key: cord-0689847-zjpb0wyv
authors: Chen, Yi-Lun; Hsu, Feng-Ming; Tsai, Chiaojung Jillian; Chia-Hsien Cheng, Jason
title: Efforts to Reduce the Impacts of COVID-19 Outbreak on Radiation Oncology in Taiwan
date: 2020-04-06
journal: Adv Radiat Oncol
DOI: 10.1016/j.adro.2020.03.005
sha: 79a505d8cfaa8de29e866d431a8dea8bbe9ad054
doc_id: 689847
cord_uid: zjpb0wyv

nan

On January 3, 2020, the World Health Organization (WHO) was notified of 44 patients in Wuhan, China experiencing pneumonia of unknown cause, which was later identified as Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Within one month the disease spread far beyond Wuhan, a city with a population of 11 million, and infected nearly ten thousand people in China. 1 As the number of infected individuals continued to rise exponentially, China's closest neighbors such as Taiwan, Japan, and South Korea soon faced the risk of their residents being infected. 2 To date, more than 800 individuals in Japan and 8,000 in South Korea have been diagnosed with COVID-19. With early proactive disease surveillance and contact isolation 3 , Taiwan has had significantly fewer cases, with less than 100 confirmed cases and one death as of March 17, 2020.

Taiwan has made tremendous efforts to minimize the spread of SARS-CoV-2 from abroad. The government has assigned overseas regions (subject to changes depending on updated data) to three levels with varying quarantine restrictions, with Level 3 regions having the highest risk of infection. Residents that have returned from Levels 1 and 2 regions are required to self-monitor for flu-like symptoms, while those from Level 3 regions are placed under a mandatory 14-day home quarantine. Furthermore, foreigners with recent travels to Level 3 regions are temporarily prohibited from entering Taiwan, and most flights from mainland China are grounded. 3 

To keep healthcare providers updated on the travel history of each resident, information from the immigration database is incorporated into the integrated circuit (IC) chip embedded in the health insurance identification cards, which are issued by the National Health Insurance Administration (NHI) and available to over 99% of the population. Additionally, distribution of personal protective equipment (PPE) is under government supervision to avoid hoarding and assure availability.

Hospitals throughout Taiwan have taken steps to minimize the virus spread. 4 Figure 1 illustrates a typical hospital screening workflow. People that have returned from Level 3 regions such as mainland China, Iran, Italy, South Korea, and certain European countries in the last 14 days are prohibited from entering hospitals, unless they need to be seen in clinic for non-COVID-19-related illnesses or have suspected infection. The NHI IC Card, which is connected to the immigration database and contains its card holder's travel and contact history, is verified by the medical staff before the card holder can enter a hospital for medical services; furthermore, everyone needing to enter a hospital, including patients, visitors, and staff members, is required to wear a disposable or cloth mask . Infrared thermal cameras are placed at hospital entrances, and individuals with abnormal thermal signals are rechecked for body temperature; those with an elevated temperature (forehead temperature ≥ 37.5 0 C or tympanic temperature ≥ 38.0 0 C) are prohibited from entering and subsequently referred to either the emergency department (travel history to Level 3 regions) or the special epidemic clinic (including travel history to areas other than Level 3 regions or suspicious travel/occupation/contact/cluster [TOCC] history) located outside the hospital building for further evaluations by infectious disease (ID) specialists. In addition, only up to two guests 3 per patient are allowed to visit the clinic/inpatient floor for one hour per day to avoid overcrowding the hospital and minimize further spread outside the hospital.

Cancer patients are more vulnerable to infection due to their compromised immune system, and active cancer therapy such as chemotherapy and radiotherapy (RT) may lead to Notably, each patient undergoing RT is provided with a new surgical mask daily and is encouraged to wear it in public spaces outside the hospital. The treatment machines and equipment are disinfected between each patient, and treatment facilities are cleaned by trained staff in compliance with recommendations from the hospital's infection control team.

At some medical centers, the medical staff, including physicians, therapists, and nurses, are divided into mutually exclusive subgroups. Direct contact between members from each subgroup is prohibited. If any member of the subgroup encountered a suspicious COVID-19 case, the whole subgroup undergoes a 14-day quarantine. Meanwhile, other subgroups can still operate the department with the least amount of impact on medical service. Hospital meetings and tumor board conferences are either canceled, reduced in frequency, or take place via online video discussions. With the proactive preventive approaches outline above, there has been no need to reduce clinical staff availability as a way to further reduce human contact and increase social distancing. All hospitals are able to maintain normal workforce to assist patients and provide cross coverage when needed, and there has been no SARS-CoV-2 transmission in the radiation oncology departments in Taiwan.

With initial success in containing COVID-19 spread in Taiwan having a departmental policy to recommend the delay. In addition, patients who were planned for RT may decide to defer the recommended therapy, especially with palliative or elective treatment. 5 The shortage of medical supplies for PPE and fear of getting infected inside hospital buildings make it stressful for both patients and healthcare professionals 6, 7 . All these impacts might affect the interaction between patients and healthcare professionals, 8 influence important decision-making processes, and potentially determine cancer therapy outcome. As COVID-19 evolves into a global pandemic, the risk of community spread in Taiwan could continue to increase. A proposed modified workflow that separates RT patients into different physical waiting/treatment space and "zones" in case of increased community spread is presented in Figure 3 . In addition, the government is considering nationwide screening of all healthcare professionals for SARS-CoV-2 antibodies to detected past infection as well as current asymptomatic infections to better triage frontline healthcare workers.

Taiwan went through the severe acute respiratory syndrome (SARS) epidemic in 2013, with 181 deaths of 668 probable infected patients. 9 Because of its high nosocomial infection and mortality rates, SARS led to the closure of medical units and isolation of many healthcare professionals in Taiwan, resulting in over 20% of RT treatment volume reduction.

With lessons learned from the SARS outbreak and concerns for other seasonal infections in a 6 densely populated country as well as air pollution, Taiwanese residents, regardless of their health status, developed the habit of wearing masks in public. Taking all the information into consideration, hospitals have adapted an updated policy to screen high-risk individuals by isolating them in designated areas outside hospital buildings to protect uninfected people and healthcare professionals, 11 taking highly hygienic steps by mandating mask-wearing for everyone inside hospital buildings, and disinfecting waiting areas and treatment units between patients. The different strategies between SARS and COVID-19 make the current workflow of fractionated RT cautiously maintained.

With experiences gained from the SARS epidemic, the Taiwanese government's efficient policies as well as strategies, and a multitude of precautionary steps implemented by hospitals, departments of radiation oncology in Taiwan have been able to provide uninterrupted radiation treatment for most cancer patients amid the current COVID-19 pandemic. Taiwan's strategic plans for limiting the spread could be a useful resource for other regions facing this serious public health threat. 

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