COVID-19: Preparedness in Nuclear Medicine Departments In
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Click HERE for more articles at the Annals, Academy of Medicine, Singapore homepage Commentary COVID-19: Preparedness in Nuclear Medicine Departments in Singapore and Response to The Global Pandemic 1 1 1 Pei Ing Ngam, MBBS, FRCR, MMed, Charles XY Goh, MBBS, FRCR, MMed, David CE Ng, MBBS, FRCP, FAMS, 2 3,4 5,6 Colin JX Tan, MBBS, FRCR, MMed, Saabry Osmany, MBBS, FAMS, FACNM, Andrew EH Tan, MBBS, FRCR, FAMS, 7 8 9 Anbalagan Kannivelu, MD, DNB, FRCR, Lenith TJ Cheng, MBBS, FRCR, MMed, Lih Kin Khor, MBBS, FRCR, MMed, 1 1 1 Aaron KT Tong, MBBS, MRCP, FAMS, Kelvin SH Loke, MBBS, MRCP, FAMS, Wai Yin Wong, MBBS, FRCR, FAMS Introduction medicine services in both public and private sectors in The first cluster of pneumonia of unknown Singapore, focusing on the key factors to consider in aetiology patients was reported in Wuhan, China, on terms of processes and policies while being flexible to 31 December 2019.1 The pathogen was subsequently adapt new practices in this rapidly evolving pandemic. identified as a new strain of coronavirus—severe acute respiratory syndrome coronavirus 2 (SARS- General Infection Control Measures CoV-2), which is the causative agent of COVID-19. Standard precautions are practised in all public and COVID-19 unfortunately could not be contained in private hospitals to minimise the risk of infection China and the World Health Organization (WHO) to patients, family members and healthcare workers declared the outbreak a pandemic on 11 March 2020.2 as well as controlling COVID-19 transmission. Singapore, with its high population density and Current evidence suggests that COVID-19 is status as an international hub for business and tourism, transmitted through respiratory droplets and contact has been badly hit by the outbreak and the economy is routes.9,10 Thus, it is mandatory for all nuclear expected to shrink between 4 and 7 per cent this year.3 medicine staff to wear surgical masks in clinical The first imported case of COVID-19 was confirmed areas at all times. Full physical personal protection on 23 January 2020.4 The disease continued to spread equipment (PPE), including N95 mask, face shield/ within the community and Singapore’s Ministry of goggles, gowns and gloves, are compulsory when Health (MOH) raised the nation’s Disease Outbreak attending to suspected or confirmed cases of Response System Condition (DORSCON) level from COVID-19. Mask fitting and training sessions were Yellow to Orange 2 weeks later.5 On 3 April 2020, organised to assist staff in selecting appropriate mask the Singapore government announced an elevated set models and to ensure the proper use of N95 masks. of safe distancing measures, as a “circuit breaker” to Social distancing between staff is actively reinforced. limit movements and interactions in public and private All staff are to maintain a minimum distance of 1 places.6 As of 3 July 2020, Singapore had reported metre apart. To facilitate this, staggered meal times and a total of 44,479 cases of COVID-19 with 26 deaths working hours have been implemented to minimise from COVID-19 complications.7 interaction. Shared facilities such as pantries and In response to government policies, the key imperatives seating areas now have strict limits on the number to strengthen the outbreak management and emergency of staff allowed at any given time. response system are to treat the suspected and Daily self-monitoring for early COVID-19 symptoms confirmed cases, while avoiding intra-hospital and is crucial for healthcare workers.11,12 Therefore, staff are cross-institutional transmission between staff and required to log their temperature twice a day and are patients, and to establish efficient contact tracing.8 In obliged to seek medical attention if they are unwell. this paper, we describe the impact on nuclear 1Department of Nuclear Medicine and Molecular Imaging, Singapore General Hospital, Singapore. 2ParkwayHealth Radiology, Mount Elizabeth Hospital, Singapore. 3RadLink PET and Cardiac Imaging Centre, Paragon Medical, Singapore. 4Osmany Pte Ltd, Singapore. 5Nuclear Medicine Centre, Raffles Hospital, Singapore. 6Department of Nuclear Medicine, Farrer Park Hospital, Singapore. 7Department of Diagnostic Radiology, Khoo Teck Puat Hospital, Singapore. 8Department of Diagnostic Imaging, National University Hospital, Singapore. 9Department of Nuclear Medicine, Advanced Medicine Imaging, Singapore. Address for Correspondence: Dr Ngam Pei Ing, Department of Department of Nuclear Medicine and Molecular Imaging, Singapore General Hospital, Singapore. Email: [email protected] Copyright © 2020 Annals, Academy of Medicine, Singapore COVID-19 in Nuclear Medicine—Pei Ing Ngam et al 497 Primary and Secondary Screening clinical assessment, the on-call infectious disease All patients and visitors undergo primary screening specialist will be activated and the referring clinician upon entry into the hospital. Individuals are required will be alerted. This modified workflow and close to fill up a declaration form, providing their personal communication with our clinician partners allows particulars, travel history, contact history with early detection and isolation of suspicious but COVID-19 patients or known clusters of disease, asymptomatic patients, and helps to combat spread of and presence of any flu-like symptoms. Temperature COVID-19 in the community. screening systems have been put in place to detect individuals with high body surface temperature. A Segregation of Patients in Space and Time doctor in-charge is consulted if any patients are found Nuclear medicine in Singapore grew out of the to be symptomatic. Singapore General Hospital’s (SGH) Radiotherapy Secondary screening is performed at the departmental Department (although there was incidental use of level. An isolation room has been designated for scintigraphy in the internal medicine department any suspected cases that inadvertently arrive at the in SGH) and became an independent ‘Department department. The duty nuclear medicine physician of Nuclear Medicine, SGH’ in 1980. We started with will review the patient in the room with necessary Technetium-99m (Tc-99m) radiopharmaceutical based precautions, depending on symptoms and contact history. diagnostic imaging and radio-iodine (Iodine-131) therapy for hyperthyroidism and thyroid cancers Ideally, pre-screening of the patients before their in 1980s. Up to the mid-1990s, nuclear medicine visits by conducting screening questionnaires over services provided by SGH, the National Heart Centre the phone a day prior to the appointment/admission is Singapore, National University Hospital (NUH) and recommended as this can potentially reduce unnecessary Mount Elizabeth Hospital sufficiently fulfilled patients’ trip to the hospital. clinical demands. The introduction of clinical According to the WHO’s guidelines, a suspected F-18fluorodeoxyglucose (F-18 FDG) PET-CT in case is defined by clinical presentation and travel/ the early 2000s prompted the setting up of PET-CT contact history with COVID-19 patients, while a services in Singapore with a central cyclotron sited confirmed case is defined by positive laboratory in SGH. Since then, therapeutic nuclear medicine, testing. Although imaging has its role in suspected and which was primarily focused on radioiodine treatment confirmed cases, there is no study evaluating the of thyroid disease, now encompasses a much broader diagnostic accuracy of imaging in asymptomatic range of targeted therapies that have entered standard 13 contacts of patients with COVID-19. However, clinical practice. Theranostics, which utilise radioactive following multiple publications on lung findings on tracers in establishing the diagnosis and treatment of computed tomography (CT) scans in COVID-19 cancer, has become increasingly relevant in the era of 14–16 patients, we have implemented screening precision medicine. Singapore is one of the pioneers protocols to pick up incidental suspicious lung findings of theranostics in Southeast Asia and attracts patients on the CT component of hybrid positron emission from many countries. tomography-CT (PET-CT) and single-photon emission The rapid evolution of nuclear medicine has resulted computerized tomography-CT (SPECT-CT) scans as in a remarkable increase in the number of new facilities well as myocardial perfusion imaging (MPI), where CT and resources, at times straining the pre-existing attenuation correction has been performed. CT images infrastructure of departments already experiencing are screened for new bilateral peripheral ground space constraints. This limitation impedes effective glass opacities before the patient is allowed to leave segregation of patients in the event of pandemics. the department. If necessary, given the typical mid- SGH, which has one of the region’s largest Nuclear inspiratory CT acquisition, a dedicated low dose Medicine departments, operates to cater for the breath-hold CT can be performed to exclude changes demands not only from Singhealth institutions but from secondary to atelectasis. However, considerable overlap other public and private clinics. Perfect segregation of in imaging findings leads to diagnostic difficulty in patients is indeed challenging. differentiating atypical viral pneumonia from therapy- related pneumonitis, especially in our practice, which Applying the concept of physical segregation is geared towards the oncology patient population. during Severe Acute Respiratory Syndrome (SARS) 11,12 These patients will first be evaluated by a nuclear epidemic, we minimise the