key: cord-0778819-90hm8i3c
authors: Papadopoulos, Nikolaos G.; Custovic, Adnan; Deschildre, Antoine; Mathioudakis, Alexander G.; Phipatanakul, Wanda; Wong, Gary; Xepapadaki, Paraskevi; Agache, Ioana; Bacharier, Leonard; Bonini, Matteo; Castro-Rodriguez, Jose A.; Chen, Zhimin; Craig, Timothy; Ducharme, Francine M.; El-Sayed, Zeinab Awad; Feleszko, Wojciech; Fiocci, Alessandro; Garcia-Marcos, Luis; Gern, James E.; Goh, Anne; Gómez, René Maximiliano; Hamelmann, Eckard H.; Hedlin, Gunilla; Hossny, Elham M.; Jartti, Tuomas; Kalayci, Omer; Kaplan, Alan; Konrandsen, Jon; Kuna, Piotr; Lau, Susanne; Le Souef, Peter; Lemanske, Robert F.; Makela, Mika J.; Morais-Almeida, Mário; Murray, Clare; Nagaraju, Karthik; Namazova-Baranova, Leyla; Garcia, Antonio Nieto; Osman, Yusuf; Pitrez, Paulo MC.; Pohunek, Petr; Pozo Beltrán, Cesar Fireth; Roberts, Graham C.; Valiulis, Arunas; Zar, Heather J.
title: Impact of COVID-19 on pediatric asthma: practice adjustments and disease burden.
date: 2020-06-17
journal: J Allergy Clin Immunol Pract
DOI: 10.1016/j.jaip.2020.06.001
sha: c0eae624d3b38f786902b052030a3777599a6a23
doc_id: 778819
cord_uid: 90hm8i3c

Abstract Background It is unclear whether asthma may affect susceptibility or severity of the Coronavirus Disease 2019 (COVID-19) in children and how pediatric asthma services worldwide have responded to the pandemic. Objective To describe the impact of the COVID-19 pandemic on pediatric asthma services and on disease burden in their patients. Methods An online survey was sent to members of the Pediatric Asthma in Real Life (PeARL) think-tank and the World Allergy Organization Pediatric Asthma Committee. It included questions on service provision, disease burden and on the clinical course of confirmed cases of COVID-19 infection among children with asthma. Results Ninety-one respondents, caring for an estimated population of >133,000 children with asthma, completed the survey. COVID-19 significantly impacted pediatric asthma services: 39% ceased physical appointments, 47% stopped accepting new patients, 75% limited patients visits. Consultations were almost halved to a median of 20 (IQR: 10-25) patients per week. Virtual clinics and helplines were launched in most centers. Better than expected disease control was reported in 20% (10-40%) of patients, while control was negatively affected in only 10% (7.5-12.5%). Adherence also appeared to increase. Only 15 confirmed cases of COVID-19 were reported among the population; the estimated incidence is not apparently different from the reports of general pediatric cohorts. Conclusion Children with asthma do not appear to be disproportionately affected by COVID-19. Outcomes may even have improved, possibly through increased adherence and/or reduced exposures. Clinical services have rapidly responded to the pandemic by limiting and replacing physical appointments with virtual encounters.

research and clinical mobilization, to understand and contain the disease 1 . COVID-19 has less 240 direct impact in children and adolescents than in adults, although all ages are affected 2 . In 241 children, as in adults, pre-existing chronic conditions appear to increase the risk for severe or 242 fatal disease 3, 4 . Despite initial clinical reports that did not identify asthma to be 243 overrepresented among COVID-19 patients 5 , it has been suggested that asthma, particularly 244 when uncontrolled, may be included among the underlying conditions imposing a risk for 245 severe COVID-19 disease 3 . Further evaluation is urgently required, since children with 246 wheezing illness/asthma constitute a significant proportion throughout the pediatric age span 247 and is the most frequent chronic condition managed by pediatricians 6,7 . 248 In order to rationalize management and instruct the public healthcare system, it is crucial 249 to understand whether asthma, allergy, or their treatments add risk, protect or have no 250 discernible effects on the health of children with asthma 8,9 . 251 Symptoms of COVID-19 in children usually include dry cough and often fever. In contrast 252 with infected adults, most infected children appear to have a milder clinical course 10 . In pediatric asthma clinics that continued accepting physical appointments, several practice 329 changes were implemented to minimize these encounters. Further to the reduction of 330 evaluated cases, the majority (62%) of clinics limited the frequency of planned monitoring 331 encounters, with 28% reviewing only children with severe asthma, while 8% accepting only 332 patients receiving biologics. Access to asthma medications was an issue in 30% of the 333 participating centres, predominantly in Asia (44%). 334

Importantly, over 90% of participating centres have launched virtual online or telephone 335 consultations to substitute or complement clinical visits, while 73% have used a help line to address the needs of their patients. About half of the participants considered virtual visits a 337 suboptimal clinical encounter, only viable in the short term. Nevertheless, a considerable 338 proportion (42%), found them acceptable, or, occasionally, as good as face-to-face visits. 339 Several tools were used by all respondents to facilitate better distal monitoring of asthma 340 control. Validated tools for evaluating asthma control, such as the asthma control test (ACT) 341 or the asthma control questionnaire (ACQ), were used by 72% of the participants. Peak 342 expiratory flow readings (31%) or portable spirometer readings (8.5%) were less often used, 343 while treatment adherence was formally monitored in 42% of practices. Symptom recording 344 apps or telemedicine platforms were used in 27% of centres. 345

There were some between-group differences in monitoring. Firstly, validated asthma control 346 questionnaires were less favoured in private/primary care practices (33%), compared to 347 proportions exceeding 80% in secondary, tertiary and university hospitals. On the contrary, 348 67% of the private practices opted for telemedicine platforms, in contrast to only 28% of the 349 clinics in secondary care and 13% of the university/tertiary care hospitals. PEFR was more 350 often used in less affluent countries (42% in low-/middle-versus 27% in high-income 351 countries), while portable spirometers were solely available in high-income countries. In our survey, the estimated population of pediatric asthma patients represented within these 435 countries was 20,000-40,000 i.e. the expected range of potential COVID-19 patients would It is possible that SARS-CoV2 does not induce bronchial hyperreactivity and asthma-like 439 pathophysiology; nevertheless, this does not exclude the possibility of children with asthma, 440 particularly uncontrolled asthma, developing more severe COVID-19 disease, as we have 441 previously reported for influenza 25 . Furthermore, the impact of atopy on SARS-CoV2 442 susceptibility needs to be further evaluated, in light of recent findings suggesting that allergic 443 sensitization and allergen exposure may reduce the SARS-Co2 receptor, ACE2 26 . However, 444 only one case requiring hospitalization was identified through this survey, drawing 445 information from a large number of children with asthma, including a large proportion with 446 severe asthma, given the large proportion of respondents from tertiary centres. Further 447 evaluation of children with asthma, poor symptom control and high severity in regards to the 448 individual response to SARS-CoV-2 will be needed to draw a firm conclusion. 449

There are several limitations to this survey. Most importantly, the clinical data that are 450 described are not based on direct evaluation of patients, but on the subjective evaluation of 451 the respondents and therefore, there is a risk of recall bias. In addition, respondents might 452 have been unaware of some of the acute presentations of their patients to alternative clinical 453 sites. However, clinicians are well aware of this issue that is not specific to the COVID-19 454 era. There is a chance that changes in clinical practice due to COVID-19 may have led more 455 patients to seek medical advice from alternative sources, however all participating centers 456 offered either physical, virtual appointments or helplines for patients with acute symptoms. 457

In parallel, children with asthma tend to have less controlled disease at the time of the initial 458 referral to the expect clinic. Therefore, the significant decrease in new referrals may partially 459 account for the respondents' perception that asthma control has improved during the 460 pandemic. However, clinicians were specifically asked to compare their perceptions about 461 disease control among patients during monitoring visits, during versus before the epidemic. represented. Similarly, the responses do not include many low-income countries, in which 473 health services, underlying susceptibility to illness and disease impact may be different. 474

In conclusion, children with asthma do not appear to be disproportionately affected by 475 COVID-19; relevant high-end services have rapidly responded, medication adherence has not 476 been negatively affected and outcomes are promising. Ongoing epidemiological studies, 477 including one initiated by this group, will be able to quantify any added and long-term risk of 478 COVID-19 on children with asthma. 479

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