Article Text

Original research
Impact of the COVID-19 pandemic on patients with paediatric cancer in low-income, middle-income and high-income countries: a multicentre, international, observational cohort study
  1. Global Health Research Group on Children’s Non-Communicable Diseases Collaborative
    1. Correspondence to Global Health Research Group on Children’s Non-Communicable Diseases Collaborative; info{at}globalchildrenncds.com

    Abstract

    Objectives Paediatric cancer is a leading cause of death for children. Children in low-income and middle-income countries (LMICs) were four times more likely to die than children in high-income countries (HICs). This study aimed to test the hypothesis that the COVID-19 pandemic had affected the delivery of healthcare services worldwide, and exacerbated the disparity in paediatric cancer outcomes between LMICs and HICs.

    Design A multicentre, international, collaborative cohort study.

    Setting 91 hospitals and cancer centres in 39 countries providing cancer treatment to paediatric patients between March and December 2020.

    Participants Patients were included if they were under the age of 18 years, and newly diagnosed with or undergoing active cancer treatment for Acute lymphoblastic leukaemia, non-Hodgkin’s lymphoma, Hodgkin lymphoma, Wilms’ tumour, sarcoma, retinoblastoma, gliomas, medulloblastomas or neuroblastomas, in keeping with the WHO Global Initiative for Childhood Cancer.

    Main outcome measure All-cause mortality at 30 days and 90 days.

    Results 1660 patients were recruited. 219 children had changes to their treatment due to the pandemic. Patients in LMICs were primarily affected (n=182/219, 83.1%). Relative to patients with paediatric cancer in HICs, patients with paediatric cancer in LMICs had 12.1 (95% CI 2.93 to 50.3) and 7.9 (95% CI 3.2 to 19.7) times the odds of death at 30 days and 90 days, respectively, after presentation during the COVID-19 pandemic (p<0.001). After adjusting for confounders, patients with paediatric cancer in LMICs had 15.6 (95% CI 3.7 to 65.8) times the odds of death at 30 days (p<0.001).

    Conclusions The COVID-19 pandemic has affected paediatric oncology service provision. It has disproportionately affected patients in LMICs, highlighting and compounding existing disparities in healthcare systems globally that need addressing urgently. However, many patients with paediatric cancer continued to receive their normal standard of care. This speaks to the adaptability and resilience of healthcare systems and healthcare workers globally.

    • paediatric oncology
    • paediatrics
    • public health

    Data availability statement

    Data are available on reasonable request. Deidentified date will be shared on request.

    http://creativecommons.org/licenses/by-nc/4.0/

    This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

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    Strengths and limitations of this study

    • This is the first large-series, global, multicentre, international cohort study to explore the effect of the COVID-19 pandemic on paediatric oncology care, which includes data from 1660 patients in 39 countries.

    • The collaborative approach for this study allowed a large series of high-quality data to be collected in a timely manner without overburdening centres, with 91 centres being involved in this study.

    • A single study database was used, which allowed for data-analysis to occur to ascertain the short-term outcome for paediatric oncology patients while the study continued to collect follow-up data.

    • This is an interim-report, and many centres involved in the wider study—including all centres in India—have not been able to gain ethical approval to share their data for this report; although approvals will be in place to share data after 12 month follow-up data has been collected in December 2021.

    • This study has limited its focus to nine of the the most common paediatric cancers globally as identified by the WHO, and hence does not capture the effects of the pandemic on rarer cancers.

    Introduction

    Approximately 200 000–400 000 children are newly diagnosed with cancer annually.1–4 Cancers in the paediatric population differ greatly from those in adults, particularly in the diagnoses seen and the availability of suitable healthcare.5 Fewer than 20% of all paediatric cancers are found in high-income countries (HICs), where multimodal care is more accessible.2 Despite being ostensibly highly curable diseases, delays in diagnosis and paucity of care for many patients with paediatric cancer has resulted in paediatric cancer being the second leading cause of non-communicable disease deaths for children worldwide.1–4 More than 90% of these deaths occur in low-income and middle-income countries (LMICs).4 The inordinately high number of person-years of life lost make paediatric cancer care a global health priority.2

    The COVID-19 pandemic may have exacerbated the imbalance of paediatric cancer outcomes between LMICs and HICs. There were reports globally on the cancellation of elective health services—including paediatric surgery and radiotherapy, essential outpatient services, shortage of essential medications, delays in diagnosis, hospital inpatient services being overwhelmed and healthcare staffing issues.6–8 During the initial phase of the pandemic, the reorganisation of paediatric cancer services worldwide was partly driven by assumptions that patients with paediatric cancer were particularly vulnerable to COVID-19. This assumption has since been refuted9 with the largest study to date on this topic identifying only 259 children with cancer suffering from severe COVID-19 infection worldwide.10 The international paediatric cancer community swiftly adapted their guidance to emphasise the importance of continuing care for patients with paediatric cancer.11 Despite this, three international cross-sectional studies conducted by different research teams at different timepoints reported that the majority of clinicians surveyed believed that their paediatric cancer centre had reduced their usual level of care either as a precaution, or due to a lack of resources or accessibility.8 12 13 These reported delays or alterations to treatment—if accurate—could prove extremely detrimental to patients with paediatric cancer in both the short term and the long term.8 14

    As all international analyses reported thus far have been cross-sectional studies focused on the perceptions of clinicians,8 12 13 there remains a need to corroborate these findings and assess the impact of the pandemic on the outcomes of patients with paediatric cancer. Therefore, we conducted an international, multicentre, cohort study with the primary aim to ascertain the short-term outcome across 16 HICs and 25 LMICs during the COVID-19 pandemic by determining 30-day and 90-day all-cause mortality rates for paediatric oncology patients who underwent treatment. We also examined the factors that influenced these outcomes including tumour specific data, patient-specific demographics, and changes to health system frameworks. Secondary objectives of this study are to evaluate (1) the changes to paediatric cancer management during the COVID-19 pandemic, (2) the factors that influenced these changes from a health systems framework (eg, infrastructure, workforce, redeployment of staff, access to services) and (3) the number of patients with paediatric cancer who were placed under palliative care or who sought abandonment of treatment during the pandemic. The WHO Global Initiative for Childhood Cancer (GICC) has primarily used six common cancers as a benchmark for assessing global paediatric cancer care: acute lymphoblastic leukaemia (ALL), Burkitt lymphoma, Hodgkin lymphoma, retinoblastoma, Wilms’ tumour and low-grade glioma.15 Therefore, this study focuses on the GICC identified cancer benchmarks and four other paediatric cancer manifestations that had been identified to be common in both LMICs and HICs: sarcoma, high-grade glioma, medulloblastoma and neuroblastomas.

    Methods

    Study design

    This is a multicentre, international, mixed (retrospective and prospective), collaborative (online supplemental appendix S1) cohort study at 91 hospitals in 39 countries (online supplemental appendix S2). Only routine, anonymised data was collected, and no clinical care pathways were changed for the study as per the study protocol.16 Participating collaborators gained local approvals in accordance with their institutional ethical regulations (online supplemental appendices S3–S5). Reporting has been conducted in line with the Strengthening the Reporting of Observational Studies in Epidemiology statement for observational studies17 (online supplemental appendix S6).

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    Study setting

    Hospitals or cancer centres in all continents providing cancer treatment to paediatric patients were eligible to participate in this study.16 The World Bank classification of the fiscal year of 2021 was utilised to categorise centres as HIC or LMIC.18 Local collaborators at all study sites were responsible for identifying eligible patients for inclusion and collecting data using the Research Electronic Data Capture (REDCap) web application.

    Participants

    Patients at participating centres were included if they were under the age of 18 years and newly diagnosed with or undergoing active treatment for an eligible cancer between 12 March 2020—the date that the WHO declared the start of the COVID-19 pandemic—and 12 December 2020. Eligible cancers were: ALL, non-Hodgkin’s lymphoma, Hodgkin lymphoma, Wilms’ tumour, sarcoma (osteosarcoma, Ewing sarcoma and rhabdomyosarcoma), retinoblastoma, glioma, medulloblastoma and neuroblastoma in keeping with the WHO GICC. Site investigators were provided with a range of written materials setting out possible strategies to capture consecutive eligible patients. In addition, investigators were invited to join social media groups and teleconferences for the purpose of troubleshooting site-specific recruitment issues and shared learning. The importance of working across paediatric oncological specialties was emphasised throughout to minimise bias that could be introduced by certain patients not being included. Sample size was calculated as per the protocol.16

    Outcome variables

    The primary outcomes were all-cause mortality at 30 days and 90 days from initial anti-cancer treatment as of 12th March 2020. The key secondary outcomes were any alterations to paediatric cancer treatment decisions during the COVID-19 pandemic and changes to health system frameworks which led to these alterations, as reported by local collaborators. Additional secondary outcomes were any complications within 30 days of first anti-cancer treatment as of 12th March 2020 and the number of patients who abandoned treatment.

    Other variables

    Baseline patient variables included age, weight at admission, patient sex and American Society of Anesthesiologists (ASA) grade at the time of presentation. Baseline tumour variables included tumour type, staging and diagnosis date. Definitions for tumour types were provided for reference.16 Treatment variables included initial multidisciplinary team (MDT) decision, date thereof and treatment type (chemotherapy, radiotherapy, immunological therapy, surgery, palliative treatment and/or no anticancer treatment). For patients receiving radiotherapy, radiation field and type was reported. For patients receiving surgery, hospital COVID-19 designation was reported; a cold hospital was defined as COVID-19-free zone and a hot hospital was defined as a zone with a confirmed COVID-19 case where active treatment for COVID-19 was administered. The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) Classification of Intervention was used to define the urgency of surgery.19 The reason for surgery—whether diagnostic, curative or palliative—and the time from admission to surgery were also reported. Specific data fields from the proforma can be found in online supplemental appendix S7.

    Supplemental material

    Data validation

    To validate the data and reduce the potential for bias due to incomplete case ascertainment, a three-stage process was performed at a randomly selected subset (10%) of participating centres. First, key processes used to recruit and follow-up eligible patients were self-reported by local leads. Second, an independent validator from the same centre quantitatively reported case ascertainment. Third, a local independent validator randomly sampled a section of the data for accuracy. The targets for validation were a secure and accurate record of patients entered onto REDCap with no case/data duplication and data accuracy >95%.

    Statistical methods

    All duplicates were removed post-data validation. Missing data for covariates were analysed to determine if they were related to the outcome and either complete-case analyses or multiple imputation techniques were used for the analyses accordingly. Baseline characteristics for LMIC and HIC countries are presented as proportions or mean (SD) or median (range) and statistical differences were determined using a chi-square test or Fisher’s exact test. Statistical differences in 30-day and 90-day mortality between LMICs and HICs were determined using Fisher’s exact test due to low event rates. A discrete time survival model was used to assess time to 30-day mortality adjusting for important prognostic factors and displayed using Kaplan-Meier plots. Multivariate logistic regression analyses were conducted between covariates and the primary outcome of 30-day mortality. The LASSO (Least Absolute Shrinkage and Selection Operator) method was utilised for variable selection, and to determine the final multi-level multivariable logistic model of covariates affecting outcomes. Results are presented as ORs or hazard ratios with corresponding 95% CIs. Data were analysed using Stata V.15.1 and SAS V.9.4.

    Patient and public involvement

    The steering committee met with the parents of 11 children from across North America, Europe, Asia and Africa during the planning of this study. Their children had a range of neoplasms including leukaemia, rhabdomyosarcoma, osteosarcoma and Wilm’s tumour. It was found that 40% of the children represented in the group had been impacted by COVID-19 in one of three key-ways: follow-up clinics had become virtual; delays in treatment; and parents having to receive news from doctors without their partners. All parents agreed on the value and benefit of the study. Two parents (one from the UK and one from Nigeria) agreed to provide their input on the findings and dissemination of the results.

    Results

    A total of 1660 patients were eligible for the study. They were recruited consecutively across the 91 hospitals (LMICs: 65/91, 71.4%) in 39 countries (figure 1, online supplemental appendices S1 and S2). A total of 1104 patients (66.5%) were from LMICs and 556 were from HICs (table 1 and online supplemental appendix S8). Patients with paediatric cancer in LMICs were typically younger, lighter in weight and had a lower ASA grade at presentation than the patients recruited in HICs (table 1). The most common paediatric cancer in both HICs and LMICs included in this study was ALL (n=614/1660, 37.0%). Retinoblastomas were more common among LMIC patients (n=87/1104, 7.9%) than HIC patients (n=4/556, 0.7%). A minority of patients with paediatric cancer in both LMICs and HICs were diagnosed with COVID-19.

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    Table 1

    Baseline characteristics

    Figure 1

    Location of the 39 countries that had centres participating in this study.

    Central nervous system (CNS) involvement data were available for 557 patients with ALL (LMICs: n=337/380, 88.7%; HICs: n=220/234, 94.0%). Most of these patients were negative for CNS involvement (LMICS: n=312/337, 92.6%; HICs: n=179/220, 81.4%). Ann Arbor staging data was available for most patients with Hodgkin lymphoma (LMICs: n=52/63, 82.5%; HICs: n=33/38, 86.8%). Among HIC patients, 17 were stage II (51.5%), 5 were stage III (15.2%), and 11 were stage IV (33.3%). Among LMIC patients, 5 were stage I (9.6%), 14 were stage II (26.9%), 14 were stage III (26.9%) and 19 were stage IV (36.5%). Similarly, Ann Arbor staging data were available for most patients with non-Hodgkin’s lymphoma (LMICs: n=61/89, 68.5%; HICs: n=23/29, 79.3%). Among HIC patients, five were stage I (21.7%), five were stage II (21.7%), sevenwere stage III (30.4%) and six were stage IV (26.1%). Among LMIC patients, 7 were stage I (11.5%), 8 were stage II (13.1%), 31 were stage III (50.8%) and 15 were stage IV (24.6%). Staging data were available for 131 patients with glioma (LMICs: n=65/73, 89.0%; HICs: n=66/69, 95.7%). Most of these patients had a low-grade glioma (LMICS: n=40/65, 61.5%; HICs: n=53/66, 80.3%). For the remaining 499 patients in LMICs with a paediatric cancer, staging was known for 400 patients (80.2%): 208 had localised cancer (52.0%), 75 had regional cancer (18.8%), and 117 had metastatic cancer (29.3%). Similarly, for the remaining 186 patients in HICs with a paediatric cancer, 68 had localised cancer (36.6%), 21 had regional cancer (11.3%) and 64 had metastatic cancer (34.4%).

    After 30 days postpresentation, 64 patients (3.9%) were lost to follow-up (figure 2 and table 2). Where data were available, the risk of death among patients with paediatric cancer in LMICs at 30 days after presentation was 4.3% (95% CI 3.1 to 5.5). The tumour types of the patients in LMICs that died at 30 days were ALL (n=8), non-Hodgkin’s lymphoma (n=7), medulloblastoma (n=7), glioma (n=6), neuroblastoma (n=6), rhabdosarcoma (n=4), retinoblastoma (n=3), Wilms’ tumour (n=3) and osteosarcoma (n=1). Of these deaths, 2 were in low-income countries (n=2/35, 5.7%), 16 were in lower-middle-income countries (n=16/488, 3.3%) and 27 were in upper-middle-income countries (n=27/528, 5.1%). The risk of death among patients with paediatric cancer in HICs at 30 days after presentation was 0.4% (95% CI 0.0 to 0.9). The tumour types of the patients in HICs that died at 30 days were ALL (n=1) and rhabdosarcoma (n=1). Relative to patients with paediatric cancer in HICs, patients with paediatric cancer in LMICs had 12.1 (95% CI 2.9 to 50.3) times the odds of death at 30 days after presentation during the COVID-19 pandemic (p<0.001). At 90 days, 187 patients (11.3%) overall had been lost to follow-up (figure 2 and table 2). The risk of death among patients with paediatric cancer in LMICs at 90 days after presentation was 7.0% (95% CI 5.4 to 8.6). The risk of death among patients with paediatric cancer in HICs at 90 days after presentation was 0.9% (95% CI 0.1 to 1.8). Relative to patients with paediatric cancer in HICs, patients with paediatric cancer in LMICs had 7.9 (95% CI 3.2 to 19.7) times the odds of death at 90 days after presentation during the COVID-19 pandemic (p<0.001). Among paediatric patients who survived to 30 days, relative to patients with paediatric cancer in HICs (0.6%), patients with paediatric cancer in LMICs (2.3%) had 4.2 (95% CI 1.2 to 14.1) times the odds of death at 90 days after presentation during the COVID-19 pandemic (p=0.0104). The tumour types of the patients in LMICs that died between 30 and 90 days were ALL (n=7), non-Hodgkin’s lymphoma (n=1), medulloblastoma (n=2), glioma (n=1), neuroblastoma (n=5), rhabdosarcoma (n=1), Wilms’ tumour (n=2), Ewing’s sarcoma (n=1) and osteosarcoma (n=1). The tumour types of the patients in HICs that died between 30 and 90 days were ALL (n=2) and non-Hodgkin’s lymphoma (n=1). All these deaths occurred in middle-income countries: 18 in lower-middle-income countries (n=18/427, 4.2%), and 3 were in upper-middle-income countries (n=3/442, 0.7%).

    Figure 2

    Kaplan-Meier survival curve of patients with paediatric cancer in high-income countries (HICs) and low-income and middle-income countries (LMICs) adjusted for COVID-19 test outcome, MDT decision: anti-cancer therapy and whether the first admission was planned. MDT, multidisciplinary team.

    Table 2

    Thirty-day and 90-day mortality

    After adjusting for confounders, relative to patients with paediatric cancer in HICs, patients with paediatric cancer in LMICs had 15.6 times the odds of death at 30 days after presentation during the COVID-19 pandemic (p<0.001) (table 3). After adjusting for confounders, relative to patients with paediatric cancer who were not proven to be COVID-19 positive, patients with paediatric cancer who were COVID-19 positive postpresentation had 22.8 times the odds of death at 30 days after presentation (table 3 and figure 3).

    Table 3

    Multivariable Generalised Linear Model analysis using Least Absolute Shrinkage and Selection Operator method for variable selection: 30-day mortality

    Figure 3

    Kaplan-Meier survival curve of patients with paediatric cancer in high-income countries (HICs) and low-income and middle-income countries (LMICs) stratified by COVID-19 positivity.

    A total of 219 children had delays or alterations to treatment. An initial MDT decision was made for 1435 of the included children (86.4%) to receive chemotherapy: 931 in LMICs and 504 in HICs. Secondary to the effects of the COVID-19 pandemic, 7 children in LMICs had their planned chemotherapy cancelled, 84 and 17 children in LMICs and HICs, respectively, had delayed delivery of their chemotherapy, 8 children in LMICs were given a reduced dose from the normal regimen that would have been given prior to the pandemic, 2 children in LMICs were given an increased dose compared with the normal regimen, 7 children in LMICs had fewer cycles of chemotherapy relative to the normal regimen, 6 children in LMICs and one child in an HIC had more cycles of chemotherapy relative to the normal regimen, 5 children in LMICs and 1 child in an HIC had a shorter duration of total treatment than would normally be given, 18 children in LMICs had a longer duration of treatment than would normally be given, 21 children in LMICs and one child in an HIC were given a different chemotherapy agent compared with the normal regimen, and 8 children in LMICs were given chemotherapy through an alternative route of administration. In addition, the families of 17 children in LMICs and 1 child in an HIC abandoned this treatment. The drivers behind these changes are listed in table 4.

    Table 4

    Reasons for the changes to the treatments

    Similarly, an initial MDT decision was made for 226 of the included children (13.6%) to receive radiotherapy: 131 in LMICs and 95 in HICs. Secondary to the effects of the COVID-19 pandemic, one child in an LMIC had their planned radiotherapy cancelled, eight and eight children in LMICs and HICs, respectively, had delayed delivery of their radiotherapy, and three children were given radiotherapy through a different modality than would normally be given. In addition, the family of one child in an HIC abandoned their treatment. An initial MDT decision was made for 48 of the included children (2.9%) to receive immunotherapy: 18 in LMICs and 30 in HICs. Secondary to the effects of the COVID-19 pandemic, 1 child in an LMIC had their planned immunotherapy cancelled, 2 and 3 children in LMICs and HICs, respectively, had delayed delivery of their immunotherapy. In addition, the family of one child in an HIC abandoned this treatment. An initial MDT decision was made for 518 patients (31.2%) to undergo surgery: 364 in LMICs and 154 in HICs. Secondary to the effects of the COVID-19 pandemic, one child in an LMIC had their planned surgery cancelled, 47 and 10 children in LMICs and HICs, respectively, had delayed surgery, 8 children in LMICs and one child in an HIC had a change in the choice of their operation, 8 children in LMICs and one child in an HIC had their operation performed in an alternative hospital (reported to have prevented a delay in surgery), once child in an LMIC underwent neoadjuvant therapy where this would not typically have been indicated, 3 children in LMICs and one child in an HIC underwent a longer course of neoadjuvant therapy, 1 child in an LMIC did not undergo a neoadjuvant therapy that would normally been indicated and 1 child was switch to palliative care. An additional 10 children in LMICs and 4 children in HICs were deemed to be for palliative care at the initial MDT. In addition, the families of three children in LMICs and one child in an HIC abandoned this treatment. The drivers behind these changes are listed in table 4.

    Discussion

    Children with cancer have had their treatments delayed, interrupted, or modified due to the direct effects of COVID-19 and the measures imposed to minimise COVID-19 mortality and morbidity. These delays and alterations only affected a minority of patients with paediatric cancer. They primarily affected patients with paediatric cancer in LMICs. Relative to patients with paediatric cancer in HICs, patients with paediatric cancer in LMICs had 12.1 and 7.9 times the risk of death at 30 days and 90 days, respectively, after presentation during the COVID-19 pandemic. After adjusting for confounders—such as age, sex, weight, ASA grade, tumour type and tumour staging, relative to patients with paediatric cancer in HICs, patients with paediatric cancer in LMICs had 15.6 times the odds of all-cause mortality during the COVID-19 pandemic. This is substantially higher than prepandemic figures of children in LMICs being four times more likely to die1 20 A minority of patients with paediatric cancer in both LMICs and HICs were diagnosed with COVID-19, with most of these cases being in LMICs. Being diagnosed with COVID-19 was associated with greater odds of death at 30 days after presentation. It should be noted that being diagnosed with COVID-19 was a reason for delays in seeking care and providing treatment as well as alterations to treatment.

    While our analyses do corroborate the perceptions of clinicians globally:8 12 13 the provision of paediatric oncology services have been adversely impacted by the COVID-19 pandemic, this has only affected a minority of patients receiving treatment. Most patients with paediatric cancer have continued to receive the standard of care that they would have received prior to the pandemic. This speaks to the adaptability and resilience of healthcare systems and healthcare workers globally. Creation of new legislation,21 increasing utilisation of technology,22 and optimising the allocation of resources12 are some of the commendable efforts that have mitigated the impact of the pandemic on patients with paediatric cancer. The benefits of these interventions could persist beyond the pandemic. The probability of this occurring is dependent on individuals, organisations dedicated to paediatric cancer care, and governments continuing to work collectively, interprofessionally and globally.

    It should be noted that the impact of the COVID-19 pandemic on paediatric oncology services highlights existing inequities in healthcare systems. Prior to the pandemic, children diagnosed with cancer in an HIC had a mean 5-year survival rate of 80%,1 20 whereby children in LMICs had a mean 5-year survival rates of 20%.1 The discrepancy is due to delays in diagnosis,23 24 lack of access,25 poor investment into services26 and inadequate support for workforce development27 in LMICs. Our results indicate the pandemic has exacerbated these issues: increasing delays, reducing access and diverting resources to other areas. While single centre studies have reported that the pandemic has caused delays to care in HICs,28 29 our results show these issues are principally affecting children in LMICs. These delays could adversely impact short-term outcomes with children in LMICs at approximately 15 times the odds of dying, which is higher than figures reported prior to the pandemic.1 30 This disparity in mortality needs urgent attention from policy-makers and health advocates globally, especially given the lack of funding for childhood cancers in LMICs. In addition, our results suggest that the COVID-19 pandemic is contributing to the existing issue of treatment abandonment in LMICs.31 All in all, the pandemic has exacerbated pre-existing disparities, and clearly demonstrated that children in the poorest nations are once again being disproportionately affected.

    It is also important to critically appraise our finding that patients with paediatric cancer who were COVID-19 positive postpresentation had an increased risk of death at 30 days after presentation. A recent systematic review reported that children with cancer and COVID-19 do not have significantly different outcomes from children with cancer given the same standard of care.32 However, in this cohort study, the patients infected with COVID-19 were not provided the same standard of care as those who did not have the infection, as it was a reason for delaying treatment or changing treatment modalities. This was especially the case for surgical treatment, which may reflect the fact that guidance suggested delaying surgery if needed.11 This underscores a problem unearthed by this study. The most common reason for children with cancer not being given their usual standard of care were changes in policy, lead clinician decision, and lockdown or travel restrictions. Changes may have been driven by the desire to reduce transmission of COVID-19 among patients with paediatric cancer, despite the fact that patients with paediatric cancer are not particularly vulnerable to COVID-199 nor is there sufficient evidence that concurrent COVID-19 infection worsens outcomes.32 Given the response to the pandemic appears to have had a larger effect on care than direct effects of the pandemic itself, the impact of the pandemic on patients with paediatric cancer can be mitigated through policy changes occurring now.

    This study did have limitations. As a cohort study, it only followed children through time who were diagnosed with cancer. However, there have been frequent reports that the pandemic has decreased the number of children being identified to have cancer.12 Therefore, the impact of the COVID-19 pandemic may be greater than that outlined here, especially as the underdiagnosis of cancer is an established reason for the increased mortality of patients with paediatric cancer in LMICs.1 3 24 Furthermore, given existing difficulties in providing care for patients with paediatric cancer in LMICs, there is the possibility that patients who had alterations to their treatment during the COVID-19 pandemic may have had similar alterations if the pandemic had not occurred. To mitigate against this bias, we requested that all data collectors attest they have only submitted new issues brought about by the pandemic. Therefore, although we are not aware of a bias towards baseline gaps in service delivery, we cannot confirm that pre-existing issues with service provision and supply chains did not contribute to the disparity in care showcased by this study. Similarly, although we are aware that children with cancer are four times more likely to die in LMICs than in HICs,1 20 we do not have specific baseline data for the centres involved in our study as this is the first study of its kind for most participating LMIC centres. Furthermore, there was a disparity in the type of hospitals participating in this study between LMICs and HICs. Participating LMIC sites tended to be tertiary hospitals, while HIC sites included a larger mix of general hospitals, paediatric hospitals and paediatric oncology hospitals (online supplemental appendix S2). There is an inherent variability in capacity for cancer care between these hospital types.33 The inclusion of hospitals in HICs that were not specialised for the care of children with cancer may have resulted in an underestimation of the effect of the COVID-19 pandemic on this population in LMICs relative to HICs. In addition, there was an 18% lost to follow-up at 90 days, and those individuals may have been different from those who were included. Ultimately, over 1400 patients across 39 countries were followed up over 90 days, suggesting we are able to provide a comprehensive report of the global effect of this pandemic on paediatric oncology care. It should be noted, however, that there was an inequitable distribution of participants from HICs and LMICs. Approximately two-thirds of all participants were based in LMICs. However, given the historical lack of presence of individuals from LMICs in international studies, these data points provide a novel opportunity to assess global surgery related knowledge and the quality of global surgery care being offered.

    This is the first large-series, geographically comprehensive, multicentre, international cohort study to explore the management of childhood cancers in low, middle and HICs across the globe during the COVID-19 pandemic. It illustrates the stark disparities that continue to exist in children’s cancer care, and the multiple impacts that COVID-19 pandemic has had on healthcare systems across the globe. Our results underscore the need for a renewed assessment of resource requirements during this pandemic and the sharing of approaches that have minimised the negative effects on paediatric cancer care. This pandemic has become the defining crisis of our generation, and its ramifications may stretch beyond the acute crisis and have far reaching consequences for the future. Understanding its true impact, taking on key lessons and identifying vulnerabilities within health systems helps us develop solutions, which will also prove critical on our path towards equitable global paediatric oncology care.

    Data availability statement

    Data are available on reasonable request. Deidentified date will be shared on request.

    Ethics statements

    Patient consent for publication

    Acknowledgments

    Thank you to the University of Oxford Medical Sciences Division IT Services Systems Team (MSDIT Systems Team) for the REDCap administration and management. Thank you to the representatives from the College of Surgeons of Southern, East and Central Africa (COSECSA), the Global Children’s Initiative for Surgery (GICS), the Pan-African Paediatric Surgical Association (PAPSA), the International Society of Paediatric Oncology (SIOP), and the International Society of Paediatric Surgical Oncology (IPSO) who made this study possible. Thank you to all our collaborators from our country leads to the members of our local mini-teams for driving this study forward.

    References

    Supplementary materials

    Footnotes

    • Twitter @GlobalChildNCDs

    • Collaborators Steering committee: Soham Bandyopadhyay [UK], Noel Peter [UK] (Asia Lead), Kokila Lakhoo [UK], Simone de Campos Vieira Abib [Brazil] (South America Lead), Hafeez Abdelhafeez [Sudan] (Africa and Middle East Lead), Shaun Wilson [UK] (Australasia Lead), Max Pachl [UK] (Europe and North America Lead), Benjamin Martin [UK] (Europe Lead), Sonal Nagras [Australia] (Australasia Lead), and Mihir Sheth [India] Operational committee: Soham Bandyopadhyay [UK], Catherine Dominic [UK], Suraj Gandhi [UK], Divya Parwani [India], Rhea Raj [UAE], Diella Munezero [Burundi], Rohini Dutta [India], Nsimire Mulanga Roseline [DRC], Kellie McClafferty [UK], Armin Nazari [UK], Smrithi Sriram [UK], Sai Pillarisetti [UK], King-David Nweze [UK], Aishwarya Ashwinee [Grenada], Gul Kalra [India], Poorvaprabha Patil [India], Priyansh Nathani [India], Khushman Kaur Bhullar [India], Muhammed Elhadi [Libya], Maryam Khan [Pakistan], Nehal Rahim [Pakistan], Shweta Madhusudanan [UK], Joshua Erhabor [UK], Manasi Shirke [UK], Aishah Mughal [UK], Darica Au [UK], Mahan Salehi [UK], Sravani Royyuru [UK], Mohamed Ahmed [Egypt], Syeda Namayah Fatima Hussain [Pakistan], Daniel Robinson [UK], Anna Casey [UK], Mehdi Khan [UK], Alexandre Dukundane [Rwanda], Kwizera Festus [Rwanda], Vaishnavi Govind [Grenada], Rohan Pancharatnam [UK], Lorraine Ochieng [UK], Elliott H Taylor [UK], Hritik Nautiyal [UK], Marta de Andres Crespo [UK], Somy Charuvila [UK], and Alexandra Valetopoulou [UK] Research Capacity Building Committee: Krithi Ravi [UK], Fatumata Jalloh [UK], Nermin Badwi [Egypt], Shahnur Shah [Kenya], Gul Kalra [India], Rohini Rajpal [India], Masooma Rana [Pakistan], Muskaan Abdul Qadir [Pakistan], Emmanuel Uwiringiyimana [Rwanda], Abdelrahman Azzam [Egypt], Mayara Fanelli [Brazil], Gustavo Mendonça Ataíde Gomes [Brazil], Igor Lima Buarque [Brazil], Isadora Schwaab Guerini [Brazil], Anfel Bouderbala [Algeria], Sarah Alfurais [Turkey], Mohamed Gamal [Egypt], Yara Hijazi [Palestine], Shatha Tailakh [Jordan], Hamza Al-Naggar [Yemen], Zain Douba [Syria], Sewar Elejla [Palestine], Abdullah Eldaly [Egypt], Ekram Sharashi [Libya], Ahmad Mansour [Palestine], Tamara Elyan [Palestine], Aouabed Nesrine [Algeria], Ammar Ayman [Egypt], Aya Zazo [Syria], Mohamed Bonna [Egypt], Safia Lorabi [Algeria], Hassan Alalami [Palestine], Rawan Yasser Emam [Egypt] Writing committee: Soham Bandyopadhyay [UK], Rohini Dutta [India], Shweta Madhusudanan [UK], Suraj Gandhi [UK], Mehdi Khan [UK], Rhea Raj [UAE], Muath Alser [Egypt], Mohamad K. Abou Chaar [Jordan], Dennis Mazingi [Zimbabwe], Hira Zuberi [Pakistan], Iyad Sultan [Jordan], Dhruva Nath Ghosh [India], Nitin James Peters [India], Reto M Baertschiger [Canada], Augusto Zani [Canada], Noel Peter [UK], and Kokila Lakhoo [UK] Statistics committee: Lucy Davies [UK] and Soham Bandyopadhyay [UK] Local teams: Abubakar Tafawa Balewa University Teaching Hospital, Nigeria 1. Kefas John Bwala 2. AM Umar 3. Abdurahaman Aremu 4. Dauda E. Suleiman 5. Tybat Aliyu Aga Khan University Hospital, Pakistan 1. Ayesha Saleem 2. Muhammad Arshad 3. Kashaf Turk 4. Sadaf Altaf Ahmadu Bello University Teaching Hospital, Nigeria 1. Oluseyi Oyebode Ogunsua 2. Tunde Talib Sholadoye 3. Musliu Adetola Tolani 4. Yakubu Alfa 5. Keffi Mubarak Musa AIC Kijabe Hospital, Kenya 1. Eric Mwangi Irungu 2. Ken Muma 3. Sarah Muma 4. Mitchelle Obat Ain Shams Hospitals "El-Demerdash", Egypt 1. Youssef Sameh Badran Al-Basheer Hospital, Jordan 1. Abdulrahman Ghassan Qasem 2. Faris Ayasra 3. Reema Alnajjar Al-Hussein University Hospital, Egypt 1. Mohamed Abdel-Maboud 2. Abdelrahman Bahaa 3. Ayat M. Saadeldin 4. Mohamed Adwi 5. Mahmoud Adly 6. Abdallah Elshenawy Alder Hey Children Hospital, UK 1. Amer Harky 2. Leanne Gentle 3. Kirstie Wright 4. Jessica Luyt 5. Olivia White 6. Charlotte Smith 7. Nathan Thompson 8. Thomas Smith 9. Imogen Harrison Bangladesh Shishu Hospital & Institute, Bangladesh 1. Ashrarur Rahman Mitul 2. Sabbir Karim 3. Nazmul Islam Benghazi pediatric hospital, Libya 1. Sara Kader Alsaeiti 2. Fatma Saleh Benkhial 3. Mohammed Miftah Faraj Almihashhish 4. Eman Salem Muftah Burzeiza 5. Hend Mohammed Masoud 6. Mabroukah Saeid Alshamikh 7. Raja Mari Mohammed Nasef 8. Fatma Mohammed Masoud Birmingham Children's Hospital, UK 1. William B Lo 2. Nyararai Togarepi 3. Elaine Carrolan 4. Benjamin Martin 5. Max Pachl 6. Benjamin J O'Sullivan Borg El Arab University Hospital, Egypt 1. Mohamed Hassanin 2. Ahmed Saleh 3. Mahmoud Bassiony 4. Mostafa Qatora 5. Mohamed Bahaaeldin 6. Shady Fadel 7. Yasmine El Chazli Centre Anti-Cancer, Batna, Algeria 1. Anfel Bouderbala 2. Kamel Hamizi 3. Safia Lorabi 4. Mehdi Anouar Zekkour 5. Rima Rahmoun 6. Boutheyna Drid 7. Salma Naje Abu Teir Centre hospitalier universitaire de Batna, Algeria 1. Safia Lorabi 2. Mohamed Yazid Kadir 3. Yassine Zerizer 4. Nacer Khernane 5. Brahim Saada Centre Hospitalo-Universitaire Ibn Sina de Rabat (CHIS), Morocco 1. Imane Ammouze 2. Yahya Elkaoune 3. Hajar Moujtahid 4. Ghita Chaoui 5. Hajar Benaouda 6. Meryem Gounni 7. Narjiss Aji 8. Laila Hessissen Centro Hospitalar Universitário de São João, Portugal 1. Joana Mafalda Monteiro 2. Susana Nunes 3. Maria do Bom-Sucesso Children's Hospital of Wisconsin, United States of America 1. Dave R. Lal 2. Brian T. Craig 3. Kerri Becktell Chittagong Research Institute For Children Surgery, Bangladesh 1. Tahmina Banu 2. Md Afruzul Alam 3. Orindom Shing Pulock 4. Tasmiah Tahera Aziz Clinic for Neurosurgery, Clinical Center of Serbia, Serbia 1. Rosanda Ilic 2. Danica Grujicic 3. Tijana Nastasovic 4. Igor Lazic 5. Mihailo Milicevic 6. Vladimir Bascarevic 7. Radovan Mijalcic 8. Vuk Scepanovic 9. Aleksandar Stanimirovic 10. Aleksandra Paunovic 11. Ivan Bogdanovic Dhaka Medical College Hospital, Bangladesh 1. Shahnoor Islam 2. AKM Amirul Morshed A. K. M. Khairul Basher 3. Mehnaz Akter 4. S. M. Rezanur Rahman 5. Zannat Ara 6. Mohammed Tanvir Ahammed 7. Tania Akter 8. Kamrun Nahar 9. Fatema Sayed 10. Ashfaque Nabi 11. Md. Asif Iqbal 12. Md. Masud Rana 13. Md. Asaduzzaman 14. Md. Hasanuzzaman Dr. Lutfi Kirdar Kartal Training and Research Hospital, Turkey 1. Kemal Tolga Saracoglu 2. Elif Akova 3. Evren Aydogmus 4. Bekir Can Kendirlioglu 5. Tufan Hicdonmez Dubai Hospital, United Arab Emirates 1. Arshiya Adhnon 2. Asim Noor Rana 3. Hani Humad 4. Anjan Madasu El Safa Hospital, Egypt 1. Ahmed Y Azzam 2. Mohammed A Azab El Sheikh Zayed Specialized Hospital, Egypt 1. Sherief Ghozy 2. Alzhraa Salah Abbas Federal Medical Center, Abeokuta, Nigeria 1. Olanrewaju Moses Federal Medical Center, Lokoja, Nigeria 1. Ibiyeye Taiye Taibat 2. Taiwo Jones 3. Kalu Ukoha 4. Olagundoye Goke 5. Okorie Ikechukwu Federal Teaching Hospital Ido-Ekiti, Nigeria 1. Abiodun Idowu Okunlola Frere Hospital, South Africa 1. Milind Chitnis 2. Helga Nauhaus 3. Danelle Erwee Gloucestershire Hospitals NHS Foundation Trust, United Kingdom 1. Robyn Brown 2. Agata Chylinska 3. Robin Simpson 4. Prasanna Gomes 5. Noel Peter GPACI - Grupo de Pesquisa e Assistência ao Câncer Infantil, Brazil 1. Marco Aurelio Ciriaco Padilha 2. Elvercio Pereira de Oliveira Junior 3. Lucas Garschagen de Carvalho 4. Fabiola Leonelli Diz Helwan University Hospital, Egypt 1. Mohamed El Kassas 2. Usama Eldaly 3. Ahmed Tawheed 4. Mohamed Abdelwahab Hôpital des Spécialités ONO, Morocco 1. Oudrhiri Mohammed Yassaad 2. Bechri Hajar 3. El Ouahabi Abdessamad 4. Arkha Yasser 5. Hessissen Laila Ibn-Al-Atheer Teaching Hospital, Mosul, Iraq 1. Farah Sameer Yahya (Department of Pediatrics, College of Medicine, University of Mosul, Mosul, Iraq) 2. Yasir Al-Agele Instituto Nacional de Enfermedades Neoplásicas, Peru 1. Maria Teresa Peña Gallardo 2. Jacqueline Elizabeth Montoya Vásquez 3. Juan Luis García León 4. Sebastián Shu Yip John Radcliffe Hospital, United Kingdom 1. Mariam Lami 2. Matthew H V Byrne 3. Duha Jasim 4. Harmit Ghattaura 5. Soham Bandyopadhyay 6. Kokila Lakhoo Johns Hopkins Hospital Bloomberg Children's Hospital, United States of America 1. Eric W Etchill 2. Daniel Rhee 3. Stacy Cooper 4. Kevin Crow 5. Morgan Drucker 6. Megan Murphy 7. Benjamin Shou 8. Alan Siegel Kanuni Sultan Süleyman Research and Training Hospital, Turkey 1. Yasin Kara 2. Gül Nihal Özdemir Kasr Al Ainy Hospital, Egypt 1. Mahmoud Elfiky 2. Ehab El Refaee Khoula Hospital, Oman 1. John George Massoud King Abdullah University Hospital, Jordan 2. Ayah Bassam Ibrahim 3. Ruaa Bassam Ibrahim 4. Faris Abu Za'nouneh 5. Ranya M. Baddourah 6. Toqa Fahmawee 7. Ayah Al_Shraideh King Fahd Central Hospital, Saudi Arabia 1. Ghazwani Salman 2. Ehab Alameer (Jazan University) 3. Al-Mudeer Ali 4. Ghazwani Yahia 5. Khozairi Waleed King Hussein Cancer Center, Jordan 1. Mohamad K. Abou Chaar 2. Iyad Sultan 3. Khalil Ghandour 4. Shaima' Al-Dabaibeh 5. Ammar Al-Basiti 6. Hazim Ababneh 7. Omaima El-Qurneh King Salman Armed Forces Hospital, Saudi Arabia 1. Yousef Alalawi 2. Ahmad Al Ayed 3. Ehab Hanafy 4. Naif Al Bolowi KK Women's and Children's Hospital, Singapore 1. Amos HP Loh 2. Anette S Jacobsen 3. Heidi Barola 4. Aubrey L Pagaduan 5. Jingdan Fan Lagos University Teaching Hospital, Nigeria 1. Olumide Abiodun Elebute 2. Adesoji O. Ademuyiwa 3. Christopher O. Bode 4. Justina O. Seyi-Olajide 5. Oluwaseun Ladipo-Ajayi 6. Felix M. Alakaloko 7. George C. Ihediwa 8. Kareem O. Musa ‪‬‬‬ 9. Edamisan O. Temiye 10. Olufemi Oni 11. Adeseye M. Akinsete Lahore General Hospital, Pakistan 1. Janita Zarrish 2. Ramsha Saleem 3. Soha Zahid 4. Atiqa Amirali 5. Ahsan Nadeem 6. Sameer Saleem Tebha 7. Zonaira Qayyum 8. Sana Tahir 9. Anneqa Tahir 10. Rabbey Raza Khan 11. Ayesha Mehmood 12. Iqra Effendi Liaquat National Hospital and Medical College, Pakistan 1. Muhammad Arshad 2. Taimur Iftikhar Qureshi 3. Pooja Kumari Mater Dei Hospital, Sir Anthony Mamo Oncology Centre, Malta 1. Victor Calvagna 2. Nathalie Galea 3. Ariana Axiaq Mayo Clinic, United States of America 1. Matthew R Schuelke 2. Jake A. Kloeber 3. Robert L. Owen 4. Alexander S. Roth 5. Catherine Yang 6. J. Hudson Barnett 7. Lucien P. Jay 8. Kirk David Wyatt 9. Paul J. Galardy Medical University of Pecs, Department of Paediatrics, Hungary 1. Agnes Vojcek Menoufia University Hospital, Egypt 1. Mahmoud Maher Abdelnaby Alrahawy 2. Seham M Ragab 3. Abdallah R Allam 4. Eman Ibrahim Hager 5. Abdelrahman Azzam 6. Ammar Ayman Ministry of Health Marmara University Pendik Research and Application Hospital, Turkey 1. Kıvılcım Karadeniz Cerit 2. Adnan Dağçınar 3. Tümay Umuroğlu 4. Ayten Saraçoğlu 5. Mustafa Sakar 6. Can Kıvrak 7. Gül Çakmak MISR Cancer Centre, Egypt 1. Ibrahim Sallam 2. Gamal Amira 3. Mohamed Sherief 4. Ahmed Sherif National Cancer Institute, Brazil 1. Simone de Oliveira Coelho 2. Arissa Ikeda 3. Licia Portela 4. Marianne Monteiro Garrigo 5. Ricardo Vianna de Carvalho 6. Fernanda Lobo 7. Sima Ester Ferman 8. Fernanda Ferreira da Silva Lima National Cancer Institute, Sudan 1. Moawia Mohammed Ali Elhassan 2. Nada Osman Yousif Elhaj 3. Hytham K. S. Hamid National Hospital, Nigeria 1. Emmanuel A. Ameh 2. Vincent E. Nwatah 3. Adewumi B. Oyesakin Nnamdi Azikiwe University Teaching Hospital, Nigeria 1. Andrew Nwankwo Osuigwe 2. Okechukwu Hyginus Ekwunife 3. Chisom Adaobi Nri-Ezedi 4. Eric Okechukwu Umeh Ola During Children's Hospital, Sierra Leone 1. Nellie Bell Olabisi Onabanjo University Teaching Hospital, Nigeria 1. Ibukunolu Olufemi Ogundele 2. Abiodun Folashade Adekanmbi 3. Olubunmi Motunrayo Fatungase 4. Olubunmi Obafemi Obadaini Ondokuz Mayıs Üniversitesi, Turkey 1. Sarah Al-Furais 2. Humaida Hemlae 3. Sreylis Nay Pantai Jerudong Specialist Centre, Brunei 1. John Mathew 2. R M Jeffri Ismail Pediatric Oncology Institute – GRAACC, Brazil 1. Simone de Campos Vieira Abib 2. Fabianne Altruda de Moraes Costa Carlesse 3. Mayara Caroline Amorim Fanelli 4. Fernanda Kelly Marques de Souza Policlinico Umberto I, Sapienza University of Rome, Italy 1. Pierfrancesco Lapolla 2. Andrea Mingoli 3. Denis Cozzi 4. Anna Maria Testi 5. Paolo Musiu 6. Paolo Sapienza 7. Gioia Brachini 8. Martina Zambon 9. Simona Meneghini 10. Pierfranco Cicerchia 11. Bruno Cirillo Prince Mohammed bin Nasser Hospital, Jazan, Saudi Arabia 1. Ghazwani Salman Raparin Pediatric Teaching Hospital, Iraq 1. Abdulrahman Omar Taha Saadna Mohamed Abdenour, Algeria 1. Aouabed Nesrine 2. Bouaoud Souad 3. Mebarki Malika 4. Bioud Belkacem Sabha Medical Centre, Libya 1. Ayman Meelad 2. Hajier Salim Alrashed Salmaniya Medical Complex, Bahrain 1. Fayza Haider 2. Fatema Naser Al Fayez Shahid Baghaei Hospital, Iran 1. Fakher Rahim Tamale Teaching Hospital, Ghana 1. Alhassan Abdul-Mumin 2. Halwani Yaninga Fuseini 3. Peter Gyamfi Kwarteng 4. Abubakari Bawa Abdulai 5. Sheba Mary Pognaa Kunfah 6. Gilbert B. Bonsaana 7. Stephanie Ajinkpang 8. Edmund M. Der 9. Francis A. Abantanga 10. Mary Joan Kpiniong 11. Kingsley Aseye Hattor 12. Kingsley Appiah Bimpong Tanta University Hospital, Egypt 1. Mohamed Elbahnasawy 2. Sherief Abdelsalam 3. Ahmed Samir The Hospital for Sick Children, Canada 1. Reto M. Baertschiger 2. Amanpreet Brar 3. Andreea C, Matei 4. Augusto Zani The Indus Hospital, Pakistan 1. Lubna Samad 2. Hira Khalid Zuberi 3. Kishwer Nadeem 4. Naema Khayyam 5. Fatima Ambreen Imran 6. Nida Zia 7. Sadia Muhammad 8. Muhammad Rafie Raza 9. Muhammad Rahil Khan Tishreen University Hospital, Syria 1. Alaa Hamdan 2. Ammar Omran 3. Ahmed Moussa 4. Bardisan Gawrieh 5. Hassan Salloum 6. Alaa Ahmed 7. Abdeljawad Mazloum 8. Ali Abodest 9. Nisreen Ali 10. Munawar Hraib 11. Victor Khoury 12. Abdulrahman Almjersah 13. Mohammad Ali Deeb 14. Mohammad Ahmad Almahmod Alkhalil 15. Akram Ahmed 16. Waseem Shater 17. Ali Farid Alelayan 18. Alaa Guzlan Tobruk Medical Centre, Libya 1. Ahmad Bouhuwaish 2. Alqasim Abdulkarim Tripoli University Hospital, Libya 1. Eman Abdulwahed 2. Marwa Biala 3. Reem Ghamgh 4. Amani Alamre 5. Marwa Shelft 6. Asmaa A. M. Albanna 7. Hoda Tawel Unit of Paediatric and Adolescent Haematology and Oncology, 2nd Department of Peadiatrics, Aristotle University of Thessaloniki, University General Hospital AHEPA, Greece 1. Emmanuel Hatzipantelis 2. Athanasios Tragiannidis 3. Eleni Tsotridou 4. Assimina Galli-Tsinopoulou Universiti Kebangsaan Malaysia Medical Centre, Malaysia 1. Dayang Anita Abdul Aziz 2. Zarina Abdul Latiff 3. Hamidah Alias 4. C-Khai Loh 5. Doris Lau 6. Azrina Syarizad Khutubul Zaman University Children's Hospital of Basel, Switzerland 1. Raphael N. Vuille-dit-Bille 2. Stefan G. Holland-Cunz 3. Nima Allafi University College Hospital (UCH), Nigeria 1. Taiwo Akeem Lawal 2. Kelvin Ifeanyichukwu Egbuchulem 3. Olakayode Olaolu Ogundoyin 4. Isaac Dare Olulana 5. Biobele J. Brown 6. Oluwasegun Joshua Afolaranmi 7. AbdulBasit Fehintola University Hospital Hamburg-Eppendorf, Germany 1. Annika Heuer 2. Christine Nitschke 3. Michael Boettcher 4. Matthias Priemel 5. Lennart Viezens 6. Martin Stangenberg 7. Marc Dreimann 8. Alonja Reiter 9. Jasmin Meyer 10. Leon Köpke 11. Karl-Heinz Frosch University of Abuja Teaching Hospital, Nigeria 1. Samson Olori 2. Uduak Offiong 3. Philip Mari Mshelbwala 4. Fashie Andrew Patrick 5. Aminu Muhammed Umar 6. Otene ThankGod N. University of Ilorin Teaching Hospital, Nigeria 1. Abdulrasheed A Nasir 2. Kazeem O. O. Ibrahim 3. Dupe S. Ademola-Popoola 4. Olayinka T. Sayomi 5. Alege Abdurrzzaq 6. Ademola A. Adeyeye 7. Khadijah O. Omokanye 8. Lukman O Abdur-Rahman 9. Olubisi Olutosin Bamidele 10. Shakirullah AbdulAzeez 11. Aminat Akinoso 12. Michael O. Adegboye University of Malaya Medical Centre, Malaysia 1. Shireen Anne Nah 2. Yuki Julius Ng 3. Syukri Ahmad Zubaidi University of Texas Medical Branch, United States of America 1. Murad Almasri 2. Sara Ali 3. Rasaq Olaosebikan 4. Akila Muthukumar University Teaching Hospital, Zambia 1. Patricia Shinondo 2. Amon Ngongola 3. Bruce Bvulani 4. Azad Patel Usman Danfodiyo University Teaching Hospital, Nigeria 1. Abdullahi Nuhu-Koko 2. Baba Jibrin 3. Ajiboye L. Olalekan 4. Christopher S. Lukong 5. Ezekiel I. Ajayi Vall d'Hebron University Hospital, Spain 1. Gabriela Guillén 2. Sergio López 3. José Andrés Molino 4. Pablo Velasco Wingat Royal Hospital, Egypt 1. Omar Elmandouh 2. Omar Hamam 3. Rim Elmandouh Yale New Haven Hospital, United States of America 1. Nensi Melissa Ruzgar 2. Rachel Levinson 3. Shashwat Kala 4. Sarah Ullrich 5. Emily Christison-Lagay Zagazig University Hospital, Egypt 1. Aya Sabry Mortada 2. Mahmoud Ahmed Ebada 3. Eman Seif Alnaser Solimam 4. Khaled Abualkher 5. Amr Mohammed Elsayed Yousf 6. Mohamed Mohamed Holail 7. Reem Mohamed Almowafy National/Regional Leads: Algeria: Salah Eddine Oussama Kacimi Bahrain: Fayza Haider Bangladesh: Tahmina Banu, Ashrarur Rahman Mitul Brazil: Simone de Campos Vieira Abib Brunei: Janice Hui Ling Wong Canada: Reto Baertschiger Egypt: Essam Elhalaby, Muath Alser, Mahmoud M. Saad Germany: Guido Seitz, Judith Lindbert Ghana: Francis Abantanga Greece: Georgios Tsoulfas, Asimina Galli-Tsinopoulou Hungary: Agnes Vojcek Iran: Maryam Ghavami Adel Iraq: Abdulrahman Omar Taha Italy: Calogero Virgone, Francesco Pata, Gaetano Gallo Jordan: Mohammad K. Abou Chaar, Faris Ayasra Kenya: Eric Mwangi Irungu Libya: Muhammed Elhadi Malaysia: Shireen Anne Nah, Dayang Anita Abdul Aziz Malta: Victor Calvagna Morocco: Outani Oumaima, Zineb Bentounsi, Hajar Moujtahid Nigeria: Adesoji Ademuyiwa Oman: Dhruva Nath Ghosh Pakistan: Muhammad Arshad, Lubna Samad Peru: Lily Saldana Portugal: Jan Godzinsky Saudi Arabia: Abdelbasit Ali, Ehab Alameer Serbia: Dragana Janic Sierra Leone: Mohamed Bella Jalloh, Nellie Bell Singapore: Annette Jacobsen, Chan Hon Chui South Africa: Milind Chitnis Spain: Israel Fernandez Pineda, Lucas Krauel, Maricarmen Olivos Sudan: Waha Rahama, Hazim Elfatih Switzerland: Raphael N. Vuille-dit-Bille Syria: Alaa Hamdan Turkey: Arda Isik United Arab Emirates: Asim Noor Rana United Kingdom: Kokila Lakhoo, Kate Cross, Max Pachl United States of America: Andrea Hayes-Jordan, Roshni Dasgupta Zambia: Patricia Shinondo, Amon Ngongola Middle-East and North Africa: Mohamedraed Elshami

    • Contributors This is a paper produced under a collaborative authorship model: Global Health Research Group on Children’s Non-Communicable Diseases Collaborative. All authors are solely listed under the collaborative authorship. A full authorship list can be found in online supplemental appendix S1. KL acts as guarantor for this study.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Map disclaimer The inclusion of any map (including the depiction of any boundaries therein), or of any geographic or locational reference, does not imply the expression of any opinion whatsoever on the part of BMJ concerning the legal status of any country, territory, jurisdiction or area or of its authorities. Any such expression remains solely that of the relevant source and is not endorsed by BMJ. Maps are provided without any warranty of any kind, either express or implied.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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