Oncology care in a lower middle-income country during the COVID-19 pandemic.

The 2019 novel coronavirus disease (COVID‐19) has affected all aspects of life globally and care of children with malignancies is no exception. We are part of a large tertiary care 2000‐bed university hospital in North India. Approximately 450 new malignancies are diagnosed annually, translating to 10 patients per week. About 200 children attend the clinics every week. Additionally, 15‐20 walk‐in patients are evaluated daily in the outpatient clinic. Patients travel from distances as far as 500 km to reach our center. Merely 20% live within 50 km of the hospital, and approximately 35% reside at a distance exceeding 200 km. Two‐thirds of the patients hail from urban areas and one‐third live in rural areas. The majority of families stay in a patient hostel in the hospital premises, and a few rent a flat in the city for the 4‐ to 9‐month duration of intensive phase of therapy. The government of India mandated a lockdown on March 24, 2020 in response to the coronavirus pandemic and the outpatient services of the hospital were closed. Borders with the neighboring states were sealed and vehicular movement curtailed with barring of public transport and suspension of all interstate and intercity travel. Citizens were advised to maintain social distancing. Our unit was faced with the formidable challenge of ensuring the well‐being of children under our care from a wide geographical spread with minimal access to pediatric oncology services in their home towns. How did we manage our patients?

Our clinics continued with approximately one‐third of patients reporting for their appointments. Only patients who reside in the city and those staying temporarily in the city during the intensive phase of therapy could attend. Patients from out of city could attend hospital, as per lockdown rules, provided they had private transport (a bare few).

We contacted our pediatrician colleagues in the neighboring cities and states. Nearly half of the pediatricians were trained from our institute and had managed febrile neutropenia and parenteral chemotherapy as well as given intrathecal methotrexate during their residency. They were requested to be part of a group to help our patients in the trying times. A “WhatsApp” group of the doctors in the unit and 35 pediatricians in the surrounding areas (up to 500 km) was made. The application was utilized for disseminating information as well as assisting in everyday patient management issues.

A telecommunication network was established with the patients. A weekly rotation schedule of registrars was made for telephone duty, 24/7. The outpatient nursing staff shared the mobile number with patients when they called in. Patients would call for any problem, emergency, or when the clinic appointment was due. The patients communicated their blood counts to the registrar by scan or telephone. Patients in the maintenance phase of acute lymphoblastic leukemia (ALL) or lymphoma therapy were advised drug doses by telephone. Patients with solid tumors due for the next cycle of chemotherapy were instructed to visit the nearest pediatrician who was a member of the WhatsApp group. Chemotherapy was administered locally by the pediatrician with the assistance of telephone instructions by our registrar. Febrile neutropenia was handled similarly. Initially, intrathecal therapy was deferred. However, as the lockdown was extended, intrathecal methotrexate was administered at a larger hospital/medical school in the vicinity of the patient.

Our leukemia research nurse made another WhatsApp group of parents of patients with leukemia on ongoing chemotherapy (approximately 200) to enable regular instructions to the families. She assisted in optimal communication with the families.

A social worker provided by a nongovernment organization for the care of children with retinoblastoma coordinated by telephone with doctors at local hospitals for administration of the scheduled 3‐weekly chemotherapy.

The availability of drugs (6‐mercaptopurine and methotrexate) became a concern as the small‐town pharmacies did not store these medications. Our pediatrician colleagues came to the rescue and requested the local pharmacies to procure the medications for the patients. Patients living in the same town assisted each other by sharing the drugs. A few families were successful in ordering the medications online after an updated prescription was sent through WhatsApp.

As we write, we have just completed 6 weeks of the total lockdown and are now in partial lockdown. We have managed to look after the children on therapy. No apparent adverse event has been reported from patients who are unable to reach the hospital and being cared for locally or by telephone. However, we have registered only 34 new patients in the 6 weeks of the lockdown as compared to 58 in the 6 weeks preceding the lockdown, though oncology is included under essential services. The distribution of solid tumors and hematological malignancies is illustrated in Figure 1. The median symptom‐diagnosis interval for children with ALL was 30 days (interquartile range [IQR]: 10‐60; n = 23) in the prelockdown period as compared to 22.5 days (IQR: 11‐52.5; n = 14) in the lockdown period (P = .37). Several patients (especially with solid tumors) are unable to reach us, and the morbidity is expected to increase. In the battle with COVID‐19, other battles are likely to be lost, especially in countries with fragile resources and weak health care systems.

FIGURE 1

Pediatric oncology patients registered in the 6 weeks prior to and during the lockdown period

CONFLICT OF INTEREST

The authors declare that there is no conflict of interest.