key: cord-0859055-7z2oaiof
authors: Burrows, Alyssa G.; Ellis, Anne K.
title: Psychological Impacts of COVID-19 on people with Asthma, Allergic Rhinitis and Food Allergy
date: 2021-12-29
journal: Ann Allergy Asthma Immunol
DOI: 10.1016/j.anai.2021.12.013
sha: 591762c621e8c34db3c80efe5bd2c27a48cf4855
doc_id: 859055
cord_uid: 7z2oaiof

OBJECTIVE: To summarize the current literature of the psychological impacts of coronavirus disease 2019 (COVID-19) on people with allergic diseases and to identify gaps in need of future research. DATA SOURCES: Ovid MEDLINE(R) and Embase Classics + Embase from 1947 to present (October 18, 2021) were searched using a search strategy that included the following keywords: allergic diseases, covid*, and psychological disorders. STUDY SELECTIONS: Primary manuscripts and abstracts using online and telephone surveys, mixed-method studies capturing patient and caregiver experiences, case studies, and published guidelines from allergic disease-specific expert groups were included. RESULTS: People with asthma and other chronic respiratory conditions are at higher risk of negative psychological outcomes, and risk factors include asthma severity, female sex, and previous history of anxiety and depression, likely owing to the perceived risk of severe disease from COVID-19. One study identified that people with allergic rhinitis had significantly high anxiety and depression scores compared with healthy controls (both, P < .001). The psychological impacts of food allergy during COVID-19 were most strongly felt by parents and caregivers. Similarly, parents of children with asthma experienced substantial psychological burden. CONCLUSION: COVID-19 had a considerable psychological impact on patients with asthma. Limited data have been published on the mental health impacts of COVID-19 on patients with allergic rhinitis and food allergy. As COVID-19 research continues to evolve and the literature captures later stages of the pandemic, it is important that physicians be aware of the potential coincidence of mental illness and chronic allergic diseases and refer these patients, and their caregivers, to appropriate resources while also continuing to manage their allergic disease(s).

Conflict of interest: AKE has the following disclosures that pose no conflict of interest to the 21 current manuscript. AKE has participated in advisory boards for ALK Abello, AstraZeneca, 22

Aralez, Bausch Health, Circassia Ltd, GlaxoSmithKline, Johnson & Johnson, Merck, Mylan, 23

Novartis, Pediapharm and Pfizer, has been a speaker for ALK, Aralez, AstraZeneca, Boerhinger-24

Ingelheim, CACME, Meda, Mylan, Merck, Novartis, Pediapharm, Pfizer, The ACADEMY, and 25

Takeda. Her institution has received research grants from Bayer LLC, Circassia Ltd, Green Cross 26

Pharmaceuticals, GlaxoSmithKline, Sun Pharma, Merck, Novartis, Pfizer, Regeneron and 27

Sanofi. She has also served as an independent consultant to Allergy Therapeutics, Bayer LLC, 28

Ora Inc. and Regeneron in the past. hospitalization or death due to Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), 51 however, the perceived risk of being at higher risk has significantly impacted the mental wellbeing of 52 people with asthma, disease severity, asthma control, female sex, and previous history of anxiety and/or 53 depression are risk factors. More research is needed, particularly in post-lockdown periods.

• AR patients reported higher anxiety and depression scores than healthy controls. Behaviour changes 55 during the pandemic, such as mask-wearing, spending less time outdoors, more time spent indoors, and 56 decreased air pollution during lockdown periods, have impacted symptom scores.

• COVID-19 mental burden on people with food allergies was exclusively studied in children, 58 adolescents and caregivers. Generally, people with FA reported concerns regarding the activation of 59 emergency services and emergency department visits due to COVID-19, delays in allergy office visits, 60 delays in oral immunotherapy, and difficulties with finding allergy-safe products during grocery 61 shopping.

• Significant burden was experienced by parents and caregivers of children with asthma and food allergy 63 compared to control groups. Referring these patients' caregivers to appropriate support groups and mental 64 health resources may be salient.

Coronavirus disease of 2019 (COVID-19) is a respiratory illness characterized by fever, cough, 74 dyspnea, fatigue, and lymphopenia. Severe COVID-19 complications can manifest as viral 75 pneumonia and may lead to severe acute respiratory syndrome and, in some cases, death [1, 2] . 76

As of December 2021, SARS-CoV-2 has caused more than 263,300,000 infections, and over 77 5,221,000 deaths. Since December 2020, over 8,033,000,000 vaccine doses have been 78 administered [3] . A global systematic review conducted during the COVID-19 pandemic of the 79 general public's psychological outcomes found relatively high rates of anxiety (6.33% to 50.9%), 80 depression (14.6% to 48.3%), post-traumatic stress disorder (7% to 53.8%), psychological 81 distress (34.43% to 38%), and stress (8.1% to 81.9%) [4] . 82

The acute symptoms of COVID-19 overlap with those of allergic rhinitis (AR) and asthma, 84 potentially impacting mental well-being and condition management ( Figure 1) severe asthma during COVID-19. One survey of severe asthma patients (n=87) undergoing 176 biological treatments found that 25% of patients showed a significant decline in symptom 177 control, and 21% experienced a decline in QoL [6]. Another survey study, which ran from April 178 20 to May 15 2020, in people with severe asthma requiring treatment with biologics found that 179 35% reported high HADS-Anxiety (HADS-A) scores and 30% reported high HADS-Depression 180 (HADS-D) scores [25] . Lastly, people with uncontrolled asthma (ACT <20) were more likely to 181 consider themselves at higher risk for COVID-19 and were more likely to be strongly impacted 182 by the lockdown. Compared to people with controlled asthma (ACT>20), the uncontrolled group 183 had increased feelings of anxiety and depression (p<0.001), a feeling of abandonment (p<0.001), 184 and reported more difficulties meeting their needs (p<0.0001) [26] . 185 186

Globally, numerous studies documented the impact of lockdown (April-July 2020) on people 188 with asthma (see Table 1 ). Participants with asthma (n=410) reported increases in shortness of 189 breath, difficulty sleeping, eating, and sleep changes (p values not provided) [22] . People with 190 asthma reported a higher rates of worsening mental health, higher perceived risk of 191 higher worry about COVID-19 infection, longer self-isolation periods, and were more likely to 192 wave medical appointments than individuals without asthma and other chronic conditions In one study, patients with newly diagnosed anxiety in 2020 were more likely to be older (>50 202 years, p<0.001) and have comorbid asthma (p<0.001) or chronic obstructive pulmonary disease 203 (p<0.001), and were more likely to have an accelerated referral rate for mental health reasons 204

[32]. The authors of this study suggested that providing accurate information to asthmatics about 205 their true risk of COVID-19 could decrease the incidence of anxiety [32] . High levels of 206 depression have been reported across age groups, adults (31% mild, 14% moderate to severe) 207 followed by children (22.7% mild, 8% moderate to severe), then adolescents (33.3% mild, 0% 208 moderate to severe) experienced the highest levels of depression measured by PHQ-9. Overall, these studies reveal how COVID-19 has adversely affected people with asthma. These 247 studies address a specific time period, early on in the pandemic when there was limited 248 information was available on the relationship between asthma and COVID-19. It would be 249 beneficial to investigate the association between asthma control and the psychological impact of 250 19 has placed a significant strain on the medical system, including emergency services. In the 327 unlikely event of an anaphylactic reaction occurring, the emergency department may be 328 particularly challenging to access during the COVID-19 pandemic either due to fear of SARS- elevated levels of concern about accidental ingestion, anaphylaxis management self-efficacy, FA 361 related worry/stress/anxiety, and fatal FA outcomes. These parents reported greater concern 362 regarding the ability to obtain safe foods, cross contamination with prepared/delivered foods, 363 activating EMS and presenting to the ED. FARE parents were found to experience a higher 364 burden than their child during COVID-19 in a parental self-vs. child-proxy report. FORWARD 365 and Stanford parents reported less concern compared to 2019, with the exception of activating 366 EMS and going to the ED for FA treatment (p-values not provided) [73] . Lastly, a survey of 54 367 FA adolescents-caregiver dyads found that 7% of adolescents and 9% of caregivers were above 368 the cut-off (>10) for GAD-7 and 13% were above the cut-off (>10) for PHQ-9. FA adolescents 369 reported poorer resiliency (ConnorDavidson Resilience Scale (CD-RISC); 76%) than their care-370 givers (44%) whereas, caregivers reported higher mean stress due to COVID-19 (COVID-19 371

Exposure and Family Impact Surveys (CEFIS); 5.69+/-2.20) than adolescents (CEFIS-372 Adolescent/ young-adult; 3.98+/-2.25) [74] . It is evident that FA adolescents and their care 373

givers endured significant impacts during COVID-19 [74] , and improving resiliency and mental 374 health is an important consideration for FA management across all age groups (Figure 3 ; Table  375 2). (PEG), which is used in many medications and cosmetics, was identified as the ingredient of 394 concern in both market mRNA vaccines (Pfizer-BioNTech, Moderna). A Canadian study using 395 electronic medical record data from the Canadian Primary Care Sentinel Surveillance record 396 found that vaccine allergy in Canada was 0.037% and PEG allergy was 0.0009%, as reported by 397 primary care providers. Patients with both vaccine allergy and PEG allergy were significantly 398 more likely to have other atopic comorbidities, including asthma (P < .001 for both), eczema 399 (P < .001 and P = .001, respectively), AR (P = .002 and P < .001, respectively), and FA (P < 400

.001 for both). Significantly higher rates of depression (P < .001 and P < .001, respectively) and 401 anxiety (P = .003 and P < .001, respectively) were found in those with vaccine allergy, or PEG 402 allergy, than those without vaccine allergy or PEG allergy [77] . In most cases the first reaction to 403 the COVID-19 vaccine may not be considered severe enough to recommend not getting the 404 second dose which demonstrates that first dose reactors can be triaged appropriately and be given Mothers of FA children aged 1.5 to 8 years, reported higher anxiety levels (33.8% above cut off) (p<0.05) with the GAD-7 score when compared to mother's without FA children (27.2%). Mothers of FA children also reported lower QoL yet day-to-day FA management improved. Several themes emerged including unexpected challenges when grocery shopping (i.e. feeling stressed or rushed, or inability to find certain common ingredients to make allergen safe foods), reporting less food-related anxiety during the pandemic because child was in direct care of one and both parents, easing logistics, and younger families reported delay in FA testing and therapy CEFIS were similar among the participants from the three databases despite the high-SES and white race/ethnicity in the FARE and Standford respondents compared to forward suggesting that impact on parents of children with FA was heterogenous. Compared to surveys conducted in 2019 FARE respondents reported slightly elevated levels of concern about accidental ingestion, anaphylaxis management self-efficacy, FA related worry/stress/anxiety, and fatal FA outcomes. These parents reported greater concern regarding the ability to obtain safe foods, cross contamination with prepared/delivered foods, activating EMS and presenting to the ED. FARE parents were found to experience a higher burden than their child during COVID-19 in a parental self-vs. child-proxy report. FORWARD and Standford parents reported less concern compared to 2019, with the exception of activating EMS and going to the ED for FA treatment.

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7% of adolescents and 9% of care givers were above the cut-off (>10) for GAD-7, 13% of both adolescents and care givers were above the cut-off (>10) for PHQ-9, FA adolescents reported poorer resiliency (Connor-Davidson Resilience Scale(CD-RISC); 76%) than their care-givers (44%) whereas, caregivers reported higher mean stress due to COVID-19 (CEFIS; 5.69+/-2.20) than adolescents (CEFIS-Adolescent/ young-adult; 3.98+/-2.25).704 705