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Implications of corona virus disease-19 pandemic on cytopathology laboratory—Challenges and solutions in resource-limited settings


 Department of Pathology, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Swami Ram Nagar, Doiwala, Dehradun, Uttarakhand, India

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Date of Submission16-Feb-2022
Date of Decision09-May-2022
Date of Acceptance11-May-2022
Date of Web Publication28-Nov-2022
 

   Abstract 


Background: Corona Virus Disease-19 (COVID-19) disease which is still showing peaks and plateau with emerging new mutational viral variants has led to the modification of working of hospitals and medical institutes. Cytopathology laboratories geared up with the changing situation to cope up with not only the COVID-19 patients but also patients of other diseases, particularly oncology patients. It was also important to adopt changes in the cytopathology residency program so as to cope up with the changing scenario. Aim: The present study was conducted to study the various measures adopted and the changes made in the cytopathology laboratory during COVID-19 infection in a resource-limited setting while catering to a large population of COVID-19-positive patients in the north Himalayan region of India. It was also intended to study the methods adopted for effective cytopathology residency training during corona times. Setting and Design: The study was conducted from March 2020 to December 2021 in the cytopathology lab, and all the samples were analyzed and compared with the samples received in pre-corona times from March 2018 to December 2019. The different methods adopted during corona times for effective cytopathology residency training were also analyzed. Results: The total number of samples received in the cytopathology laboratory in pre-corona times from March 2018 to December 2019 were 6822, and samples received from March 2020 to December 2021 were 6567 with decrease of 1.9% of cases. There was increase in 17.4% for the samples of the respiratory tract received in the lab with an increase in cases of infections including aspergillosis, mucormycosis, and tuberculosis. There was 10.3% increase in cytological diagnosis of malignant cases during corona times. Use of 90% alcohol for fixation rather than air drying of smears, avoiding of pneumatic tubes, judicious use of personal protective equipment (PPE) kits along with access to the digital cytology slide database were included in the changes made in the lab. Conclusions: There was a marginal decrease in cytopathological diagnosis during COVID-19 with substantial increase in the malignancy rate of 10.3% in cytological diagnosis of different organs. Diagnosis of mucormycosis, aspergillosis, and tuberculosis infections of respiratory tract cytology increased during this period. Judicious use of limited available resources led not only to smooth functioning of the cytopathology lab but also prevented any infection in the working health personals. Newer online resources were explored and modified for continuous training of the cytopathology residents. Emotional support with effective communication was the key to alleviate any psychological stress among all health professionals in the cytopathology laboratory.

Keywords: Corona Virus Disease-19, cytopathology, malignancy rate, residency training


How to cite this URL:
Chandra S, Kusum A, Gaur DS. Implications of corona virus disease-19 pandemic on cytopathology laboratory—Challenges and solutions in resource-limited settings. Indian J Pathol Microbiol [Epub ahead of print] [cited 2023 Feb 2]. Available from: https://www.ijpmonline.org/preprintarticle.asp?id=362059





   Introduction Top


Coronavirus disease-19 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was initially identified in Wuhan, China, in late 2019.[1] However, since then, the cases of this disease showed exponential growth, spreading to almost all parts of the world, which led the World Health Organization (WHO) to declare it as a pandemic in March 2020.[2] Globally, 39,65,58,014 confirmed cases of COVID-19 with 57,45,032 deaths have been reported by the WHO until February 8, 2022.[3] The disease is still showing peaks and plateau with emerging new mutational variants of the virus. This pandemic has affected all ages, involving financial, social, or psychological aspects of life. Various emergency measures are still being taken by the governments of different countries to prevent rapid spread of the disease including lockdowns, shutdown of the schools, malls, etc., Hospitals and medical institutes have also modified their activities depending on the situation to manage COVID-19 patients, which to some extent had a possible detrimental effect on patients of other diseases. The cytopathology laboratories have also geared up with the changing situation to cope with not only COVID-19 patients but also patients of other diseases, particularly oncology patients. In addition, the focus is also to prevent any coronavirus infection in healthcare professionals working in these laboratories. Literature search shows commentaries, studies, and review articles describing various measures which were taken by cytopathology laboratories in different parts of the world to cope with the corona virus disease.[4],[5] However, these studies are mostly from the developed worlds with adequate resources. Therefore, it is essential that there is a knowledge of working of cytopathology laboratories and the changes made in resource-limited settings while catering to heavy burden of corona-positive patients. This is to provide not only adequate diagnostic services to the patients but also safeguarding the laboratory healthcare personnel from infection. India is the second most COVID-19-affected nation after the USA with a total burden of confirmed 4,23,39,611 cases and 5,04,062 deaths until February 8, 2022.[3] Presently, the country is also coping with the third wave of the Omicron variant with active cases of corona being 8,92,828 until February 8, 2022.[4] It is also essential that changes are made in the cytopathology residency training program in teaching institutes so as to cope with the changing scenario. The present study was therefore conducted to study the various measures adopted and the changes made in the cytopathology laboratory during COVID-19 infection in a resource-limited setting while catering to the large population of COVID-19-positive patients in the north Himalayan region of India.


   Materials and Methods Top


The study was conducted from March 2020 to December 2021, and all samples received or processed in the cytopathology lab were analyzed and compared with the samples received in matched pre-corona times from March 2018 to December 2019. The changes made in the cytopathology laboratory and residency training program to cope with the working during the corona period were also studied. The approval of research and ethics commitee was taken vide letter no. SRHU/HIMS/RC/2022/56 dated 12.3.22.


   Results Top


The total number of samples received in the cytopathology laboratory during pre-corona times from March 2018 to December 2019 were 6822, and samples received from March 2020 to December 2021 were 6567 with a decrease of 1.9% of cases. [Table 1] shows the comparison of number of cases of different organs received in the cytopathology lab during the pre-corona and corona periods. It shows that there was an increase of 17.4% of samples of the respiratory tract received in the lab. [Figure 1] shows the increase in cases of fungal infections in the respiratory tract including aspergillosis, mucormycosis, along with cases of tuberculosis. [Table 2] shows the diagnosis of malignant cases of different organs in the cytopathology lab. It shows that there was an increase in cytological diagnosis of malignant cases (10.3%) during corona times. [Table 3] shows the different changes that were made in the lab during corona times so as to cater to COVID-19-positive cases and prevent infections in health personnel working in the lab including technicians, doctors, and other workers.
Figure 1: Fungal and tuberculosis cases on cytology of respiratory tract during pre-COVID-19 and COVID-19 periods

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Table 1: Change in number of cases for cytology during pre-COVID-19 and COVID-19 periods

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Table 2: Number of malignant cases diagnosed on cytology during pre-COVID-19 and COVID-19 periods

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Table 3: Changes in the cytopathology laboratory during COVID-19 period

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   Discussion Top


The increase of COVID-19 cases worldwide with different waves of infection has prompted changes in every aspect of life including the health sector. With the emergence of newer variants of this virus, it is still not clear when this infection will end and what will be its severity in near future. It is therefore essential that sharing of knowledge is done among different health professionals regarding the changes made in their settings so as to provide better patient care, especially in resource-limited settings. It was observed in the present study that there was a marginal decrease (1.9%) of cases diagnosed in the cytopathology lab during COVID-19 times. The decrease was mostly related to cases in which fine needle aspiration cytology (FNAC) is usually indicated for benign lesion cases. This is especially related to thyroid cytology (decrease of 19.2%) because most of the cases received in our lab during pre-corona times for thyroid FNAC were related to Bethesda thyroid reporting category II. In addition, there was a substantial decrease in cervicovaginal Pap screening (19.5%), cytology of skin (38.8%), and the male genital tract (28.5%) during corona times. This is mainly because the patients and clinicians were in favor of postponing cytology in not-so-relevant cases to avoid unnecessary exposure of patients as well as healthcare professionals to infective conditions. Similar findings have been observed by other studies in different parts of the world.[5],[6] It was also observed in the present study that cytology of respiratory tract lesions increased by 17.4% during corona times. This is understandable as SARS-CoV-2 mainly affects the respiratory system, and bronchoalveolar lavage was the most common cytological material received in the laboratory. Interestingly, it was observed that there was an increase in cases of tuberculosis, aspergillosis, and mucormycosis infections on cytological examination of the respiratory tract [Figure 2]. This may be related to immunocompromised states of patients due to irrational steroid therapy during COVID-19 infection. Patel et al.[7] observed in their multicentric study from India that 65.2% patients of mucormycosis were associated with COVID-19 with 2.1-fold increase of cases during the corona period. They also concluded that COVID-19-associated hypoxemia and improper glucocorticoid use were independently associated with coronavirus disease-associated mucormycosis.
Figure 2: (a) Bronchial brush smear shows cryptococcus (hematoxylin–eosin; ×100), (b) bronchoalveolar lavage smear shows candidial pseudohyphae (silver methanamine stain; ×100), (c) bronchoalveolar lavage smear shows broad, aseptate hyphae of Mucor (silver methanamine stain; ×40), and (d) bronchoalveolar lavage smear shows thin, acute-angle septate hyphae of Aspergillus (Periodic acid stain; ×40)

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Another interesting finding observed in the present study was increase in diagnosis of malignancy (10.3%) on cytology in all organs during the COVID-19 period in comparison to pre-COVID-19 period. This is due to the fact that mostly oncology patients or those suspected of malignancy visited hospital for diagnosis during the COVID-19 period. Vigliar et al.[8] have also concluded from their study in Italy that there was a significant decrease in cytological cases during COVID-19 due to the sample prioritization policy but with an increase in malignant cytological diagnosis (P < 0.001). However, we observed only 1.9% decrease in cytological cases during COVID-19 but a substantial increase in malignant cytological diagnosis especially for ovarian (51.8%) and pancreatic (37.1%) malignancies. A multicentric international survey involving 23 countries by the University of Naples also confirmed an average volume reduction of 45.3% of cytological cases ranging from 0.1 to 98.0% with an overall increase of 5.56% of the malignancy rate.[9] The present study from India observed an increase of an overall cytological malignancy rate of 10.3%.

Guidelines have been provided for specimen collection, transportation, and processing of suspected or COVID-positive samples in laboratory by the WHO, Centers for Disease Control and Prevention (CDC), as well as Indian Academy of Cytologists.[10],[11],[12] Our cytopathology laboratory also followed these guidelines with certain modifications depending on the availability of resources and manpower. As a biosafety cabinet was not available during centrifugation in the cytology lab, it was carried out in a separate room with windows and the technician performing it was using a PPE kit.

Judicious use of PPE kits in the FNAC procedure room was recommended due to its limited availability, and instead, N 95 masks, sterile gowns, gloves, head gear, and caps were used. Preferably, use of 90% alcohol fixation than air drying or agitating the smears to avoid droplet formation was also done [Table 3]. As the vaccination drive was started by the Government of India from January 16, 2021, all medical professionals, technicians, and other lab personnel were encouraged to get vaccinated, and within stipulated time, all cytopathology lab personnel were completely vaccinated.

Another important aspect that was tackled during COVID-19 was training and teaching of cytopathology residents. Although few studies have provided guidelines for cytopathology training for residents, it has to be modified according to persisting scenarios in different teaching institutes.[10],[13] Use of Zoom (Zoom Video Communications, Inc. San Jose, CA) and Google Meet/Classroom were the apps which were used for this purpose in our study. Digital cytology slide database for learning at different websites including the International Academy of Cytologists, Indian Academy of Cytologists, Papanicolaou Society, etc., were also used. The use of WhatsApp groups (WhatsApp LLC, California, USA) for discussing important cytology cases with upload of photographs was an important part of learning cytology on a day-to-day basis. In addition, residents were encouraged to attend various webinars, conferences, continuing medical education (CME), YouTube lectures, etc., to enhance their cytology knowledge. Sets of glass slides from archives of important cytological diagnosis were also distributed among residents to be served individually and then discussed either on Google Meet or WhatsApp groups.

Another important point that was taken into consideration in the present study was decreasing psychological stress and fear in the residents or lab technicians during COVID-19 by being in continuous touch with them through WhatsApp, telephonically, e-mail, or personally with strict corona-appropriate behavior. The increased psychological stress may be related to workload, fear of contact of infection, any affected family member, or themselves being COVID-19-positive. It was also important to update everyone in the lab about any change in policy or schedule implemented by the government or the institute depending on the corona situation.


   Conclusion Top


The study concludes that there was a marginal decrease of 1.9% in cases for cytopathological diagnosis during COVID-19 with major bulk constituted by respiratory tract, pancreatic, hepatobiliary, and ovarian cytology. A substantial increase in malignancy rate of 10.3% was noted in cytological diagnosis of different organs. Diagnosis of mucormycosis, aspergillosis, and tuberculosis infections in respiratory tract cytology increased during this period. Judicious use of limited available resources led not only to smooth functioning of the cytopathology lab but also prevented any infection in the working health personnel. Newer online resources were explored and modified for continuous training of the cytopathology residents. Emotional support with effective communication was the key to alleviate any psychological stress among all health professionals in the cytopathology laboratory.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al. China novel coronavirus investigating and research team. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med 2020;382:727-33.  Back to cited text no. 1
    
2.
WHO Director-General's opening remarks at the media briefing on COVID19 -March 2020 [Google Scholar]  Back to cited text no. 2
    
3.
World Health Organization Coronavirus (COVID-19) dashboard. Available from: https://covid19.who.int/. [Last accessed on 2022 Feb 09].  Back to cited text no. 3
    
4.
Ministry of Health and Family Welfare, Government of India dashboard. Available from: https://www.mohfw.gov.in/ [Last accessed on 2022 Feb 09].  Back to cited text no. 4
    
5.
Iaccarino A, Pisapia P, Vigliar E, Vielh P, Troncone G. Juggling the COVID-19 pandemic: A cytopathology point of view. Cytopathol 2021;32:299–303.  Back to cited text no. 5
    
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Vrachimis A, Iakovou I, Giannoula E, Giovanella L. Endocrinology in the time of COVID-19: Management of thyroid nodules and cancer. Eur J Endocrinol 2020;183:G41–8.  Back to cited text no. 6
    
7.
Patel A, Agarwal R, Rudramurthy SM, Shevkani M, Xess I, Sharma R, et al. MucoCovi Network3. Multicenter epidemiologic study of coronavirus disease-associated mucormycosis, India. Emerg Infect Dis 2021;27:2349-59.  Back to cited text no. 7
    
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Vigliar E, Iaccarino A, Bruzzese D, Malapelle U, Bellevicine C, Troncone G. Cytology in the time of coronavirus disease (COVID-19): An Italian perspective. J Clin Pathol 2021;74:261–3.  Back to cited text no. 8
    
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Vigliar E, Cepurnaite R, Alcaraz-Mateos E, Ali SZ, Baloch ZW, Bellevicine C, et al. Global impact of the COVID-19 pandemic on cytopathology practice: Results from an international survey of laboratories in 23 countries. Cancer Cytopathol 2020;128:885-94.  Back to cited text no. 9
    
10.
Srinivasan R, Gupta P, Rekhi B, Deb P, Nijhawan VS, Prasoon D, et al. Indian academy of cytologists national guidelines for cytopathology laboratories for handling suspected and positive COVID-19 (SARS-COV-2) patient samples. J Cytol 2020;37:67-71.  Back to cited text no. 10
  [Full text]  
11.
World Health Organization. (2020). Laboratory testing for coronavirus disease (COVID-19) in suspected human cases: Interim guidance. World Health Organization. 19 March 2020. Available from: https://apps.who.int/iris/handle/10665/331501.  Back to cited text no. 11
    
12.
Centers for Disease Control and Prevention (CDC). Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens From Persons for Coronavirus Disease 2019 (COVID-19). Available from: https://www.cdc.gov/coronavirus/2019-nCoV/lab/guidelines-clinical-specimens.html.  Back to cited text no. 12
    
13.
Pambuccian SE. The COVID-19 pandemic: Implications for the cytology laboratory. J Am Soc Cytopathol 2020;19:202-211.  Back to cited text no. 13
    

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Correspondence Address:
Smita Chandra,
Department of Pathology Himalayan Institute of Medical Sciences Swami Ram Nagar, Doiwala, Dehradun - 248 140, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijpm.ijpm_173_22



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