Letter to Editor

Dear Editors: 

Hiwa cancer hospital is found in Sulaimaniyah town in the northeast of Iraq and southeast of Kurdistan. Townhomes have a population of 800,000 folks as of 2016. Hiwa cancer hospital was designed by the government and pass by each government and charitable donations, and it is the sole cancer hospital in Sulaimaniyah town, it has 170 inpatient and 50 outpatient beds and yearly receives around 1600-2000 new adult oncology and hematology cases. 100 percent of all patients accepted for cancer treatment utterly freed from charge, regardless of race or nationality

Coronavirus-19 (COVID-19) is an emerging and quickly evolving situation globally (1, 2), now Europe is the epicenter of the pandemic. Italy, France, England, and Spain have obligatory lockdowns (3).  By the spread of the virus in neighboring countries especially Iran with whom we have got long border and the virus outbreak was very severe there, Kurdistan region government (KRG) took serious action in collaboration with Iraq government to prevent virus outbreak since the region have restricted resources concerning ICU units, ventilation, personal protective measures and manpower. The KRG started with closing all borders particularly with Iran, closing schools and universities starting from February 2020. By diagnosis of first case with COVID-19 in early march 2020, KRG imposed public holiday across all the Kurdistan Regional Government entities, except health and law enforcement departments, forcing people to stay home with keeping social distancing. All traffic movement between cities was banned. A mayoral committee was formed with the participation of police and security forces to issue special permits in emergency cases. Any citizen outside Iraq was informed to return before the deadline of banning all flights from and to Iraq, all travelers where ought to undergo screening by medical teams. All religious and ritual activities and ceremonies, including Friday sermons - in mosques, churches, and temples throughout the Kurdistan Region were halted until further notice was made.

With such strict action from the KRG and compliance of citizens to the orders, the total diagnosed cases in Kurdistan region at the time of writing this article (March 2021) is 109,350 cases,  103,744 has been cured, 3,522 death and 2,084 active cases are available (4), 640 of them has active cancer from Hiwa cancer hospital.

Covid-19 crisis made cancer care more complicated than it already is due to its expensive and prolonged treatment course (5).The travel ban, economic uncertainty made normal cancer care delivery restricted. On another side cancer patients are thought to be particularly vulnerable, especially those who are undergoing active treatment with chemotherapy or radiotherapy, and those with compromised immune systems are deemed to be at heightened risk of severe health problems from COVID-19. 

We tried to treat cancer patients within the same approach as traditional circumstances; however, because of restricted resources, we couldn’t take this risk. Taking advantage of Italian experience (6) and other countries with a high burden of COVID-19, along with guidelines (7-10) guided us to make some strategic decisions in Hiwa cancer hospital regarding cancer care during this crisis. 

inpatient admission of cancer patients with relatively mild disease suspended, not taking new cancer cases, benign hematological cases was suspended and curtailed cancer follow-up visits, all chemotherapy, and radiation treatments had to be modified to mirror the current reality, Those patients that completed neoadjuvant therapy had to wait longer than traditional for planned surgery, and may need to have additional treatment cycles. Individual chemotherapy cycles are spaced out, and radiation treatments are being given more compactly, with fewer fractions, aiming to decrease hospital visits.

For outpatient cases; solely the patient was allowed to enter the hospital campus without their companions as its custom in our society, whereas for inpatient; guests have been severely limited. All patients had to wear masks and gloves and the restricted number was allowed to enter at a time, for this purpose we placed a group of hospital employees at the entrance of the hospital to provide directions and instructions to the patients. 

Anyone entering the hospital campus, either staff hospital employee or patient, undergoes initial screening for symptoms related to COVID-19 infection including fever, shortness of breath, and cough. All those with such symptoms had to wear a mask and be referred to a 24/7 hospital dedicated just for COVID-19 for further evaluation.

A special clinic was formed for a phone consultation, from this clinic all patients were called and informed concerning this facility, providing all psychological support for the patients to feel safe while they’re home, any required investigation was ordered online by a screenshot and sent to the patients by SMS to be done in any medical centers or nearby hospital, instruction was given about not coming to the hospital except in specific situation and certain condition to avoid unnecessary trips to the hospital. Although we don’t have courier serves in our country, for any required medication the patients had to buy it from outside, this was one of the biggest problems that we faced since most of the time the patient couldn’t buy needed medications due to ban or economic issue; this fact may have negative feedback on their cancer progression.

Radiology services continued to operate, for inpatients as well as for those on active cancer treatment, however only urgent imaging studies are being carried out while omitting elective imaging and all screening activity. The laboratory and histopathology department continued their duties.

At the beginning we faced shortage of personal protective equipment (PPE), in particular N95/Filtering Face-piece Particles (FFP) masks, later on several local manufacturers stepped in and now are able to produce adequate surgical masks, gowns and other protective clothing except N95 masks with adequate numbers to meet expected needs. Government and ministry of health are tasked with purchase, import and distribution of essential equipment particularly N95masks, but they’re facing difficulties in sourcing such supplies due to global shortage and worldwide demand (7,8).

Our study has important limitations, related to the fact that data was collected solely from Hiwa Cancer Hospital in Sulaimaniyah and in a general way registry is under estimated, till now many cases with COVID-19 have not been diagnosed nor registered, no data on cancer death by COVID-19 is available. For this reason more study is warranted.

Public education like promotion of hand hygiene, effective social distancing and other preventive protocols must be rapidly and strictly implemented. Personal protective equipment for healthcare worker and facilities for critical care should be provided, and most importantly paying adequate attention to the extra human resources (nurses, trained intensivists, and respiratory care technicians) needed for running these services.

Conflicts of interest

The authors declare that no competing financial interests exist.

References

1. Li R, Pei S, Chen B, Song Y, Zhang T, Yang W, et al. Substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (SARS-CoV2). Science. 2020;3221(January):1–9. 

2. Culp WC. Coronavirus Disease 2019. A A Pract. 2020;14(6):e01218. 

3. Burki TK. Cancer care in the time of COVID-19. Lancet Oncol [Internet]. 2020;21(5):628. Available from: http://dx.doi.org/10.1016/S1470-2045(20)30201-1

4. Government KR. No Title [Internet]. Available from: https://gov.krd/english/government/

5. Desai A, Sachdeva S, Parekh T, Desai R. Covid-19 and cancer: Lessons from a pooled meta-analysis. JCO Glob Oncol. 2020;6:557–9. 

6. Lambertini M, Toss A, Passaro A, Criscitiello C, Cremolini C, Cardone C, et al. Cancer care during the spread of coronavirus disease 2019 (COVID-19) in Italy: Young oncologists’ perspective. ESMO Open. 2020;5(2). 

7. ESMO Recomendation E. No Title [Internet]. Available from: https://www.esmo.org/guidelines/cancer-patient-management-during-the-covid-19-pandemic?page=1

8. ASCO. For most updated content, visit https://www.asco.org/asco-coronavirus-information COVID-19 Clinical Oncology Frequently Asked Questions (FAQs). 2020;1–8. 

9.NICE. COVID-19 rapid guideline: delivery of systemic anticancer treatments. 2020;(April):1–16. Available from: https://www.nice.org.uk/terms-and-

10.ESMO-Recommendations-Covid-19-General-Slide-Set.

a Hiwa Cancer Hospital, Medical Oncology Department, Sulaimani, Iraq.

b Department of Obstetrics and Gynecology,  College of Medicine, University of Sulaimani, Kurdistan Region, Iraq