Nationwide survey of COVID-19 prevention measures in Japanese radiotherapy departments via online questionnaire for radiation oncologists.

Coronaviruses are pathogens that target the human respiratory system. Previous outbreaks of coronaviruses include severe acute respiratory syndrome (SARS) [1] and Middle East respiratory syndrome (MERS) [2]. In December, 2019, an outbreak of pneumonia of unknown cause was reported in Wuhan, China [3]. Chinese scientists rapidly identified the causative agent as a novel coronavirus (SARS-CoV-2) by sequencing the complete genome from lower respiratory tract samples of patients in Wuhan [4]. The WHO named this disease “coronavirus disease 2019” (COVID-19). Having quickly spread around the world, COVID-19 is now a global health concern. According to the WHO report, the top 10 global cases of COVID-19 by April 23, 2020 were 800,926 in the United States, 208,389 in Spain, 187,327 in Italy, 148,046 in Germany, 133,499 in the United Kingdom, 117,961 in France, 98,674 in Turkey, 85,996 in Iran, 84,302 in China and 62,773 in Russian Federation [5]. In Japan, the first patient with COVID-19 was detected on January 15, and the number of cases reached 12,192 in Japan by April 23, 2020 [6], which is relatively low compared to other countries, despite the early outbreaks. COVID-19 is now an important issue in Japanese radiotherapy departments. According to the DIRAC database, Japan has 800 radiotherapy centers, the third largest number in the world [7]. Chinese researchers report that cancer patients and cancer survivors are at increased risk of severe events associated with COVID-19 compared to noncancer patients [8]. Additionally, cancer patients might have more chance to exposed to SARS-CoV-2 because they are supposed to receive radiotherapy every weekday for multiple weeks. For these patients, treatment would have to be discontinued for several weeks if they were to contract COVID-19, potentially leading to inferior treatment outcomes [9]. Therefore, COVID-19 prevention measures in radiotherapy departments are urgently needed to protect patients.

Infection prevention and control (IPC) usually include standard precautions and transmission-based precautions [10]. Careful adherence to the recommended IPC practices is known to decrease the transmission of infectious agents in healthcare settings [11], [12]. It was reported that suboptimal hand-washing, suboptimal hand hygiene before and after contact with patients, and improper personal protective equipment (PPE) were significant risk factors for COVID-19 infection among healthcare workers [13]. Radiation oncologists in Wuhan, China recently pointed out the importance of patient education and staff training to prevent infection in radiotherapy settings during the COVID-19 pandemic [14]. Whether radiotherapy departments in Japan are aware of and properly practice IPC measures is unknown. Here, we investigate the current status of the practice of COVID-19 prevention measures in Japanese radiotherapy departments using an online questionnaire.

This study was approved by the academic committee of the Japanese Society for Radiation Oncology (JASTRO). The online questionnaire was developed using Google Forms (www.google.com/forms). The questions and answers were shown in Table 1 . Our first version of the online questionnaire was distributed to radiation oncologists in Osaka to investigate the measures used to prevent COVID-19 as of April 10, 2020, 3 days after the first declaration of a state of emergency for 7 prefectures including Tokyo and Osaka. This version of the questionnaire contained 28 questions. One question was added, and the questionnaire then was sent to JASTRO members throughout Japan via JASTRO-gram on April 16, 2020, when the areas under declaration of state of emergency were expanded to all 47 prefectures in Japan. We also asked the respondents to revise their responses if their COVID-19 measures had changed or if there was an infection outbreak in their institutions. The aggregated results were analyzed using the autoanalysis function of Google Forms and disclosed immediately to respondents. All questionnaire results were downloaded from the website on April 23, 2020 for our research.

Table 1

Study questions and responses.

	Question	Answer choices	Respondents(n = 184)
			n	%
1	What is your institution type?	Research instituteCommunity hospitalClinic	4812610	26.168.55.4
2	What types of radiotherapy does your institution offer? (multiple answers allowed)	X-rayProton therapyCarbon-ionBrachytherapy	1807460	97.83.82.232.6
3	Number of annual radiotherapy cases at your department	~200201~500501~10001001~15001501~	47854453	25.546.223.92.71.6
4	Does your institution accept COVID-19 patients for hospitalization?*	YesNo	15033	82.018.0
5	Does your institution practice any infection control measures to prevent COVID-19?	YesNo	35149	19.081.0
6	Do you check patients for COVID-19 symptoms daily?	YesNoI don’t know	144319	78.316.84.9
7	Do you check RT staff for COVID-19 symptoms daily?	YesNoI don’t know	149305	82.016.32.7
8	Do RT staff who have contact with patients practice hand hygiene?	YesNoI don’t know	18211	98.90.50.5
9	Do RT staff who have no patient contact practice hand hygiene?	YesNoI don’t know	159520	86.42.710.9
10	Do RT patients practice hand hygiene?	YesNoI don’t know	1002757	54.314.731.0
11	Do RT staff who have contact with patients wear masks?	YesNoI don’t know	17770	96.23.80
12	Do RT staff who have no patient contact wear masks?	YesNoI don’t know	157207	85.310.93.8
13	Do RT patients who see other patients wear masks?	YesNoI don’t know	93874	50.547.32.2
14	Do you wear PPE when contacting with RT patients?†	YesNo	15167	8.291.8
15	Do you sanitize what everyone touches? (keyboards, doorknobs, electrical switches, etc.)§, ||	YesNo	12229	80.819.2
16	Do you ventilate the air in the Examination rooms?*	YesNo	10876	58.741.3
17	Do you ventilate the air in patient waiting rooms?	YesNo	11074	59.840.2
18	Do you ventilate the air in RT operating rooms?*	YesNo	79104	43.256.8
19	Do you ventilate the air in RT treatment rooms?*	YesNo	38145	20.879.2
20	Do you ventilate the air in RT staff break rooms?*	YesNo	9192	49.750.3
21	Is social distancing maintained between patients?	YesNoI don’t know	1165711	63.031.06.0
22	Is social distancing maintained between staff at work?	YesNoI don’t know	601186	32.664.13.3
23	Is social distancing maintained between staff during breaks?	YesNoI don’t know	877225	47.339.113.6
24	Is radiation treatment time divided into outpatient and inpatient hours?*	YesNo	53130	29.071.0
25	Have you postponed patient follow-up dates?*	YesNoOther	114627	62.333.93.8
26	Have you postponed the start of RT when possible?‡	YesNo	72109	39.860.2
27	Have COVID-19 cases occurred in patients served by your RT department?	YesNo	0184	0.0100.0
28	Have COVID-19 cases occurred among your RT department staff?	YesNo	1183	0.599.5
29	Have COVID-19 cases occurred at your institution outside the RT department?	YesNo	57127	31.069.0

Abbreviations: RT, Radiotherapy; PPE, personal protective equipment.

* 1 missing data, † 2 missing data, ‡ 3 missing data, § 33 missing data, || This question was added on April 16, 2020.

The majority of the respondents (81.0%) indicated that they had taken some infection control measures for COVID-19. Proper hand hygiene was practiced at some but not all of the institutions, with 54.3% of the respondents reporting that patients performed hand hygiene, 96.2% reporting that staff who had contact with patients performed hand hygiene, and 86.4% reporting that staff who did not have contact with patients performed hand hygiene. Only 50.5% of respondents indicated that all patients wore masks; 96.2% reported that all staff who had direct contact with patients wore masks, and 85.3% reported that all staff who had no direct contact with patients wore masks. Only 8.1% of the respondents reported that they used PPE in their radiotherapy practice. The number of respondents indicated that the radiotherapy clinic was ventilated was 58.7% for the examination room, 59.8% for the patient waiting room, 42.9% for the operation room, 49.5% for the staff room, and 20.7% for the treatment room. In addition, 63.0% of the respondents indicated that proper social distancing was maintained between patients, while fewer respondents reported such between staff at work (32.6%) or while on breaks (47.3%). These results indicated that there were differences in IPC measures for COVID-19 between radiotherapy departments. In addition, at this time, it was found that COVID-19 occurred in only one institution, and that COVID-19 had little impact on radiotherapy practice in Japan as a whole. Although the number of COVID-19 in Japan is relatively low compared to other countries, the impact of COVID-19 on radiotherapy should continue to be closely monitored.

This study has several limitations. While Japan has 800 radiotherapy centers, only 184 respondents participated in this study. These respondents might be radiation oncologists who were interested in COVID-19 prevention measures. If all radiation oncologists in Japan were asked to respond, the percentage of those taking measures to prevent COVID-19 might be even lower. Furthermore, some overlap in the responses may exist because the questionnaire response is not strictly limited to one respondent per institution. In order to overcome the limitations of our survey, JASTRO have decided to conduct periodic nationwide surveys of radiotherapy departments.