key: cord-0807776-zbdcam90 authors: Yang, Ze; Wang, Xiang; Wan, Xi‐gang; Wang, Meng‐lei; Qiu, Zong‐hua; Chen, Jia‐li; Shi, Man‐hao; Zhang, Shi‐yi; Xia, Yong‐liang title: Pediatric asthma control during the COVID‐19 pandemic: A systematic review and meta‐analysis date: 2021-11-18 journal: Pediatr Pulmonol DOI: 10.1002/ppul.25736 sha: 03b4709472296aec5d29a6ee852cc8b0229e5371 doc_id: 807776 cord_uid: zbdcam90 BACKGROUND: With the onset of the coronavirus disease 2019 (COVID‐19) pandemic, many experts expected that asthma‐associated morbidity because of severe acute respiratory syndrome coronavirus 2 infection would dramatically increase. However, some studies suggested that there was no apparent increasing in asthma‐related morbidity in children with asthma, it is even possible children may have improved outcomes. To understand the relationship between the COVID‐19 pandemic and asthma outcomes, we performed this article. METHODS: We searched PubMed, Embase, and Cochrane Library to find literature from December 2019 to June 2021 related to COVID‐19 and children's asthma control, among which results such as abstracts, comments, letters, reviews, and case reports were excluded. The level of asthma control during the COVID‐19 pandemic was synthesized and discussed by outcomes of asthma exacerbation, emergency room visit, asthma admission, and childhood asthma control test (c‐ACT). RESULTS: A total of 22,159 subjects were included in 10 studies. Random effect model was used to account for the data. Compared with the same period before the COVID‐19 pandemic, asthma exacerbation reduced (odds ratio [OR] = 0.26, 95% confidence interval [CI] = [0.14–0.48], Z = 4.32, p < 0.0001), the odds of emergency room visit decreased as well (OR = 0.11, 95% CI = [0.04–0.26], Z = 4.98, p < 0.00001). The outcome of asthma admission showed no significant difference (OR = 0.84, 95% CI = [0.32–2.20], Z = 0.36, p = 0.72). The outcome of c‐ACT scores were not analyzed because of the different manifestations used. Overall, c‐ACT scores reduced during the pandemic. CONCLUSION: Compared to the same period before the COVID‐19 pandemic, the level of asthma control has been significantly improved. We need to understand the exact factors leading to these improvements and find methods to sustain it. The novel coronavirus disease , which is associated with significant morbidity and medical complications induced by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has rapidly spread sparking alarm worldwide. 1, 2 In June 2020 WHO declared COVID-19 a global pandemic which has made many countries to shut down their borders. 3 Asthma has become the most common chronic respiratory disease in children. [4] [5] [6] Because respiratory viruses are a common trigger of poor asthma control and exacerbations, many experts expected an increase in respiratory morbidity among patients with asthma. [7] [8] [9] However, some studies suggested that there was no apparent increase in asthma-related morbidity in children with asthma, 10 it is even possible that due to reduced exposures due to confinement, such children may have improved outcomes. 11 The main objective of this study was to identify how is asthma in children during the COVID-19 pandemic controlled compared with the time before it. We searched PubMed, Embase, and Cochrane Library for the updated articles published from the inception of each database to We also reviewed abstracts and presentations from major conference proceedings up to June 1, 2021 to ensure that no additional studies were overlooked. Our meta-analysis is reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement and had been registered at the International Prospective Register of Systematic Reviews (number: CRD42021266458). 12 Studies that met the following criteria were included: (1) the aim of the primary studies: comparing the level of asthma control the year of the pandemics with the year before the pandemics; (2) children and adolescents aged < 19 years; (3) the population are diagnosed as asthma; and (4) the background of the study is COVID-19 pandemic. We did not include abstracts, reviews, case reports, letters, duplicate publications, or studies with incomplete or unidentified data. Two independent investigators (Z.Y. and X.W.) evaluated the quality of all studies according to an 11-item checklist that was recommended by the Agency for Healthcare Research and Quality (AHRQ) 13 subjectively. "0" will be scored if it was answered No or Unclear and "1" will be given to the answer Yes. The quality of articles was assessed as follows: "0-3" means low quality, "4-7" means moderate quality, and "8-11" means high quality. The following information was extracted: first author, publication time, study design, source of population, mean age or age range, the sample size, and outcomes. A random-effect model was used to estimate the asthma exacerbation, asthma admissions, emergency room visits. Pooled odds ratio (OR) and 95% confidence intervals (95% CI) were calculated to report dichotomous data and mean difference (MD) with 95% CI were used to report continuous data. Statistical heterogeneity was considered to be present when p < 0.1 or I 2 > 50%. Sensitivity analysis was used to analyze the source of heterogeneity. Publication bias was evaluated visually by funnel plots and considered significant when p < 0.05 in either Begg's test or Egger's test when the inclusion was more than 10 articles. Outcomes in the studies are shown as follows: asthma exacerbation, asthma admissions, emergency room visits, and childhood asthma control test (c-ACT). The main characteristics of the 10 articles were summarized in Table 1 . AHRQ scores suggested that all studies scored at 8-9 as high quality. 14 Four studies 14, 15, 20, 20, 23 were included in this outcome, with 835 cases during COVID-19 pandemic, and 945 cases before COVID-19 pandemic. Heterogeneity test analysis suggested that there was heterogeneity (I 2 = 75%, p = 0.007) (Figure 2A The random effects model was used. The meta-analysis demonstrated there was significant difference between two groups (OR = 0.26, 95% CI = [0.14-0.48], Z = 4.32, p < 0.0001) ( Figure 2B ). Five studies 16, 17, 19, 19, 21, 22 were included in this outcome. The metaanalysis showed that there was no significant difference between two groups in asthma admission (OR = 0.84, 95% CI = [0.32-2.20], Z = 0.36, p = 0.72) (Figure 3 ). Heterogeneity test analysis suggested there was high heterogeneity (I 2 = 91%, p < 0.00001), so random effects model was used. ( Figure 4) , during COVID-19 pandemic, the emergency room visits of asthma were lower than that before COVID-19 pandemic. The outcome of c-ACT scores were not analyzed, which was mainly because of the different manifestations used. Overall, compared with the same period before COVID-19 pandemic, c-ACT scores reduced during the pandemic. We cannot use the funnel plot to reflect publication bias because all outcomes are included of fewer than 10 articles. We have shown that the level of asthma control was significantly improved during the COVID-19 pandemic compared to the same period before it, with a reduction of asthma exacerbation, and emergency room visits. One reason for these results is probably associated with the lockdown measures during COVID-19 pandemic, which limits viral disease transmissions, reduces the possible exposure to asthma triggers, such as viral infections, outdoor allergens, physical activities, and air pollution. [24] [25] [26] It might also be explained by caregivers' afraid to bring children to the hospital because of the risk of exposure to SARS-Co-V2. 27 And increased treatment adherence is also an important factor. Caregivers are afraid of going to the hospital in the special time, so they pay more attention to their health than that before the pandemic and treat their children's asthma in time, and take the treatment actively, thus the times of visits to the hospital has decreased and the frequency of asthma exacerbation has also decreased. Anyway, these results mean less medication and healthcare resources are used in the control of children's asthma. There was no significant difference between the two groups in asthma admission. A study of Levene et al. 19 Our review has several limitations. First, the sample size of this meta-analysis was relatively small. As a result, the unknown risk of bias caused by incomplete data could constrain our results. Second, our results are based on observational studies, which are susceptible to design bias, selection bias, and residual confounding. Third, in this study was that heterogeneity across the studies was substantial, which could be attributed to different definitions of severity used or sample size. Despite these limitations, this meta-analysis provides information on the association between children's asthma control and the COVID-19 pandemic. In summary, compared to the same period before the COVID-19 pandemic, the level of asthma control has been significantly improved. We need to understand the exact factors leading to these improvements and find methods to sustain them. This meta-analysis can guide children and their caregivers to restore, maintain and promote effective asthma management during, and more importantly, after the pandemic. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease-2019 (COVID-19): the epidemic and the challenges 2019-nCoV outbreak declared as public health emergency of international concern: what next? 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