key: cord-1053663-swcpap5h authors: Oreskovic, Nicolas M.; Kinane, T Bernard; Aryee, Emmanuel; Kuhlthau, Karen A.; Perrin, James M. title: The Unexpected Risks of COVID-19 on Asthma Control in Children date: 2020-06-01 journal: J Allergy Clin Immunol Pract DOI: 10.1016/j.jaip.2020.05.027 sha: 61981454d1c3c26c597e3733ea8e6b7168b73322 doc_id: 1053663 cord_uid: swcpap5h Abstract Much is being learned about clinical outcomes for adult COVID-19 patients with underlying chronic conditions, however, there is less coverage on how the COVID-19 pandemic impacts the management of chronic medical conditions in children and youth, such as asthma. Asthma is a common chronic medical condition in children that is uniquely susceptible to changes brought upon by COVID-19. Sudden dramatic changes in the environment, medical practice, and medication use have altered the asthma management landscape with potential impacts on asthma outcomes. In this paper, we review how changes in transportation and travel patterns, school attendance, physical activity, and time spent indoors, along with changes in healthcare delivery since the start of the pandemic all play a contributing role in asthma control in children. We review potentially important influences of asthma control in children during the COVID-19 pandemic worthy of further study. Much is being learned about clinical outcomes for adult COVID-19 patients with underlying 38 chronic conditions, however, there is less coverage on how the COVID-19 pandemic impacts 39 the management of chronic medical conditions in children and youth, such as asthma. Asthma 40 is a common chronic medical condition in children that is uniquely susceptible to changes 41 brought upon by COVID-19. Sudden dramatic changes in the environment, medical practice, 42 and medication use have altered the asthma management landscape with potential impacts on 43 asthma outcomes. In this paper, we review how changes in transportation and travel patterns, 44 school attendance, physical activity, and time spent indoors, along with changes in healthcare 45 delivery since the start of the pandemic all play a contributing role in asthma control in children. 46 We review potentially important influences of asthma control in children during the COVID-19 47 pandemic worthy of further study. As the COVID-19 pandemic unfolds, we are learning about the multitude of ways, many 62 unforeseen, that response efforts to contain COVID-19 affect people's illnesses and chronic 63 diseases. While the risk of existing chronic disease on COVID-19 outcomes receives much 64 attention, less discussion has focused on the impact of societal changes resulting from the 65 COVID-19 pandemic on the course of specific chronic conditions. Changes in the environment, 66 medical practice, and medication management and use have rapidly altered the immediate 67 asthma management landscape with likely long-term impacts on asthma outcomes. Where 68 people spend time, daily habits, and travel patterns, have altered the natural environment in 69 ways that affect asthma. Changes in healthcare availability, delivery, and utilization have 70 important implications for asthma and other chronic conditions that require ongoing medical 71 attention. Finally, changes in medication management in asthma represent another important 72 COVID-19 related trend. Chronic asthma has particular vulnerabilities to the changes brought 73 on by COVID-19, with many shared pathways and risk factors, including air quality, the indoor 74 environment, physical activity, weight control, medication management, and healthcare delivery 75 (see Figure 1 ). Below, we review and postulate how significant changes in three domains, 76 environment, medical practice, and medication management, have altered asthma management 77 in the United States with likely longer-term implications for asthma outcomes. 78 79 Environmental changes: As different municipalities and states implement social distancing, 80 including stay-at-home orders, to control the COVID-19 pandemic, they impact many factors 81 that relate to asthma control, morbidity, and mortality. School cancellations mean that children 82 no longer have exposure to viruses from other schoolchildren that can cause upper respiratory 83 illnesses that may exacerbate asthma. Staying at home limits children's opportunities for 84 physical activity, known to be beneficial in asthma. Children now confined to small indoor 85 spaces, without access to school playgrounds or outdoor parks, lose use of spaces that are 86 conducive to physical activity. Children who actively commute to school by walking or bicycling 87 4 have also lost daily opportunity for physical activity. At the same time, remaining indoors means 88 children have greater exposure to indoor environments that can exacerbate asthma, including 89 secondary tobacco smoke exposure and indoor allergens including mold, mice, and roaches. May 2020, the hospital saw a corresponding decline in the usual volume of pediatric asthma-111 related ED visits (see Table 1 ). This sharp decrease may reflect families avoiding healthcare where COVID-19 hot spots have been reported. Variation in governmental stay-at-home orders 135 will directly impact many of the risk factors listed above, including physical activity and exposure 136 to indoor and outdoor air quality. Accordingly, the impact of COVID-19 on asthma control and 137 outcomes will likely vary from state to state and especially by municipality within states. The These COVID-19 changes in the environment, in medical practice, and medication management 160 will likely have major impact on childhood asthma, with many already manifesting. These 161 several risk factors will often work in opposite directions at the same time. With the pandemic 162 natural experiment absent a control group, it is difficult to foretell the ultimate impacts these 163 broad societal changes will have on childhood asthma. Despite these difficulties, this paper 164 aims to start by identifying key changes in some of the underlying associated risk factors to help 7 the scientific community learn from the pandemic, better guide management of pediatric 166 asthma, and indicate research questions that merit study during these unprecedented times. 167 The exact relationship and impact of the many contributing risk factors will be difficult to 168 measure. Many of the potential influences we highlight in this paper are not typically collected in 169 datasets available for study. Data on some key variables which could help understand the 170 changes and impacts of the COVID-19 pandemic on asthma control are available, including 171 pharmacy claims data, health care utilization measures including asthma-related ED visits and 172 hospitalizations, air quality data, and school closure dates. Innovative studies that combine 173 these disparate datasets will be important to help the scientific community more broadly 174 understand the pandemic's full impact. Pandemic Worthy of Investigation. 220 Impact of changes in 193 transportation and commuting behaviors during the 1996 Summer Olympic Games in 194 Atlanta on air quality and childhood asthma The silver lining to coronavirus lockdowns: Air quality is 196 improving. The Washington Post Propeller data shows 14.5% med adherence lift since COVID-19 outbreak began. Madison, 198 WI: Propeller Health Factors associated with prolonged viral 202 RNA shedding in patients with COVID-19 The effect of corticosteroid treatment on 204 patients with coronavirus infection: a systematic review and meta-analysis Status of childhood asthma in the United 207 COVID-19) Table 1: Change in Volume of Pediatric Asthma Emergency Department Visits During the COVID-19 Pandemic * Includes patients under 20 years of age with a J45 ICD-10 primary or secondary asthma diagnosis code. The average monthly number of asthma visits in 2019 was 69 patients The authors wish to thank Dr. Ari Cohen and Cassie Kraus for their assistance with providing 16 pediatric emergency department data.