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.
References
- Global Initiative for Asthma. Global Strategy for Asthma Management
and Prevention, 2020. Available from:https://ginasthma.org/. Accessed
May 9, 2020.
- World Health Organization. Coronavirus disease 2019 (COVID-19)
situation report. Available from:https://www.who.int/emergencies/diseases/novel-coronavirus-2019.
Accessed May 10, 2020.
- Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and
risk factors for mortality of adult inpatients with COVID-19 in Wuhan,
China: a retrospective cohort study. Lancet .
2020;395(10229):1054‐1062. doi:10.1016/S0140-6736(20)30566-3
- Huang K, Yang T, Xu J, Yang L, Zhao J, Zhang X, et al. Prevalence,
risk factors, and management of asthma in China: a national
cross-sectional study. Lancet . 2019;394(10196):407‐418.
doi:10.1016/S0140-6736(19)31147-X
- Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epidemiological
and clinical characteristics of 99 cases of 2019 novel coronavirus
pneumonia in Wuhan, China: a descriptive study. Lancet .
2020;395(10223):507‐513. doi:10.1016/S0140-6736(20)30211-7
- Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features
of patients infected with 2019 novel coronavirus in Wuhan,
China. Lancet . 2020;395(10223):497‐506.
doi:10.1016/S0140-6736(20)30183-5
- Zhang JJ, Dong X, Cao YY, Yuan YD, Yang YB, Yan YQ, et al. Clinical
characteristics of 140 patients infected with SARS-CoV-2 in Wuhan,
China. Allergy . 2020;10.1111/all.14238. doi:10.1111/all.14238
- Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical
Characteristics of 138 Hospitalized Patients With 2019 Novel
Coronavirus-Infected Pneumonia in Wuhan, China. JAMA .
2020;323(11):1061‐1069. doi:10.1001/jama.2020.1585
- Garg S, Kim L, Whitaker M, O’Halloran A, Cummings C, Holstein R, et
al. Hospitalization Rates and Characteristics of Patients Hospitalized
with Laboratory-Confirmed Coronavirus Disease 2019 - COVID-NET, 14
States, March 1-30, 2020. MMWR Morb Mortal Wkly Rep .
2020;69(15):458‐464. Published 2020 Apr 17. doi:10.15585/mmwr.mm6915e3
- National Institute for Health and Care Excellence. COVID-19 rapid
guideline: severe asthma. Available from:https://www.nice.org.uk/guidance/ng166.
Accessed May 9, 2020.
- National Health Service. Clinical guide for the management of
respiratory patients during the coronavirus pandemic. Available from:https://www.england.nhs.uk/coronavirus/publication/specialty-guides/.
Accessed May 9, 2020.
- Shaker MS, Oppenheimer J, Grayson M, Stukus D, Hartog N, Hsieh E, et
al. COVID-19: Pandemic Contingency Planning for the Allergy and
Immunology Clinic. J Allergy Clin Immunol Pract .
2020;8(5):1477‐1488.e5. doi:10.1016/j.jaip.2020.03.012
- Brough HA, Kalayci O, Sediva A, Untersmayr E, Munblit D, Rodriquez Del
Rio P, et al. Managing childhood allergies and immunodeficiencies
during respiratory virus epidemics - the 2020 COVID-19
pandemic. Pediatr Allergy Immunol . 2020;10.1111/pai.13262.
doi:10.1111/pai.13262
- Su N, Lin J, Chen P, Li J, Wu C, Yin K, et al. Evaluation of asthma
control and patient’s perception of asthma: findings and analysis of a
nationwide questionnaire-based survey in China. J Asthma .
2013;50(8):861‐870. doi:10.3109/02770903.2013.808346
- Kaye L, Theye B, Smeenk I, Gondalia R, Barrett MA, Stempel DA. Changes
in medication adherence among patients with asthma and COPD during the
COVID-19 pandemic. J Allergy Clin Immunol Pract .
2020;S2213-2198(20)30412-8. doi:10.1016/j.jaip.2020.04.053
- Van Bever HP, Chng SY, Goh DY. Childhood severe acute respiratory
syndrome, coronavirus infections and asthma. Pediatr Allergy
Immunol . 2004;15(3):206‐209. doi:10.1111/j.1399-3038.2004.00137.x
- Global Initiative for Asthma. Recommendations for Inhaled Asthma
Controller Medications. Available from:https://ginasthma.org/recommendations-for-inhaled-asthma-controller-medications/.
Accessed May 9, 2020.
- Centers for Disease Control and Prevention. Severe acute respiratory
distress syndrome. Available from:https://www.cdc.gov/sars/.
Accessed May 9, 2020.
- Amirav I, Newhouse MT. Re Transmission of coronavirus by nebulizer—a
serious underappreciated risk! Available from:https://www.cmaj.ca/content/re-transmission-corona-virus-nebulizer-serious-underappreciated-risk.
Accessed May 9, 2020.
- van Dormalen N, Bushmaker T, Morris D, Holbrook M, Gamble A,
Williamson B, et al. Aerosol and surface stability of HCoV-19
(SARS-COV-2) compared to SARS-CoV-1. Available
from: https://doi.org/10.1101/2020.03.09.20033217.
Accessed May 9, 2020.
- Desai M, Oppenheimer J, Lang DM. Immunomodulators and Biologics:
Beyond Stepped-Care Therapy. Clin Chest Med .
2019;40(1):179‐192. doi:10.1016/j.ccm.2018.10.011
- Malipiero G, Paoletti G, Puggioni F, Racca F, Ferri S, Marsala A, et
al. An academic allergy unit during COVID-19 pandemic in
Italy. J Allergy Clin Immunol . 2020;S0091-6749(20)30489-9.
doi:10.1016/j.jaci.2020.04.003
- Centers for Disease Control and Prevention (U.S.). Coronavirus Disease
2019 (COVID-19)/People Who Need Extra Precautions/People Who Are At
Higher Risk/People with Moderate to Severe Asthma. Available from:https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/index.html.
Accessed May 9, 2020.
- Abrams EM, Szefler SJ. Managing Asthma during Coronavirus
Disease-2019: An Example for Other Chronic Conditions in Children and
Adolescents. J Pediatr . 2020;S0022-3476(20)30528-X.
doi:10.1016/j.jpeds.2020.04.049
- Teach SJ, Gergen PJ, Szefler SJ, Mitchell HE, Calatroni A, Wildfire J,
et al. Seasonal risk factors for asthma exacerbations among inner-city
children. J Allergy Clin Immunol . 2015;135(6):1465‐73.e5.
doi:10.1016/j.jaci.2014.12.1942