key: cord-0832025-qus4thh4 authors: Faura, Anna; Rives, Susana; Lassaletta, Álvaro; Sebastián, Elena; Madero, Luis; Huerta, Jorge; García‐Morín, Marina; Martínez, Antonio Pérez; Sisinni, Luisa; Astigarraga, Itziar; Velasco, Pablo; Gros, Luis; Moreno, Lucas; Carboné, Ana; Rodríguez‐Vigil, Carmen; Riesco, Susana; Mendoza, María del Carmen; Macias, Elena García; Trabazo, Maria; Torrent, Montse; Badell, Isabel; Fuster, José Luis; Dominguez‐Pinilla, Nerea; Juan Ribelles, Antonio; Pérez‐Alonso, Vanesa; Fernández Sanmartín, Manuel; Baragaño, Marta; Gorostegui, Maite; Perez‐Jaume, Sara; Fernández‐Teijeiro, Ana; Morales La Madrid, Andrés; Dapena, José Luis title: Initial report on Spanish pediatric oncologic, hematologic, and post stem cell transplantation patients during SARS‐CoV‐2 pandemic date: 2020-07-16 journal: Pediatr Blood Cancer DOI: 10.1002/pbc.28557 sha: 76490e40e71a324ae5fa4c0d86c69627a0aecc41 doc_id: 832025 cord_uid: qus4thh4 nan To the Editor: In December 2019, the SARS-CoV-2 outbreak started in China and rapidly progressed into a pandemic. 1 Spain was one of the first countries in Europe reporting increasing numbers of both confirmed cases and deaths. As of April 24, 2020 , 202 990 cases had tested positive and 22 524 deaths were reported due to COVID-19. The clinical presentation of COVID-19 may range from asymptomatic cases to severe forms. 2 In contrast, pediatric patients rarely develop critical illness. 3, 4 In Spain, cases under the age of 19 represented only 0.9%. Furthermore, only 2.8% of these cases required pediatric intensive care unit (PICU) admission with a mortality rate of 0.3%. 5 Children diagnosed with cancer under immunosuppression have a higher risk for opportunistic infections. To this date, reports describing the clinical and epidemiological characteristics of this collective with COVID-19 are scarce. A survey in Europe of SARS-CoV-2 infections in pediatric patients with anticancer treatment identified only nine patients with mild infections. 6 A reasonable fear exists that SARS-CoV-2, like other coronaviruses, 7 could cause more severe infections in immunocompromised children, as has been observed in adults with cancer. 8, 9 We surveyed all Spanish institutions treating pediatric cases (1 month-18 years of age), with solid and hematologic malignancies, nonmalignant hematologic conditions receiving immunosuppressive treatment or bone marrow failure syndrome and after allogeneic-stem cell transplantation (allo-SCT), or CAR T-cell therapy who were diagnosed with COVID-19 from January 31 to April 24, 2020. Information was received from 41 hospitals (representing 97.6% of pediatric cancer patients in Spain). 10 All data related to RT-PCR confirmed SARS-CoV-2 infection of 47 cases are summarized in Table 1 . We Respiratory viral infections in immunosuppressed patients usually present a more severe clinical evolution and higher mortality rate, 11 including HCoV cases. 12 In our country, 1300 children and adolescents are diagnosed with cancer every year. 10 Including only cancer diagnosis, we observed a COVID-19 infection rate of approximately 2.5% among this patient population. Most of the reported patients (68%) were from the states of Madrid and Catalonia, the two most affected areas in Spain. 13 Fifteen of the patients included in the present study were previously reported recently by de Rojas et al. 14 Initial experiences from Italy (Lombardy), 15 China (Wuhan), 16, 17 and Europe suggest a low number and severity of COVID-19 cases in this patient population, 6 contrary to France, where a higher incidence of critical patients was observed. 18 Although in our case series, majority of patients were asymptomatic (25%) or had a mild course (51.1%), the percentage of critical patients (23.4%) was higher in comparison to the Chinese cohort (3-10.6%). 3 Moreover, the PICU admission rate was 8.5% in our study, higher to that observed in the general pediatric population. 19 Of note, all four critical patients were either receiving intensive chemotherapy or severely immunosuppressed post allo-SCT. Noteworthy, low total lymphocyte counts and high ferritin levels at onset of symptoms were observed in cases admitted to the PICU. One of the deaths in the post allo-SCT subgroup was probably related to an uncontrolled systemic inflammatory response that closely resembled a macrophage activation syndrome, as has been described. 20 Regarding therapy, hydroxychloroquine and antivirals were used mainly in early stages. 22 In those with a more aggressive disease and/or hyperinflammation component, immunomodulatory treatments were administered. 23 Specific treatment recommendations should be available soon with ongoing basic and clinical trials progress. 24 According to our data, most patients will have a good outcome. However, patients receiving intensive chemotherapy, severely immunosuppressed, or GVHD may be at a higher risk of morbidity and even mortality. During this pandemic, concern exists whether children with cancer may present late for diagnosis or not receive appropriate oncological treatment. 25 Limitations of this report include the small sample size retrospective data collection. However, since most of Spanish PHO units took part in this initiative, we believe our report represents an accurate infection prevalence among this population at a national level. This is one of the largest series of COVID-19 in pediatric cases with solid and hematological malignancies, benign hematologic conditions, and post allo-SCT, observing that most patients present a favorable clinical evolution. However, severe forms of infection can be seen in highly immunosuppressed patients, in those with chronic comorbidities such as GVHD, or patients receiving CAR T-cell therapy. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia COVID-19 pandemic -a focused review for clinicians Epidemiological characteristics of 2143 pediatric patients with 2019 coronavirus disease in China CDC COVID-19 Response Team. Coronavirus disease 2019 in children -United States Actualización n o 50 Flash survey on severe acute respiratory syndrome coronavirus-2 infections in paediatric patients on anticancer treatment ECIL-4): guidelines for diagnosis and treatment of human respiratory syncytial virus, parainfluenza virus, metapneumovirus, rhinovirus, and coronavirus Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China Patients with cancer appear more vulnerable to SARS-CoV-2: a multi-center study during the COVID-19 outbreak Registro Español de Tumores Infantiles Estadísticas Cáncer infantil en España cohortes. 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Estote Parati. (Be Ready The COVID-19 pandemic: a rapid global response for children with cancer from SIOP