Portal de Periódicos da CAPES

Early advice on managing children with cancer during the COVID‐19 pandemic and a call for sharing experiences

2020; Wiley; Volume: 67; Issue: 7 Linguagem: Inglês

10.1002/pbc.28327

1545-5017

Éric Bouffet, Julia Challinor, Michael Sullivan, Andrea Biondi, Carlos Rodríguez‐Galindo, Kathy Pritchard‐Jones,

COVID-19 Clinical Research Studies

We are living very difficult times. The pandemic caused by SARS-CoV-2 (COVID-19) is rapidly affecting the delivery of care for children with cancer around the world. We have written this commentary to facilitate the dissemination of helpful information and useful links, and to place in perspective what we do and do not know about the COVID-19 pandemic and its impact in the practice of paediatric oncology. Generally speaking, the impact that this virus may have on the paediatric population, and the management of children with cancer, remains unclear and poorly documented. The next two sections outline what has been published or communicated via academic websites, both in children and adults with cancer. So far, very few reports describe the impact of COVID-19 in the paediatric population. Dong et al described the epidemiology of the infection in 2143 suspected or confirmed cases in Chinese children aged up to 18 (median age 7 years).1 In this publication, only 4.4% of children were asymptomatic, while the majority (89.7%) presented with mild or moderate symptoms. Children under 1 year of age were more likely to develop severe or critical forms (10.1%). One child died from the infection. This report does not mention any relationship with underlying conditions, including cancer. A recent systematic literature review suggests that children account for < 5% of diagnosed COVID-19 cases, and that they often have milder disease than adults.2 Only one report has described the clinical course of COVID-19 in children with cancer. Chen et al described the case of a child with high-risk acute lymphoblastic leukaemia on maintenance chemotherapy who developed a neutropenic fever and cough in late January 2020, 8 days following a course of moderate-dose cyclophosphamide and cytarabine.3 Chest CT showed bilateral pneumonia with mild pleural effusion. The patient tested positive for Influenza A and was treated with broad-spectrum antibiotics and oseltamvir, without any evidence of improvement. The child remained febrile and a repeat chest CT scan 11 days after symptom onset showed progressive changes. At that time, 2019-nCoV was suspected and testing proved positive. The child was isolated and treated with umifenovir, ribavirin and recombinant interferon α-1b nebulized inhalations, in addition to methylprednisolone and immunoglobulins. Seven days later, the child's blood count had recovered and the 2019-nCoV test result became negative, however, his overall condition deteriorated. Four days later, the 2019-nCOV test was positive again and he required transfer to the intensive care unit for increasing hypoxia. The report did not further document this case. To this date, there are few published reports of COVID-19 in children with malignancies, though this situation will no doubt change rapidly. A description of the Italian experience at a major childhood cancer centre in Lombardy has recently been accepted for publication.4 This documents five positive cases in patients with childhood cancer, all of whom had a mild course and survived. Three patients were managed at home, and two in hospital. We would like to highlight the need to create a system for open case reporting and registration to help advance our knowledge on the disease course in children with cancer and to share experiences in its management. SIOP, St Jude and other stakeholders are working on a multi-stakeholder initiative for the creation of a COVID-19 information resource centre that is planned to include an open registry and a platform for experience sharing. So far, we have had a limited number of reports of COVID-19 cases in adult patients with cancer. Liang et al reported 18 patients in a cohort of 1590 Chinese cases.5 Only four of these patients had received chemotherapy or had had a surgical intervention in the preceding month; 12 patients were on follow-up. The report found that compared to the general population, patients with cancer were prone to more severe events (defined as admission to the intensive care unit requiring invasive ventilation or death). However, other factors such as age and current or former smoking habits may also explain this difference. As far as the general management of patients is concerned, there is no reason to discontinue daily activities in paediatric haematology/oncology units or to turn away children with suspected cancer during this pandemic. Whether patients undergoing treatment should have their treatment altered remains unknown though it seems prudent to postpone high-intensity treatments where feasible and to prepare to triage according to prognosis. Based on their experience, Chen et al recommend avoiding intensive chemotherapy for children with leukaemia in remission.3 However, the rarity of cases reported precludes the development of clear chemotherapy guidelines. As more information is available, it may be pertinent to create an international task force to provide evidence-based consensus recommendations. Services should also anticipate staff shortages due to illness, the need to care for sick relatives or requirements to self-isolate if living with or in close contact with a person suspected of having COVID-19. Experience from other sudden catastrophes, such as the 2011 earthquake in Christchurch, New Zealand, have emphasised the need to move rapidly to 'short staff' rotas that are already deployed for work over extended holiday periods.7, 8 This can help continuity of care and conserve staff morale through reasonable scheduled 'down time'. Staff also need to be cared for in other ways, with good information and protocols, confidence in their PPE and regular communications with a dedicated COVID-19 response team in their hospital. Clear information for parents and families is also essential and several sources are already available (Table 1). www.childrensoncologygroup.org www.survivorshipguidelines.org https://www.cure4kids.org/ums/home/ https://www.cure4kids.org/ums/home/groups/detail/documents.php?groups_id = 338 (login required) https://sph.nus.edu.sg/covid-19/ (freely available download) Several governments and international agencies have provided information and/or recommendations regarding COVID-19 (Table 1). Due to the large amount of misinformation and potentially harmful advice available on the Internet, we strongly recommend to consult guidance from established health authorities. We will be publishing further guidance in the coming weeks, describing clinical consensus on acceptable adaptations to treatment protocols during the COVID-19 crisis. These guidelines will be stratified according to country resource levels. Finally, our ability to continue our work is closely interdependent with our respective health care systems' ability to respond to this pandemic.9 The recent stark warning from physicians in Bergamo, Italy, emphasises the need for the whole of society to be prepared.10 Urging the people close to each of us to do their part to limit the virus' spread – through self-isolation, social distancing and avoiding all non-essential travel – is crucial, as is the coming together of communities to help equip and protect the most vulnerable (including the elderly, homeless or those with underlying health conditions) through the coming months. The authors declare that there is no conflict of interest.