Discussion
Since the first SARS-CoV-2-positive case in March 2020, 8 935 746 cases
have been confirmed in Argentina. Of these, 8% (720,147) were patients
between 0 and 19 years of
age26 and
0.1% (n= 888) were pediatric patients with concomitant oncological
disease, who mostly presented with mild clinical manifestations or
asymptomatic disease. The low incidence rate in our study is similar to
that reported in other
studies27,7but slightly higher than that estimated for the general pediatric
population.8This low incidence could be related to the early implementation of
social distancing and prevention measures,11 but may
also suggest underreporting, given that children predominantly have mild
or asymptomatic forms of
COVID-19.27
Almost 60% of the children that
tested positive for SARS-CoV-2 had leukemia or lymphoma, followed by
central nervous system tumors in 13.5%, which is consistent with the
distribution of cancer diagnoses in the general pediatric population. In
addition, the distribution of diagnoses according to the ICCC-3 in
children with SARS-CoV-2 infection was similar to that reported in
previous
series.5,7,8,10,14,17,28
In our series, 41.1% of patients were asymptomatic at the time of
COVID-19 diagnosis. This is twice the rate published for the general
population of patients under 18 years of age in
Argentina.29This difference may be explained by the greater number of tests
performed in cancer patients as a result of screening prior to
admissions, procedures, and
transfers.30
In the majority of patients, clinical manifestations consisted of mild
respiratory symptoms with minimal requirement for hospital admission and
not leading to an increase in COVID-19-related morbidity or mortality,
coinciding with reports from other
countries.12,31The symptoms most frequently observed were fever and cough, similar to
those reported by other authors both in general pediatric population and
in the pediatric population with cancer.2,5,7,8,10,12,17,28,32
Although these children are immunocompromised with greater
susceptibility to infection, unlike what was initially thought for
adults with
cancer,33more than 70% of children with cancer and SARS-CoV-2 infection evolved
favorably and remained asymptomatic or developed mild disease. Only 3 %
of cases presented critical disease, consistent with those reported in
other pediatric series.6,11,17,28
Madhusoodhan et al. found a higher rate of asymptomatic patients than in
the general pediatric population in the same geographic
region.7Similar to other series, our evaluation showed that only a small number
of patients who were asymptomatic at diagnosis developed symptoms later.
Although in our study mortality was high compared to previously
published
series.7,15,18,28,32when the causes of death in our population were analyzed, 88% were
found to be due to progression of the underlying disease or to
disease-associated
complications2,7,14and not attributable to SARS-CoV-2. There was also no difference in
COVID-19-related mortality (n=7) in children with leukemia or lymphoma
when comparing the three waves, despite different circulating strains.
One of the major interrogatives during the pandemic was whether
immunosuppressive treatment should be continued in patients with cancer
and SARS-CoV-2 infection. In the first months of the pandemic,
recommendations were developed to guide treating physicians in the
management of cancer therapies. Different studies show that initially it
was decided to discontinue or modify chemotherapies, immunotherapies,
surgeries, and radiation therapies, motivated by uncertainty regarding
outcome and prognosis of SARS-CoV-2 infections in cancer
patients.2,3,8,17,20,21Due to a lack of data on treatment discontinuation or modification in
our study, we cannot be sure if the same occurred in Argentina.
One of the strengths of our study is that ROHA has national coverage of
more than 90% of pediatric cancer patients by including all PHOUs in
the country. The creation of the epidemiological registry of patients
with SARS-CoV-2 infection in the registry allowed for the dynamic and
almost real-time reporting of positive cases. Based on this information,
weekly epidemiological reports were prepared and sent back to each
institution resulting in data-driven decision-making in the face of this
new disease.
It should be noted that the unexpected outbreak of COVID-19 confronted
us with a general population, including pediatric cancer patients and
their families that had to comply with isolation protocols and
restrictions and warranted the implementation of healthcare measures to
combat the virus. Although changes in the management over time led to
some delays, most patients were able to safely continue their treatment
even during the most complicated moments of the
pandemic.14,17,18,19,21
Future studies will be necessary to know the true impact of SARS-CoV-2
on the oncological disease of these patients.
Conclusion In conclusion, based on our data we may infer that the impact of
SARS-CoV-2 in pediatric patients was low in terms of incidence and
mortality exclusively attributed to SARS-CoV-2. The clinical course of
COVID-19 was mild in the majority of cases.
The PHOU, which adapted to the epidemiological situation in each
jurisdiction, continued to care for their patients. In all cases,
changes in the hospital care model were reported.
The pediatric oncology units, adapted to the epidemiological reality of
each jurisdiction, continued to assist their patients. In all cases,
modifications in care attention model at the hospital were reported.
Based on the experience gained, which demonstrated the favorable
evolution and the absence of severe complications in most cases of
SARS-Cov2 in pediatric cancer patients and the increased risk associated
with inadequate oncological management, the interruption of the
treatments was limited to the small number of critically ill patients.
As lessons learned, we should include better preparation of health
services to deal with infections, improved communication between centers
and networking, as well as the use of telemedicine as an element of
training that we should incorporate and continue to strengthen beyond
the end of the pandemic.
Finally, it would be important to highlight the impact on the physical
and psychological health of healthcare personnel, as well as the deaths
caused by SARS-CoV-2. Social distancing, hand hygiene, greater awareness
of infections, and the mandatory use of masks, which lead to a decrease
in infections, were reflected in a decrease of non-covid-related
infectious-contagious complications.
Based on the ROHA data, we may conclude that in pediatric oncology
patients, contrary to what was initially expected, morbidity and
mortality were not increased.