key: cord-0829408-sy74d24i authors: Seth, Rachna; Das, Gargi; Kaur, Kanwaljeet; Mohanaraj, R.; Siri, Prasanth; Wajid, M. Abdul; Mandal, Piali; Sahoo, Debasish; Thomas, Tincy; Raina, Meenakshi; Gupta, Aditya K.; Meena, Jagdish P. title: Delivering pediatric oncology services during a COVID‐19 pandemic in India date: 2020-06-26 journal: Pediatr Blood Cancer DOI: 10.1002/pbc.28519 sha: b9acf01a8310a2daeb6fb48e79fb8fbeb687969c doc_id: 829408 cord_uid: sy74d24i nan To the Editor: 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 treatment. 1, 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 hosts. [3] [4] [5] [6] [7] [8] There is shortage of personal protective equipment (PPE) for health personnel, restricted inpatient and intensive care facilities, and limited blood bank supplies and diagnostic services. 4 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 neutropenia. 3, 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 the pandemic was imparted to patients by telephone and during day care visits. Patients with suspected COVID-19 were screened. Testing/quarantine/admission was advised on a case-by-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evaluation of patients with febrile neutropenia was modified: throat examination and aerosol generating procedures were withdrawn.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 The hospital had temporarily withdrawn outpatient and specialty clinic services, hence new patients were not registered.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. Those requiring inpatient admissions for intensive chemotherapy adhered to a strict appointment system. The lockdown: By the third week of COVID-19 pandemic, a nationwide lockdown had been declared. We set a system of triage for our patients that helped the oncology team to make 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: Triage 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 needed modification, as these therapeutic modalities were temporarily suspended due to COVID-19 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) . India and has been designated a COVID-19 center. 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 telehealth: Patients were contacted and helped by telephone, helplines, and emails and using a support group called "Sambhav." More than 170 exchanges were done. 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 scarce. 9 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-19 positive in addition had features of meningoencephalitis. A balance needs to be created keeping in mind risks associated with COVID-19 and the timely management of a child with cancer. 12 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 3 years and facilitating delivery of all pending chemotherapy that was postponed during the initial phases of the pandemic. We acknowledge the support provided to all the children with cancer by AIIMS (the entire medical staff and administration who facilitated care of our affected children) and CANKIDS-KIDSCAN (our NGO partner). This is to certify that there are no ethical issues related to this paper and no human subject data are involved. Therefore, no patient consent was required either. 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