How Covid-19 has affected child cancer care in Malaysia

The Covid-19 pandemic has impacted both the provision of healthcare services to child cancer patients, as well as the seeking of such services by these patients and their families. — 123rf.com

Every year, nearly 1,000 children in Malaysia are diagnosed with various types of cancer.

These include leukaemia, brain tumours, lymphoma and sarcoma, among others.

Some types of cancer are unique to children aged less than five years old, as they arise from embryonal tissue, e.g. hepatoblastoma, retinoblastoma and neuroblastoma.

The majority of Malaysian children with cancer are managed in the 10 public paediatric cancer centres throughout the country.

In many of these centres, multidisciplinary sub-specialised teams are available to provide the necessary support for optimal care for these children.

Generally speaking, childhood cancer is largely curable, with an overall survival rate of 65% or more across the various cancer types.

Less services and patients

Just as seen in almost every facet of life since the beginning of last year (2020), paediatric oncology services have also been affected by the impact of Covid-19.

Optimal childhood cancer care requires prompt diagnosis, referral to oncology centres, and timely and coordinated therapy, as well as supportive care.

To gain a global snapshot of the pandemic’s effect on paediatric cancer care, a survey was conducted by St Jude Children’s Research Hospital in the United States, between June and August 2020.

The survey done by Dr Dylan Graetz and colleagues, which was published in the journal Lancet Child and Adolescent Health, involved 213 institutions in 79 countries from all World Health Organization (WHO) regions.

Fifteen centres (7%) reported complete closure of childhood cancer services for up to three months, and one-third reported increased abandonment of treatment.

Other areas affected were:

• Reduced surgical care (72%)
• Reduction in available clinical staff (66%)
• Abandonment of treatment (34%)
• Interruptions to delivery of radiotherapy (28%), and
• Decrease in number of available paediatric oncology beds (19%).

Although a similar audit has not been performed in Malaysia, a decline in ward admissions has been noted in the two largest paediatric cancer centres in the country, namely Hospital Tuanku Azizah (HTA, formerly known as the Women and Children Hospital Kuala Lumpur) and Universiti Malaya Medical Centre (UMMC), both in Kuala Lumpur.

HTA paediatric oncology services head Dr Zulaiha Muda shared that in 2019, there were 2,298 ward admissions.

In contrast, 2,016 cases were admitted in 2020, a decline of 12%.

In UMMC, a similar pattern was seen.

New referrals for childhood cancer to UMMC declined from 118 (2019) to 73 (2020), while outpatient clinic attendance fell by 23% from 1,658 patients to 1,273.

The reasons for this decline remain undetermined, but travel restrictions, financial challenges, fear of catching the SARS-CoV-2 virus in hospitals, and changes in family dynamics, may be contributory factors.

Additionally, policies in response to rising Covid-19 cases and the prioritisation of these cases – as practised in UMMC – led to hospital-mandated cuts in clinic appointment slots.

Another area that has been significantly affected is blood transfusion services – a key component of childhood cancer care.

In the global survey above, 127 out of 213 centres reported blood product shortages.

According to UMMC Transfusion Medicine head Dr Christina Lee, who manages the institution’s blood bank, a steep decline in the number of volunteer blood donors was noted from the announcement of the movement control order in March 2020.

Annual blood donations fell by 27% last year, compared to 2019, and shortage of blood and its components still remains a challenge today.

Blood donations, a key component of childhood cancer treatment, have dropped significantly since the current pandemic began early last year. — AZMAN GHANI/The Star

At higher risk

Generally, most children who are infected with the SARS-CoV-2 virus have a milder disease course, compared to adults.

However, individuals with cancer and those receiving chemotherapy have a weakened immune system, and may experience severe Covid-19 symptoms.

In mid-2020, a five-month survey of British hospitals managing children with cancer reported 54 cases of Covid-19, of whom 49 (91%) had either no or mild symptoms only.

These reassuring findings are in contrast to more recent research published in the journal Lancet Oncology.

This study of 1,500 children from 131 hospitals in 45 countries found that 65% of children with cancer who developed Covid-19 were hospitalised, and nearly 20% required high-dependency or intensive care.

Of concern, 4% of these paediatric oncology patients died due to Covid-19, compared to the 0.7% death rate from Covid-19 in other children.

Thus, children with cancer are a particularly vulnerable group to the ill effects of Covid-19.

To date, 15 children with cancer who are undergoing treatment at UMMC have had proven SARS-CoV-2 infections.

The majority of cases have been mild, with none requiring mechanical ventilation.

Azra Shahmina, three, who is currently undergoing treatment for Stage 4 neuroblastoma, is one of those patients.

Her mother, schoolteacher Suhana Hirdjat, shares that they both had fever as the first symptom and were admitted to UMMC.

Suhana, who experienced loss of taste and smell, as well as generalised body aches, recovered completely after 10 days.

She believes her vaccinated status played a large part in preventing more severe symptoms.

She is thankful that Azra was relatively well throughout her infection and did not require any medical intervention, despite being immunocompromised.

Nevertheless, the Covid-19 diagnosis caused a three-week delay in Azra’s scheduled tumour resection surgery and subsequent care.

Fortunately, the little girl is a fighter and recently underwent stem cell transplantation successfully.

Protecting the children

Vaccinations against the SARS-CoV-2 virus are the light at the end of this dark pandemic tunnel.

Suhana, seen here with Azra in UMMC, believes that her fully-vaccinated status prevented her from developing more serious Covid-19. — Prof Dr HANY ARIFFIN

Large clinical trials for the various types of vaccines have demonstrated that they are safe and effective in preventing severe forms of Covid-19.

Currently, the Pfizer/BioNTech mRNA-based vaccine has been approved for children above the age of 12 years.

Vaccination for Malaysian adolescents is currently being rolled out under the National Covid-19 Immunisation Programme (PICK).

Patients with malignancies, especially those with blood cancers, should take the vaccine.

There may however, be issues with regards to its effectiveness, compared to individuals with an intact immune system.

A recent study published in the Annals of Internal Medicine by a group from Washington University School of Medicine in the US reported that 88% of immunocompromised patients responded to the mRNA-based vaccine, although their anti-coronavirus antibodies were only a third as high as normal subjects.

Thus, people taking immunosuppressive medication, including chemotherapy, should receive a third dose of the SARS-CoV-2 vaccine to strengthen their immune response and protect themselves from Covid-19.

This recommendation was also recently endorsed by the US Centers for Disease Control and Prevention (CDC).

Vaccination is the key way to protect the community from severe Covid-19.

Equally important is that it will also help shield children with cancer who are vulnerable to Covid-19, but are still unable to receive the vaccine themselves, as it will decrease the amount of virus circulating within the community.

The journey ahead

The effect of the Covid-19 pandemic has been devastating for children in many aspects, from disruption of school to reduction in family finances and social isolation.

For children with cancer, these issues are magnified by the need to battle a life-threatening disease.

Fortunately, Malaysian childhood cancer healthcare services and its providers have demonstrated resilience in responding to these challenges to ensure that children with cancer do not experience delayed diagnosis or therapy disruptions.

Both HTA and UMMC paediatric oncology centres had experienced Covid-19 outbreaks this year (2021), which led to a temporary stop to new admissions and transfer of in-patients to other hospitals outside Klang Valley.

It is hoped that Malaysia’s journey ahead is one of universal vaccination of all eligible individuals, lifestyle practices to prevent Covid-19 spread and a greater awareness of the need to shield vulnerable groups in the community.

With efficient and uninterrupted delivery of multimodal cancer therapies, as well as increased support for economically-disadvantaged families, children battling cancer in Malaysia should be able to achieve the high cure rates experienced before SARS-CoV-2 ravaged our planet.

Professor Dr Hany Ariffin is a senior consultant and head of UMMC’s Paediatric Haematology-Oncology and Bone Marrow Transplant Unit. For more information, email [e-mail]. The information provided is for educational purposes only and should not be considered as medical advice. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this article. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.