The coronavirus disease 2019 (COVID-19) pandemic has presented health-care systems worldwide with significant challenges. The majority of countries have experienced a lockdown and a shift in allocation of healthcare resources to cope with the increased burden of COVID-19 cases. In many regions the healthcare systems have been stressed to their limits, having to reduce non urgent procedures and concentrate all available resources to attend to COVID-19 patients. In doing so, the global provision of in- and outpatient services for other diseases have been compromised to varying degrees, including by the necessity to implement additional infection prevention and control measures (16–18).
The impact of the pandemic on nuclear medicine departments and their services worldwide was recently assessed by a survey conducted by the IAEA (13). It showed a global decrease in procedures performed in April 2020; studies done with 99mTc decreased by 54%; PET studies decreased by 36% and radionuclide therapies by 45% on average. The main reasons for this decline were attributed to the postponement of non-emergent procedures and to the disruption in the supply chain, mainly affecting LMICs.
Today, the pandemic and the associated lockdown have redesigned the usual risk/benefit ratio which compares the infection exposure risk (for the patient and for staff) vs. the risk associated with delaying or cancelling nuclear medicine procedures. As we enter another phase of the pandemic, plans have been initiated to restore the provision of deferred services.
According to the IAEA medical imaging and nuclear medicine global resources database – IMAGINE (19) there are approximately 27,000 SPECT scanners available worldwide, of which, less than 0.1% are installed in LICs, 3% in LMICs, 16.5% in UMICs and 20.3% in HICs. Regarding PET scanners, there are approximately 5,700 scanners available, of which less than 0.1% are installed in LICs, around 8% in LMICs, 15% in UMICs and 77% in HICs (19).
The aim of this new IAEA online survey was to measure the impact of COVID-19 on nuclear medicine departments at two fixed times in 2020, namely June and October. The selection of temporal baselines for analysis was based on the stage of the pandemic. In June, most countries were in a post-peak phase, while in October most were experiencing a new wave.
It was noted that the decline of nuclear medicine procedures in June was greater that in October, and higher than what was reported in the survey conducted in April 2020 (13), at the beginning of the pandemic, and still far from returning to average numbers of procedures before COVID-19.
Although, the results of this follow-up survey cannot be directly compared with the previous one (13), given than few of the responses (less than 20%) came from the previous respondents. However, it allows to have an overview of the global impact of COVID-19 on the practice of nuclear medicine.
The reason for this lower response rate could be attributed to the lower motivation of potential respondents to repeat the survey and to the great number of surveys and virtual event that have been deployed during the pandemic. Thus, only June and October 2020 are compared herein. Recovery phases are not discussed as regions differed in this regard.
A total of 505 centres from 96 countries responded to the questionnaire. However, after removal of duplicates and insufficient replies, available data could be extracted from 355 questionnaires. The received responses came from institutions uniformly distributed across the world and according to income status. This highly balanced distribution among participating centres was not obtained in our previous survey, where the responses from high-income countries were preponderant (13).
Globally, the volume of nuclear medicine procedures (diagnostic and therapeutic) decreased by 73.3% in June 2020 and 56.9% in October 2020, compared to the average number of procedures performed before the COVID-19 pandemic, varying markedly between regions and countries, with the greatest regional decreases in Latin America. Significant reductions affected about 80% and 60% of conventional diagnostic procedures, 65% and 40% of PET, and 70% and 50% of therapeutic procedures in June and October, respectively. The biggest impact was seen in low- to low-middle income countries, both in June and October (despite the partial recovery), while high-income countries exhibited greater continuity of nuclear medicine services since the outset of the pandemic. This observation was also seen in a recent national survey in examining the impact of COVID-19 on Nuclear Medicine services in 2020 compared to 2019 (20). The initial significant reduction in nuclear medicine procedures in the first three weeks of the COVID-19 pandemic did not continue, but there was no compensation of the previously not performed services (21). The decrease in diagnostics and therapy procedures of benign diseases was particularly severe (20).
Similar to the interpretation of the April 2020 survey, this decrease could be attributed to several factors such as changes in scheduling workflow with reduction in the number of appointments, reluctancy of patients to visit a medical centre due to safety concerns, deferral of non-urgent studies, deferral of surgeries and pre- or perioperative evaluations, shortages of essential supplies, implementation of infection prevention and control (IPC) measures including social distancing and decreasing the number of health workers at a given time to reduce staff exposure, and increasing the time assigned to each patient to include greater disinfection and cleaning procedures (13).
Also, the decline in diagnostic tests was more pronounced for conventional nuclear medicine studies (thyroid, cardiac, bone, and lung scans) than for PET/CT scans. This may be for two reasons: first, PET tracers are produced through local cyclotrons, whereas most of the countries rely on international flights for the supply of 99mTc/99Mo generators and other radioisotopes; and second, the more urgent nature of cancer assessments is with PET/CT.
Regarding clinical indications for referral to both conventional nuclear medicine and PET/CT, the greatest reduction in exams was seen for myocardial perfusion and non-oncological studies. This could be attributed to the trepidation of patients fearing exposure to the virus in a healthcare setting and, as above, to certain exams being deemed less urgent, a pragmatic choice in this period of crisis. Compared to the previous survey (13), the global decrease was more pronounced, probably because of the minor impact felt by high-income countries which represented a larger constituent group in the first survey. Specifically, the changes in availability of technetium or gallium generators and of radiopharmaceutical delivery in general were less detrimental to the continuity of services in high-income countries whereas low- to low-middle income countries experienced greater insufficiencies in supplies of radioisotopes, generators, and kits.
Notably, some centres reported an increase in their activities, namely 6.5% and 13% for conventional nuclear medicine diagnostic procedures, 10.5% and 21% for PET, and 5.5% and 13% for therapeutic procedures in June and October respectively. This aspect, uniformly distributed across the world and according to income status, reflects a trend towards the recovery of previous activity.
As for radionuclide therapies, the main reduction was reported in radioiodine therapies for benign thyroid disease followed by thyroid cancer and radiosynovectomy in June, similar to what was reported in the previous survey (13); and in radiosynovectomy in October. Compared to less affected procedures, such as selective internal radiation therapy, peptide receptor radionuclide therapy, and prostate-specific membrane antigen radioligand therapy, the latter are treatments that could be deferred with less impact on patient prognosis.
Adoption of IPC measures is essential to protect health workers and patients while continuing to provide medical services (10, 11, 22–24). Thus, availability of PPE is critical. In our survey, 35% and 25% of participants, respectively in June and October 2020, reported shortage of PPE, with no significant differences among geographic regions. Regarding the 50% rate reported in the previous survey conducted in April (13), the trend of a general return to normality is evident, due to the increase of supplies. Conversely, COVID-19 infections in staff were reported in 60% of surveyed centres, with a great increase in nosocomial infections compared to 15% reported in April (13).
The overall significant decrease in nuclear medicine procedures also resulted in a reduction of working hours in almost half of the responding centres, affecting large numbers of staff.
The reduction of essential supplies was more frequently reported for Africa, Asia, Oceania, and Latin America. Surveys conducted by international bodies such as the IAEA highlight the need to ensure a uniform and consistent supply of radioisotopes, generators, and kits across the globe and to ensure regional imbalances in service delivery are minimised. This can enable the return to pre-pandemic activity levels and hopefully lay the foundation for greater health system strengthening to meet enhanced demands for patient care, as well as for vital educational, research and developmental activity.