Results:
From 795 pediatric oncologists, medical directors and residents/fellows
contacted, the response rate among all four surveys ranged between
43-57%. A total of 453 of 795 pediatric onco-hematologists from 20
countries responded to the first survey. The participation for
subsequent surveys remained above 85% among the original respondents:
408 participants in June 2020 (90%), 386 in October 2020 (85.2%) and
389 in April 2021 (85.9%). (Supplementary data Table S1). In all four
surveys, respondents were pediatric oncologist (50-59%), medical
directors (31%) and residents/fellows (10%). Participants were
affiliated to public hospitals (58-63%), public-private (22-24%) or
private (15-17%). The most frequent facility type was children’s
hospitals (41%), followed by general hospital (35%) and cancer centers
(23%).
The first three surveys took place during the beginning, peak and
resolution of the first wave in most participating countries, except for
Uruguay, whose first wave started late in April 2021 (Figure 2 and 3).
During those first three surveys, on average, respondents reported
partial or complete suspension of outpatient procedures (54.2%),
decreases in surgical services (43.6%), radiation therapy sessions
(28.4%), SCT (69.3%) and off therapy surveillance consultations
(81.2%) (Table 1). Even though more than 95% of the participants
surveyed reported that new and active patients received oncologic
treatment during all four surveys, they also reported disruptions in
treatment availability that conditioned the type of treatment they
offered (Figure 1, 2 and 3).
Univariate logistic regression analysis was performed on each survey.
Factors including incidence rate of more than 100 cases per 100,000,
case fatality rate above 2% and HCE less than 7% were significantly
associated with suspensions of some or all of the following services:
outpatient procedures, oncologic surgeries, patient surveillance,
radiotherapy sessions and SCT. In contrast, suspension of treatment of
new and active ongoing patients was not, as physicians continue treating
patients with the treatments modalities that were available.
Multivariable logistic regression analysis showed that when COVID-19
cases were rising at the beginning of the first wave (June 2020), LATAM
countries with an HCE below 7% were more likely to report a decrease in
outpatient procedures (OR:1.84, 95%CI: 1.19;2.8) and surgeries (OR:3,
95%CI: 1.9;4.6), controlling for other indicators of COVID-19 burden.
In addition, suspension of radiation therapy sessions also increased in
those countries with HCE less than 7% (OR:6, 95%CI: 3.5;10.44).
Surveillance consultations were suspended in countries with a case
fatality rate above 2% (OR:3, 95%CI:1.4;6.2); and SCT were suspended
in countries where COVID-19 incidence rate was above 100 cases per
100,000 (OR: 3.48, 95%CI: 1.6;7.45) (Supplementary data Table S4). At
the end of the first wave, in October 2020, the association between HCE
and the suspension of outpatient procedures, surgeries, radiotherapy
sessions and SCT suspensions remained, even as the first wave resolved
and indicators of national burden of COVID-19 improved in most countries
(Supplementary data Table S5).
In April 2021 (beginning of the second wave), with cases of COVID-19
rising exponentially again in most countries, most participants reported
an improvement in pediatric cancer services availability. Only 36% of
respondents reported suspension of outpatient procedures (down from 50%
in June 2020), 30.6% reported suspensions in surgeries (down from 41%
in June 2020), 16% suspension of radiotherapy sessions (down from
25.1% in June 2020), 37.5% suspension of SCT (down from 68.1% in June
2020); and 48.1% reported suspension of surveillance consultations
(down from 80.7% in June 2020) (Table 1). In April 2021, only countries
with HCE below 7% continued to have an increase in radiotherapy
sessions suspension (OR:3.16, 95%CI:1.7;5.89) and in SCT suspensions
(OR:7.16 – 95%CI:3.17;16.15), while other indicators of national
COVID-19 burden did not show any association (Supplementary data Table
S6).
At the beginning of the pandemic, 35.6% of participants reported
chemotherapy regimen modifications due to drug shortages and 45.2% a
significant decrease in access to blood products. Deeper into the
pandemic, (June-October 2020), chemotherapy availability improved as
only 15% and 18% of participants reported chemotherapy shortages.
However, an average of 55% still reported decrease in access to blood
products during the last 3 surveys (Supplementary data Table S7).
As shown in Figure 4, participants reported that since the beginning of
the pandemic there were frequent delays in diagnosis (33%), frequent
treatment abandonment (17.2%) and an increase in family out-of-pocket
expenses (42.2%).
Responses about access to SCT and radiation therapy varied within
countries and between surveys. During all four surveys, on average,
48.5% of participants reported not having access to SCT and 15.4% of
participant reported not having access to radiation therapy.
Notably, during all four surveys, from 60% to 82% of respondents
reported some percentage of hospital staff reduction due to COVID-19
infection or quarantine, but only maximum of 3.75% reported more than a
50% staff reduction (in April 2020). In addition, a maximum of 1.5% of
respondents reported more than a 50% displacement of pediatric
oncologist to work in other sectors of the hospital due to COVID-19 (in
June 2020) (Table1).
On average, 55% of participants had access to some form of telemedicine
during the first year of the pandemic (including institutional
telemedicine platforms and non-professional communication channels such
as WhatsApp, Facebook or Zoom). In April 2021, more than 80% of
participants reported that they would like to have an institutional
telemedicine platform to follow their patients, as more than half of
them (50.4%) had only access to non-professional communication
channels.
By April 2021, 99 (25%) participants reported having contracted
COVID-19, 298 (76%) reported being immunized with two doses of a
SARS-CoV2 vaccine, and 64 (16.4%) with only one dose. Only 5
participants (1.5%) refused to be vaccinated (Supplementary data Table
S9)