Although previous studies have suggested that the complications and mortality rate related to COVID-19 are substantially lower in the paediatric population, 1 it is reasonable to consider that children with underlying conditions such as cancer will be at increased risk of severe disease. 2, 3 Some reports have examined the impact of COVID-19 in children with cancer; in all cases no deaths or disease-related complications have been reported. [4] [5] [6] In order to prevent the rapid spread of the virus as seen in many European countries, most Latin American countries implemented early epidemiological actions with social distancing, interruptions of commercial activities, transportation, and schooling. Preparation for the pandemic throughout Latin America, in terms of hospital capacity, human resources, and testing capacity is, however, heterogeneous. 7 In this scenario, there is emerging concern about the collateral effect of the COVID-19 pandemic on access to diagnosis and treatment in children with cancer. 8 In response to this problem, the global paediatric oncology community has summarised some of the anticipated challenges. 9 To examine the potential impact of COVID-19 on the management of children with cancer in Latin America, we did a cross-sectional survey of paediatric oncohaematologists in April 12-19, 2020, early in the spread of the outbreak in the region (appendix p 1). The survey was electronically distributed through the Latin American Society of Pediatric Oncology (SLAOP) email list and St Jude Global regional partners. Additionally, SLAOP's national delegates for each country contacted their centres for an increased response and reviewed the responses from their countries for validation before analysis.
453 paediatric onco-haematologists (267 faculty members, 142 medical directors, and 44 residents from public and private institutions) from 20 countries were surveyed (appendix p 2 In 36% of cases, modification of chemotherapy regimens was required because of shortage of drugs (figure; appendix p 3).
Multivariate logistic regression revealed that the type of oncology hospital, number of paediatric onco-haematologists in a centre, travel restrictions, COVID-19 incidence rate and fatality rate (appendix p 4), and national health-care expenditure were independent factors for any type of discontinuation of or modification to oncological therapy in children (appendix pp 5-6).
Nearly 60% of respondents reported a decrease in their paediatric onco-haematology staff because of COVID-19 infection or quarantine. Half of the surveyed respondents reported that their centres did not provide a platform for telemedicine consultations, although non-professional social media channels were used. Shortage of blood products was reported by 79% of respondents, which was significantly more frequent in countries with travel restrictions, high COVID-19 incidence rates, and a health-care expenditure less than 7% of GDP (appendix pp 5-6). In countries with the highest health-care expenditure and lowest COVID-19 incidence and case-fatality rates, physicians stated that they perceived the pandemic would not affect children with cancer, probably due to greater confidence in their Less than 30% 30-60% More than 60% Less than 30% 30-60% More than 60% Less than 30% 30-60% More than 60% health-care systems (appendix pp 5-6). Facility funding, participants position, and tests per million population at risk were not independently associated with any outcome (appendix pp 5-6). Almost all participants (99%) reported that their hospitals are implementing social distancing measures, suspension of functions of non-essential personnel and students, reorganisation of teams to reduce exposure, and implementation of educational materials that are aligned to recently published international recommendations (appendix p 7). 10 However, some participants expressed concerns about the lack of governance of health-care systems overwhelmed with COVID-19, poor availability of personal protective equipment, issues in the shipment and processing of pathology samples (by flow cytometry and for minimal residual disease assessment), and delays in access to diagnosis in new cases, mostly in countries where treatment is centralised (appendix p 7).
The major strength of this study is its high participation rate and geographical coverage, with responses from all Latin American countries with official paediatric oncology programmes. However, the main limitation was the imbalanced number of participants between countries, making it difficult to compare across countries.
Our data suggest that even in this early epidemiological phase where health-care systems have not been substantially affected in Latin America, COVID-19 has already affected the care of children with cancer. In addition to the potential risk of severe disease by COVID-19 in these patients, prognosis could be negatively affected because of alterations to paediatric oncology management. As the pandemic evolves and the burden on health-care systems increases, these disruptions might be even more severe if preventive actions are not taken.