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

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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