key: cord-0961140-t4q5cccs
authors: Shen, Minxue; Xiao, Yangjian; Yuan, Yan; Chen, Xiang; Li, Jie
title: Perceived stress links income loss and urticaria activity during the COVID-19 pandemic
date: 2020-08-17
journal: Ann Allergy Asthma Immunol
DOI: 10.1016/j.anai.2020.08.019
sha: a41b0d15fed3b076b4094b4a0157c30ba151a03d
doc_id: 961140
cord_uid: t4q5cccs

nan

The pandemic of coronavirus disease 2019 (COVID-19) has caused substantially adverse effects 3 on health and economy at both individual and societal levels. It was estimated that the worldwide 4 unemployment rate might increase from 4.9% to 5.6% owing to the pandemic. 1 Decades of research 5 have accumulated evidence on the adverse impacts of unemployment on poverty-related health 6 outcomes and mental illness such as stress and anxiety. 2 Interestingly, it has been well established that 7 allergic diseases are associated with higher socioeconomic status (SES). 3 However, it is less known 8

whether adverse life events such as loss of income would trigger or enhance the activity of allergies. 9

Few epidemiologic studies have addressed this question, but a recent review summarized the 10 neuro-immuno-cutaneous crosstalk as a mechanism that links psychological stress and urticaria. 4 The 11 outbreak of COVID-19 uniquely creates a quasi experiment and provides an opportunity to study this 12 association. We assumed that the income loss could increase urticaria activity through mental stress, 13 and conducted a social media-based investigation in adult Chinese patients between 27 Feb 2020 and 14 11 Mar 2020. A link was distributed to two WeChat groups consisting of 980 patients who were 15 diagnosed as urticaria in the Department of Dermatology, Xiangya Hospital. 16

Loss of income was inquired by a question "Since the epidemic of COVID-19, is there any Health Questionnaire-2, PHQ-2). The cut-offs were 7, 3, and 3 for stress VAS, GAD-2, and PHQ-2, 24 respectively. 5, 6 Covariates for adjustments included sex, age, education, income, history of disease, 25 and outdoor activity restriction during the pandemic. Multivariable logistic regression was used to 26 estimate the associations with adjustments. The effect size was presented as adjusted odds ratio (aOR) 27 and 95% confidence interval (CI). The mediation effect of stress was tested and estimated using the 28 bootstrapping method. A P<0.05 was considered statistically significant. The data were analyzed with 29 R version 3.5.

A total of 234 valid questionnaires were collected, and 182 of them were adult patients with 31 chronic urticaria. The mean age of the patients was 33.7±10.9, and 55.5% were women. Only 68 32 (37.3%) reported unaffected income, while 54 (29.7%) reported reduced income and 60 (33.0%) 33 reported complete loss of income. By comparing participants' characteristics, income loss was 34 significantly associated with sex, educational level, income, and outdoor activity, which were further 35 adjusted in multivariable models. In general, loss of income was dose-dependently associated with 36 urticaria activity with respect to the severities and frequencies of wheals and itch (Table 1) . However, 37 after adjustments for covariates, significant associations were only observed in the frequency of 38 wheals (aOR=2.45 for reduced income and aOR=2.13 for loss of income) and intensity of itch 39 (aOR=2.19 for loss of income). Unexpectedly, income loss was not significantly correlated with the 40 UAS sum score. 41

Income loss was not significantly correlated with anxiety in the multivariable model, although a 42 higher proportion of anxiety could be observed in patients who reported income loss. Income loss was 43 associated with perceived stress with the largest effect size (aOR=4.56, P=0.029). According to the 44 total effect of income loss on urticaria activity (P=0.040). The estimate for indirect effect was 0.03 46 (95%CI: 0.01-0.06, P=0.04). More importantly, income loss was no longer significantly correlated 47 with urticaria activity after modeling stress (P=0.080). 48

Our study examined the association of income loss with urticaria activity, in terms of the 49 frequency of wheals and the intensity of itch, and this association is partly mediated or modified by 50 perceived stress. The study has implications for the management of patients with chronic urticaria and 51 further study on the neuro-immuno-cutaneous interactions. The study also has limitations, including 52 selection bias owing to the non-probability sampling method, limited generalizability to non-Chinese 53 and non-urticaria population, lack of longitudinal observations, incapability to infer a causal 54 relationship owing to the observational study design, and recall bias related to the self-reported 55 measurements. Nevertheless, to our knowledge, this is the first study that established an association of 56 the pandemic-related impacts with adverse outcomes of chronic urticaria, and proposed a hypothesis 57 for the black box of association. 58

Chronic urticaria has detrimental effects on quality of life and mental health, while psychiatric 59 comorbidities could aggravate urticaria activity in turn, resulting in a vicious circle. More importantly, 60 the needs for disease control remain largely unmet in chronic urticaria, as a substantial number of 61 patients benefit little from H 1 -antihistamines. 7 Consequently, research for novel mechanisms that 62 involve in the neuroimmune inflammation in urticaria are needed, as it will enlighten the development 63 of new therapeutic strategies for patients with unsatisfied disease control and impaired quality of life. 64

Admittedly, we realized that social stressor was not urticaria's Achilles' heel, as it only contributed to 65 approximately 20% of the total effect. In addition, we observed no significant correlation between 66 income loss and UAS total score, partly because of the lack of associations of income loss with the 67 frequency of itch as well as the severity of wheals. This might introduce additional measurement 68 errors and conceal the true effect towards null. Another possible explanation is the effect modification 69 by SES. A study found that lower SES was associated with a larger increase in perceived stress and 70 higher levels of interleukin-6 in survivors who experienced a disaster, indicating that individuals from 71 different SES backgrounds respond differently to stressors both psychosocially and biologically. 8 In 72 summary, during this pandemic period, dermatologists and psychologists can work together and 73 remotely, to identify patients who experienced loss of income and social distancing, and to provide 74 personalized care to minimize the adverse outcomes of urticaria and many other allergic diseases. J o u r n a l P r e -p r o o f

COVID-19, unemployment, and suicide

Health and unemployment

Adult eczema prevalence and associations with asthma and other 82 health and demographic factors: a US population-based study

GAD-2: a systematic review and diagnostic metaanalysis

Unmet clinical needs in chronic spontaneous 93 urticaria. A GA(2)LEN task force report

Socioeconomic status and 95 differential psychological and immune responses to a human-caused disaster

COVID-19, unemployment, and suicide

Health and unemployment

Adult eczema prevalence and associations with asthma and other health and demographic factors: a US population-based study

Psychological stress and chronic urticaria: A neuro-immuno-cutaneous crosstalk. A systematic review of the existing evidence

Validity of occupational stress assessment using a visual analogue scale

Screening for anxiety disorders with the GAD-7 and GAD-2: a systematic review and diagnostic metaanalysis

Unmet clinical needs in chronic spontaneous urticaria. A GA(2)LEN task force report

Socioeconomic status and differential psychological and immune responses to a human-caused disaster