• Users Online: 116
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
Year : 2021  |  Volume : 46  |  Issue : 4  |  Page : 195-200

Stress effect of COVID-19 pandemic among Egyptian children and adolescents with malignancy: a single-center experience

Department of Pediatrics, Faculty of Medicine, Ain Shams University, Cairo, Egypt

Date of Submission24-May-2021
Date of Acceptance26-May-2021
Date of Web Publication18-May-2022

Correspondence Address:
Asmaa W.A Aziz
Lecturer of Pediatric, Faculty of Medicine. Ain Shams University, Abbassia, Cairo, Postal Code: 11517
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ejh.ejh_43_21

Rights and Permissions

Background Thoughts and feelings of stress and worry are common for any person facing the challenges of a serious illness.
Aim The aim was to assess the effect of COVID-19 on the psychological well-being of patients with malignancy compared with age-matched and sex-matched controls and to compare the psychological effect of COVID-19 with the psychological effect of malignancy among the patient group.
Patients and methods This case–control study included 46 participants diagnosed with malignancy who were compared with 45 healthy age-matched and sex-matched individuals serving as a control group. Their ages were more than 8 years. All patients and controls were subjected to history taking with an emphasis on age, sex, educational level, history of chronic medical illness in the family, disease status, physical symptoms during the last 14 days, and data about COVID-19 infection. The psychological effect was measured using the Children’s Revised Impact of Event Scale Crises-13.
Results Mean age of the patient group was 11.76±3.31 years. There were 30 male and 16 female in the case group, who were compared with 45 age-matched and sex-matched healthy children and adolescents. There was a significantly higher prevalence of psychological stressful effect among the healthy children group than the oncological pediatric patients. The psychological effect related to malignancy diagnosis was significantly higher than the psychological effect related to COVID-19.
Conclusion COVID-19 pandemic is a stressful event; however, the psychological effect related to cancer diagnosis among the oncological patients showed a higher stressful effect.

Keywords: cancer, COVID-19, pediatric, stress

How to cite this article:
Elraheem Ali HG, Aziz AW, Abdelmageed RI, Sayed SM. Stress effect of COVID-19 pandemic among Egyptian children and adolescents with malignancy: a single-center experience. Egypt J Haematol 2021;46:195-200

How to cite this URL:
Elraheem Ali HG, Aziz AW, Abdelmageed RI, Sayed SM. Stress effect of COVID-19 pandemic among Egyptian children and adolescents with malignancy: a single-center experience. Egypt J Haematol [serial online] 2021 [cited 2022 Aug 13];46:195-200. Available from: http://www.ehj.eg.net/text.asp?2021/46/4/195/345386

  Introduction Top

COVID-19 started in December 2019 as a viral outbreak in Wuhan City of central Hubei Province of China [1]. On February 11, the WHO announced a name for the new coronavirus disease: COVID-19 [2]. On March 11, the WHO declared COVID-19 as a pandemic, as by then ∼114 countries were affected [2].

Changes in daily life have been swift and unprecedented, owing to the surge in the cases of the virus surge, escalation in the death toll, and implementation of draconian measures to contain the disease’s spread increase across regions of the globe. Although there has been substantial attention to measures to identify people with the coronavirus infection, identifying the mental health care needs of people affected by this pandemic has been relatively neglected [3].

The concerns in society generally affect everyone to variable extents. The current evidence suggests that persons who are kept in quarantine develop significant distress in the form of anxiety, anger, and post-traumatic stress symptoms [4].

Fear and stress are usual psychological responses during devastating circumstances [5]. However, the excessive persistent stress with social isolation can act as a role for developing a pathological mental state [6].

The influence of pediatric oncology is huge [7]. Children have challenges in coping with the stresses of chemotherapy and radiation [8]. Children with malignancy have many psychosocial problems and need an exceptional method to intellectualize the concerns they face [8],[9],[10],[11],[12]. Psychosocial effects can express as increased amounts of depression, fear, and worries about mortality [11],[13].

Although the concentration on the outcomes of the COVID-19 pandemic has primarily centered on adult patients, children, particularly those in high-risk groups such as the immunocompromised, are also affected psychologically and physically. Bouffet et al. [14] emphasized the need for critical preparation to protect the pediatric malignancy population by sharing experiences regarding the effect of the pandemic with these patients.

  Patients and methods Top

A case–control study was performed in the interval from June 2020 to August 2020. It comprised 46 children and adolescents with a confirmed diagnosis of malignancy who were enrolled from the pediatric oncology clinic. Moreover, 45 age-matched and sex-matched healthy children from the outpatient clinic were joined in this study as a control group. Patients with known intellectual impairment, those taking any psychopharmacological drugs, patients with any related genetic syndromes, and those with chronic illnesses were excluded.

All patients and control enrolled in the current study were subjected to the following: thorough history taking (name, age, sex, educational, and socioeconomic levels) and physical symptoms related to COVID-19 infection over the last 14 days (fever, chills, headache, myalgia, cough difficulty in breathing, sore throat, etc.).

Data about disease status in patients’ group were collected from their files, including type of cancer, site, risk, stage, on treatment or survival, type of treatment curative or palliative, treatment modalities (chemotherapy, radiotherapy, or both), surgical treatment, or bone marrow transplantation.

Data from confirmed cases with COVID-19 were collected and included time from start symptom till diagnosis, severity, place of isolation, treatment modalities, median recovery time, and contact history.

Data asking about precautionary measures against COVID-19, the average number of hours staying at home per day to avoid COVID-19, and whether they felt too much, unnecessary worry had been made about the COVID-19 epidemic were included.

The psychological effect of COVID-19 was assessed using the Arabic form of the Children’s Revised Impact of Event Scale (CRIES-13), which is a self-reporting screening method for post-traumatic stress disorder (PTSD) that can be used in children aged eight years and older [15]. The CRIES-13 comprises four items that measure intrusion, four items that measure avoidance, and five additional items that measure arousal. Items are scored on a nonlinear scale as follows: 0 (not at all), 1 (rarely), 3 (sometimes), and 5 (often), with no reversed items. The scale scores range from 0 to 65, with higher values indicating more PTSD symptoms. The revised scale showed to have good psychometric properties in previous studies [16],[17]. The cut-off score for screening cases of PTSD is 30 or above. We used the Arabic version of CRIES-13 and showed high reliability in previous studies [18].

This study was approved by the Ethics Committee of Ain Shams University Hospitals (Ethical Committee No. FMASU R /111).

Statistical analysis

Statistical analysis was performed using a Statistical Program for the Social Sciences version 25.0 (SPSS; SPSS Inc., Chicago, Illinois, USA). Quantitative data were expressed as mean±SD. The Student t-test was used to compare two means. Qualitative data were expressed as frequency and percentage. χ2-test with Fisher’s exact test, if needed, was used to compare proportions between two qualitative parameters. So, the P value was considered significant at the level of less than 0.05.

  Results Top

Characteristics of participants (patients and controls)

The study’s sample consisted of 46 patients with a confirmed diagnosis of cancer, with a mean age of 11.76±3.31 years. There were 30 (65.2%) male and 16 (34.8%) female patients, who were compared with 45 age-matched and sex-matched healthy children and adolescent.

Disease status among the patient group

Among the patient group, seven (15.2%) patients were survivors [six out of seven (85.7%) had leukemia one of them was a post-transplant patient, and one of seven (14.2%) with Hodgkin lymphoma, who also was a post-transplant patient]. A total of 39 (84.7%) patients were on treatment. Most of them [29 (74.3%)] had leukemia [23 (79.3%) had acute lymphoblastic leukemia pre-B, two (6.8%) had T-cell leukemia, three (10.3%) had acute myeloid leukemia, and one patient (3.4%) had chronic myeloid leukemia], followed by five (12.8%) patients had lymphoma, two (5.1%) patients with osteosarcoma, and one (2.5%) patient each with Ewing sarcoma, neuroblastoma, and medulloblastoma.

Most patients [35 (76.1%)] were on chemotherapy, whereas only one with low-risk rhabdomyosarcoma (2.2%) was on both chemotherapy and radiotherapy. Four patients (8.7%) underwent surgery during the COVID-19 pandemic, but one patient (2.2%) with osteosarcoma had her surgery delayed.

Awareness and attitude toward coronavirus

Most of the participants were aware of the basic elements of the disease and the method of spread. Of the total patients, 27 (58.7%) felt too much unnecessary worry had been made about the COVID-19 epidemic in comparison with 36 (80.0%) in the control group, with a significant difference, as P value of 0.028. However, patients were more adherent to the precaution measures; 31 (67.4%) patients had the concept of wearing a mask regardless of the presence or absence of symptoms VS 16 (35.6%) in the control group, with P value of 0.002. Most of the participant patients and controls (84.8 and 91%, respectively) acknowledged that washing hands frequently could stop the spread of infection.

There was no significant difference between the two groups regarding other measures like avoidance of sharing of utensils, covering mouth when coughing and sneezing, or washing hands immediately after coughing, sneezing, or rubbing the nose.

The mean number of hours staying at home per day to avoid COVID-19 in patients and controls was 21.98±2.47 and 21.22±3.86, respectively, with no significant difference, with P value of 0.268.

COVID-19 infection status

Of 36 symptomatic patients tested for COVID-19, 10 (27.8%) patients were found to be positive for the SARS-CoV-2 by NP swab: five (50%) of them had mild disease and five (50%) had moderate disease. All of them were isolated at the hospital, and they received only medical treatment with no need for ICU admission leading to the proposition that a SARS-CoV-2 infection might be expressed as mild to moderate disease in children with cancer.

In contrast, of 45 control children and adolescents, only three (6.6%) were symptomatic and suspected to have COVID-19 infection, where one (33.3%) of them was found to be positive by NP swab, and the three were isolated in their home and improved on medical treatment.

There was no significant difference in median recovery time between patients with cancer with COVID-19 infection and controls with COVID-19 infection (19.00±10.98 and 13.50±0.71, respectively, with P=0.541).

The psychological effect of COVID-19 outbreak

The psychological effect of the COVID-19 pandemic measured using the CRIES-R scale among oncological patients showed a median score of 17.5 (10–25), which was statistically significantly less than the median score of control group [25 (20–33)], with a P value of 0.000. Of all participants, only seven (15.2%) from the oncological patients described possible psychological effects (score >30) versus 17 (37.8%) from the control group, which was also statistically significant, with P of 0.015. Regarding the scoring of subscales of avoidance and intrusion, both were highly significantly greater in the control group than the oncological patients (P=0.00) ([Table 1]).
Table 1 Comparison between patient group and control group regarding Children’s Revised Impact of Event scale crises-13 related to COVID-19

Click here to view

The psychological effect related to cancer diagnosis among the oncological patients showed a higher statistically significant median score of 39 (31–51), in comparison with the psychological effect of COVID-19 pandemic score of 17.5, with a P value less than 0.001. Most of the participants [38 (82.6%)] showed possible psychological effects (score >30). ([Table 2]).
Table 2 Comparison between effect of COVID-19 and effect of malignancy diagnosis among malignant patient group

Click here to view

  Discussion Top

The mental health outcomes of biological catastrophes have been explored a lot in the preceding years. Several studies described PTSD as a frequent mental health challenge among survivors. Children are susceptible to develop traumatic stress after facing an environmental catastrophe [17].

An international pediatric oncology society offered data on COVID-19 incidence in nearly 10,000 children cured with chemotherapy or prolonged immunosuppression. Of 200 manifested children tested, only 8 children were discovered to be positive for the SARS-CoV-2, leading to the suggestion that a SARS-CoV-2 infection might be detected as a mild form in children with cancer [19]. In our study, of 36 symptomatic children tested for COVID-19, 10 (27.8%) patients were shown to be positive for the SARS-CoV-2 by NP swab, where five (50%) of them had mild disease and five (50%) had a moderate disease. Two latest studies reported that patients with cancer are at a high risk of more severe infection and consequent difficulties [17],[20].

COVID-19 can cause distress, which may be of augmented intensity in susceptible patients, like oncology patients. Patients with cancer feel lonely and can feel guilty if their caregivers introduced support in daily living actions, which can be countered to the suggested social separation [21]. Quarantine, a general actuality through the COVID-19 outbreak, may trigger stressful events, particularly when applied for extended times [4]. The social separation and the necessity to ‘stay at home’ trigger isolation, which is associated with an increased risk of death in patients with cancer [22],[23]. It is known that apparent hesitation increases personal expressive distress, and this, in sequence, has negative effects on clinical consequences in oncology patients [24],[25].

So, our aim in this study was to measure the COVID-19 pandemic-related psychological stress effect on children with an oncology disease in comparison with their healthy peers.

We found a significantly higher prevalence of psychological stressful effect among the healthy children group than the oncological pediatric patients, and this was contrary to several studies that found patients with cancer are at higher risk for CoVID-19 pandemic effect; for example, a recent research study in patients with cancer in Milan, which involved young participants, revealed that a large proportion of patients with cancer were worried and felt at risk of serious sequelae, with their parents’ concern for them as an additional burden [26].

However, our results come in concordance with a study done by Cakiroglu et al. [27], who studied the anxiety level of children with a hematology-oncology disease to COVID-19 pandemic and surprisingly found their anxiety levels did not differ from the healthy control group.

These findings could be explained by that perhaps children with cancer who have experienced the fear of disease before have developed more adaptive strategies to manage future crises compared with healthy children [28].

The present study found that the psychological effect related to malignancy diagnosis was significantly higher than that of COVID-19. This matches with the literature, which suggests that hematology-oncology disease raises psychological stress owing to fear of death, frequent hospitalizations, and the physical burdens of treatment [29].

  Conclusion Top

Our results highlight acute medical emergencies may last many months and may be years, and therefore, until we have an effective preventive or curative treatment for COVID-19, the primary focus would continue to be manpower development and resource allocation for detection and management of active cases. However, at the same time, we cannot ignore the psychological aspect of this pandemic. So, we recommend generating evidence by well-conducted studies, delivering active psychological and psychiatric intervention to those in need.

Study limitation

The present study was a hospital-based case–control study that included a small number of participants from one center. Therefore, it may not represent the actual scenario of the epidemiological variables in the community.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Holshue ML, DeBolt C, Lindquist S, Lofy KH, Wiesman J, Bruce H et al. Washington State 2019-nCoV Case Investigation Team. First Case of2019 Novel Coronavirus in the United States. N Engl J Med 2020; 382:929–936.  Back to cited text no. 1
WHO, Rolling updates on coronavirus disease (COVID-19). 2020c. Available at: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/events-as-they-happen [Accessed March 31, 2020].  Back to cited text no. 2
Xiang Y, Yang Y, Li W, Zhang L, Zhang Q, Cheung T, Ng CH. Timely mental health care for the2019 novel coronavirus outbreak is urgently needed. Lancet 2020; 7:228–229.  Back to cited text no. 3
Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, Rubin GJ. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet 2020; 395:912–920.  Back to cited text no. 4
Dong L, Bouey J. Public mental health crisis during COVID-19 pandemic, China. Emerg Infect Dis 2020; 26:1616–1618.  Back to cited text no. 5
Goyal K, Chauhan P, Chhikara K, Gupta P, Singh MP. Fear of COVID 2019: first suicidal case in India!. Asian J Psychiatry 2020; 49:101989.  Back to cited text no. 6
Li HC, Chung OK, Chiu SY. The impact of cancer on children’s physical, emotional, and psychosocial well-being. Cancer Nurs 2010; 33:47–54.  Back to cited text no. 7
McCaffrey CN. Major stressors and their effects on the well-being of children with cancer. J Pediatr Nurs 2006; 21:59–66.  Back to cited text no. 8
Fochtman D. Phenomenology in pediatric cancer nursing research. J Pediatr Oncol Nurs 2008; 25:185–192.  Back to cited text no. 9
Ensk̈ar K, von Essen L. Physical problems and psychosocial function in children with cancer. Pediatric Nurs 2008; 20:37–41.  Back to cited text no. 10
Cantrell MA. The art of pediatric oncology nursing practice. J Pediatr Oncol Nurs 2007; 24:132–138.  Back to cited text no. 11
Yeh CH, Wang YF. Competence of and emotional/behavioral problems in pediatric oncology patients in Taiwan. Cancer Nurs 2004; 27:413–422.  Back to cited text no. 12
Savage E, Riordan AO, Hughes M. Quality of life in children with acute lymphoblastic leukemia: a systematic review. Eur J Oncol Nurs 2009; 13:36–48.  Back to cited text no. 13
Bouffet E, Challinor J, Sullivan M, Biondi A, Rodriguez-Galindo C, Pritchard-Jones K. Early advice on managing children with cancer during the COVID-19 pandemic and a call for sharing experiences. Pediatr Blood Cancer 2020; 67:e28327.  Back to cited text no. 14
Perrin S, Meiser-Stedman R, Smith P. The Children’s Revised Impact of Event Scale (CRIES): validity as a screening instrument for PTSD. Behav Cogn Psychother 2005; 33:487–498.  Back to cited text no. 15
Smith P, Perrin S, Dyregrov A, Yule W. Principal components analysis of the impact of event scale with children in war. Pers Individ Dif 2003; 34:315–322.  Back to cited text no. 16
Zhang N, Zhang YQ, Wu KK, Zhu ZH, Dyregrov A. Factor structure of the Children’s Revised Impact of Event Scale among children and adolescents who survived the2008 Sichuan earthquake in China. Scand J Psychol 2011; 52:236–241.  Back to cited text no. 17
Thabet AA, Abu Tawahina AA, Sarraj E, Vostanis P. Exposure to war trauma and PTSD among parents and children in the Gaza Strip. Eur Child Adolesc Psychiatry 2008; 17:191–199.  Back to cited text no. 18
Hruska O, Kalina T, Wolf J, Balduzzi A, Provenza M, Rizzardi C et al. Flash survey on severe acute respiratory syndrome coronavirus-2 infections in pediatric patients on anticancer treatment. Eur J Cancer 2020; 132:11–16.  Back to cited text no. 19
Liang W, Guan W, Chen R, Wang W, Li J, Xu K et al. Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China. Lancet Oncol 2020; 21:335–337.  Back to cited text no. 20
Sirintrapun SJ, Lopez AM. Telemedicine in cancer care. Am Soc Clin Oncol Educ Book 2018; 38:540–545.  Back to cited text no. 21
D’Ippolito S, Ambrosini E, Shams M, Calì G, Pastorelli D. The effect of loneliness on cancer mortality. Ann Oncol 2017; 28:vi82.  Back to cited text no. 22
Hill EM, Hamm A. Intolerance of uncertainty, social support, and loneliness in relation to anxiety and depressive symptoms among women diagnosed with ovarian cancer. Psychooncology 2019; 28:553–560.  Back to cited text no. 23
Bortolato B, Hyphantis TN, Valpione S, Perini G, Maes M, Morris G et al. Depression in cancer: the many biobehavioral pathways driving tumor progression. Cancer Treat Rev 2017; 52:58–70.  Back to cited text no. 24
Reis JC, Antoni MH, Travado L. Emotional distress, brain functioning, and biobehavioral processes in cancer patients: a neuroimaging review and future directions. CNS Spectr 2020; 25:79–100.  Back to cited text no. 25
Casanova M, Pagani Bagliacca E, Silva M, Patriarca C, Veneroni L, Clerici CA et al. How young patients with cancer perceive the COVID‑19 (coronavirus) epidemic in Milan, Italy: is there room for other fears?. Pediatr Blood Cancer 2020; 67:e28318. doi: 10.1002/pbc.28318. Epub 2020 Apr 22. PMID: 32240567.  Back to cited text no. 26
Cakiroglu S, Yeltekin C, Fishin T, Oner OB, Aksoy BA, Bozkurt C. Are the anxiety levels of pediatric hematology-oncology patients different from healthy peers during the COVID-19 outbreak? J Pediatr Hematol Oncol 2021; 43:e608–e612. doi: 10.1097/MPH.0000000000001924. PMID: 32852396.  Back to cited text no. 27
Senkalfa BP, Eyuboglu TS. Effect of the COVID-19 pandemic on anxiety among children with cystic fibrosis and their mothers. Pediatr Pulmonol 2020; 55:2128–2134.  Back to cited text no. 28
Günay O, Sevinç N, Arslantaş EE. State and trait anxiety levels among mothers of inpatient children and related factors. Turk J Public Health 2017; 15:176.  Back to cited text no. 29


  [Table 1], [Table 2]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Patients and methods
Article Tables

 Article Access Statistics
    PDF Downloaded75    
    Comments [Add]    

Recommend this journal