COVID - 19: Notes from Members around the world

As more cities and countries become “hot-spots” for this pandemic, we thought members might be interested to see how various clinics are handling cases at this time. It is not an endorsement of any particular action plan. We respect the decisions of local healthcare systems and our hard-working colleagues in these cities and countries. 

We also wish to recognize the difficulties and hard work that our members in these areas undergo and extend our best wishes for their good health during these times.

We would really like to hear of your experiences. Please feel free to add your comments below.

Wishing everyone safety and good health.

Region

Country/State

Reported by

Date

Clinic Status

USA

San Francisco, UCSF

Naomi Jay

April 2020

We have triaged patients who need to be seen urgently as those with clinically suspicious cancers so that they can be referred for appropriate treatment without delay. We are able to see our patients in a fairly low-risk clinic which is not part of the hospital. The city has been shelter-in-place very early and we hope to see a flattening of the curve earlier than elsewhere. This should be clearer in about a week.

USA

Portland, Oregon

Ellen Lairson

April 2020

At present I am not completing HRA at the Providence Dysplasia Clinic in Portland, Oregon. They also stopped seeing pts at Kaiser. 

Europe

Italy

Roberto Paola

April 2020

 I give you my experience. I hope that it could be useful. I live in Emila Romagna the second region of Italy for death and cases of COVID-19. My hospital is a COVID hospital. It closed all surgical procedures and outpatient visits except Urgence procedures. In these three weeks I had the authorization from my hospital to perform 4 DTC treatment for HSIL in patient without symptoms of COVID . I used ffp2 mask to perform this operation. I didn't perform other 2 patients because they lived in city of the region with a lot of cases. I don't know if it has been correct. Perhaps the risk of infection in hospital in HIV pos patients is more dangerous that HSIL at the moment in my country. I will stop all the HRA until the situation will be more clear.

I wish good luck to everybody.

Europe

UK

Jules Bowring

April 2020

 We've spent the last 2 weeks dismantling our service and have completed our last HRA last week.

Europe

Netherlands, London

April 2020

We believe in the Netherlands and in in London we  need to limit face to face consultations, we need to take proper caution if undertaking surgery and accept a larger volume of patients will have HSIL for longer whilst they wait to come back for treatment.
In London they started off believing they could still see urgent cases and potential cancers, things have changed significantly over this last week and from Monday they are only able to see patients where there would be a risk to life or limb if left over 4 weeks, AIN3 does not meet the criteria.
In the Netherlands we have stopped all HRA screening all together. We have appointed one HRA clinic in the country to assess only high suspicion of anuscancer or if someone has symptoms. Probably what is most important is trying to keep a list to prioritize the risk once HRA is available again. You need to  have confirmation from a radiation and medical oncologists that if you diagnose cancer they will treat them. We have just managed to get the treatment continued of those confirmed cases. We are still in the process of securing a treatment if necessary. I believe if it occur we will be able to make a plan then. Another issue for the Netherlands is, there is no operation time if we want a deeper diagnostic biopsy in theatre. So if we cannot get the biopsy done at a HRA clinic it has to wait. It is not considered essential care.

Jan Prinsis in the frontline with the dutch outbreak management team that provide advice to the goverment and Olivier Richel manages covid units up south.

Henry de Vries works in the frontline of the GGD(community health services) providing advice to the public and government.

Europe

Italy, Netherlands, London

Esther Kuyvenhoven

April 2020

In Italy, London and the Netherlands we  have stopped all laser, electrocoagulation. there is an issue regarding PPE, it’s not universally available and the risk of bringing them to the hospital especially if immunosuppressed is too high.  Electrocoagulation and laser and even cryotherapy is really unwanted because of the high risk ov generating aerosols. All untreated HSIL patients have been reviewed and where possible converted to topical therapy (UK regime: imiquimod, catehen, 5 FU in that order)(Netherlands regime: 5FU, imiquimod, veregen) In the UK and Netherlands we  are running the service now with nurse led telephone consultations and will only see  patients who display symptoms suggestive of cancer. In the UK national  cervical screening has been suspended and I expect colposcopy will follow soon. The UK is behind Italy and Spain by a few weeks, and still hasn’t hit the peak. In the Netherlands and in the UK we  are being redeployed to cover the wards and ER so in the next week the UK service is expected to be suspended.

In the Netherlands if someone come to a ER with complaints we can still do a DARE. If we find deviations > than 1 cm  we consider a MRI.

Latin America

Naomi Jay

April 2020

HRA clinics are all closed in Argentina, Brazil, and Mexico City.  Only oncology and urgent surgery. 

Latin America

Salvador, Brazil

Ana Travassos

We are very worried about the next weeks about the Covid-19 pandemic in Latin America. 

I would like to update you on other cities -  I talked with Fabio, PI of Rio, and Carlos, PI in Salvador about the impossibility for invited the patients to HRA training. Our public transport is limited and we are in isolation strategy for 4 weeks at least. Salim, in Mexico, has similar troubles. 

Australia

Tasmania

Richard Turner

April 2020

Current practice for my HRA clinics in Tasmania is:

  • Routine follow-ups and new referrals deferred for 3 months, then review the situation – unless the latter suggest high suspicion for anal cancer (“pain/lump/bleeding”)
  • Offer TCA to a tail of patients with biopsy-proven HSIL – if amenable.
  • Extensive HSIL requiring ablative treatment deferred for 3 months (pending review); DARE should be done to ensure no palpable lesions.

Australia

Sydney

Richard Hillman

April 2020

All patients triaged as per IANS COVID-19 Guidelines. We continue to perform diagnostic HRAs on Category 1 patients. Category 2 patients have been contacted, reviewed for symptoms & their next telehealth consult arranged at three months. Category 3 patients will have telehealth reviews around the time of their scheduled review, and re-categorised, pending symptoms.

Africa

Kenya and South Africa

April 2020

All HRA clinics are suspended and there is not the capacity to see anyone even in the case of high suspicion.


We would really like to hear of your experiences. Click on "Add Post" to add your comments below:
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  • Wednesday, April 15, 2020 7:39 PM | Bridget Morris

    Our newest HRA clinic has canceled patients from early March through June and our clinic is currently serving as an infusion center. We also have the challenge of conserving PPE. Our colorectal surgeon may be taking select high-risk patients in the OR. We are in the midst of COVID surge now. We are considering doing consult visits via telemedicine beginning in May and hope to open HRA clinics in June prioritizing symptomatic patients and HSIL.

    Great COVID tracker here: https://coronavirus.jhu.edu/us-map

    Thank you for the guidelines and support. Stay sane and safe everyone!

  • Friday, April 10, 2020 7:16 AM | Kelli Welsh (Administrator)

    Thank you very much for the recommendations sent from Paraguay we have suspended all the clinics and centers of attention of the Lower Genital Tract and therefore the evaluation of the anal canal. All the offices have been closed, we have decided to initially defer the studies in a minimum of 3 months , despite having few COVID + cases, even the isolation measures are in force.

    The drama of having personal protective equipment is a sad reality, and even for emergencies it does not exist in sufficient quantity, if we currently have the N95 masks available and insist on frequent hand washing, distancing patients and now provided for the use of the population in general form of masks, especially when going to hospitals.

    Kind regards and hope to restart soon.

    dra Marina Ortega Paraguay

    Muchas gracias por las recomendaciones enviadas desde Paraguay hemos suspendidos todas las clinicas y centros de atencion del Tracto Genital Inferior y por ende la evaluacion del canal anal.Se han cerrado todos los consultorios ,hemos decidido diferir en un principio los estudios en un minimo 3 meses,a pesar de tener pocos casos COVID + aun las medidas de aislamiento estan vigentes.

    E l drama de contar con los equipos de protección personal es una triste realidad ni aun para las urgencias existe en cantidad suficiente,si tenemos disponible por el momento las mascarillas N95 e insistimos en el lavado frecuente de manos,distanciamiento de las pacientes y ahora se dispuso el uso de la poblacion en forma general de tapabocas sobre todo al acudir a los hospitales.

    Saludos cordiales y esperemos reiniciar pronto.

    dra. Marina Ortega

    Paraguay

  • Thursday, April 09, 2020 4:51 PM | Gregory Barnell

    Starting March 23, all HRAs were suspended through the end of April. This meant sending electronic messages to cancel >100 scheduled patients. We also sent out preemptive messages to patients due in May, letting them know that their follow-up would be delayed. We plan to send preemptive messages for patients due in June and July, as soon as we can manage.

    Our next step was to set up an excel spreadsheet that we shared on a Teams group. Medical assistants input patients' name, MRN, date last seen, and date cancelled (or due for follow-up). HRA providers then triaged all booked, due soon and new referral pts, a total of 192 thus far. Our triage levels are no delay (new diagnosis cancer, suspected cancer, and first post-CRT assessment for remission status), ASAP (most worrisome HSIL, hx anal cancer in first year of surveillance), minimal delay (less worrisome HSIL, hx anal cancer years 2-5 surveillance; new referrals with anal Pap ASC-H), longer delay (no, minimal or distant HSIL hx, new referrals with Pap LSIL). MA's then sent messages to all pts with our “best guess” of when they might be seen.

    Northern California seems to be flattening the COVID curve, so I am hopeful that we will be able to start seeing our “no delay” and “ASAP” groups as soon as next week. This will be done with modifications to our normal practice. We plan to see fewer patients per clinic, to maintain social distancing and give time between procedures to let droplets precipitate before cleaning. Our usual HRA approach is biopsy and electrocauterization of lesions that appear to be HSIL. We would instead plan for biopsy and patient-applied efudex, or even presumptive use of efudex based on appearance.

    When we get back to something like normal footing, we plan to add extra clinics and possibly add one more HRA per clinic day. Even under the best-case scenario, we expect delays through the end of 2020.

    Hang in there everyone!


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