Early impact of the COVID-19 pandemic on paediatric cancer care in Latin America
Authors: Liliana Vasquez, Claudia Sampor, Gabriela Villanueva, Essy Maradiegue, Mercedes Garcia-Lombardi, Wendy Gomez-García, Florencia Moreno, Rosdali Diaz, Andrea M Cappellano, Carlos Andres Portilla, Beatriz Salas, Evelinda Nava, Silvia Brizuela, Soledad Jimenez, Ximena Espinoza, Pascale Yola Gassant, Karina Quintero, Soad Fuentes-Alabi, Thelma Velasquez, Ligia Fu, Yessika Gamboa, Juan Quintana, Mariela Castiglioni, Cesar Nuñez, Arturo Moreno, Sandra Luna-Fineman, Silvana Luciani, Guillermo Chantada
Journal: The Lancet Oncology (2020)

Although previous studies have suggested that the complications and mortality rate related to COVID-19 are substantially lower in the paediatric population,1Dong Y Mo X Hu Y et al.Epidemiology of COVID-19 among children in China.Pediatrics. 2020; (published online March 16.)DOI: 10.1542/peds.2020-0702Crossref Scopus (2689) Google Scholar it is reasonable to consider that children with underlying conditions such as cancer will be at increased risk of severe disease.2Ogimi C Englund JA Bradford MC Qin X Boeckh M Waghmare A Characteristics and outcomes of coronavirus infection in children: the role of viral factors and an immunocompromised state.J Pediatric Infect Dis Soc. 2019; 8: 21-28Crossref PubMed Scopus (127) Google Scholar, 3Kotecha RS Challenges posed by COVID-19 to children with cancer.Lancet Oncol. 2020; 21: e235Summary Full Text Full Text PDF PubMed Scopus (70) Google Scholar 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.4Balduzzi A Brivio E Rovelli A et al.Lessons after the early management of the COVID-19 outbreak in a pediatric transplant and hemato-oncology center embedded within a COVID-19 dedicated hospital in Lombardia, Italy. Estote parati.Bone Marrow Transplant. 2020; (published online April 20.)DOI:10.1038/s41409-020-0895-4Crossref Scopus (104) Google Scholar, 5Chen Z Xiong H Li JX et al.COVID-19 with post-chemotherapy agranulocytosis in childhood acute leukemia: a case report.Zhonghua Xue Ye Xue Za Zhi. 2020; 41 (in Chinese).: E004PubMed Google Scholar, 6Hrusak O Kalina T Wolf J et al.Flash survey on severe acute respiratory syndrome coronavirus-2 infections in paediatric patients on anticancer treatment.Eur J Cancer. 2020; 132: 11-16Summary Full Text Full Text PDF PubMed Scopus (139) Google Scholar 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.7de Freitas E Silva R Pitzurra R What are the factors influencing the COVID-19 outbreak in Latin America?.Travel Med Infect Dis. 2020; (published online April 11.)DOI:10.1016/j.tmaid.2020.101667Crossref Scopus (21) Google Scholar 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.8Lazzerini M Barbi E Apicella A Marchetti F Cardinale F Trobia G Delayed access or provision of care in Italy resulting from fear of COVID-19.Lancet Child Adolesc Health. 2020; 4: e10-e11Summary Full Text Full Text PDF PubMed Scopus (901) Google Scholar In response to this problem, the global paediatric oncology community has summarised some of the anticipated challenges.9Sullivan M Bouffet E Rodriguez-Galindo C et al.The COVID-19 pandemic: a rapid global response for children with cancer from SIOP, COG, SIOP-E, SIOP-PODC, IPSO, PROS, CCI and St Jude Global.Authorea. 2020; (published online April 25.) (preprint).DOI: 10.22541/au.158777298.87289192Google Scholar 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 onco-haematologists 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). Most participants reported that chemotherapy was administered for newly diagnosed (429 [95%]) and active ongoing (441 [97%]) treatment cases. However, indefinite postponement or delay of surveillance consultations (405 [89%]), outpatient procedures (264 [58%]), cancer surgeries (206 [45%]), radiotherapy schedules (122 [33%]), outpatient consultations (119 [26%]), stem-cell transplantation (173 [73%]) and palliative care (87 [19%]) were reported. 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 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).10Bouffet E Challinor J Sullivan M Biondi A Rodriguez-Galindo C Pritchard-Jones K Early advice on managing children with cancer during the COVID-19 pandemic and a call for sharing experiences.Pediatr Blood Cancer. 2020; (published online April 2.)DOI:10.1002/pbc.28327Crossref Scopus (92) Google Scholar 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. We declare no competing interests. Download .pdf (.35 MB) Help with pdf files Supplementary appendix