N , total number of qualified subjects for evaluation; n(%), frequency (percentage of frequency); 95% CI, 95% confidence interval. M ±SD, average ± standard deviation.

Discussion

To our knowledge, there have been no studies on the status of asthma control, exacerbation and treatment during the COVID-19 pandemic. Although the current COVID-19 pandemic may fade away and hopefully a vaccine may be eventually available, it is unavoidable that new respiratory viruses will appear and that similar pandemics will happen in the future13. Guidance on how to manage patients with asthma during the pandemic is strongly needed. Our survey was conducted to comprehensively evaluate the status of asthma control, medication and compliance, and healthcare resource use in Beijing during the COVID-19 pandemic.
Our survey found that, during the COVID-19 pandemic, in 89.3% of the patients, asthma remained controlled as defined by GINA, which is higher than the results of general population before the pandemic. A multi-center, retrospective, cross-sectional study in China14 indicated that less than one-third (28.7%) of the patients had controlled asthma, and the control rate in Beijing was 31.4%. We speculate that this might be due to social distancing and mandatory closure of places where aggregation may occur, stepped-up public hygiene measures and the wearing of masks during the COVID-19 pandemic, thereby reducing contact with allergens and viruses. Interestingly, a database survey in the US, in which data were collected from a digital platform that tracked inhaler use through electronic medication monitors and sent alerts to patients for missed doses, found that adherence to asthma controller inhaler use had improved during COVID-19 pandemic15.
During the COVID-19 pandemic, 25.6% of our patients experienced an acute attack of asthma, which is more than the general population before the COVID-19 pandemic. A cross-section study in China showed that the proportion of people with asthma experiencing an exacerbation (including an ED visit) in the previous year before the study was 15.5%4. A questionnaire-based survey14 showed that the rate of ED visit and hospitalization in Beijing in one year was 25.8% and 12.2%, respectively. In our survey, during the year before the COVID-19 pandemic, 6.7% of the patients visited ED and 4.5% of the patients were hospitalized due to exacerbations of asthma. But during the COVID-19 pandemic, only 1.1% of the patients visited ED, and no one was hospitalized. Indeed, during the outbreak of SARS in Singapore, the incidence of acute respiratory infections and acute asthma attacks (triggered by respiratory viruses) declined dramatically16. The patients enrolled in our study had a higher rate of asthma exacerbation but lower rates of ED visit and hospitalization. It is not surprising to see that 32.4% of them worried about the risk of exposure to SARS-CoV-2 in the hospital, although most patients (67.6%) regarded their symptoms as not severe and could be relieved by self-management with asthma medication.
In our survey, the majority of the patients (85.6% before and 91.4% during the COVID-19 pandemic, respectively) used ICS plus LABA as maintenance therapy, which is consistent with guideline recommendations10, 12, 17. Indeed, there is no evidence regarding whether currently available asthma and allergy treatments, including antihistamines, corticosteroids and bronchodilators increase the susceptibility to or severity of COVID-191. On the contrary, it may be more likely that a patient with asthma would have an exacerbation from other causes, including seasonal pollen exposure or a virus other than SARS-CoV-2 if they stopped regular use of indicated controller therapy. An exacerbation may drive asthmatic patients to seek medical treatment, which would put them at increased risk of being exposed to SARS-CoV-2 during the current pandemic12. Continuing the original treatment plan is supported by multiple international organizations1, 12, 18. Because the use of nebulized therapy is more likely to aerosolize SARS-CoV-2 and increase the risk of contagion, asthma therapy delivered by metered dose inhaler or dry powder inhaler, for example, ICS plus LABA, would be most appropriate both in the health care setting and at home19-21.
Also of note is that, during the COVID-19 pandemic, 13.5% of our patients had worried about insufficient maintenance medications, among whom 45.8% (11/24) had reduced medication dosing for this reason, and 27.3% (3/11) of them experienced asthma aggravation. At the very beginning of the spreading of COVID-19 in Beijing, the medical insurance sector had informed healthcare providers that, for patients with chronic diseases, such as asthma and COPD, medications for maintenance therapy per prescription could be increased from 2 weeks to up to 3 months, hoping that this contingency measure could reduce medical visits and potential cross-infection in the hospital.
Experts recommend the use of telehealth in asthma treatment within a risk-stratified context of the SARS-CoV-2 pandemic12. However, in our interview, only a few patients used online consultation during the COVID-19 pandemic. Telehealth can limit exposure to SARS-CoV-2 and provide access to rapid evaluation for potential COVID-19 infection and status of asthma control. Patients with mild-to-moderate or well-controlled asthma were encouraged to use digital medicine services including phone, video, and email consults22-24. Outpatient service should be prioritized for patients who have poorly controlled asthma, have worsening asthma symptoms, or who have required dose escalations of their asthma medications in the past several months’ time12.
Since our survey was cross-sectional, no definite conclusion can be drawn about the causal relationship between risk factors and uncontrolled asthma. The enrollment of study participants was largely dependent on patients’ willingness to be surveyed. These participants may be more compliant to therapy and have well-controlled asthma, which might result in selection bias, and therefore the proportion of patients with poorly controlled disease may be underestimated. However, since the participants were enrolled from a tertiary hospital, it is likely that the symptoms of these patients were more severe. Moreover, the study was carried out in spring (from January 25 to April 25) when seasonal aeroallergens, and other respiratory viruses were also prevalent25, which may be associated with higher asthma exacerbation.
In conclusion, our survey revealed the status of asthma control, exacerbations, self-management and healthcare utilization during the COVID-19 pandemic in Beijing, which supports the recommendation that patients continue taking their prescribed asthma medications as usual and maintain good asthma control during the ongoing pandemic. While social distancing is being encouraged, measures should be taken to mitigate the negative impact on asthma.

Acknowledgments

This study was supported by the National Natural Science Foundation of China. [No. 81970028]

Conflict of interest

The authors declare that they have no relevant conflicts of interest.

Author Contributions

Chang Chun: Conceptualization, Methodology, Writing - Original Draft, Supervision, Project administration, Funding acquisition.
Zhang Linlin: Formal analysis, Investigation, Data Curation, Writing - Original Draft.
Dong Fawu: Formal analysis, Investigation, Data Curation, Writing - Original Draft.
Liang Ying: Investigation, Data Curation.
Chen Yahong: Investigation, Data Curation.
Shang Ying: Investigation, Data Curation.
Abulikemu Mairipaiti: Investigation, Data Curation.
Sun Yongchang: Conceptualization, Writing- Reviewing and Editing.

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