Head and Neck Cancer Care in a Pandemic: Prioritizing Safe Care

Section 1

General Considerations

1

Epidemiology of COVID-19 and Its Relation to Head and Neck Cancer Patients

Young Jae Byun MD

Daniel T. Lackland DrPH

Shaun A. Nguyen MD

Core Messages

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the infectious agent that causes coronavirus disease 2019 (COVID-19) and is responsible for the global pandemic affecting over 25 million people in over 170 countries at the time of this printing.

Population surveillance suggests certain groups may be disproportionately affected by COVID-19.

Typical symptoms of infection include fever, fatigue, cough, myalgia, and pneumonia-like presentations; however, this may be confounded by patients’ underlying medical conditions.

A surge in COVID-19-associated hospitalization threatens to overwhelm hospital capacity, jeopardizing optimal patient care.

Special consideration must be given to head and neck cancer (HNC) patients given that COVID-19 affects populations that encompass a significant portion of HNC patients.

Obstacles of safe management of HNC patients include limited screening and testing of SARS-CoV-2, high viral loads in anatomic locations of interest in HNC, relatively high-risk procedures involved in HNC treatment, and limited availability of personal protective equipment for healthcare professionals.

Introduction

In December 2019, the first cases of a severe disease-causing respiratory dysfunction and pneumonia were reported in Wuhan, China. Since then, the number of cases has increased dramatically, spreading across continents and worldwide (Figure 1-1). By mid-March 2020, more than 400,000 cases of the disease were confirmed with over 18,000 deaths globally, prompting the declaration of national emergencies in several countries. The causative agent was determined to be a novel coronavirus (CoV) and the World Health Organization (WHO) subsequently announced the official name of the disease as coronavirus disease 2019 (COVID-19). Its viral genome was determined to be phylogenetically similar to that of the causative agent that was responsible for the severe acute respiratory syndrome coronavirus (SARS-CoV) outbreak in 2002.¹ In light of this discovery, the International Committee on Taxonomy of Viruses (ICTV) labeled the new coronavirus SARS-CoV-2.²

Figure 1-1. Timeline of early COVID-19 pandemic events. A total of 41 confirmed cases occurred between December 2019 and January 13, 2020. Epidemiologic data showed that person-to-person transmission occurred via close contact at this point.

Reprinted with permission from Sun J, He WT, Wang L, et al. COVID-19: Epidemiology, Evolution, and Cross-Disciplinary Perspectives. Trends Mol Med. 2020;26(5):483–495.

Various coronaviruses, which are enveloped, positive-sense, single-stranded RNA viruses, have been known to infect humans and animals. For instance, about 15 to 30% of common colds are attributed to human coronaviruses (HCoVs). Some animals are reservoirs of the virus, harboring the infectious agent that can be transmitted to humans to cause outbreaks. The SARS-CoV outbreak in 2002³ and the Middle East respiratory syndrome coronavirus (MERS-CoV) outbreak in 2012 were results of human transmission from animal reservoirs.⁴ Similarly, reports suggest that SARS-CoV-2 may have been transmitted by bats, snakes, or pangolins.⁵,⁶

Epidemiology

The number of COVID-19 cases began to soar at an alarming rate since the first report in December 2019. While the number of confirmed cases in China grew until leveling off in mid-February 2020, cases began to emerge throughout the world since then. At the time of this writing (May 2020), the number of COVID-19 cases continues to grow and evolve (over 4 million cases worldwide) and is reported in over 170 countries (Figures 1-2 and 1-3). Currently, Europe and the Americas are particularly impacted by this pandemic; in the United States alone, there are 1,271,645 laboratory-confirmed COVID-19 cases with 76,916 deaths (approximately 6.0% mortality) reported as of May 12, 2020 (Figure 1-4).⁷

Figure 1-2. Number of confirmed COVID-19 cases through May 15, 2020. Cases reported by date and WHO region, from December 30, 2019 through May 15, 2020.

Other* includes cases reported from an international conveyance (Diamond Princess cruise ship).

Reprinted from Coronavirus disease (COVID-19) Situation Report – 116. Data as received by WHO from national authorities by 10:00 CEST, 15 May 2020.

Figure 1-3. Global case comparison of WHO regions by May 15, 2020.

Adapted from Situation by WHO Region. WHO Coronavirus Disease (COVID-19) Dashboard (https://covid19.who.int/).

Figure 1-4. COVID-19 cases in the United States reported by state. As of May 15, 2020, 29 states reported more than 10,000 cases of COVID-19.

Adapted from CDC COVID Data Tracker. United States COVID-19 Cases and Deaths by State. (https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html).

A population-based surveillance for laboratory-confirmed COVID-19-associated hospitalization in the United States conducted in March 2020 presented an age-stratified COVID-19-associated hospitalization rate. This report showed that hospitalization rates were the highest (13.8%) among adults aged 65 years and older (Figure 1-5). Available data on underlying medical conditions of these patients revealed that 89.3% had one or more underlying conditions: The most common conditions in descending order were hypertension (49.7%), obesity (48.3%), chronic lung disease (34.6%), diabetes mellitus (28.3%), and cardiovascular disease (27.8%) (Table 1-1).⁸

Figure 1-5. Hospitalization rates of COVID-19 confirmed cases by age group. Number of patients hospitalized with COVID-19 per 100,000 persons collected via COVID-19-associated hospitalization surveillance network (COVID-NET).

Reprinted from Garg S, Kim L, Whitaker M, et al. Hospitalization Rates and Characteristics of Patients Hospitalized with Laboratory-Confirmed Coronavirus Disease 2019—COVID-NET, 14 States, March 1–30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(15):458–464.

Table 1-1. Underlying Conditions Among Hospitalized Adults With Coronavirus Disease 2019 (COVID-19)

Abbreviations: COPD, chronic obstructive pulmonary disease; CAD, coronary artery disease; CHF, congestive heart failure; GI, gastrointestinal

Data from Coronavirus Disease 2019—Associated Hospitalization Surveillance Network (COVID-NET) from 14 states in the United States (California, Colorado, Connecticut, Georgia, Iowa, Maryland, Minnesota, New Mexico, New York, Ohio, Oregon, Tennessee, Utah) from March 1–30, 2020.

The catchment population data in the surveillance suggest that males and black populations may be disproportionately affected by SARS-CoV-2. In this survey, approximately 49% of patients were male but 54% of COVID-19-associated hospitalizations were male. Likewise, blacks represented approximately 18% of surveyed patients but they accounted for 33% of hospitalized patients. This unequal representation of COVID-19 burden is also presented in the New York State Department of Health report, where blacks and Hispanics accounted for 15% and 18% of deaths, respectively (population representation of 12% and 9%, respectively).⁹

The reported overall mortality rate of SARS-CoV-2 is 3.8%,¹⁰ which is lower than that of SARS-CoV (10%)¹¹ or MERS-CoV (37%).¹² However, the number of relative infection rates is more than 10 times higher in SARS-CoV-2 than that of SARS-CoV or MERS-CoV. This rapid spread of the virus may be attributed to the fact that SARS-CoV-2 can be transmitted from asymptomatic carriers or people who have mild symptoms.¹³ Ultimately, these findings highlight the importance of taking preventative measures to protect the general public, especially those with underlying medical conditions and older adults who may be more susceptible to succumbing to the infection.

Clinical Features

The incubation period of COVID-19 is approximately 5.2 days.¹⁴ The time from the onset of symptoms to death has ranged between 6 and 41 days with a median of 14 days.¹⁵ This period likely depends on factors including patient age and immune system status. For instance, patients 70 years or older have had earlier onset of symptoms and resultant death than did those under the age of 70.¹⁵

Initial symptoms of COVID-19 infection include fever, cough, fatigue, myalgia, anosmia, dysgeusia, and dyspnea. Atypical symptoms, including diarrhea, headache, and vomiting, also have been reported (Figure 1-6). Chest computed tomography (CT) scans reveal pneumonia-like features. However, the clinical feature of COVID-19 is confounded by the fact that approximately 25% of all infected patients have at least one or more underlying medical conditions.¹⁶ In addition, clinical characteristics have evolved with different phases of the pandemic. Patients in the initial phases of the epidemic were older and more likely to be male. The predominant features on CT scans in this early phase were bilateral patchy shadows or ground-glass opacity in the lungs. In addition, the mortality rate of the early phase ranged from 4.3 to 15.0%, which is significantly higher than the 1.4% that has been determined for the later phase.

Figure 1-6. Systemic and respiratory signs and symptoms caused by COVID-19. Typical symptoms of COVID-19 include fever, cough, myalgia, and dyspnea. Atypical symptoms including diarrhea also have been reported.

Reprinted from Rothan HA, Byrareddy SN. The epidemiology and pathogenesis of coronavirus disease (COVID-19) outbreak. J Autoimmun. 2020;109:102433.

COVID-19 and Head and Neck Cancer

A longstanding, first-line treatment option for head and neck cancer (HNC) patients has been surgery. However, a surge in COVID-19-associated hospitalizations threatens to overwhelm hospital capacity, jeopardizing optimal patient care.¹³,¹⁷,¹⁸ In particular, management of HNC patients must be approached with prudence, given that COVID-19 disproportionately affects the elderly and individuals with comorbid conditions, which encompasses a significant portion of this population.¹⁹,²⁰ Hence, HNC management paradigms must be reassessed in the rapidly evolving circumstances of the COVID-19 pandemic.

Special Considerations in Head and Neck Cancer Management

Head and neck carcinomas encompass cancers of the oral cavity, oropharynx, nasopharynx, larynx, as well as cancers of the skin, soft tissues, salivary, and endocrine glands. Among these, over 53,000 patients are diagnosed with oral and oropharyngeal cancers annually. These cancers often affect the elderly (average age at diagnosis is 62 years) and are the eighth most common cancers among men. Each year, an estimated 10,700 deaths occur from these cancers.²¹ Unfortunately, the anatomic sites of routine HNC surgery are also locations where SARS-CoV-2 replicates. High viral loads are found in the nasal cavity, nasopharynx, and oropharynx, even among the asymptomatic and subclinical patients.²²,²³

Viral shedding and disease transmission often occur during the incubation period. Although most exposed patients develop symptoms by two weeks, between 7 and 13% of COVID-19-positive patients remain asymptomatic or have subclinical symptoms.¹³ In addition, studies show that patients may continue to shed the virus even after resolution of symptoms.²⁴ This subgroup of patients poses a threat to viral containment and highlights the need for robust screening and testing for SARS-CoV-2. However, current ability to screen for potential surgical candidates via negative COVID-19 testing is limited due to insufficient availability of testing. Furthermore, sensitivity and specificity of currently available tests are inadequate. For instance, false negative test rates in symptomatic patients have ranged between 16 and 24%.²⁵ Thus, insufficient and inadequate testing puts the public and healthcare professionals at risk of contracting the infection, and can exacerbate containment efforts.

Cancer patients are not only more susceptible to COVID-19, but also are associated with poorer outcomes than their COVID-19-negative counterparts. In a nationwide study of patients in China, those with a history of cancer were more likely to be infected with COVID-19 than patients without such history.²⁶ These patients were also more likely to require invasive ventilation with ICU admission than were non-cancer COVID-19-positive patients. In addition, the perioperative mortality rate of COVID-19-positive patients can be up to 22%.¹³ These patients may be susceptible to adverse outcomes due to an ongoing infection and or inflammatory processes that may be exacerbated by surgery and postoperative aspiration.

Consideration also must be given to operating room personnel, who may be subject to increased risk of infection transmission. Surgeries performed under general anesthesia involve several aerosol-generating procedures (AGP) such as bag-valve mask ventilation and intubation; these AGPs have been associated with nosocomial infections during the previous coronavirus epidemic.²⁷ HNC surgeries often involve additional AGPs, such as tracheotomy, endotracheal tube manipulation (i.e., during total laryngectomy), and airway suctioning.²⁷ It has been reported that aerosolized SARS-CoV-2 from AGPs can remain airborne for at least three hours.²⁸ In addition, virus has been detected in airborne samples in the hallways of COVID-19 units,²⁹ further complicating management of HNC patients on the floor if patients are COVID-19-positive. Several hospitals in hard-hit areas of the United States have already described shortages in personal protective equipment (PPE).³⁰ Thus, healthcare workers and personal caretakers are at especially high risk in this pandemic. Given these substantial risks of operating during this pandemic, cautious approach to HNC management should be maintained.

Conclusions

HNC patients are often elderly and frequently have multiple comorbidities that are specifically associated with increased risk for COVID-19. Inadequate and insufficient testing prohibits proper screening procedures to select potential HNC surgical patients. The risk of nosocomial COVID-19 infection is high given that the virus can remain airborne for several hours. Caution must be maintained in selecting and managing potential surgical candidates in head and neck cancer treatment.

References

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Coronaviridae Study Group of the International Committee on Taxonomy of V. The species Severe acute respiratory syndrome-related coronavirus: classifying 2019-nCoV and naming it SARS-CoV-2. Nat Microbiol. 2020;5(4):536–544.

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Coronavirus Disease (COVID-19) Situation Report-116. https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200515-covid-19-sitrep-116.pdf?sfvrsn=8dd60956_2. Published 2020. Updated May 15, 2020. Accessed May 15, 2020.

Garg S, Kim L, Whitaker M, et al. Hospitalization rates and characteristics of patients hospitalized with laboratory-confirmed Coronavirus Disease 2019—COVID-NET, 14 States, March 1–30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(15):458–464.

New York State Department of Health COVID-19 Tracker: Fatalities. https://covid19tracker.health.ny.gov/views/NYS-COVID19-Tracker/NYSDOHCOVID-19Tracker-Fatalities?%3Aembed=yes&%3Atoolbar=no&%3Atabs=n. Published 2020. Accessed May 15, 2020.

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2

Health System Approaches to COVID-­19 Patients and the Impact on Head and Neck Cancer Care

Michael Au MD FRCSC

John Kim MD FRCPC

Jonathan C. Irish MD MSc FRCSC FACS

Core Messages

Health system approaches to the COVID-­19 pandemic require coordination of rigorous public health measures and health system strategies between all levels of governments and jurisdictions.

Health system response to COVID-­19 includes preservation and expansion of acute medical and critical care bed capacity, which may involve drastic reductions or cancellations in elective clinical activity, including surgeries.

The COVID-19 pandemic has significantly disrupted delivery of radiation and systemic therapies and reduced elective surgical volumes, including head and neck cancer surgeries, which will create challenges for addressing large surgical backlogs during the clinical recovery phase.

Radiation and systemic therapy can play significant roles in treatment deferral strategies when head and neck cancer surgery is unavoidably delayed.

Multidisciplinary discussion is critical to identify optimal treatment strategies for head and neck cancer patients during the COVID-19 pandemic.

Introduction

On December 31, 2019, Chinese health authorities identified a new (or novel) coronavirus, COVID-19, through a series of reported cases of pneumonia in Wuhan, China. Coronaviruses are a large family of viruses that can cause diseases, ranging from the common cold with mild respiratory symptoms and fever, to acute respiratory disease syndrome (ARDS) and death in severe cases. According to the World Health Organization (WHO), the definition of a pandemic is a worldwide spread of a new disease and, on March 11, 2020, the COVID-19 outbreak was declared a pandemic by the WHO.¹

COVID-19, caused by the SARS-CoV-2 strain, has globally impacted health, politics, and the economy in a short period of time with more than 5 million confirmed cases, as of May 23, 2020 (Figure 2-1). The clinical syndrome from the virus can consist of mild respiratory symptoms and fever, to acute respiratory disease syndrome (ARDS) and death in severe cases.

Figure 2-1. Global COVID-19 timeline and milestones.

Reprinted with permission from American Society for Microbiology.¹

The effects on a healthcare system from a pandemic are different than a mass-casualty event where an acute event (minutes to hours) is followed by an acute and relatively short response (hours to days). During a pandemic response there is a prolonged course of resource overutilization, including human healthcare resources, which ultimately, leads to exhaustion (weeks to months).

The strain on healthcare systems has been significant. It is expected that the impact on the healthcare system will be variable, but the following principles will be common:

A pandemic will hit in one or more waves. Each wave may last for several weeks.

At the peak of the pandemic wave, a significant proportion of staff will be ill, or not available to work (e.g., contact isolation, self-quarantine, school closures and childcare demands, family obligations, and fear).

Hospital inpatient and outpatient areas will experience capacity challenges.

Clinical staff, where feasible and with appropriate training, will be deployed to the most critical/essential areas.

Follow-up services, including home and community care-based services will be stressed.

There will be a need to provide care for patients who do not have a pandemic-related illness (e.g., infection) but require time-urgent care such as cancer treatment, cardiac care, and transplant services.

The ability to care for patients with both pandemic-related illness and other non-pandemic-related illnesses will be variable and dependent on the local impact of the pandemic on healthcare services. In larger healthcare systems, there may be asymmetric local or regional responses in maintaining normal healthcare service delivery due to the variation in pandemic impact on the population.

Healthcare Systems

Healthcare systems in most countries are delivered with national oversight combined with regional implementation. While there may be variations from country to country or from region to region (e.g., state, province, or administrative region), the health systems embrace the following principles: public administration and oversight, comprehensiveness, universality, portability, and accessibility.

Most national healthcare systems develop principles which guide the delivery of care to its citizens. Public administration refers to the administration and operation of a healthcare plan by a public authority. In many countries, there is a portion of the system that operates on a non-profit basis and is funded by government tax dollars and ensures that there is a basic level of healthcare provision for the entire population. The comprehensiveness criteria of a health system plan ensure coverage of all medically necessary and required health services provided by hospitals, medical practitioners, and dentists, although there is debate concerning the scope and definition of ensured health services. Universality ensures that all residents within the country are covered on uniform terms and conditions, which prevents preferential access and ensures entitlement to all insured health services. Portability ensures that insured residents maintain coverage of health services when traveling or moving between regions within a country under certain reasonable terms and conditions. Finally, accessibility provides reasonable access to all insured health services by preventing any user charges from impeding or precluding care.

Healthcare systems are also responsible for the development of robust public health programs with the responsibility of maintaining the health of a country’s population. Fundamental to a public health program is the development of public health surveillance to inform disease prevention and control measures. The WHO recommends the public health surveillance in order to (1) serve as an early warning system and to identify public health emergencies, (2) guide public health policy and strategies, (3) document the impact of an intervention or progress toward specified public health targets and goals, and (4) understand and monitor the epidemiology of a condition to set priorities and guide public health policy and strategies.² The WHO also describes an effective surveillance system with the following functions:

Detection and notification of health events

Collection and consolidation of pertinent data

Investigation and confirmation (epidemiological, clinical, and/or laboratory) of cases or outbreaks

Routine analysis and creation of reports

Feedback of information to those providing the data

Feed-forward (i.e., the forwarding of data to more central levels)

Reporting of data to the next administrative level

COVID-19 Pandemic Response

Pandemics consist of two pre-pandemic intervals—investigation and recognition—and four pandemic intervals—initiation, acceleration, deceleration, and preparation or recovery.³ There does not have to be a linear progression through the phases, especially in the case of COVID-19 where there is currently no vaccine. Subsequent waves may cause reentry into the acceleration, deceleration, and preparation phases (Figure 2-2).⁴

Figure 2-2. Phases of COVID-19 pandemic hospital-based mitigation measures related to surgical and procedural care. Subsequent waves of the pandemic may necessitate repeat cycles of ramping-down and ramping-up of clinical activity.

Adapted from Resolve to Save Lives: An Initiative of Vital Strategies. https://resolvetosavelives.org/. Accessed May 19, 2020.

All levels of healthcare systems have been involved throughout the COVID-19 pandemic response, as a safe and effective response for the population requires coordination of multiple services and roles between the different levels and jurisdictions across the continuum of care. This includes coordination between regulatory authorities for health professionals, hospitals, long-term care facilities, paramedic services, public health authorities, laboratories, and varying levels of government.

Federal governments may be responsible for instituting international travel restrictions, facilitating national procurement of personal protection equipment and other critical supplies such as ventilators and medications, mobilizing medical equipment in national stockpile systems, establishing national responses to the devastating economic effects of the pandemic, and providing regulatory oversight regarding medical equipment and supplies in context of critical global shortages.

Regional governments may be responsible for implementing legislation to facilitate public health measures and ensuring adequacy of medical equipment and supplies for their frontline workers. Local governments also would be responsible for developing plans for surge capacity and coordinating their pandemic response within healthcare organizations such as hospitals, laboratories, and long-term care facilities.

A clear governance structure is required for a command and control response in a public health crisis. In Ontario, the provincial government established an enhanced response structure in early March 2020, with the establishment of a Health System COVID-19 Oversight Table (COVID-19 Command Table) as the single point of oversight to provide executive leadership and to coordinate the planning and implementation in five healthcare regions within the province.⁵ The Command Table is supported by a Scientific Table led by public health officials to provide evidence-based scientific and technical support and an Ethics Table to provide ethical guidance in decision-making. The response structure also includes Data & Analytics, Critical Care, Diagnostic and Testing Capacity, Supply Chain Management, Communications, and Emergency Care.

Although the speed of spread of COVID-19 is significant, many countries have been able to learn from the experiences of countries who had been affected earlier. South Korea, Italy, Iran, Germany, and other countries were significantly affected early in the pandemic experience, and countries affected later have been able to implement public health measures early because of this knowledge. Rapid testing of the population; aggressive case and contact management approaches; closure of workplaces, schools, churches, parks, and other congregate care settings; prohibition of gatherings of people; implementation of social isolation practices; and self-isolation of travelers were measures implemented earlier in some jurisdictions than in others and often in response to countries who had an earlier experience in the COVID-19 pandemic. In particular, the province of Ontario has managed to avoid the anticipated surges of COVID-19 that could have overwhelmed the healthcare system, a reflection of the successful implementation of measures across public health and healthcare systems (Figure 2-3). In Canada, the first case of COVID-19 was confirmed in Toronto on January 25, 2020. The first death attributed to COVID-19 in Ontario occurred on March 11, 2020.⁶ To date, on May 23, there have been 25,500 cases of confirmed COVID-19 with 2152 deaths in Ontario among a population of more than 14 million people.⁷ Across Canada, the total number of confirmed COVID-19 cases is 85,175 with 6466 deaths.⁸

Figure 2-3. Key COVID-19 Public Health Measures Timeline in Ontario.

During the pandemic, healthcare systems need to manage the burden of possibly overwhelming cases of suspected or confirmed COVID-19, while continuing to serve the urgent non-COVID-19 healthcare needs of the population, such as patients with cancer. Therefore, effective pandemic response requires a combination of strict measures to reduce transmission, slow the rate of infection, and reduce the peak number of infections (flattening the curve), while increasing hospital capacity and availability in the healthcare system (Figure 2-4).

Figure 2-4. COVID-19 patients in Ontario—actual ICU bed use each day versus predicted ICU bed demands. The worst-case scenario, as seen in Italy, would overwhelm the healthcare system in Ontario despite health system measures to preserve and expand critical care capacity. Modeling shows the medium-case scenario where Ontario has managed to avoid anticipated surge secondary to implementation of rigorous public health measures.

Adapted from COVID-19: Modelling and Potential Scenarios - COVID-19 Command Table Media Briefing materials (May 2020). Copyright McKinsey & Company 2020.

Below, we outline the public health measures and healthcare system considerations in managing the COVID-19 pandemic with a focus on head and neck cancer patients.

Public Health Measures

Public health measures are particularly important in outbreaks like COVID-19 where there is currently no vaccine. They consist of non-pharmaceutical interventions to decrease community transmission of disease outbreaks. Social distancing involves both individual- and population-based measures to minimize community exposure and transmission. These interventions include cornerstone measures such as promotion of hand hygiene, respiratory etiquette, and environmental cleaning and ventilation. Public education and awareness campaigns are also necessary to promote self-monitoring for COVID-19 symptoms and voluntary self-quarantine where appropriate. Simple but effective individual measures that can be implemented to reduce transmission include:

Limit non-essential trips out of your home.

Keep 2 meters (6 feet) distance from others, or wear a mask or face covering.

Clean your hands often. Use soap and hot water or an alcohol-based (70–90%) hand sanitizer.

Avoid touching your face with unwashed hands.

Cover your cough or sneeze with your elbow or a tissue. Immediately throw the tissue in the garbage and wash your hands.

Clean and disinfect frequently touched objects and surfaces.

Avoid close contact with people who are sick.

Stay home if you are feeling unwell.

The use of face masks among the asymptomatic general population during the COVID-­19 pandemic has been the subject of great debate throughout the world, especially in North America and Europe. The World Health Organization, United States Centers for Disease Control (CDC), and the Public Health Agency of Canada all originally advised against the use of masks except in the care of COVID-­19 patients. The reluctance on the part of health agencies to recommend face coverings stemmed from ongoing concern regarding shortage of masks and PPE for healthcare workers and inconclusive evidence regarding the efficacy of non-­particulate respirator (such as N95) surgical masks or other face coverings. There were also concerns that face coverings would instill a false sense of security and undermine other preventative measures including the threat of self-­contamination due to the improper removal of masks. Nonetheless, there continues to be growing evidence that mask wearing prevents the asymptomatic transmission of COVID-­19 and there is increasing support for requiring the general population to wear a mask. While the World Health Organization continues to recommend against routine use of masks and face coverings for the general public without symptoms, both the CDC and, more recently, the Public Health Agency of Canada, have reversed course with the CDC recommending use of non-­medical face coverings in all public settings, while Canada recommends face covering in public settings where physical distancing is not possible.⁹,¹⁰

Community-­based measures may include travel and border restrictions, including the restriction of foreign nationals from entering a country for non-­essential travel. For essential travel or citizens returning home, self-­isolation and quarantine for 14 days may be mandated by lawful order. Further community-­based measures may include prohibition of public group gatherings and closure of schools and non-­essential workplaces to support social distancing measures. Closures may also include outdoor recreational amenities; public spaces such as libraries, sporting arenas, theaters, cinemas, and concert venues; and bars or restaurants (except for take-­out and delivery). Jurisdictions may need to declare states of emergency to allow enforcement of emergency orders.

Based on the experiences of countries that have successfully managed COVID-19 such as Australia, Iceland, South Korea, and Singapore, it is evident that widespread testing and aggressive contact tracing play essential roles in the management strategy given the mounting evidence regarding the significant role in transmission by asymptomatic individuals. Comprehensive testing and contact tracing allow for effective isolation and quarantine to reduce the rate of infection and prevent further outbreaks. Inadequate testing can occur secondary to the shortage of testing reagents, as well as lack of equipment and inability by laboratory systems to keep up with the volume. Given the challenges involved with the arduous and resource-intensive task of traditional contact tracing using public health workers in COVID-19, the pandemic has seen a wave of mobile phone applications backed by national governments that allow for digital contact tracing through Bluetooth or geolocation. However, there are concerns regarding digital contact tracing applications, largely centered around privacy, confidentiality, and civil liberties.¹¹

Healthcare Systems

During a pandemic, especially in the initiation and acceleration phases, it is critical to develop surge capacity in the healthcare system by preserving or even increasing both acute medical and critical care bed capacity (Figure 2-5). Preservation of surge capacity includes reducing or canceling elective surgeries and procedures, relocating inpatients to alternate settings, and increasing home and community care capabilities to facilitate earlier discharges. Bed capacity expansion includes funding for additional acute care and critical care beds, redeployment of surgical nursing staff to acute medicine units, and deployment of ventilators from stockpiles. As many healthcare systems often have shared hospital rooms (two to four beds), some jurisdictions may restrict the number of patients within these shared hospital rooms to one or two patients for physical distancing to reduce infection risk. This further reduces bed capacity, which makes the preservation and expansion of bed capacity especially important in the context of infectious outbreaks and pandemics.

Figure 2-5. Government measures (public health and health systems) in COVID-19 pandemic response.¹² Public health measures help flatten the curve while health system strategies preserve and expand hospital capacity to handle COVID-19 pandemic.

Understandably, there are significant tensions associated with the extreme measure of canceling elective surgeries for both patients and surgeons. However, beyond preserving and maximizing bed capacity by reducing post-surgical patient demand for ward and intensive care unit (ICU) admission, deferral of elective surgeries allows for redeployment of surgical and operating room (OR) staff including nurses, anesthesiologists, and respiratory therapists; reduction of nosocomial exposure and transmission of COVID-19; and conservation of personal protective equipment, drugs, and other supplies. Cancellation of elective surgeries also increases surge capacity by providing additional facilities for ventilation and critical care capabilities in operating rooms where healthcare system resources are otherwise exhausted.

The Ontario Ministry of Health and Long-Term Care released guidance for hospitals in Ontario to begin a measured ramping-down of elective surgery to improve capacity for COVID-19 patients in mid-March 2020 (Figure 2-6). This led to hospitals reducing surgical volumes significantly with some regional variability, depending on the expected impact of COVID-19 in the community within which the hospital is located. Some hospitals ramped down to only life or limb surgical procedures, accounting for only 10 to 20% of regular surgical volume activity while other hospitals maintained 20 to 30% of regular surgical activity. The cancellation of elective surgeries throughout the province resulted in availability of 6849 acute care and 583 critical care beds with ventilators over the course of one month.¹²

Figure 2-6. Ramp-down of surgical volumes during the COVID-19 pandemic in Ontario.¹³ Graphs show decrease in cancer (33%), benign (93%), vascular (70%), and pediatric (94%) surgeries in 2020 (blue line) during COVID-19 pandemic compared to 2017–2019 (gray lines). In Ontario, target times for surgeries are determined by priority levels from P1 through P4. For cancer surgeries, P1 targets treatment within 24 hours, P2 targets treatment within 14 days, P3 targets treatment within 28 days, and P4 targets treatment within 84 days. P1 surgeries are considered urgent surgeries, which have continued during the COVID-19 pandemic with appropriate PPE and precautions. Target times for levels P2 through P4 vary for vascular, pediatric, and non-oncologic surgeries.

It is evident that the collection of high-quality data by health systems is essential to effective pandemic planning and successful pandemic response. Health systems data is invaluable for decision-making during resource-scarce situations such as pandemics, where important decisions need to be made regarding resource allocation and need for deployment (Figure 2-7). As the pandemic evolves quickly, healthcare systems must develop a strategy for real-time data collection to monitor healthcare service use. Essential parameters include baseline resource capacity (acute care ward beds, ICU beds, ventilators), utilization (acute care ward bed and ICU bed occupancy), and demand (wait time queue/performance) to allow frontline workers, surgical leaders, and healthcare system administrators to deploy and redistribute resources during and after the pandemic. In addition, decisions regarding resource allocation need to consider the impact that the pandemic is having on overall healthcare resources while recognizing that there is variability in the impact from region to region. In Ontario, there is a Critical Care Inventory, which provides daily updates during the COVID-19 pandemic regarding critical care census and occupancy (Figure 2-8). The benefits of developing infrastructure for collecting high-quality healthcare systems data such as occupancy, diagnostic imaging volumes, and wait times extends beyond the pandemic, as it can be used by policy-makers and researchers to improve health systems and conduct research to ultimately provide optimal clinical care, with the ultimate goal of optimizing patient outcomes and experiences.

Figure 2-7. High-quality health systems data is essential to effective pandemic planning and successful pandemic response. It allows for accurate pandemic modeling and dictates how and when to implement public health measures and health system strategies.

Adapted from Canadian Institute for Health Information (CIHI)’s Health System Capacity Planning Tool [information sheet]. Ottawa, ON: CIHI; 2020.

Figure 2-8. Example of the Critical Care Services Dashboard during COVID-19 in Ontario. The dashboard provides information on critical care occupancy across the province along with regional breakdown with daily updates. The number of confirmed and suspected COVID-19 cases in ICU with and without ventilation is also available.

The measures that have been imposed to reduce transmission and preserve hospital capacity have prompted widespread adoption of telemedicine or virtual care, which is the remote delivery of healthcare services using communications technology through telephone calls and videoconferencing. Telemedicine has become an indispensable tool as the pandemic significantly disrupts non-urgent and elective patient care, especially in the ambulatory clinic setting. Traditionally, telemedicine was used to enable patients in remote locations to receive medical care without traveling hundreds of miles. However, telemedicine has widespread benefits during pandemics, as it reduces transmission by decreasing risk of exposure and maintaining physical distancing, while providing an avenue for patients with less urgent medical issues to continue receiving care. Virtual meetings, educational forums, multidisciplinary cancer conferences, and quality assurance rounds are other examples of risk mitigation activities to preserve the health of the medical workforce.

Finally, even despite rigorous implementation of public health measures and systemic changes and adaptations, it is possible that COVID-19 may overwhelm and exceed health system capabilities. Therefore, it is important for systems to establish clinical triage protocols to be used as a last resort based on ethical and pragmatic principles upon consultation with bioethical experts for appropriate allocation of critical care resources, especially ventilators. The triage process should incorporate triage decision support protocol, infrastructure, processes, legal/regulatory protections, and training.¹⁴

During a time of resource scarcity, such as this COVID-19 pandemic, healthcare systems need to balance the paramount value of each human life with population outcomes. These principles may be applied by various decision-making bodies, including at the national, provincial, or state level for general guidance; at the hospital level to address the needs of surgical patients in the context of services that are available at an institution which will be dependent on the resources being redeployed for the care of the COVID-19 patient population; and finally, at the staff level by providers for triaging patient care. It is strongly recommended that decisions regarding triaging patients be made with multidisciplinary consultation, rather than by a single surgeon, radiation oncologist, or medical oncologist.

It is important that healthcare system leaders establish a consistent, transparent, and equitable framework for hospitals and healthcare providers to allocate resources in a resource-limited environment. The following are principles to consider as a basis for ethical decision-making:

Utility—Maximizing the benefits produced by scarce resources. This principle ensures that resources are deployed to save the most lives and the most life-years. Utility takes into consideration that timely, planned intervention is preferable to emergency intervention and also considers the avoidance of permanent disability.

Fairness. This principle ensures that patients are treated equally. This can be accomplished by

Consistency in decision-making.

Replacing first-come-first-serve with random selection, when all other factors are similar.

Proportionality. The response to the need for rationing shouldn’t have a greater negative impact than the approach being replaced.

Transparency. Determinants of which patients receive surgery should be clear to all parties.

Robust communication.

Basing prioritization on scientific evidence when possible and well-defined processes if evidence is not available.

Ensuring accountability.

Considering patients with and without COVID-19, as equal, in terms of overall resource allocation.

Equity. This principle ensures that scarce resource allocation and decision-making are not differentially allocated between different groups based on non-clinical factors such as but not limited to race, income, or gender. This principle ensures inclusiveness so that all people should feel that access to care and scarce resources is not disproportionately based on non-clinical factors.

Priority—giving attention to those most in need.

Autonomy.

Minimization of harm. Particular attention to personal protective measures should ensure minimal risk to providers so that they can continue to provide care.

Harmony. This principle ensures a systems approach to coordination and sharing of scare resources, and access across the province.

Decisions regarding care also need to take into consideration the impact that a patient will have on potentially scarce healthcare resources, including the impact on PPE use, the need for ICU and ventilator support after surgery, and the need for prolonged inpatient bed stay and other healthcare resources.

Unexpected Challenges

Disproportionate Impact on Long-Term Care

Long-term care residents are especially vulnerable to COVID-19, given their advanced age, frailty, poor performance status, multi-morbid status, and need for intimate personal care. Most long-term facilities have high-risk residents living in close quarters within communal facilities that make it difficult to accommodate appropriate social distancing measures.

The devastation of COVID-19 on continuing care facilities highlights both pandemic preparedness deficiencies and preexisting systemic issues. The combination of inadequate PPE supply, lackluster COVID-19 testing, and difficulty in applying physical distancing is especially deadly in the long-term care population.¹⁵ Systemic issues include chronic shortages in staffing in long-term care facilities with personal support workers (PSWs), who tend to be employed part-time with concerns regarding low pay and absence of extended health benefits. This prompted many PSWs to work multiple shifts at multiple homes, which facilitated the spread of COVID-19 across facilities, before jurisdictions implemented measures restricting workers to only one site. The single-site order has further exacerbated staffing shortages, prompting redeployment of hospital frontline workers and other non-medical workers to long-term care facilities. In Canada, this remained inadequate to address the staffing crisis, leading to the deployment of the Canadian Armed Forces in multiple long-term facilities in Ontario and Quebec. Many jurisdictions also have boosted pay for frontline workers, including PSWs, during the pandemic to support the single-site order. It is felt that the policy measures that have been implemented would benefit long-term care beyond COVID-19, given that outbreaks of respiratory infections were common even prior to the current pandemic.¹⁶

COVID-19 appears to have hit long-term care facilities in Canada disproportionately harder than in other countries, given that Canada has fewer total COVID-19 deaths compared to countries such as France, Germany, and Belgium. As of May 10, 2020, long-term care residents account for 20 to 22% of all COVID-19 cases in Canada, yet they have accounted for 70 to 82% of all deaths related to COVID-19 with a case fatality rate of 26 to 29%.¹⁷ This figure indicates that Canada has by far the highest proportion of deaths from COVID-19 in long-term care homes among 14 countries, based on figures from the International Long-Term Care Policy Network.¹⁸ The disproportionate impact of COVID-19 on long-term care in Ontario extends beyond the residents to frontline workers, as six out of eight healthcare workers who have died from COVID-19 were PSWs or nurses in these continuing care facilities.¹⁹

Given the vulnerable and high-risk characteristics of this population, a coordinated pandemic response needs to occur across all levels within the government and healthcare system to ensure implementation of effective policies and measures in the acute healthcare system. Particular attention must be paid to aggressive testing, contact tracing, appropriate isolation, and establishment of information systems to facilitate data collection, given that geriatric populations may have atypical presentations of COVID-19. Similar to hospital organizations, long-term care facilities need to restrict visitors while implementing single-site policies for its workers to prevent transmission of infection.

Personal Protection Equipment Shortages

Concerns have been raised regarding personal protection equipment (PPE) shortages during pandemics throughout the world since the SARS pandemic in 2003 and H1N1 pandemic in 2009. In Canada, a sweeping set of recommendations was made by a committee of pandemic control experts in the aftermath of SARS, which included recognizing that the reliable sourcing of essential medical supplies and equipment may be more important and beneficial than static stockpiles through the National Emergency Stockpile System (NESS).²⁰

The unprecedented global demand and worldwide shortage of PPE has exposed many jurisdictions’ inability to establish a secure supply chain with continued reliance on international supply sources, mostly through China. In Canada, this was exacerbated by the expiry of millions of N95 masks and other medical supplies in the stockpiles of multiple provinces, including Ontario, leaving them reliant on the emergency federal stockpile through the NESS.²¹ However, it has been reported that the federal stockpile is likely inadequate, secondary to the lack of coordination and information sharing between federal and provincial governments regarding the inventory and needs of each province.²²

Governments may benefit from building supply chains necessary to continue the current COVID-19 response along with planning for recovery and future pandemics through negotiation and diplomacy by federal procurement agencies. Many governments also have facilitated a significant increase in domestic manufacturing capacity by mobilizing businesses and manufacturers through rapidly scaling up production of domestic PPE manufacturers and shifting of manufacturing lines of companies such as automakers.²³ Regulatory authorities also have expedited approvals and licenses for companies that want to begin manufacturing PPE, along with approving the importing and distribution of PPE without National Institute for Occupational Safety and Health (NIOSH) certification, which include respirators produced in countries that have standards similar to the NIOSH standards in North America.²⁴

Given the widespread shortages of PPE, guidelines have been established to optimize and conserve the PPE supply, including scenarios for extended use, limited reuse, or sterilization and disinfection, especially of N95 respirators.²⁵,²⁶ Other strategies include the use of expired N95 respirators from existing stockpiles and use of non-NIOSH-certified particulate respirators. Strategies to increase the supply of PPE have included procuring supplies from other medical settings, such as dentists, and non-medical