The COVID-19 pandemic has been pushing governments and healthcare systems to their limits in both high and low resources settings. As of 29 April 2020, the total confirmed COVID-19 cases reached beyond 3 million, and 207,973 deaths have been reported worldwide .
In the Levant, where political conflict and economic crises are endemic, healthcare systems and supply chains are inherently fragile. For years, Syria and Iraq have been involved in active conflict; Lebanon, Jordan and Turkey have subsequently accommodated large numbers of refugees and migrants. Government imposed lockdowns to contain the spread of the virus have been rapidly implemented, however it is likely that deepening existing social and economic disparities will lead to far reaching regional consequences.
Lebanon, Syria, Jordan and Iraq have reported a total of 3137 COVID-19 cases, as of 29 April 2020. Turkey, which shares borders with Syria and Iraq, reported 114,693 total cases of COVID-19 infection  (Figure 1). Infection of vulnerable groups, such as patients with underlying chronic medical conditions, immunocompromised patients and the elderly may lead to severe complications and the potential need for respiratory support .
Patients with a diagnosis of cancer are considered to be at higher risk of COVID-19, and coupled with the concerns regarding limited resources for testing and hospital intensive care capacity, the workflow and delivery of oncology care in the region has been significantly impacted. In this article, we discuss the various changes that have been made, and its impact on cancer patient management.
Figure 1. COVID-19 cases/million in Iraq, Jordan, Lebanon, Syria and Turkey. Total cases/million are plotted against the date since the first case was identified in Lebanon on 21 February 2020. The figure highlights the evolution of confirmed COVID-19 cases per million population in Lebanon, Jordan, Iraq and Syria since 21 February 2020, when the first case in Lebanon was confirmed. Since then, the evolution of the virus took similar trends in Lebanon, Iraq, and Jordan, even though as of 6 May 2020, COVID-19 testing is 6549/million in Lebanon and 2821/million in Iraq, and 8984/million in Jordan (worldometer.info). Turkey, which has the highest number of cases/million amongst the mentioned countries has also tested the most (14,281 /million). Lastly, the cases and testing data coming from Syria is not very reliable given the dismantlement of the healthcare system caused by the prolonged conflict in the country. The databases used were ECDC for the COVID-19 confirmed cases and the World Bank for population data.
Daily practice in Lebanese oncology centers has witnessed a major shift from the norm. Guidelines issued by the Lebanese Society of Medical Oncologists recommend that physicians prioritize different treatments based on their therapy type and stage . The number of daily clinic appointments has been reduced and spaced out. Data from the Naef K. Basile Cancer Institute at the American University of Beirut Medical Center (Beirut, Lebanon), comparing February and March 2020, has shown a drop of almost 30% in outpatient clinic appointments.
Physicians and specialist nurses have been using telemedicine to offer patients virtual clinic appointments. This has been rapidly implemented using the video conferencing facility linking the hospital electronic medical record system and patient telephone application. This has been welcomed by patients and staff, particularly for routine follow-up visits for patients concerned about travelling to the hospital.
In line with the experience from other tertiary referral centers in Lebanon, hospital admissions and numbers of patients attending for ambulatory infusion appointments remained relatively stable between February and March 2020; however, we expect figures for April to be lower. Elective surgery and elective procedures such as endoscopy have been suspended but radiation therapy is ongoing. However, new case referrals have dropped significantly.
Due to lack of testing capacity, it is not possible to test all patients for COVID-19 who are undergoing treatment. All patients and visitors are verbally screened for history of sick contacts and are checked for fever on entry to the cancer center. Face-to-face meetings within the hospital including tumor boards are being conducted using video conferencing.
Screening and enrolment for clinical trials has largely been suspended with the exception of urgent interventional studies with no additional risk of exposure to patients or research staff beyond required clinical care in consultation with the Institutional Review Board.
In Syria, oncologists are following recommendations issued by the National Committee for Cancer Care. The pandemic has affected the delivery of oncology services on multiple fronts. Similar to Lebanon, physicians are forced to prioritize cases, such as the newly diagnosed with curable disease or those requiring urgent care. Diagnostic testing is available only in limited locations with a prolonged turnaround time.
In addition, many hospitals are short on personnel protective equipment (PPE), negative pressure units, isolation units and appropriately trained staff. The sanctions imposed on the Syrian government along with the sweeping economic crisis striking the region have set limitations on the acquisition of many cancer drugs and radiotherapy equipment in the country. This had made it more difficult for patients to acquire and purchase chemotherapy drugs that the Syrian Ministry of Health is lacking.
Furthermore, some patients’ chemotherapy regimens have been interrupted as restrictions on transportation have raised an additional challenge, especially for patients living in remote areas. These limitations are reflecting not only on patients’ protocol efficacy, but also on the patients’ and their family’s mental health; some of whom, have decided to suspend treatments altogether.
In Jordan, there was a quick government response to contain the virus spread after the diagnosis of the first case on 2 March 2020. Jordan was one of the quickest countries to implement a complete lock down, early in the course of the pandemic, by enforcing a nationwide curfew on 20 March 2020. King Hussein Cancer Center (KHCC), the only comprehensive cancer center in the country [4,5], has implemented significant procedures and protocols in response to the announcement of the first case by the Jordanian Ministry of Health, in order to fight the epidemic, contain the disease and protect patients, families and staff.
A drive through COVID-19 screening unit was created to screen and triage all patients prior to hospital entry. An isolation unit was identified to conduct COVID-19 testing for all suspected cases requiring hospital admission, a separate inpatient unit and intensive care unit beds were also identified and prepared to receive COVID-19-positive cases.
COVID-19 phone screening was also implemented, as well as use of virtual clinics and telemedicine for routine non-urgent cases to minimize contact with patients, and all prescribed medications are delivered to patients’ homes across Jordan using a local delivery service.
Screening clinics were stopped, together with elective chemotherapy, radiotherapy and surgeries. A hotline was activated and staffed by experienced health care professionals and operated to receive calls 24/7. Staff protection was a priority, therefore ensuring sufficient supply of PPE and continuous education.
In-person meetings were cancelled and switched to virtual teleconferences using digital meeting platforms: this included multidisciplinary clinics and administrative meetings. Palliative care services continued; however, most patient care carried out at home, utilizing KHCC homecare team visits.
Screening and enrolment of new patients on clinical trials was paused following recommendations from the Jordan Food and Drug Administration. Nonetheless, considering their limited number, patients who were already enrolled on clinical trials continued to be seen in clinics, and their safety tests and procedures were done on time as per protocol requirements. They also received their chemotherapy sessions as per study protocol. Some trials that required the collection of samples from patients for central lab testing experienced a few deviations due to restrictions on flights and airport closures. Also, some trial patients experienced delays in scheduled surgeries, which were halted in the early phase of virus containment. Incoming shipments of study drugs continued to be received despite a few delays, however, most patients were able to receive their treatments within the protocol allowed window.
As cases of COVID-19 surfaced in Iraq, response efforts were quickly implemented to curtail the viral outbreak. At AL-Amal National Hospital in Baghdad, the first tertiary healthcare center dedicated for diagnostic and therapeutic oncology services, several protection and prevention measures were taken to secure the safety and continuity of cancer management practices during this pandemic.
First, to ensure proper protection of patients and hospital staff, a hospital pandemic safety plan was developed. All hospital staff members were equipped and educated on the proper use of daily PPE, including masks, surgical gowns and face shields. Alcohol-based disinfectants and hand gel sanitizers were distributed around all hospital floors. Disinfection was also carried out twice daily throughout the entire hospital. Furthermore, educational lectures on COVID-19 transmission, clinical course, treatment and daily prevention measures were conducted for all healthcare staff members. Similarly, patient awareness campaigns on COVID-19 infection control were established.
Second, daily inpatient, outpatient and visitor workflow processes were also adjusted to protect patients’ safety and reduce the risk of contracting the virus. Hospital staff members were provided with evidence-based guidelines on patient assessment and monitoring of illness. Patients were requested to conform with the strict use of preventive actions such as wearing masks and gloves throughout the hospital wards. Patient visitations were also reduced to only twice-weekly and waiting time in reception areas was minimized as much as possible, whilst adhering to appropriate social distancing measures. Further, non-urgent consultations with patients were conducted through telephone calls.
Finally, cancer management practice was adjusted as per international cancer management guidelines to guarantee timely and safe delivery of anticancer treatment. These practices include: decreasing the number of in-person hospital visits by transitioning to oral rather than injectable treatment options when applicable, switching from dose-dense chemotherapy (every two weeks) to 3-week treatment plans and adjusting treatment protocols to avoid prolonged hospital stay, as well as the administration of toxic agents. In addition, patient numbers in the radiology department has been reduced and treatment in the radiotherapy department was limited to palliative care.
In Turkey, the first case was reported on 10 March 2020. In accordance, measures to regulate clinical practice and patient care have been set forth. Routine follow-up appointments, including clinical visits and imaging appointments have been postponed, while patients currently receiving chemotherapy continue to do so in accordance with the governmental and hospital infection control committee decisions.
Additionally, many patients are being referred to the nearest oncology centers as travel limitations continue. Protocols to manage training practice include the education of faculty and staff on the proper use of PPE and infection prevention practices, as well as the establishment of a plan on readiness if cases of COVID-19 are diagnosed in oncology departments. Moreover, in-person meetings and tumor boards were cancelled and replaced with teleconferences and online meeting tools.
The increasing burden on hospitals and oncology centers is one of the key challenges facing oncologists in Turkey today, necessitating the need to establish a robust plan of action if COVID-19 cases surge further.
While the majority of the countries in the region have rapidly and successfully implemented comprehensive measures to ensure optimal care for cancer patients, concerns arise regarding the longer-term consequences of the pandemic.
The drop in the number of outpatient appointments, suspension of many screening and diagnostic procedures and the lack of clinical trial enrolment are some of the immediate effects of COVID-19 that oncology centers have witnessed. These diagnostic and treatment delays coupled with the economic impact of the pandemic are to likely have unfavorable consequences on stage at presentation, and the clinical outcome of patients with cancer.
Moving forward, it is essential to improve local and national data collection to ensure cost-effective allocation of restricted resources, limit healthcare inequalities and mitigate delays in healthcare access.
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The opinions expressed in this Editorial are those of the author and do not necessarily reflect the views of Oncology Central or Future Science Group.
Dr. Zahi Abdul Sater, Dr Deborah Mukherji, Dr Tezer Kutluk and Dr Omar Shamieh receive funding from the UK Research and Innovation GCRF grant Research for Health in Conflict (R4HC-MENA) (ES/P010962/1)
Lina Hamad1, Zahy Abdul Sater2, Tezer Kutluk3, Omar Shamieh 4, Amal Al Omari5, Zahera Fahed6, Maha Manachi 7, Tahseen Alrubai 8, Rafid Abboud 9, Asem Mansour10, Deborah Mukherji1