COVID‐19 disease in New York City pediatric hematology and oncology patients

To the Editor: It is well established that viral respiratory infections in chronically ill and immunocompromised children are associated with increased morbidity and mortality compared to the general population.1 Specifically, immunocompromised children have an increased risk of severe lower respiratory tract disease caused by human coronaviruses including strains OC43, NL63, HKU1, and 229E.2 Little is known about the effect of COVID-19 disease on pediatric hematology, oncology, and hematopoietic stemcell transplant (HCT) patients.3 A report from Italy describes five pediatric cancer patients with COVID-19 each having a mild, self-limited course.4 A single case from China details a child with acute lymphoblastic leukemia who required prolonged intensive care treatment.5,6 To date, NewYorkCity (NYC) is home to nearly one-third of all pediatric cases (<18 years) of COVID-19 in the United States.7 Together, Memorial Sloan Kettering Cancer Center (MSK) and New York PresbyterianHospital (NYP, affiliatedwith both ColumbiaUniversity Irving Medical Center (CUIMC) and Weill Cornell Medical Center [WCMC]) care for a sizeable portion of the city’s pediatric hematology, oncology, and HCT community, providing an opportunity to describe the impact of COVID-19 in this vulnerable population. This retrospective study was approved by the Institutional Review Boards of MSK, CUIMC, and WCMC. Informed consent was waived. All patients 21 years old or younger with clinical laboratory COVID19 testing at MSK and NYP were included. For COVID-19 positive (COVID-19+) patients, data on demographics, presence of COVID19 symptoms, complete blood counts, inflammatory markers, imaging, hospital course, and impact on cancer-directed therapy were extracted from the electronic medical record. All laboratory and radiologic assessments were performed at the discretion of the treating physicians. Testing strategies varied between institutions during the observational period. MSK tested all symptomatic patients and screened all patients prior to admission, procedures requiring sedation, and planned myelosuppressive chemotherapy. NYP tested only those patients for whom a positive test would alter management, including those who were symptomatic, likely COVID-19 exposed, or with planned disposition to a chronic care facility. A confirmed case of COVID-19 was defined as a positive result by reverse transcriptase polymerase chain reaction (RT-PCR) on a nasopharyngeal swab specimen. Only laboratory-confirmed cases were included in this review. Descriptive statistics were used to summarize the data. No imputation was made for missing data. Associations between patient demographics and theCOVID-19 PCR result were examined using chisquare analysis and logistic regression. All statistical tests were twosided with statistical significance level of . 05. Statistical analysis was performed using SPSS v26. From March 10 through April 6, a total of 174 patients underwent laboratory testing for COVID-19. Demographic characteristics are shown in Table 1. Nineteen patients tested positive (11%): three patients with nonmalignant hematologic diagnoses, 14 with cancer, and two postallogeneic HCT. The mean age of COVID-19+ patients was 10.2 years (range 5 months to 20 years); 79% were male; 58% were non-Hispanic White, 21% Hispanic, 11% African American, and 11% Asian. The two institutions differed in the prevalence of COVID19+ cases (7% at MSK compared with 20% NYP; P < .01), consistent with the different testing criteria; they also differed in insurance payer distribution. A trend toward higher incidence of COVID-19 infection was observed in males. After adjusting for institution, insurance, and ethnicity, males appeared three times more likely to have positive test results compared with females (OR 3.2 95% confidence interval 0.90, 11.1) with borderline significance (P= .08). Table 2 shows the clinical findings of the COVID-19+ pediatric patients. Sixteen (84%)were symptomatic, beginning amedian of 1 day prior to testing (range 0-14). The most common symptoms were fever (68%), cough (47%), and dyspnea (37%). Eleven patients were hospitalized, four (21%) required supplemental oxygen, and two (11%) required mechanical ventilation. Only three of 19 (16%) received COVID-19-directed therapy. All five patients requiring pediatric intensive care unit (PICU) level care were male. Four had cancer: three with significant comorbidity including chronic graft versus host disease, trisomy 21, and cerebral mutism, and one with hyperleukocytosis and new onset B-ALL presenting 2 days after losing his father to COVID19. One 12-year-old boy with previously mild hemoglobin SC disease developed acute chest syndrome and died of COVID-19-related complications onhospital day 4. Full patient details can be found in the Supporting Information (case descriptions and Tables S1 and S2). Most COVID-19+ patients had relatively mild disease, with almost half treated outpatient. Hospitalized COVID-19+ cancer patients were generally admitted for expected complications of cancer therapy rather than complications of COVID-19 disease. Nine of 14 had their cancer-directed treatments delayed for COVID-19+ infection. Five tested positive for COVID-19 during or immediately postmyelosuppressive chemotherapy; all did well without any significant complications from COVID-19. Even the four cancer patients requiring PICU level care and demonstrating clear evidence of lung involvement