Investigating the impact of COVID-19 on patients with cancer from areas of conflict within the MENA region treated at King Hussein Cancer Center

Background There is a paucity of evidence regarding the impact of COVID-19 on cancer care among refugees or patients from areas of conflict. Cancer care for these populations remains fragmented due to resource scarcity and limited infrastructure. Aims To explore the effect of COVID-19 on cancer care among patients from areas of conflict treated at King Hussein Cancer Center (KHCC). Methodology We performed a retrospective chart review of all patients from areas of conflict, treated at KHCC from 2018 to 2021. Patients' demographics and clinical characteristics are presented in the form of descriptive statistics. Interrupted Time Series (ITS) analysis was utilized to investigate the impact of COVID-19 on the number of admissions throughout the study's period. Results A total of 3317 patients from areas of conflict were included in the study. Among these, 1546 were males (46.6%) while 1771 (53.4%) were female. Libyans (34.6%), Palestinians (24.8%), Iraqis (24.5%), Syrians (15.3%), and Sudanese patients (0.9%) constituted our study sample. ITS analysis demonstrated that the start of the COVID-19 lockdown significantly decreased admissions by 44.0% (p = 0.020), while the end of the COVID-19 restriction significantly improved admissions by 43.0% (p = 0.023). Among those with available SEER stages, more than a quarter of patients had distant metastasis (n = 935, 28.2%) irrespective of age and biological sex. Advanced presentations during 2020 had approximately a 16% and 6% increase compared to 2018 and 2019, respectively. Breast cancer (21.4%), hematolymphoid cancers (18.1%), and cancers of the digestive system (16.5%) were the most common cancers among our cohort. Conclusion Restrictions associated with COVID-19 had a significant effect on the number of admissions of patients from areas of conflict. In the long term, this effect may impact the survival outcomes of affected patients.

Investigating the impact of COVID-19 on patients with cancer from areas of conflict within the MENA region treated at King Hussein Cancer Center.

Background: There is a paucity of evidence regarding the impact of COVID-19 on cancer care among refugees or patients from areas of conflict. Cancer care for these populations remains fragmented due to resource scarcity and limited infrastructure. Aims: To explore the effect of COVID-19 on cancer care among patients from areas of conflict treated at King Hussein Cancer Center (KHCC). Methodology: We performed a retrospective chart review of all patients from areas of conflict, treated at KHCC from 2018 to 2021. Patients' demographics and clinical characteristics are presented in the form of descriptive statistics. Interrupted Time Series (ITS) analysis was utilized to investigate the impact of COVID-19 on the number of admissions throughout the study's period. Results: A total of 3317 patients from areas of conflict were included in the study. Among these, 1546 were males (46.6%) while 1771 (53.4%) were female. Libyans (34.6%), Palestinians (24.8%), Iraqis (24.5%), Syrians (15.3%), and Sudanese patients (0.9%) constituted our study sample. ITS analysis demonstrated that the start of the COVID-19 lockdown significantly decreased admissions by 44.0% (p = 0.020), while the end of the COVID-19 restriction significantly improved admissions by 43.0% (p = 0.023). Among those with available SEER stages, more than a quarter of patients had distant metastasis (n = 935, 28.2%) irrespective of age and biological sex. Advanced presentations during 2020 had approximately a 16% and 6% increase compared to 2018 and 2019, respectively. Breast cancer (21.4%), hematolymphoid cancers (18.1%), and cancers of the digestive system (16.5%) were the most common cancers among our cohort. Conclusion: Restrictions associated with COVID-19 had a significant effect on the number of admissions of patients from areas of conflict. In the long term, this effect may impact the survival outcomes of affected patients.

Religion, Islam, and Compliance with COVID-19 Best Practices.

While many have implemented best practices intended to help stem the spread of COVID-19, there are also a substantial number of citizens, both domestically and abroad, who have resisted these practices. We argue that public health authorities, as well as scientific researchers and funders, should help address this resistance by putting greater effort into ascertaining how existing religious practices and beliefs align with COVID-19 guidelines. In particular, we contend that Euro-American scholars-who have often tended to implicitly favor secular and Christian worldviews-should put added focus on how Islamic commitments may (or may not) support COVID-19 best practices, including practices that extend beyond the domain of support for mental health.

Knowledge, Attitudes, and Practices of Healthcare Workers in Jordan towards the COVID-19 Vaccination.

The rapid development of COVID-19 vaccines raises concerns over vaccine hesitancy among healthcare workers (HCWs) and the general public, which made understanding the factors influencing hesitancy crucial in the maintenance of a solid healthcare system. This cross-sectional study investigated the knowledge, attitudes, and perceptions (KAP) of Jordanian HCWs to the COVID-19 vaccine from February to March 2021, using a self-administered questionnaire validated by a panel of public health experts. A total of 364 Jordanian HCWs were included in the final analysis, in which women accounted for 48.8% of the total sample. HCWs subjected to the seasonal flu vaccine were significantly more likely to uptake the COVID-19 vaccine. In comparison to nurses, physicians were significantly more likely to take or register for the vaccine. They demonstrated significantly higher knowledge of the vaccine's effectiveness, side effect profile, recommended doses, and target population. Among our participants, the most common reasons for vaccine hesitancy include a lack of confidence, inadequate knowledge, and disbelief in effectiveness. Vaccine hesitancy among Jordanian HCWs is low, with discrepancies between nurses and physicians. It is pertinent for independent committees and trusted authorities to provide interventions and raise awareness regarding the vaccine's safety and efficacy.

An Overview of King Hussein Cancer Center Institutional Review Board Over 12 Years (2009-2020), Successes and Challenges, Including Those Imposed by the COVID-19 Pandemic.

The problem: Running an efficient institutional review board (IRB) can be challenging. The research subjects: To ensure an efficient committee, our IRB adopted several operational metrics. Methods: Analysis of retrospective data from the IRB records, database, and annual reports over 12 years. Results: The IRB roster comprises 11 members. The average medical to nonmedical member ratio is 5:6, and the male to female ratio is 4:7, which has not been consistent over the years. One thousand three hundred and twenty-four proposals were reviewed including 1077 exempt (81.3%), 126 expedited (9.5%), and 121 full board (9.2%) with a median turnaround time to approval of 4.0, 35.0, and 68.0 days, respectively. Training of the IRB members was conducted to enhance their knowledge and skills. IRB at King Hussein Cancer Center has managed to stay abreast and efficient during the COVID-19 pandemic, by working remotely. Conclusion: Running an efficient IRB mandates implementing a number of operational metrics.

Ethical Considerations for Treating Cancer Patients During the SARS-CoV-2 Virus Crisis: To Treat or Not to Treat? A Literature Review and Perspective From a Cancer Center in Low-Middle Income Country.

Providing routine healthcare to patients with serious health illnesses represents a challenge to healthcare providers amid the SARS-CoV-2 pandemic. Treating cancer patients during this pandemic is even more complex due to their heightened vulnerability, as both cancer and cancer treatment weaken the immune system leading to a higher risk of both infections and severe complications. In addition to the need to protect cancer patients from unnecessary exposure to SARS-CoV-2 infection during their routine care, interruption, and discontinuation of cancer treatment can result in negative consequences on patients' health, in addition to the ghost of rationing healthcare resources in high demand during a global health crisis. This article aims to explore the ethical dilemmas faced by decision-makers and healthcare providers caring for cancer patients during the SARS-CoV-2 pandemic. This includes setting triage criteria for non-infected cancer patients, fairly allocating limited healthcare resources between cancer patients and SARS-CoV-2 patients, prioritizing SARS-CoV-2 treatment or vaccine, once developed, for cancer patients and non-cancer patients, patient-physician communication on matters such as end-of-life and do-not-resuscitate (DNR), and lastly, shifting physicians' priorities from treating their own cancer patients to treating critically ill SARS-CoV-2 infected patients. Ultimately, no straightforward decision can be easily made at such exceptionally difficult times. Applying different ethical principles can result in very different scenarios and consequences. In the end, we will briefly share the experience of the King Hussein Cancer Center (KHCC), the only standalone comprehensive cancer center in the region.

Smartphone Use Among University Students During COVID-19 Quarantine: An Ethical Trigger.

To reduce the spread of COVID-19, Jordan enforced 10 weeks of home quarantine in the spring of 2020. A cross-sectional study was designed to assess this extended quarantine's effect on smartphone addiction levels among undergraduates. A random sample of 6,157 undergraduates completed an online questionnaire (mean age 19.79 ± 1.67 years; males 28.7%). The questionnaire contains different sections to collect socio-demographic, socio-economic, academic, quarantine-related information, and smartphone usage. The smartphone addiction scale-short version was used to assess the degree of addiction during the quarantine. The mean addiction score across the whole sample was 35.66 ± 12.08, while the prevalence of addiction among participants was 62.4% (63.5% in males and 61.9% in females). The majority of the participants (85%) reported that their smartphone usage during the quarantine increased or greatly increased (27.6 and 57.2%, respectively), with some 42% using their smartphones for more than 6 h a day. Nevertheless, three-quarters of the students wished to reduce their smartphone usage. Several demographic and quarantine factors have been assessed, and students' gender, the field of study, parental education, household income in addition to the location of quarantine (urban, rural) and the house specifications (apartment, independent house, with/without a garden) showed statistically significant associations with smartphone addiction during the quarantine. Female students, students studying scientific- and medical-related majors compared to those studying humanity majors, those with higher incomes, those who had been quarantined in an apartment without a garden, and those who lived in urban areas showed significantly higher addiction scores.

DNR and COVID-19: The Ethical Dilemma and Suggested Solutions.

Ethics are considered a basic aptitude in healthcare, and the capacity to handle ethical dilemmas in tough times calls for an adequate, responsible, and blame-free environment. While do-not-resuscitate (DNR) decisions are made in advance in certain medical situations, in particular in the setting of poor prognosis like in advanced oncology, the discussion of DNR in relation to acute medical conditions, the COVID-19 pandemic in this example, might impose ethical dilemmas to the patient and family, healthcare providers (HCPs) including physicians and nurses, and to the institution. The literature on DNR decisions in the more recent pandemics and outbreaks is scarce. DNR was only discussed amid the H1N1 influenza pandemic in 2009, with clear global recommendations. The unprecedented condition of the COVID-19 pandemic leaves healthcare systems worldwide confronting tough decisions. DNR has been implemented in some countries where the healthcare system is limited in capacity to admit, and thus intubating and resuscitating patients when needed is jeopardized. Some countries were forced to adopt a unilateral DNR policy for certain patient groups. Younger age was used as a discriminator in some, while general medical condition with anticipated good outcome was used in others. The ethical challenge of how to balance patient autonomy vs. beneficence, equality vs. equity, is a pressing concern. In the current difficult situation, when cases top 100 million globally and the death toll surges past 2.7 million, difficult decisions are to be made. Societal rather than individual benefits might prevail. Pre-hospital triaging of cases, engagement of other sectors including mental health specialists and religious scholars to support patients, families, and HCPs in the frontline might help in addressing the psychological stress these groups might encounter in addressing DNR in the current situation.

Delayed Intravitreal Anti-VEGF Therapy for Patients During the COVID-19 Lockdown: An Ethical Endeavor.

PURPOSE: To assess the impact of Jordanian's Corona Virus Disease (COVID-19) lockdown on visual acuity and macular thickness in patients with macular edema receiving intravitreal injections, and to assess the ethical endeavor of lockdown among serious sight threatening conditions. PATIENTS AND METHODS: This retrospective observational study included patients planned for intravitreal injections who did not complete the planned course before the lockdown (ie, before 20th of March 2020). Data included demographics, indication for the intravitreal injection, corrected distance visual acuity (CDVA), and central macular thickness on Optical Coherence Tomography (OCT) before and after the lockdown. RESULTS: One-hundred and sixty-six eyes of 125 patients were studied, 68 (54.4%) patients were males, and the mean (± standard deviation, SD) age was 64.79 (±9.41) years. Mean (±SD) duration of delay in the planned injection was 60.97 (±24.35) days. The change in visual acuity was statistically significant for patients with diabetic macular edema (p= 0.045 improvement), patients with central retinal vein thrombosis (CRVO) (p= 0.05 deterioration), and patients with age-related macular degeneration (AMD) (p= 0.005 deterioration). Of interest, delay of more than 2 months and the previous need for 3 or more injections were significant poor prognostic factors for visual outcome for patients with diabetic macular edema (p=0.027 and 0.045). CONCLUSION: The impact of delay in the scheduled intravitreal injections resulted in variable outcomes depending on the indication. Triaging the urgency of patients should be based on the indication to support the equity principle of bioethics, where those in need are prioritized against others, depending on potential adverse outcome.

Effect of COVID-19 Quarantine on the Sleep Quality and the Depressive Symptom Levels of University Students in Jordan During the Spring of 2020.

Objectives: This study was designed to assess the effect of COVID-19 home quarantine and its lifestyle challenges on the sleep quality and mental health of a large sample of undergraduate University students in Jordan. It is the first study applied to the Jordanian population. The aim was to investigate how quarantine for several weeks changed the students' habits and affected their mental health. Methods: A cross-sectional study was conducted using a random representative sample of 6,157 undergraduate students (mean age 19.79 ± 1.67 years, males 28.7%) from the University of Jordan through voluntarily filling an online questionnaire. The Pittsburgh Sleep Quality Index (PSQI) and the Center for Epidemiologic Studies-Depression Scale (CES-D) were used to assess sleep quality and depressive symptoms, respectively. Results: The PSQI mean score for the study participants was 8.1 ± 3.6. The sleep quality of three-quarters of the participants was negatively affected by the extended quarantine. Nearly half of the participants reported poor sleep quality. The prevalence of poor sleep quality among participants was 76% (males: 71.5% and females: 77.8%). Similarly, the prevalence of the depressive symptoms was 71% (34% for moderate and 37% for high depressive symptoms), with females showing higher prevalence than males. The overall mean CES-D score for the group with low depressive symptoms is 9.3, for the moderate group is 19.8, while it is 34.3 for the high depressive symptoms group. More than half of the students (62.5%) reported that the quarantine had a negative effect on their mental health. Finally, females, smokers, and students with decreased income levels during the extended quarantine were the common exposures that are significantly associated with a higher risk of developing sleep disturbances and depressive symptoms. Conclusions: Mass and extended quarantine succeeded in controlling the spread of the COVID-19 virus; however, it comes with a high cost of potential psychological impacts. Most of the students reported that they suffer from sleeping disorders and had a degree of depressive symptoms. Officials should provide psychological support and clear guidance to help the general public to reduce these potential effects and overcome the quarantine period with minimum negative impacts.

The Fair Allocation of Scarce Medical Resources: A Comparative Study From Jordan.

The allocation strategies during challenging situations among the different social groups is based on 9 principles which can be considered either individually: sickest first, waiting list, prognosis, youngest first, instrumental values, lottery, monetary contribution, reciprocity, and individual behavior, or in combination; youngest first and prognosis, for example. In this study, we aim to look into the most important prioritization principles amongst different groups in the Jordanian population, in order to facilitate the decision-making process for any potential medical crisis. We conducted an online survey that tackled how individuals would deal with three different scenarios of medical scarcity: (1) organ donation, (2) limited hospital beds during an influenza epidemic, and (3) allocation of novel therapeutics for lung cancer. In addition, a free-comment option was included at the end of the survey if respondents wished to contribute further. Seven hundred and fifty-four survey responses were gathered, including 372 males (49.3%), and 382 females (50.7%). Five groups of individuals were represented including religion scholars, physicians, medical students, allied health practitioners, and lay people. Of the five surveyed groups, four found "sickest-first" to be the most important prioritization principle in all three scenarios, and only the physicians group documented a disagreement. In the first scenario, physicians regarded "sickest-first" and "combined-criteria" to be of equal importance. In general, no differences were documented between the examined groups in comparison with lay people in the preference of options in all three scenarios; however, physicians were more likely to choose "combination" in both the second and third scenarios (OR 3.70, 95% CI 1.62-8.44, and 2.62, 95% CI 1.48-4.59; p < 0.01), and were less likely to choose "sickest-first" as the single most important prioritization principle (OR 0.57, CI 0.37-0.88, and 0.57; 95% CI 0.36-0.88; p < 0.01). Out of 100 free comments, 27 (27.0%) thought that the "social-value" of patients should also be considered, adding the 10th potential allocation principle. Our findings are concordant with literature in terms of allocating scarce medical resources. However, "social-value" appeared as an important principle that should be addressed when prioritizing scarce medical resources in Jordan.

Allocation of the "Already" Limited Medical Resources Amid the COVID-19 Pandemic, an Iterative Ethical Encounter Including Suggested Solutions From a Real Life Encounter.

The shortage of healthcare providers is well-documented in low-income countries (LIC) prior to COVID-19, due to various causes including the migration to developed countries, scarcity of supplies, poor healthcare infrastructure, limited ICU facilities, and lack of access to guidelines and protocols. One of the important hitches in LIC is the insufficient testing capacity that precluded accurate assessment of disease burden and subsequently resource allocations. Trying to adhere to the principles of bioethics including respect to others, beneficence, and justice should be applied on the ground in the particular setting of the LIC. Solutions should be tailored to the tangible needs and possibility of implementation in real life in the face of the "already" limited resources by making use of simple, yet plausible, measures. Implementing guidelines and frameworks that were set to work in the better-resourced nations is a call for futility. The adoption of novel solutions to overcome the unique challenges in the LIC is exigent. These include the use of automated screening algorithms and virtual video clinics. Moreover, integrating electronic intensive care unit (e-ICU) software may allow for remote monitoring of multiple patients simultaneously. Telemedicine could help in getting consultations worldwide. It can also enhance healthcare workers' knowledge and introduce new skills through teleconferences, e-workshops, and free webinars. Healthcare workers can be remotely trained to enhance their skills. Agencies, such as the WHO, should develop comprehensive programs to tackle different health issues in LIC in collaboration with major institutions and experts around the world.