Almost six months since the earliest detected cases of COVID-19 in Wuhan Province China, the pandemic has since spread rapidly in breadth and depth. The increased strain the disease has placed on healthcare facilities is being realised in countries with the highest number of cases. This insight is intended to provide an update on its impact on the X-ray market.

Combatting COVID-19 via X-ray powered imaging

Almost six months since the earliest detected cases of COVID-19 in Wuhan Province China, the pandemic has since spread rapidly in breadth and depth. The increased strain the disease has placed on healthcare facilities is being realised in countries with the highest number of cases. This insight is intended to provide an update on its impact on the X-ray market.

COVID-19 has diverted stimulus funds to diagnostic X-ray systems to help facilitate much needed diagnostic imaging facilities, resulting in a higher than anticipated uplift in the radiography market in Q1 and Q2 of 2020 than predicted previously pre-COVID-19. Mobile digital radiography (DR) systems are at the forefront in providing an initial screening for pneumonia, a secondary and more progressive stage of COVID-19 in severe cases. Imaging is not routinely designated in asymptomatic individuals with mild COVID-19 symptoms unless they are at risk for disease progression. Mobile DR systems are used heavily to track progression of pneumonia due to the capabilities of bed side imaging enabling use in emergency rooms, A&E facilities and in the ICU. Mobile DR imaging has benefits of offering quicker, and less costly imaging services than other modalities.

Benefits of mobile DR systems for COVID-19 patient diagnosis

Portable mobile DR systems were recommended by the American College of Radiology (ACR) task force on COVID-19 on March 11, 2020, which endorsed the modality for use in ambulatory care facilities due to the ease with which surfaces can be cleaned.

One of the advantages that mobile radiography has for imaging COVID-19 patients is its portability. Mobile general radiography systems are a cost-efficient alternative to a fixed radiography room and allow technicians to bring the equipment to the patient, rather than having to bring the patient to the equipment. This can help save critical time for serious cases of COVID-19 in reaching an initial diagnosis, resulting in more efficient workflows and usage in A&E facilities, ICU and designated COVID-19 units.  Mobile DR equipment dedicated to COVID-19 imaging can be set up closer to intensive care units, decreasing risk of virus transmission, with some mobile DR systems becoming dedicated for COVID-19 cases.

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CT vs mobile DR

Even though industry consensus discourages the use of chest imaging for COVID-19 diagnosis, the role of both chest X-Ray (CXR) and chest CT continues to emerge.

  • For emerging countries, mobile DR systems are relied upon more heavily to provide imaging capabilities for diagnosis of COVID-19 and due to their increased affordability over CT systems.

  • The time required for a CT room to be decontaminated and sterilized after imaging COVID-19 patients is timely and heavy on resource. If a suspected or diagnosed patient with COVID-19 has been scanned, the room must be shut down and cleaned for 70 minutes.

  • CT should not be used to screen for or as a first-line test to diagnose COVID-19. CT should be used sparingly and reserved for hospitalized, symptomatic patients with specific clinical indications for CT.

  • Chest X-ray is often the first imaging exam acquired after a positive RT-PCR if a patient is at risk for disease progression.

  • Overuse of chest CT can exhaust hospital resources and bring infected patients into contact with non-infected individuals, thus increasing the risk of disease transmission.

  • CT is appropriate in patients with functional impairment and/or low blood oxygen after COVID-19 recovery.

Expected uplift of mobile DR systems

Manufacturers have seen a rapid sale of mobile DR to hospitals in Q1 2020, the manoeuvrability of the systems make them essential for early diagnosis of COVID-19 patients. On 6th May 2020 the World Health Organization (WHO) reported a total of 3,663,222 cases of COVID-19, the high severity of the crisis worldwide has had a significant impact on the healthcare system across the globe, healthcare expenditures have accelerated as hospitals rush to treat COVID-19 cases.

Prior to COVID-19 the digital radiography (DR) segment (inclusive of fixed DR rooms and mobile DR systems) was forecast to increase by 9% in the number of unit shipments (base growth). However, due to a surge of demand for diagnosis of COVID-19, the unit shipment of the systems is forecast to sharply rise. In the maximal-growth scenarios, the best-case scenario for growth, the global DR segment is forecast to increase by 35% in shipments in 2020; primarily driven by uplift in demand in the first half of 2020. Growth is then forecast to slow down in Q3 and Q4 2020 due to low availability of mobile DR systems and as the number of new COVID-19 cases declines. In the minimal-growth scenario, worse-case growth, the growth of the global DR segment is forecast at 13% in unit shipments. This is due to the lack of availability of systems, mobile DR manufacturing capacities and a drop in demand for mobile DR systems as the number of new infections continue to fall in latter part of 2020. The existing installed analogue mobile X-ray systems at hospital facilities have also seen an upgrade to digital mobile technology via retrofit solutions in another step towards increasing availability of mobile DR systems.

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Impact on the wider X-ray market

With hospital funds being diverted to diagnostic X-ray systems, in particular mobile digital radiography, image guided therapy X-ray systems, such as interventional X-ray and mobile C-arm systems, have experienced a decline in demand in the first quarter in 2020. In countries most impacted by COVID-19, non-critical surgeries and diagnostic procedures have been postponed or delayed, most medical professionals have been redeployed to more critical departments to help tackle the pandemic.

The utilization of interventional X-Ray is projected to decline in 2020; as the number of interventional procedures are projected to fall in the short term, thus delaying new purchases until the COVID-19 pandemic subsides. Due to their saturated markets, similar declines are projected for mammography and mobile C-arm X-ray solutions, as priorities are focused on increasing diagnostic imaging in COVID-19 patients.

Demand for interventional X-ray, mobile C-arm and mammography X-ray systems is forecast with gradual return in 2021 and 2022, with delayed or pending orders being processed.

FDA change in legislation for imaging of COVID-19

To increase availability of key medical imaging supplies in response to COVID-19, the US Food and Drug Administration (FDA) is relaxing its guidelines on modification of radiology equipment. FDA believes the policy included in this guidance will address the urgent public health concerns by helping to increase availability and capability of imaging products needed for diagnosis and treatment of lung disease in patients with COVID-19. Increasing the availability of mobile and portable systems could increase facilities to image patients both inside and outside of healthcare facilities, which could help to reduce the spread of COVID-19.

Healthcare facilities globally are attempting to tackle the surge in demand for diagnosis and treatment of COVID-19 patients, however the need to utilise imaging resources needs to also factor the safety of staff from potential infection.

As a result, providers of radiology services have modified mobile DR systems to enhance protection of staff by having glass barriers to increase separation and reduce risk of infection. Additionally, some imaging systems have also been modified into mobile systems to reduce the need of transporting patients who require imaging to large healthcare facilities. As a result, the FDA have declared that it will not oppose to such modifications to FDA approved systems.

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2020 and beyond

As a result of the COVID-19 pandemic, pending orders for mobile DR systems for late 2020 and 2021-2022 have been brought forward to early 2020. Therefore, demand is forecast to retract in Q3 and Q4 of 2020, as well as in 2021. Spend has been diverted from image guided therapy X-ray systems to mobile diagnostic DR systems to increase and enable more diagnostic capabilities and treatment of COVID-19.

Due to demand plummeting for mammography, interventional and mobile C-arms in countries most highly impacted by COVID-19, recovery is projected in late 2020 through to 2022.

The sheer necessity to access mobile DR systems has meant purchasers have increased flexibility on specifications, with purchasing decisions purely founded on supply available by mobile DR manufacturers. In light of the COVID-19 pandemic there have not been any changes in pricing dynamics or price cutting of mobile DR systems.

In order to future proof against similar pandemics in the futures, hospitals may focus purchasing towards mobile DR systems with anti-microbial coatings and ease of sterilization, software and hardware features which enable increased patient and radiographer protection, quicker image processing, workflow optimization and artificial intelligence assisted clinical decision-making software. Artificial intelligence tech companies are forecast to be more reactive in developing bespoke solutions to help tackle such pandemics. For instance, Qure.ai, a healthtech company specializing in artificial intelligence (AI), launched its COVID-19 progression monitoring software at Bolton NHS Foundation Trust. Qure.ai’s software automates the interpretation of COVID-19 progression by quantifying changes on chest X-rays, enabling localization, qualification of lesions and a case priority score being generated in under a minute.