Hematology Oncology Patients’ Care in a Pandemic Situation of COVID-19: Where Do We Stand?

Introduction

In December 2019, the rising incidence of the Coronavirus disease (COVID-19) caused by the novel Corona virus (SARS-CoV-2) infections in Wuhan, Hubei province, China has gained global interest. Due to an outrageous cluster of COVID-19 reported cases, the health authorities of Wuhan have locked down the wholesale market of seafood (the place where live and wild animals are sold) because of suspected cases connection with epidemic. ¹ Similarly, its rapid dissemination around the worldwide created an emergency of lock down in many countries. Pakistan was also listed as one of the affected countries. First lock down in Pakistan on March 20, 2020 to April 3rd which is now officially extended to April 14, 2020.

COVID-19 and Pakistan

On April 27, 2020, there are 13 844 known cases and 292 deaths with novel COVID-19 reported in Pakistan. ² First case documented on February 26, 2020, since then Pakistan has brought its alleviation action that were bordered around flight operations suspension either national or international, screening at point of entrance, isolation, keeping social distance, management of COVID-19, and home quarantine. ³ In order to minimize the spread of COVID-19, the federal government forced a limited shutdown in which specifically public places and schools were shut. Government vehicles suspended. Government hospitals were converted into isolations wards, people working in the offices were advised to work online from home. Shops of necessary items were opened for specific time hours as advised by the legal authority for instance, vegetables shop, bakeries, and diary shop. Public were only allow outside of their homes for emergencies and essential trips. ⁴ After reexamining the scenario depending on rising incidence in Pakistan, Government has continued the limited shutdown on April 15, 2020 till May 10th. ⁵

Due to its potential risk of transmission from human to human, healthcare facilities are occasionally gathering platform that will carry a worst impact of infectious diseases. In order to minimize the COVID-19 transmission, majority of the hospitals in Pakistan has taken strict actions to minimize their outpatients services and also limit the inpatient admissions whenever possible aiming to reduce any potential exposure and minimize nosocomial transmission of COVID-19. For instance, only emergent and urgent surgeries can be entertained. On the contrary, elective services are suspended or rescheduled.

Moreover, interruptions of scheduled chemotherapy cycles or delaying treatment may raise the possibility of clinical deterioration, particularly for individuals with high grade or aggressive malignancies. In Pakistan, a total of 173 937 cases of malignancy was reported in 2018, out of which 7139 (4.1%) were leukemia cases. During this pandemic situation of COVID-19 in Pakistan, the scheduled chemotherapy cycles for hematology-oncology indications were unavoidably affected. ⁶

As a result of implementing strong infection control measures and prevention, the COVID-19 epidemic dissemination is under control in Pakistan compared to other developed countries. Till April 6, 2020, 3755 COVID-19 cases are confirmed all over Pakistan, out of which Punjab was ranked the highest with 1918 documented cases while Sindh has 932 cases and the remaining confirmed cases are distributed in other provinces. As of April 6, 2020, number of new diagnosed cases and mortality due to COVID-19 has crossed more than 100 countries around the globe including US, Spain, Italy, Japan, South Korea, Singapore, and others with a total of 2 940 190 COVID-19 cases. ⁷ The high contagiousness, rapid spread, and longer incubation period of 2 to 21 days are alarming signs of the strong dissemination of COVID-19. The COVID-19 has been declared as a health emergency concern at both national and international level by World Health Organization. However, it could have a negative global effect on management and diagnosis of cancer patients. ⁸

Patients with malignancies are commonly geriatric age group with co-morbid conditions and compromised immunity. Consequently, these patients are at higher risk of severe complications and increased mortality from COVID-19 compared to the young patients. ⁷ Additionally, cancer patients can be at higher risk of exposure to COVID-19 while seeking medical treatment during hospital visits and being in contact other patients or even healthcare providers. In order to minimize the potential risk of infection and its complications in patients with malignancy, implemnting virtual clinic visits, home delivery of medicines needs to be adopted and implemented in the oncology setting. Four strategies are suggested and described below in order to manage such pandemic situation in oncology and hematology setting.

Examination at the Entrance

First, on-site measuring of temperature was implemented at the hospital entry, outpatient clinics, and medical wards. Queries of suspected individuals regarding their travel and contact histories are also recorded.

Pre-Appointment Booking

Secondly, a schedule booking system for outpatients is available to facilitate both on-site registrations and phone call appointments. The booking system subsequently minimizes the overflow of individuals in the hospital leading to a potentially low exposure. Similarly, such measures can also help conserving necessary personal protective equipment (PPE), hand sanitizer, gloves, and mask to be used for admitted patients in the hospital. Additionally, phone calls (telemedicine) consultations for patients with malignancies are routinely open on a regular basis to help patients following up their treatment plan, taking medications, and reporting cancer management-related symptoms to their primary physicians.

Eligible Admission

Third, for individuals who are considered eligible for hospital admission, COVID-19 symptoms including dry cough and temperature has to be frequently monitored and documented. Baseline routine blood tests and COVID-19 virus nucleic acid tests by polymerase chain reaction (PCR) will be used to confirm COVID-19 diagnosis. If the PCR result is positive for COVID-19, the patient has to be referred to isolation department allocated by Government of Pakistan for incubation period.

Alternatives

Fourth, chemotherapy medications that are administered through intravenous infusion mostly switched to an alternative oral dosage form whenever possible; for instance, methotrexate, cyclophosphamide, and melphalan.

Conclusion

During the current COVID-19 pandemic, special consideration should be given to cancer patients as a population of interest. Appropriate arrangements of antineoplastic chemotherapy ordering and administration and preventing cross transmission of COVID-19 among cancer patients are intensely important. These taken steps may be of high value to guide cancer patients safely and smoothly through the outbreak.