpinning these observations include older patients, immunosuppressive therapies, and recurrent hospital visitations. 5, 11 Robust infection control measures are therefore crucial to prevent cross-transmission between patients and between patient and healthcare workers within the compounds of a cancer centre. Herein, we shared our single institution experience in the management of cancer patients undergoing RT from a cancer centre that was based in Wuhan, where the outbreak first started. Our infection control protocol was comprehensive, covering a stepwise clinical pathway to manage suspect cases (questionaire, CT, and RT-PCR assays), on-site screening, re-organisation of the RT facility, and protection of healthcare workers. The extremely low rates of infection among our patients (0.48%) and healthcare workers (0%) were a testament to the efficacy of our measures. Notably, one patient who was treated in our RT facility became infected . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 24, 2020. . with SARS-CoV-2 on Jan 26, 2020 (3 days after the lock-down). We were able to establish a contact history with 70 other patients over the preceding 14-day window. Amazingly, none of the patients developed COVID-19 pneumonia on follow-up, which again highlights the effectiveness of our infection control protocol. Unfortunately, due to the lock-down, only 18 of these patients were able to resume RT, as the remaining 52 patients were not allowed to return to the city. Some limitations of this study deserve mention. First, it is apparent that the number of patients decreased substantially following the lock-down (a 10-fold drop in case-load; Figure 3) . While it is unknown if such a meticulous protocol would be applicable in high-volume cancer centres from other parts of the world, reduction of case-load constitutes a key step of limiting human-to-human transmission of SARS-CoV-2, and thus, patients' treatment ought to be prioritised accordingly. Finally, it is important to assess the impact on the long-term prognosis of these cancer patients, especially for those individuals who were unable to resume their treatment, which is the undesired consequence of a lock-down and robust infection control measures. To conclude, we described infectious control measures that were undertaken to prevent human-to-human transmission among patients with cancer undergoing RT and healthcare workers. The early result of a 0.48% infection rate validates the effectiveness of our protocol. Longer-term follow-up will inform on the implications of this pandemic on the survival outcomes of cancer patients. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 24, 2020. *Includes lung, breast,and oesophageal cancer patients. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 24, 2020. . . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 24, 2020. . . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 24, 2020. . is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 24, 2020. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. 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