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Does asthma predispose higher risk of severe COVID-19?

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In this Contemporary Pediatrics® interview, Samir Gautam, MD, (Pulmonary, Critical Care and Sleep Medicine), Yale School of Medicine, senior author of a recently published study in the Journal of Allergy and Clinical Immunology: In Practice, reviews key findings of the study and explains how they relate to the pediatric population. Watch the full interview below.

Transcript (editoed for clarity):

Contemporary Pediatrics:

Hi, thank you so much for joining us. I’m Joshua Fitch, editor of Contemporary Pediatrics.

Samir Gautam, MD, PhD:

Hi I’m Samir Gautam. I’m an assistant professor of medicine for the section of Pulmonary Critical Care, at the Yale School of Medicine. Thanks very much for having me.

Contemporary Pediatrics:

Of course, thank you so much for being here. First can you explain your recent study and go into a little bit of detail on how it can affect the pediatric population, and your findings overall, this related to “Differences in Mortality Among Patients with Asthma and COPD Hospitalized with COVID-19,” published in The Journal of Allergy and Clinical Immunology: In Practice.

Gautam:

Absolutely. So, the question we wanted to address was what lung diseases, specifically what airway diseases, predispose patients to higher risk of developing severe COVID-19. The 2 major airway diseases we studied were Chronic obstructive pulmonary disease (COPD), which is not as relevant of course to the pediatric population, and asthma, which is. What we found was that COPD, consistent with some other studies did dispose to developing severe COVID-19, but asthma was actually protective. We further found that some markers of allergic inflammation like blood eosinophil count were also associated with protection from severe COVID-19. I think the underlying immunologic conclusion that we make is that type 2 inflammation, meaning allergic inflammation, may be protective from developing severe, life-threatening COVID-19.

Contemporary Pediatrics:

Based on your study that was contradictory to some degree of previously established criteria, correct?

Gautam:

Yes. That's exactly right. The recommendations by [the Centers for Disease Control and Prevention] (CDC) and many other major, regulatory bodies had suggested that having asthma would predispose a severe disease, but we didn't find that. We found that it was markedly protected.

Contemporary Pediatrics:

Thank you, Dr. Gautam. Related to the pediatric population, what kind of patient numbers did you see in your study and in your research? How is that applied to the overall findings, and can it be even, so to speak, taken a little further in a pediatric population? Are more studies needed?

Gautam:

First of all, our study included patients from age 12 and onward. We didn't stratify by age to do a specific study on the pediatric population. However, I think there are 2 major questions that have come up, with respect to COVID, in the pediatric folks. One is, does having asthma predispose a pediatric patient to multisystem inflammatory syndrome (MIS-C). If we can extrapolate from our data here, it would suggest that it would not predispose to developing a severe inflammatory response, but actually would probably be protective. That has to be studied directly to prove one way or the other. The other major question is in asthmatic children after they get COVID-19, will their asthma get worse? Will they have an asthma exacerbation? That is actually a very different question, and that was recently studied. There was a paper in patients under 18 months old, it was published in Annals of the American Thoracic Society. They did not find that COVID-19 infection, worsened the asthma control in these patients. But as far as I know, it hasn't been studied in children. While I think, having asthma is protective against developing severe inflammation that brings you into the hospital and that is life threatening, I strongly suspect that asthma can flare from COVID-19.

Contemporary Pediatrics:

Thank you, Dr. Gautam. Anything else you would like to add as it relates to the pediatric population or any potential indications, or even further studies that you may have gotten wind of related to this going forward?

Gautam:

I think one other developing theme is that long COVID, it may be slightly more prevalent in patients with asthma. Then we can sort of think of 3 different outcomes: One is severe COVID-19, which is rare children; two is an asthma exacerbation, which is certainly possible; and the third is the development of long COVID. That is very much a question that needs to be studied in detail. As far as I'm aware, I don't think anything's ongoing right now.

Contemporary Pediatrics:

For healthcare professionals who have a child come in with asthma and a COVID diagnosis or previous COVID-19 diagnosis, what are some of the questions they should be asking parents or the patient themselves given this information?

Gautam:

Yeah, that's a really good question and in my care of patients this has come up. Commonly, if somebody's having an asthma exacerbation, a post viral asthma exacerbation, people consider giving steroids depending on the severity of the exacerbation. Right now, you could probably defend giving steroids on to 2 bases: One, that it would prevent severe COVID-19 and two, that it might prevent an asthma exacerbation or treat an asthma exacerbation. I think that the question, in addition to whether or not steroids are appropriate, is if the patient should also be treated with [nirmatrelvir tablets and ritonavir tablets] (Paxlovid; Pfizer). Now usually children don't carry a comorbidity that would allow them to receive [nirmatrelvir tablets and ritonavir tablets], but I think this is a reasonable question to wonder whether you should treat with [nirmatrelvir tablets and ritonavir tablets], which of course will aid in clearance of the virus, while at the same time giving steroids, which will impair the ability to clear the virus.

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