Children with cancer more likely to have severe COVID-19 illness

September 27, 2021

3 minutes reading

Source/Disclosures Published by:

Mukkada does not report any relevant financial disclosures. A study author reports the role of a data safety supervisory or advisory board at Bayer and Novartis, as well as support in institutional clinical trials at Bristol Myers Squibb and Roche.


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Children with cancer who contracted COVID-19 developed more serious infections and had a greater chance of hospitalization or death than the general pediatric population, according to research results published in The Lancet Oncology.

In addition, data from the Global Registry of COVID-19 in Childhood Cancer suggests that the severity of these children’s COVID-19 outcomes may be influenced by biological and regional economic factors.

Data derived from Mukkada S, et al. Lancet Oncol. 2021:doi:10.1016/S1470-2045(21)00454-X.

The registry, launched by St. Jude Children’s Research Hospital and the International Society of Pediatric Oncology, collected data on the impact of the pandemic on the pediatric cancer population worldwide. The effects identified in the study seemed more pronounced in low- and middle-income countries, where children with cancer and COVID-19 are six times more likely to develop a serious or critical illness compared to those in high-income countries.

Sheena MukkadAn

“The results clearly and definitively show that children with cancer do worse with COVID-19 than children without cancer,” researcher Sheena MukkadAn, MD, faculty member in the departments of global pediatrics and infectious diseases at St. Jude, said in a press release. “This global collaboration helps clinicians make evidence-based decisions about prevention and treatment, which unfortunately remain relevant as the pandemic continues.”

Mukkada spoke to Healio about the study and what needs to be done to protect children with cancer who may be particularly vulnerable to severe COVID-19 disease.

Study results

For the multinational cohort study, Mukkada and colleagues evaluated data from 131 institutions in 45 countries on laboratory-confirmed SARS-CoV-2 infections in children and adolescents younger than 19 years of age with cancer or a history of hematopoietic stem cell transplantation.

The study included 1,500 patients (median age, 8 years) between April 15, 2020 and February 1, 2021, of whom 1,319 had complete 30-day follow-up data available.

Disease severity and change in cancer treatment regimens served as the primary outcomes.

The results showed that 889 patients (67.4%) were hospitalized and 231 (17.5%) required hospitalization or transfer to a higher level of care.

In addition, 259 (19.9%) of 1,301 patients had an infection that would be categorized as severe or critical, and 50 (3.8%) of 1,319 died from COVID-19-related causes. In studies of the general pediatric population, only 1% to 6% reported serious COVID-19 infections, with mortality rates ranging from 0.01% to 0.7%, according to the press release.

“Our study was not designed to capture the ‘why’ behind the worse outcomes,” Mukkada told Healio, “but descriptively we can see that those with lower numbers and lower function of immune cells, as well as those receiving more immunosuppressive therapy. had a more serious illness.”

Of the 1,092 patients undergoing active cancer treatment, 609 (55.8%) had changes in their cancer-targeted therapy, and 44.6% were withholding chemotherapy during COVID-19 treatment.

Factors associated with greater likelihood of serious or critical illness on multivariable analysis included World Bank country’s income level (low or lower middle income, OR = 5.8; 95% CI, 3.8- 8.8, upper middle income, OR = 1.6, 95% CI, 1.2-2.2); age 15 to 18 years (OR = 1.6; 95% CI, 1.1-2.2); absolute lymphocyte count of 300 or fewer cells per mm3 (OR = 2.5; 95% CI, 1.8-3.4) or 500 or fewer cells per mm3 (OR = 1.8; 95% CI, 1.3 -2.4); and intensive treatment (OR = 1.8; 95% CI, 1.3-2.3).

Factors associated with changes in treatment included upper-middle-income country status (OR = 0.5; 95% CI, 0.3-0.7), primary diagnosis of haematological malignancies other than acute lymphoblastic leukemia or acute lymphoblastic lymphoma (OR = 0.5; 95% CI, 0.3-0.8); symptomatic COVID-19 at presentation (OR = 1.8; 95% CI, 1.3-2.4) and one or more co-morbidities (OR = 1.6; 95% CI, 1.1-2.3).

Next steps

The study was conducted before vaccinations were available for older children in some parts of the world and before the identification of certain COVID-19 variants, including the delta variant. It’s not clear whether these variables would influence the findings, Mukkada said.

“Vaccination is still not widely available in many of the sites contributing to this study,” Mukkada told Healio. “We didn’t look at transmission rates, just what happened to infected patients, so it’s not clear that those findings would change as a result of vaccination.”

The registry provides insight into the potential risks to the pediatric cancer population, especially those with socioeconomic barriers, Mukkada said.

“The majority of children with cancer do not develop serious illness as a result of COVID-19,” she said. “However, the disease can be severe in certain groups, so we need to do what we can to protect this potentially vulnerable population, including optimal infection prevention and vaccination of qualified patients and healthcare providers.”


Mukkada S, et al. Lancet Oncol. 2021: doi: 10.1016/S1470-2045(21) 00454-X.
Press release. COVID-19 in children with cancer: serious illness and disrupted treatment. Available from: COVID-19 in Children with Cancer: Severe Illness and Interfering Treatment – St. Jude Children’s Research Hospital ( Accessed August 31, 2021.


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