Childhood Cancer and COVID -19 disease

Childhood Cancer and COVID -19 disease


Children with cancer and their families have had to face numerous challenges during the COVID-19 pandemic. One of the important hurdles to care includes, how families access care in the presence of serious lockdowns and curfews. At the same time it is critical to be aware that as per International recommendations, children suspected of having cancer should be investigated without delay. It has also been shown that treatment interruptions and delays are anticipated to affect patient outcomes as childhood cancer is otherwise a largely curable disease. Given this scenario we address below certain frequently asked questions related to childhood cancer and COVID-19.

COVID-19 is often more severe in those with underlying lung or heart conditions or those with reduced immunity (immune-compromised) and older persons > 60 years of age.

While children are generally thought to be at less risk of severe SARS-CoV-2 infection than adults, comprehensive population-based evidence for the risk in children with cancer is unavailable.

Children with cancer are frequently immune-compromised due to the disease and its treatment and visit the hospital frequently to receive their anti-cancer therapy. This would appear to make them more vulnerable and exposed to infection with corona virus. A recent publication from the UK Paediatric Coronavirus Cancer Monitoring Project reveals that children with cancer with SARS-CoV-2 infection do not appear at increased risk of severe infection compared to the general paediatric population. This is reassuring and supports the policy of continuing to provide routine cancer therapy to children during the pandemic.

The first thing is to contact the treating pediatric cancer doctor, who will asses whether the symptoms are mild and home care is possible or the child needs hospitalization. Even though most children with COVID-19 have asymptomatic or mild illness, severe outcomes, including deaths, have been reported in children. Therefore one should take this condition seriously and carefully follow the doctor’s advice.

There are two important factors, which help decide whether cancer treatment can be continued. Firstly, is the COVID-19 infection asymptomatic (no symptoms), mild, moderate or severe. Secondly, is the planned treatment intensive (eg. injectable chemotherapy) or mild and non-immunosuppressive (oral tablets). Based on these observations the treating cancer doctor will follow the hospital infectious disease guidelines and advise the family. The decision has to be individualized and balance needs to be made between risk of delay (in curable cancers) and risk of serious COVID-19 illness.

There is not enough data or experience to know if the vaccine is effective and safe in immuno-compromised individuals. Moreover the trial data is not yet available for safety in children less than 16-18 years of age. It is hoped that a vaccine for children will be available by the end of this year.

They should continue to follow social distancing, use of frequent hand washing/ hand sanitizer and masks (for children older than 2 years).

Covid-19 Vaccine in Children

With a population of 1.3 billion, India has one of the largest numbers of children in the world.  Nearly one quarter of our population is in the age group 0-14 years and they account about 320 million children in this age group.

In India, 17% of all deaths in children <5 years old are due to pneumonia. Most studies have implicated RSV as the most common and consistent virus associated with LRTI in Indian children. Other viruses that have been implicated for respiratory viral infections in children are Influenza, parainfluenza, rhinovirus, adenovirus, enterovirus, EBV, human corona virus (SARS-CoV-2) .

In the past, it was rare to have children with corona virus induced  pneumonia  as  most viral pneumonias were treated with supportive care measures, without etiological agent being tested. However in the last year, with onset of pandemic, there has been a rise in  cases of SARS-CoV-2, which appears to have affected adults more than the pediatric population.

Children of all ages are at risk for SARS-CoV-2 infection.The true incidence of SARS-CoV-2 infection in children is not known because most of the testing has been prioritised for adults and those with severe illness. Some studies show that children and adolescents tend to have milder disease compared to adults.

The age distribution for COVID infection in India (ICMR) shows that children are less affected than adults (Figure 1). However,  at-least 50 per cent of the children surveyed during the fifth round of serological surveillance in Delhi were found to have antibodies against Covid-19, indicating that children do have equal exposure and an adequate number of antibodies levels when compared to adults.

Most patients, including children may be asymptomatic carriers, and detected to be COVID positive on mere contact screening.

The most commonly reported clinical manifestation present with fever only, respiratory symptoms only (cough and coryza), or combined (fever and respiratory symptoms).

Other manifestations reported in current studies are gastrointestinal symptoms like diarrhea and vomiting, which is more common in children than adults.

Rarely, children may present with manifestations of hyper inflammatory states and/or Kawasaki-like disease and may a diagnostic challenge, thus high index of clinical suspicion is required.

As per WHO (April 2021): There is not yet enough evidence on the use of vaccines against COVID-19 in children to make recommendations for children to be vaccinated against COVID-19.In light of the safety and immunogenicity results from recent adult COVID-19 vaccine clinical trials, children should have the opportunity to be included in clinical trials in parallel to ongoing adult phase 3 clinical trials in a manner that is careful, methodical and transparent. There is already data from certain vaccines that the vaccine is safe in the 12-18 year ages.

Children could benefit both directly and indirectly from vaccination.

Children are also susceptible to downstream effects of COVID-19, including social isolation and interruption in education. Developing a paediatric COVID-19 vaccine could prevent disease, mitigate downstream effects and enable children to re-engage in their world. It will help alleviate the concerns of parents and teachers alike regarding the spread of infection within schools. It is more preferable than mass testing and mitigation measures in the longer term. Moreover, if we really want to get back to normalcy, we really need to achieve herd immunity across all the groups including children.

Three vaccines have received emergency use authorization for adults, and one can also be given to teens age 12 and older.  C​linical trials are now underway in children as young as six months old.

Various vaccine manufacturing companies (India and western world) plan eventually to enroll children under five who might still be due to receive boosters of polio vaccines and jabs against measles, mumps and rubella, as well as other immunizations, but children will need to be up to date on their vaccination schedules to participate. Studies of how a COVID-19 vaccine should best be integrated into a child’s immunization schedule will need to come later, once a safe and effective vaccine is found.

The vaccine has side effects profile similar to most other flu vaccines. The most common side effects following COVID-19 vaccines are fatigue, a fever, headaches, body aches, chills, nausea, diarrhea, and pain at the site of injection, according to the World Health Organization.

Research shows the vaccines are remarkably effective and safe. The American Academy of Pediatrics (AAP) urges children and adults to get the COVID-19 vaccine as soon as it is available to them. This is especially important with a rise in cases caused by variant strains of the virus, which seem to be more contagious

Life threatening events are very rarely reported, and so far none of the trials have reported any mortality due to COVID vaccine in pediatric trials.

It is quite likely that vaccines with demonstrated safety and transmission efficacy data in children will not be available anytime soon, so what can we do to keep our children safe?
  1. Awareness of disease, its symptoms and prompt medical consultation if symptoms of COVID occur, leads to early intervention and low morbidity and mortality.
  2. Routine measures of wearing mask, social distancing and hand washing remain mainstay of preventive measures.
  3. Ensure complete vaccination of all adults in the family and at school.
  4. Let’s make sure we continue vaccinating healthy and vulnerable children according to Nationally recommended schedules to protect them and avoid other epidemics in the future-with vaccine-preventable diseases like measles, mumps, hepatitis etc.
  5. Due to community mitigation measures and school closures, transmission of SARS-CoV-2 to and among children may have been reduced.
  6. Home isolation for those affected from those who are not, is the key for management of those with asymptomatic disease or with mild symptoms.
Age distribution of COVID-19 patients in India
Figure 1: Age distribution of COVID-19 patients in India (ICMR data)

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