COVID-19, Asthma and Equity: What We’re Learning and Doing

With the COVID-19 outbreak, we hope you, your families and your communities remain healthy. These are extraordinary and exceedingly stressful times, and we see the many impacts the coronavirus is having on our colleagues – both personally and as stakeholders working to reduce the burden of asthma.

As we at RAMP continue to work toward our mission during this new reality, click here to learn what we’re doing to help keep communities healthy.

We also want to share what we’re learning about the implications of COVID-19 on people with asthma. Below is some summary information, supplemented by emerging research.  We’ll update this webpage regularly.

COVID-19 and asthma

While our understanding of the virus is evolving, data suggest that people with asthma are not more susceptible to contracting COVID-19. Are people with asthma at greater risk for becoming severely ill if they do contract COVID-19? The World Health Organization and U.S. Centers for Disease Control and Prevention say that people with moderate to severe asthma may be at higher risk of getting very sick from COVID-19. But, at this point in time, the current body of research—which is growing by the day—is less conclusive.

What we know for sure is that people with asthma should take precautions with any respiratory virus. That includes the precautions that everybody should be taking— social distancing, washing hands, avoiding touching the face, etc. It also includes keeping asthma well controlled through following medication regimens and avoiding or reducing exposure to environmental asthma triggers.

Regarding medications, there has been a lot written about the use of oral steroids in recent medical literature on COVID- 19. Oral steroids are prescribed by doctors to reduce inflammation in the lungs, which is present in people with COVID-19. However, oral steroids impair the immune system’s ability to fight the virus and indeed experts say that use of oral steroids for COVID-19 could cause significant harm. But, oral steroids remain an important tool for people with asthma when their asthma is severely out of control. Doctors agree that, in those cases, it’s still important to use them. This means that it’s more important now than ever to help individuals keep their asthma well controlled by following medical providers’ instructions, including using inhaled corticosteroids to keep inflammation down.

Of course, reducing exposure to environmental asthma triggers is also an important piece of asthma management. A lot of common household cleaners are respiratory irritants. In fact, bleach has been labeled an asthmagen, meaning it can cause asthma in otherwise healthy people. As grocery stores struggle to keep cleaning products on their shelves, we know that the use of cleaning products has increased. We can help increase awareness of the risks among families affected by asthma and help them identify asthma-friendlier alternatives. See below for practical suggestions.

Another asthma-related challenge is that certain areas of the country are experiencing shortages of albuterol inhalers due to their increased use in hospitals for COVID-19 and suspected COVID-19 patients to help with respiratory issues. If people with asthma have difficulty filling albuterol prescriptions, they should work with their clinicians. Of course, it’s important to not overuse albuterol, which underscores the importance of keeping asthma under control by using inhaled corticosteroids and avoiding triggers.

For additional information about COVID-19 and asthma, we recommend the following websites:

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COVID-19’s inequitable impacts

While the data are evolving, in some communities we’re seeing rates of hospitalizations and deaths from COVID-19 that are disproportionately high for low-income communities and communities of color.

Frankly, we’re not surprised. Low-income communities and communities of color have higher rates of preexisting health conditions, some of which put people at higher risk for poor COVID-19 outcomes. But more to the point, as with asthma and most public health issues, inequitable social and environmental conditions are likely driving these disparate outcomes.

Low-income individuals, for example, are more likely to live in multi-generational or multi-family households to help make ends meet, thus increasing risks of spread of disease. They’re also more likely to work in service jobs where they may be more at risk of exposure, less likely to have paid sick leave, and more likely to face reduced hours or lay-offs. They’re also more likely to be uninsured or underinsured making access to essential care more challenging.

The inequitable burden of air pollution is also likely playing a role. For example, a study from Harvard University shows a slight increase in particulate matter (PM2.5) is associated with a 8% increase in deaths due to COVID-19. Another study in the journal Science in the Total Environment found an association between higher levels of nitrogen dioxide and increased deaths due to COVID-19. Yet another study showed an association between an increase in PM2.5 and COVID-19 cases and hospital admissions. An abundance of research has shown that air pollution is often higher in low-income communities and communities of color.

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Emerging research

Study Suggests Type of Asthma (Allergic vs. Non-allergic) Impacts COVID-19 Severity in Adults
Posted August 3, 2020
Researchers Zhu et al from the Harvard T.H. Chan School of Public Health and Massachusetts General Hospital analyzed data from 492,768 participants in the UK Biobank, which stores biologic samples from participants and is linked to their medical records. The researchers found 65,677 participants had asthma and 641 patients had severe COVID-19. “After adjusting for age, sex, body mass index, and other factors, the researchers found that having non-allergic asthma increased the risk of severe COVID-19 by as much as 48%. They also found that the risk of severe COVID-19 increased by as much as 82% among people with asthma and chronic obstructive pulmonary disease. Importantly, however, the study showed that people with allergic asthma had no statistically significant association with severe COVID-19.” The researchers published their results in the Journal of Allergy and Clinical Immunology in June.

Philanthropy’s Response to COVID-19 and Inequalities 

Posted July 27, 2020
In a Viewpoint published on July 23, 2020 in the Journal of the American Medical Association, the president of the Ford Foundation, Darren Walker, connects the disproportionate impacts on low-income communities and communities of color from COVID-19 with broader inequities and racism in our economy, policing and other systems. He calls on philanthropic and other wealthy organizations to meet these tumultuous times with larger and ever more generous contributions. “[F}oundations also are obligated by law to improve the economic and political systems that created the imbalance of wealth. Today, at this moment of unprecedented, intersecting crises, this obligation has never been greater, or more important. Foundations have the responsibility to take real and meaningful action.” He notes, for example, the Ford Foundation’s recent and groundbreaking move to finance one billion dollars in grant-making through the sale of bonds, and other major foundations are taking similarly unusual steps. “This is only the beginning. If the ultimate goal is to build a better, fairer society for all, other industries and sectors also must think and act creatively. Influential individuals and institutions in other systems and arenas must take their own bold steps toward justice.” He also argues for similarly new approaches across sectors: “What if substantially resourced private hospitals could consistently dispatch physicians, other clinicians, protective gear, and medical equipment to cash-strapped clinics in rural areas? What if thriving, affluent school districts redistributed classroom resources to neighboring schools desperate for funds? What if global corporations with large profit margins injected capital directly into locally owned shops and restaurants, particularly in communities of color?” Read the full Viewpoint here.

Largest Cohort Study Yet Affirms No increased Mortality with COVID-19 in Asthma Patients
Posted July 20, 2020
On July 8, 2020, in the journal Nature, authors Elizabeth J. Williamson et al, reviewed results of the largest cohort study conducted by any country to date. They looked at risk factors connected to 10,926 COVID-19 deaths in the UK. They found that “COVID-19-related death was associated with: being male….; older age and deprivation (both with a strong gradient); diabetes; severe asthma; and various other medical conditions.” As explained by the COVID-19 Response Task Force of the American Academy of Allergy, Asthma, and Immunology, the study results suggested that asthma patients who had received oral steroids (OCS) in the past year also had increased mortality. They state, “However, when the data were limited to those in whom BMI, smoking history, and ethnicity were known (and, thus, could be controlled for), asthma with or without OCS use did not demonstrate a significant increased risk for death from COVID-19. Therefore, even with this paper, the preponderance of published data continues to demonstrate no increased severity or mortality with COVID-19 in asthma patients.”

Scientists Advocate for More Attention on the Role of Airborne Transmission of COVID-19
Posted July 13, 2020
On July 6th, authors Lidia Morawska and Donald K. Milton published, “It is Time to Address Airborne Transmission of COVID-19.

Signed by 239 scientists, the stated purpose of the publication is: “We appeal to the medical community and to the relevant national and international bodies to recognize the potential for airborne spread of COVID-19. There is significant potential for inhalation exposure to viruses in microscopic respiratory droplets (microdroplets) at short to medium distances (up to several meters, or room scale), and we are advocating for the use of preventive measures to mitigate this route of airborne transmission.” The authors explain that multiple studies have demonstrated that viruses are released during exhalation, talking, and coughing in microdroplets small enough to remain aloft in air and pose a risk of exposure at distances beyond 1 to 2 m from an infected individual.  This poses the risk that people sharing environments can potentially inhale these viruses, resulting in infection and disease. This problem is especially acute in indoor or enclosed environments, particularly those that are crowded and have inadequate ventilation relative to the number of occupants and extended exposure periods.

The authors recommend that, in addition to the current public health measures recommended, it is important to:

  • Provide sufficient and effective ventilation (supply clean outdoor air, minimize recirculating air) particularly in public buildings, workplace environments, schools, hospitals, and aged care homes.
  • Supplement general ventilation with airborne infection controls such as local exhaust, high efficiency air filtration, and germicidal ultraviolet lights.
  • Avoid overcrowding, particularly in public transport and public buildings.

The main purpose of the publication was to ask the World Health Organization to acknowledge the role of aerosol transmission in the spread of COVID-19. Following this publication, the World Health Organization released a brief in which they maintain that the virus is mostly spread through close contact with infected people but call for more research into the matter of transmission by aerosolized particles.

While the relevance of this exchange is not directly tied to asthma, it has direct impacts on policies and practices related to indoor air quality, which do have a direct impact on asthma.

Caring for Pregnant Patients With Asthma During the COVID-19 Pandemic
Posted July 6, 2020
On July 1, 2020, the American Academy of Asthma Allergy and Immunology updated its information sheet on Caring for Pregnant Patients with Asthma During the COVID-19 Pandemic. The authors explain that “Few data exist to indicate that having asthma is associated with an increased risk of becoming infected with COVID-19 or a more severe course in the non-pregnant infected patient. Recent reassuring data show that having asthma was not associated with an increased risk of hospitalization or even mortality in COVID-19 hospitalized patients. There are even fewer data for pregnant asthmatic women with COVID-19.” Current recommendations emphasize the need to maintain asthma control during pregnancy. Reducing controller therapy could put pregnant women with asthma at increased risk of an asthma exacerbation necessitating medical care, which could then put them at an increased risk of being exposed to COVID-19. Questions addressed in this information sheet include:
  • Is timing of delivery affected by COVID-19?
  • Does COVID-19 present an increased risk of adverse perinatal and fetal outcomes?
  • Is breastfeeding safe during COVID-19 infection?
  • Are there ongoing studies to which pregnant women could be referred?
Additional Research Suggests Asthma is Not a Risk Factor for Poor COVID-19 Outcomes
Posted June 29, 2020
A research letter published online in CHEST on June 6 by Lieberman-Cribbin W. et al  noted that among the 11,405 patients within the Mount Sinai Health System in New York City who had a COVID-19 related hospital encounter, “asthma was not associated with a higher risk of mortality.” The authors also noted a low prevalence of asthma in the Mount Sinai Health System COVID-19 registry. The authors explain that there are limitations to their analysis: “asthma was self-reported, and information on treatments prior to admission, including inhaled or oral corticosteroids, was not available.” They suggest that further research is needed on the role of asthma and asthma medications in individual response to COVID-19.
On June 26, in Morbidity and Mortality Weekly Report, Killerby et alshared an analysis of data from 220 hospitalized and 311 non-hospitalized COVID-19 adult patients from six metropolitan Atlanta hospitals and associated clinics. Risk factors associated with hospitalization included older age, Black race, lack of insurance, male sex, smoking and obesity. Of note was that chronic respiratory disease was not a risk factor.

Study Finds Neither a Diagnosis of Asthma nor Use of Inhaled Corticosteroids was Associated with an Increased Risk of COVID-19-related Hospitalization
Posted June 22, 2020
In a study published in the June 2020 edition of the Journal of Allergy and Clinical Immunology, authors Chibba et al assess the prevalence of asthma in hospitalized and non-hospitalized patients with COVID-19 through reviewing over 1,500 patient charts across 10 hospitals. Of 1,526 patients identified with COVID-19, 220 (14%) were classified as having asthma. Asthma was not associated with an increased risk of hospitalization after adjusting for age, sex, gender, and comorbidities. The ongoing use of inhaled coricosteroids did not increase the risk of hospitalization either.  Anju T. Peters, MD, MSCI, FAAAAI, one of the study authors stated, “We would usually expect for asthmatic patients to have worse outcomes, as viral illness often can set off asthma exacerbations. More studies must be done to look at the underlying immune modulation caused by asthma or asthma treatment to see what impact it may have on COVID-19 outcomes.”

EPA Adds More Indoor Air Quality Questions and Answers to Its COVID-19 FAQ Webpage
Posted June 15, 2020
RAMP and partners working to reduce the burden of asthma have long recognized the importance of healthy indoor air quality. Whether we’re talking about improving air filtration and ventilation (through HVAC systems or portable air purifiers) or avoiding things that make the air quality worse (like environmental tobacco smoke or harmful cleaning products), we educate people about ways to reduce exposure to particulates and contaminants in the indoor air. But, as we’re in the midst of the COVID-19 pandemic, are there ways to reduce exposure to viruses as we address indoor air quality?

The EPA and the Centers for Disease Control and Prevention (CDC) have guidance for states & territories, tribes, and local governments (including public health agencies), homeowners, business owners, schools, and others to address questions about risks, exposures and protection from COVID-19.  They recently added some new questions about indoor air quality. Their full list of FAQs can be found here. Some examples of questions include:
  • Will an air cleaner or air purifier help protect me and my family from COVID-19 in my home?
    • When used properly, air purifiers can help reduce airborne contaminants including viruses in a home or confined space. However, by itself, a portable air cleaner is not enough to protect people from COVID-19. When used along with other best practices recommended by the Centers for Disease Control and Prevention, operating an air cleaner can be part of a plan to protect yourself and your family.
  • Can running the HVAC system in my home help protect me from COVID-19?
    • By itself, running your HVAC system is not enough to protect yourself and your family from COVID-19. However, when used along with other best practices recommended by the Centers for Disease Control and Prevention, operating the HVAC system can be part of a plan to protect yourself and your family, since running your HVAC system filters the air as it is circulated.
  • Where can professionals who manage school, office, and commercial buildings get information on ventilation and filtration to respond to COVID-19?
    • Professionals who operate school, office, and commercial buildings should consult the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) guidance for information on ventilation and filtration to help reduce risks from the virus that causes COVID-19. In general, increasing ventilation and filtration is usually appropriate; however, due to the complexity and diversity of buildings types, sizes, construction styles, HVAC system components, and other building features, a professional should interpret ASHRAE guidelines for their specific building and circumstances.

CDC and AAAAI Differ on Asthma Management at School During COVID-19 Pandemic
Posted June 8, 2020
On June 3, 2020, the US Centers for Disease Control and Prevention updated their FAQs on students returning to school in the context of the COVID-19 pandemic. Specifically related to students with asthma, the FAQs address: asthma treatments with inhalers/spacers, the use of nebulizers, and the use of peak flow meters.

The CDC provides the following recommendations during this COVID-19 pandemic:
  • Asthma treatments using inhalers with spacers are preferred over nebulizer treatments whenever possible.
  • Nebulizer treatments at school should be reserved for children who cannot use or do not have access to an inhaler
  • Peak flow meters can be used in schools
  • Schools should obtain the appropriate personal protective equipment (PPE) for staff who administer nebulizer treatments and peak flow meters to students with asthma.

More detail, including the studies cited by the CDC in the development of their recommendations can be found here.

On June 5, 2020, the American Academy of Asthma, Allergy, and Immunology’s COVID-19 Task Force responded to these recommendations with some concerns:
  • The CDC suggests that aerosols generated from nebulizers may not be infectious. The task force states, “The supporting data for this is very poor, however.”
  • The task force does not believe the CDC goes far enough with their PPE recommendations for performing nebulized therapy
  • The task force questions the overall safety of peak flow usage in public without wearing gloves, mask and eye coverage.

The AAAAI response can be found here (scroll toward the bottom of the page for the relevant post).

Asthma, Spirometry and COVID-19
Posted June 1, 2020
In late May, 2020, two articles were published on the use of lung function testing during the COVID-19 pandemic. On May 29th, the Lancet published “Lung function testing in the COVID-19 endemic” by James H Hull et al.  On May 24th, the Italian Journal of Pediatrics published “Italian Pediatric Respiratory Society Recommendations on Pediatric Pulmonary Function Testing During COVID-19 Pandemic” by Elisabetta Bignamini et al. The Lancet authors, in reference to spirometry, state, “This procedure requires patients to repeatedly undertake forced exhalatory manoeuvres and as such frequently precipitates coughing and the production of sputum. It also requires clinicians and patients to be in close proximity and thus, even with the use of device filters, in a COVID endemic phase, enhanced infection prevention and control is crucial.” Recognizing this concern, the Italian Journal of Pediatrics authors state, “Pulmonary function testing should be performed in children with chronic lung disease only if it is needed to guide management.” While spirometry is a key component of asthma diagnosis and management, the concerns expressed in these articles mirror statements from the American Academy of Allergy, Asthma, and Immunology (AAAAI) and the American Thoracic Society.  The AAAAI statement includes, “As things begin to open up there will be pressure to resume spirometry and ENO, but these will all require the use of full PPE (face mask, N95 respirator, gown, and gloves)…. As PPE becomes more available, spirometry and ENO could then be resumed in outpatient offices — provided full PPE is used, as per the CDC guidelines.”

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New data on COVID-19 mortality by race and ethnicity underscore disparities
Posted on May 26th, 2020
New figures compiled by the non-partisan APM Research Lab and released on May 20th  provide further evidence of the staggering divide in the COVID-19 death rate between black Americans and the rest of the United States population. Authors were able to gather and analyze data on race and ethnicity for 88% of COVID-19 deaths across 40 states and the District of Columbia. Of note, 1 in 2,000 Black Americans has died (or 50.3 per 100,000), at a rate 2.4 times higher than whites. The authors describe other racial disparities, explaining “If they had died of COVID-19 at the same rate as White Americans, about 12,000 Black Americans, 1,300 Latino Americans and 300 Asian Americans would still be alive.” Click here to view the full report, titled, The Color of Coronavirus: COVID-19 Deaths by Race and Ethnicity in the U.S. 

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Impact of asthma medications on COVID outcomes
Posted on May 11th, 2020
On May 6, 2020, in the Annals of Allergy, Asthma & Immunology, Johns Hopkins researchers published “Asthma, Biologics, Corticosteroids, and COVID-19.” The authors reinforce the message that current data on the risk of acquiring COVID-19 or disease severity in patients with asthma is limited and they identify recommendations for future research (in the table below). In this article, they share information about the impact on COVID-19 of both steroids and biologics used to treat asthma. The researchers believe that the effect of steroids on acquiring COVID-19 and/or the severity of COVID-19 likely depends on a number of individual factors, including baseline asthma control and dose of the steroid. They do not believe any of the biologics used for asthma treatment would increase the risk of acquiring COVID-19 or the severity of it. They state, “On the contrary, we postulate that the reversal of the Th2 skew and the improvement in airway allergic and eosinophilic inflammation and bronchial responsiveness induced by these biologics, could be advantageous in patients with asthma who are already on these medications prior to contracting COVID-19.” They conclude that, as we continue to learn more, patients with asthma should continue to exercise caution to prevent contracting the disease.

For a full sized version of the table, click on the image.

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Obesity may lead to more severe COVID outcomes among younger individuals
Posted on May 4th, 2020
On April 30, 2020, researchers from Johns Hopkins University published “Obesity could shift severe COVID-19 disease to younger ages in The Lancet. The researchers looked at obesity as a potential factor influencing the younger age of people admitted to the ICU in the United States, as compared to China, Spain, and Italy. They noted that prevalence of obesity in the United States is around 40%, versus a prevalence of 6.2% in China, 20% in Italy, and 24% in Spain. The researchers found a significant inverse correlation between age and body mass index, in which younger individuals admitted to the hospital were more likely to be obese “Obesity can restrict ventilation by impeding diaphragm excursion, impairs immune responses to viral infection, is pro-inflammatory, and induces diabetes and oxidant stress to adversely affect cardiovascular function. We conclude that in populations with a high prevalence of obesity, COVID-19 will affect younger populations more than previously reported. Public messaging to younger adults, reducing the threshold for virus testing in obese individuals, and maintaining greater vigilance for this at-risk population should reduce the prevalence of severe COVID-19 disease.” This is important information for asthma stakeholders as obesity is significantly associated with the development of asthma, worsening asthma symptoms, and poor asthma control.

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Data on the risk of severe COVID among people with asthma
Posted on April 27th, 2020
On April 23rd, the Editorial Team from The Lancet Respiratory Medicine published, Reflecting on World Asthma Day in the era of COVID-19. They note that there has been debate about the risk of severe COVID among people with asthma, stating, “It was predicted that patients with chronic respiratory diseases would be more vulnerable both to infection and to subsequent severe disease.” However, that presumption does not align with medical literature to date. In fact, the previous day, April 22nd, the Journal of the American Medical Association published, Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area by Richardson et al, showing that just 9% of people hospitalized in New York due to COVID had asthma (which is lower than state asthma prevalence.)  The Lancet Editorial Team speculates that lower reported prevalence across several studies, “might be due to underdiagnosis or lack of recognition of chronic respiratory diseases in those with COVID-19, effects of differing immune responses elicited by chronic respiratory diseases, or a protective effect of inhaled corticosteroids.”

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Impacts of smoking and COPD on COVID outcomes
Posted on April 23rd, 2020
Last week, on April 15th, researchers from China published an article in the Journal of Medical Virology looking at the impact of COPD and smoking on the development of severe COVID-19. They conducted a meta-analysis and found that COPD increased the likelihood of severe COVID-19 outcomes by 4.38, while smoking increased the likelihood of severe outcomes by 1.98. Similarly, researchers at UCSF also conducted a meta-analysis and shared in a pre-print version of their article that they found a 2.25 odds ratio of progression of COVID-19 among smokers. These studies underscore the importance of helping people quit smoking. For those in California, the California Smokers’ Helpline remains available during the pandemic online at https://info.nobutts.org/ or at 1-800-NO-BUTTS.

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