Delivering Pediatric Oncology services during a COVID-19
Pandemic in India
The global pandemic of the novel
coronavirus
disease, COVID-19 is having a serious impact on pediatric patients,
making it difficult for them to continue treatment1,
2.
Providing medical care to children with cancer is challenging during the
COVID -19 pandemic, given the risks of death from cancer versus death or
serious complications from COVID-19 infection in immunocompromised
hosts3-8. There is shortage of personal protective
equipment (PPE) for health personnel, restricted inpatient and intensive
care facilities, limited blood bank supplies and diagnostic
services4 .In this correspondence we describe the
strategy used in our unit to deliver optimum oncology services during
COVID -19 pandemic best suited to our system.
In the initial phases of the COVID -19 pandemic the main focus
was on staying at home, hand/respiratory hygiene and social distancing.
The patients were asked to stay indoors and continue oral chemotherapy
wherever feasible and defer the intensive chemotherapy, which would
require hospital visits and possible subsequent admission for febrile
neutropenia3, 5.
Preventive measures during hospital visits : Strict
implementation of protective measures, including mask use by patients
and their caregivers, hand hygiene, appropriate respiratory etiquette
and social distancing was enforced. Health education regarding pandemic
was imparted to patients telephonically and during day care visits.
Patients with suspected COVID were screened.
Testing/quarantine/admission was advised on a case to case basis. The
protocol followed in the unit for evaluation of patients with febrile
neutropenia was modified: throat examination and aerosol generating
procedures were withdrawn. Children may act as asymptomatic carriers
leading to community spread. Strict crowd control for patients’
attendants was implemented. The hospital had temporarily withdrawn
outpatient and specialty clinic services, hence new patients were not
registered. Patients presenting with oncologic emergencies and those
requiring high dose chemotherapy were admitted. For those requiring
in-patient admissions for intensive chemotherapy a strict appointment
system was adhered.
The lockdown : By the third week of COVID-19 pandemic a
nationwide lockdown had been declared. We set a system of triaging for
our patients that helped the oncology team to take decisions for our
patients.(Table 1)
Patient tracking/ Teleconsultations was done by our nurses and
social workers and assisted by the doctors.(Table 1)
Revisiting the treatment plan : Triaging was done for patients
on chemotherapy. Patients were allocated to a risk zone and relevant
treatment advice was given. Treatment protocols requiring
surgery/radiation/hematopoietic stem cell transplantation (HSCT) needed
modification as these therapeutic modalities were temporarily suspended
due to COVID concerns. Occasionally, patients were switched to low dose
/less toxic chemotherapy to tide over this critical period.(Table 1)
Reorganization of day-care services was done to facilitate
treatment.(Table 2)
Resource utilization : Ours is a premier tertiary medical
Institute in India and has been designated a COVID centre. Understanding
the nature of the COVID-19 disease and requirements of the pandemic, the
team of doctors and nurses was split into two. This splitting of
resources keeps a reserve pool of medical staff, should one team
inadvertently be exposed to a COVID-19 case.
Role of Tele-health: Patients were contacted and helped by
telephone, helplines and email and using a support group called
“Sambhav”. More than 170 exchanges were done.
NGO interface : Our NGO partners helped with antibiotic
administrations, transport within the city and across states,
accommodation and coordination with local hospitals. They also helped
transfer medicines to distant patients.
Blood donation : The lockdown had drastically reduced the number
of voluntary blood donations/donations from relatives resulting
in shortage of blood components in the blood bank. Travel documents were
issued by the treating team to permit donors to come for voluntary blood
donation.
Discussion : The pandemic caused by SARS-CoV-2 (COVID-19) has
greatly affected the delivery of care for children with cancer
worldwide. Information on COVID 19 infection in pediatric cancer
patients is scarce9. In our unit we conducted COVID
-19 testing for seven patients, of which one tested positive. All
patients were febrile, had cough and tachypnoea (of these two were
hypoxic), shock was present in two and pneumothorax was present in one
patient. One patient came from a hotspot area. The one patient who was
COVID positive in addition had features of meningoencephalitis.
A number of studies from around the world 3,5,8,10,11have suggested dose reductions, increasing intervals between cycles
depending on the physical status of patient, disease status and risk of
chemotherapy. It seems desirable to postpone high- intensity treatments
where feasible and to prepare to triage according to
prognosis5, 8,10. A recent publication has focused on
providing guiding principles for management of various childhood
cancers, in particular the ones with best clinical outcomes (acute
lymphoblastic leukemia, Hodgkin lymphoma, retinoblastoma, Wilms tumor
and low- grade glioma) 12.
A balance needs to be created keeping in mind risks associated with
COVID-19 and the timely management of a child with
cancer12. At the onset of the pandemic and lockdown
where the focus was on social distancing, staying at home and using a
triage system to deliver oncology services it was realized that this
cannot go on indiscriminately. We are now tracking all our patients who
received chemotherapy in the last three years and facilitating delivery
of all pending chemotherapy that was postponed during the initial phases
of the pandemic.