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Early in the pandemic, patients with asthma were considered at a higher risk for COVID-19 infection and illness-related hospitalization. In addition, social distancing measures were shown to help lower rates of emergency visits and hospitalizations for pediatric patients who have asthma. Whether symptomatic asthma in pediatric patients is associated with population-level COVID-19 illness exposure or reduction strategies is not well understood. Authors of a study published in JAMA Network Open evaluated whether symptomatic asthma was positively associated with population COVID-19 overall mortality, and would then be, conversely, associated with population-level completion of the COVID-19 primary vaccination series with state face mask mandates.
For this cross-sectional study, the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines were followed. Additionally, the follow data were included: state-level data regarding parent-reported current asthma symptom prevalence in their children from the National Survey of Children’s Health from 2018-2019 and 2020-2021; age-adjusted COVID-19 overall mortality rates—a proxy for SARS-CoV-2 exposure—from the CDC during 2020 and 2021; the proportion of population aged 5 years and older who completed the primary COVID-19 vaccination series in 2020 and 2021 (also from the CDC); and face mask requirements in enclosed spaces through August 2021, which was gathered from 20 states and the District of Columbia. Data were analyzed in February 2024.
Additionally, the authors calculated state-level change scores for parent-reported childhood asthma symptom prevalence for 2020 to 2021 compared with 2018 to 2019, then assessed state-level time trends. Trend associations were evaluated with concurrent state-level variables, according to the authors.
The data demonstrated that the mean state-level prevalence of parent-reported childhood asthma symptoms had decreased from approximately 7.77% (95% CI, 7.34%-8.21%) from 2018 to 2019, and to 6.93% (95% CI, 6.53%-7.32%) from 2020 to 2021 (P < .001), with an absolute mean change in score of approximately -0.85%. Additionally, the mean (SD) age-adjusted state-level COVID-19 mortality rate was 80.3 (30.2) per 100,000 in 2020, and this rate increased to 99.3 (33.9) in 2021. Further, the mean state-level COVID-19 primary series vaccination rate through December 2021 was approximately 72.3% (10.3%).
Key Takeaways
- Reduction in Childhood Asthma Symptoms: The study found a significant decrease in the prevalence of parent-reported childhood asthma symptoms from 2018 to 2019 and 2020 to 2021, suggesting a possible benefit from COVID-19 vaccination and other pandemic-related measures.
- Impact of COVID-19 Vaccination: Higher COVID-19 vaccination rates were associated with a reduction in childhood asthma symptoms, indicating that vaccination may offer protection against asthma exacerbations, potentially through cross-reactive antibody responses.
- Lack of Association with Mask Mandates and COVID-19 Mortality: The study found no association between state-level face mask requirements or COVID-19 mortality rates and the prevalence of asthma symptoms in pediatric patients. This finding suggests that other factors—such as vaccination rates—may play a more significant role in influencing asthma outcomes.
The investigators also observed that with each 10% increase in COVID-19 vaccination coverage, the prevalence of parent-reported child asthma symptoms decreased by 0.36%. Additionally, the prevalence of child asthma symptoms reported by their parents were not associated with state-level COVID-19 mortality, or with face mask requirements. State-level COVID-19 vaccination rates were inversely correlated with the state-level COVID-19 mortality rate in 2021 (r = −0.75; P < .001); however, this was not true for 2020 (r= −0.75; P < .001). There were also positive associations with mask mandates (r = .49; P < .001).
According to the investigators, this study is the first to evaluate population-level and parent-reported childhood asthma symptoms prevalence and COVID-19 vaccination. The findings demonstrate that higher COVID-19 vaccination rates may provide protection against pediatric patients’ symptomatic asthma, and that vaccination might also provide some benefits against SARS-CoV-2 infection and other human coronaviruses through cross-reactive antibody responses in individual children. This suggests that community-level immunity in states that have higher vaccination rates may also contribute to the reduction of children’s risk to asthma. Alternatively, simultaneous exposure to high population-level burden of COVID-19-attributed disease and sustained state-level face mask requirements were not associated with parallel trends in patient-reported symptomatic childhood asthma.
The authors note that there are limitations to the study, such as the lack of state-level estimates of COVID-19 vaccination rates among children with a history of asthma in the analysis because of the unavailability of the data. Because of this, differences in symptomatic asthma among vaccinated pediatric patients compared with unvaccinated children could not be made. Despite this, the investigators confirm that reduction in symptomatic asthma among pediatric patients in 2020 and the overall individual-level COVID-19 mortality reduction with vaccination offer outside support for the state-level findings. Further, the lack of association of COVID-19 vaccination—that was primarily administered in 2021—along with population-level COVID-19 mortality in 2020 acts as a negative control. According to the investigators, the findings should be confirmed with additional research to help determine whether asthma symptom prevalence in pediatric patients may be reduced by the sustained efforts of vaccination against COVID-19.
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