COVID-19 in Children With Cancer in New York City

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COVID-19 in Children With Cancer
in New York City
Data on the prevalence of severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2) infection in children, 1-4and in chil-
dren with cancer specifically have been limited. Less than 1%
of cases reported from China were in children younger than
10 years.
3The MSK Kids pediatric program at Memorial Sloan
Kettering Cancer Center (MSK) is one of the largest pediatric
cancer programs in the US. Starting in mid-March, 2020, we
instituted a screening and testing plan to mitigate risk associ-
ated with coronavirus disease 2019 (COVID-19).
Methods|On presentation for outpatient or inpatient care, pa-
tients were screened for the presence of symptoms of COVID-19
or exposure to contacts with known SARS-CoV-2 infection. We
also instituted testing for SARS-CoV-2 using a RT-PCR assay for
3 cohorts of individuals: (1) patients exposed to COVID-19
(screen positive) or with symptoms of infection (symptom posi-
tive); (2) asymptomatic patients (symptom negative) prior to
deep sedation, myelosuppressive chemotherapy, or admis-
sion to the hospital; and (3) caregivers accompanying pa-
tients for admission or multiday outpatient chemotherapy. Data
for this report were gathered a retrospective research proto-
col approved by the MSK institutional review board with waiver
of informed consent owing to the retrospective and deidenti-
fied nature of the data used. Groups were compared using a
2-tailed Fisher exact test.
Results|Between March 10 and April 12, 2020, a total of 335
tests for SARS-CoV-2 were performed on pediatric patients and
their caregivers (Table 1). Of the 178 unique pediatric patients
(107 male and 71 female) tested (mean [SD] age 11.1 [8.5] years),
20 (11.2%) had positive test results (mean [SD] age 15.9 [6.6]
years). Of patients specifically tested for positive screening or
symptoms (screen positive or symptom positive), the rate of
positivity for SARS-CoV-2 was 29.3%. By comparison, in the
120 asymptomatic patients without known exposure (screen
negative and symptom negative) the rate of SARS-CoV-2 posi-
tivity was only 2.5% (29.3%; 95% CI, 18.1%-42.7% versus 2.5%;
95% CI, 0.5%-7.1%;P< .001) (Table 1). Of the 20 patients who
tested positive for SARS-CoV-2, only 3 were female (Table 2),
a significant sex skewing when compared with pediatricpatients who tested negative (15%; 95% CI, 3%-38% vs 43%;
95% CI, 35%-51%;P= .02).
Only 1 patient with COVID-19 illness required noncritical
care hospitalization for COVID-19 symptoms. Three other pa-
tients without significant COVID-19 symptoms were admit-
ted for concomitant fever and neutropenia, cancer morbid-
ity, or planned chemotherapy. All other pediatric patients had
mild symptoms and were managed at home.
We also instituted testing of adult caregivers of patients
(Table 1). Of the 74 individuals tested, 13 caregivers (17.6%) of
10 patients tested positive for SARS-CoV-2. Notably among 68
asymptomatic and unexposed caregivers (screen negative and
symptom negative), 10 tested positive for SARS-CoV-2 (14.7%).
Simultaneous detection of virus in patient and caregiver was
found in 5 patient/caregiver dyads, whereas 5 patients were
negative for virus despite close exposure to caregivers with
Discussion|Although this report is limited by small numbers,
the data show that (1) the overall morbidity of COVID-19 in
pediatric patients with cancer is low with only 5% requiring
hospitalization for symptoms of COVID-19; (2) that the rate of
Table 1. Results of COVID-19 Testing at Memorial Sloan Kettering (MSK)
Variable No.SARS-CoV-2
positive, No. (%)
March 10-April 12, 2020
Total pediatric outpatient visits 1267
Total unique patients 505
Total pediatric patients swabs 244 25 (10.2)
Total pediatric unique patients 178 20 (11.2)
Total unique patients screen positive
or symptom positive58 17 (29.3) a
Total unique patients screen negative
and symptom negative120 3 (2.5) a
Total adult caregiver swabs 91 15 (16.5)
Total unique adult caregivers 74 13 (17.6)
Total unique caregivers screen
positive or symptom positive6 3 (50.0)
Total adult caregivers screen negative
and symptom negative68 10 (14.7)
Total patients tested at MSK, April 12, 2020 2932 608 (20.7)
Abbreviation: COVID-19, coronavirus disease 2019.
aP<.001, Fisher exact test comparing [screen positive or symptom positive] to
[screen negative and symptom negative].
Table 2. Sex Distribution in Pediatric Cohort
Variable Male FemalePvalue
All pediatric patients tested 107 71
Pediatric patients screen positive or symptom positive 34 24
Pediatric patients screen negative and symptom negative 73 47
SARS-CoV-2 positive 17 3 .02
Fisher exact test comparing
SARS-CoV-2–positive with
SARS-CoV-2–negative groups. OncologyPublished online May 13, 2020E1
© 2020 American Medical Association. All rights reserved.Downloaded From: on 09/01/2020

SARS-CoV-2 infection among asymptomatic pediatric pa-
tients is very low; (3) that unrecognized SARS-CoV-2 infec-
tion in asymptomatic caregivers is a major infection control
consideration; and (4) that consistent with the sex difference
previously seen in adults with critical disease,
5there is a male
bias in SARS-CoV-2 infections in children, suggesting a bio-
logical basis in skewed infectivity.
This report suggests that pediatric patients with cancer may
not be more vulnerable than other children
2-4 to infection or
morbidity resulting from SARS-CoV-2. Although the asymp-
tomatic SARS-CoV carrier rate in children in the general popu-
lation is not known, our testing of 120 asymptomatic pediat-
ric patients with cancer revealed only a 2.5% rate of SARS-
CoV-2 positivity. By comparison, we observed a 14.7% rate of
SARS-CoV-2 positivity in their asymptomatic caregivers (2.5%;
95% CI, 0.5%-7.1% vs 14.7%; 95% CI, 7.3%-25.4%;P= .002),
which closely matches the asymptomatic carrier rate in preg-
nant women in New York (13.5%).
6Together, our results do not
support the conjecture that children are a reservoir of unrec-
ognized SARS-CoV-2 infection.
Farid Boulad, MD
Mini Kamboj, MD
Nancy Bouvier, BA
Audrey Mauguen, PhD
Andrew L. Kung, MD, PhD
Author Affiliations:Department of Pediatrics, Memorial Sloan Kettering Cancer
Center, New York, New York (Boulad, Bouvier, Kung); Department of Medicine,
Memorial Sloan Kettering Cancer Center, New York, New York (Kamboj);
Department of Epidemiology and Biostatistics, Memorial Sloan Kettering
Cancer Center, New York, New York (Mauguen).
Corresponding Author:Andrew L. Kung, MD, PhD, Department of Pediatrics,
Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065
Accepted for Publication:April 27, 2020.Published Online:May 13, 2020. doi:10.1001/jamaoncol.2020.2028
Author Contributions:Drs Boulad and Kung had full access to all of the data in
the study and take responsibility for the integrity of the data and the accuracy
of the data analysis.
Concept and design:Boulad, Kung.
Acquisition, analysis, or interpretation of data:All authors.
Drafting of the manuscript:Boulad, Kung.
Critical revision of the manuscript for important intellectual content:All authors.
Statistical analysis:Mauguen, Kung.
Administrative, technical, or material support:Bouvier, Kung.
Supervision:Kamboj, Kung.
Funding/Support:These studies were supported by internal institutional
funding from the Memorial Sloan Kettering Cancer Center.
Role of the Funder/Sponsor:The Memorial Sloan Kettering Cancer Center
had no role in the design and conduct of the study; collection, management,
analysis, and interpretation of the data; preparation, review, or approval of the
manuscript; and decision to submit the manuscript for publication.
Additional Contributions:We thank the healthcare providers who conducted
the SARS-CoV-2 testing and responded to COVID-19 illness described in this
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NEJMc2009316 Letters
E2 JAMA OncologyPublished online May 13, 2020(Reprinted)
© 2020 American Medical Association. All rights reserved.Downloaded From: on 09/01/2020