To the editor,
Coronavirus Disease 2019 (COVID-19) has emerged as a major new public
health threat, with high rates of morbidity and mortality among patients
with chronic medical conditions. The Disease was classified as pandemic
by March 2020 after its widespread over the world.(1)
Globally, up to 28th July 2020, there has been more
than 16 millions of confirmed cases of COVID-19, causing more than
650,000 deaths with the fatality rate of almost 4%.(2)As of
28th July 2020, a total of 77,904 laboratory confirmed
COVID-19 cases reported in Oman with mortality rate of 0.52%. Up to
this date, 6315 children <14 years of age were diagnosed with
COVID-19 which account for 8.1% of total confirmed cases with no
recorded deaths.(3) In Oman, children with mild COVID-19 are managed at
home and those with moderate and severe disease are managed as
inpatients. Ludvigssonet al in their systematic review found that
COVID-19 in children tend to have a milder course and better prognosis
compared to adults. (4)There is a limited literature describing
SARS-CoV-2 infection in children with cancers and post haematopiotic
stem cell transplantations . (5)
Despite extensive testing of any fever or URTI symptoms in these
vulnerable children, there were only 3 children with cancersand
post-haematopiotic stem cell transplantations (HSCT) tested positive and
required admission for COVID-19 in Oman for the last 5 months; 2 with
acute leukemia and one is post-HSCT for primary immune deficiency.
Patients were tested for SARS-CoV-2 infection by sending nasopharyngeal
specimens either for clinical suspicion of COVID-19 or as a screening
following exposure to SARS-CoV-2. The first one has relapsed acute
lymphoid leukemia (ALL) and was admitted for non-COVID-19 related
issues. He has mild course of COVID-19 and chemotherapy was stopped with
no additional management. Another child with ALL who has just completed
his chemotherapy courses was admitted for pneumonia and started on oral
azithromycin for 3 days and IV ceftriaxone for 1 week. His CBC remained
normal with normal coagulation profile, D-dimers andCRP of 7 mg/l. He
was discharged in excellent good general condition. The
3rd patient is post-HSCT for primary immunodeficiency
tested positive for SARS-CoV-2 following surveillance done following
exposure and was admitted for short period for non-COVID-19 related
issues.
Although there is a theoretical concern that children with cancers are
at risk of severe COVID-19 because they are immunocompromized, the
limited available data does suggest that COVID-19 in this population is
generally mild with self-limited course similar to the presentationof
SARS-CoV-2 infection in healthy children. (5)Our series of children with
cancers and post-HSCT showed similar results to what have been described
in Italy, France and United States. Boulad et al. reported a low overall
morbidity of COVID-19 in children with cancer with only 5% (1/20)
required hospitalization for management of COVID-19. (6)Rossoff et al
described their experience from Chicago where they reported 6 children
with cancers and post HSCT who got SARS-COV-2 infection. All of them had
mild SARS-CoV-2-related symptoms and none were admitted for COVID-19
related issues. (5)Nazon et al described 6 children managed by their
haematology/oncology unit at Strasbourg, France over 3 months period and
all were either asymptomatic or have mild disease and none require
admission for management of COVID-19.(7)Flash survey on children with
cancer from 25 countries which follow up about 10,000 children at risk
by March 2020, revealed that 9 out of >200 children tested
for COVID-19 had the infection and 8/9 were either asymptomatic or have
mild course.(8)
Severe COVID-19 has been described among five children (5/33, 15%) by a
prospective nationalsurvey conducted by the French society of
pediatriconcology among 30 French centers by Mid-April. These children
required intensive care for respiratory support following mild initial
course of COVID-19. At the time of writing the report, 4 of them were
still managed in ICU and none have died.(9)
The Spanish Group of Transplantreported their experience of 8 children
post HSCT with COVID-19; 5 required management as inpatients and 3
managed at home. Two children required intensive care admission for
mechanical ventilation; one was still on extracorporeal membrane
oxygenation (ECMO) and one died secondary to alveolar haemorrhage.
Lymphopenia and low ratio CD4/CD8 was associated with severe COVID-19 in
this small cohort. (10)
Our case series and the available experience reported from different
countries showed that most of the children with cancer and post-HSCT
have either asymptomatic or mild COVID-19 and these children have
similar vulnerability and risk morbidity resulting from COVID-19 to
healthy children.(11). Decisions on whether or not to postpone
chemotherapy/HSCT need to made on a case-by-case basis and according to
the risk of cancer progression which can results in a poor outcome.(5,
6)