On May 2, 2020, World Asthma Day will again focus on the needs of people with asthma across the globe. Previous themes have included managing asthma and living with the disease. These themes resonate more than ever this year, as any discussions are likely to be dominated by current debates in relation to the coronavirus disease 2019 (COVID-19) pandemic and its effects on asthma care and management.
In fact, the risk of infection, and of severe disease once infected, has been a major topic of debate among patients with asthma during the pandemic. As the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) results in respiratory manifestations such as pneumonia and acute respiratory distress syndrome, it was predicted that patients with chronic respiratory diseases (CRDs) would be more vulnerable both to infection and to subsequent severe disease. However, a Comment published in the journal suggests that the prevalence of CRDs, including asthma, among patients with COVID-19 might be lower than that expected from population levels of these diseases. The authors speculate that the lower reported prevalence might be due to underdiagnosis or lack of recognition of CRDs in those with COVID-19, effects of differing immune responses elicited by CRDs, or a protective effect of inhaled corticosteroids. The New York Times noted that asthma did not appear in the top ten comorbidities in patient fatality data from the Department of Health. COPD is listed as eighth, probably due to the age and frailty of this population, but again featuring further down the list than might be expected when compared with rankings in Global Burden of Disease data. However, evidence for an effect of CRDs or their treatment on the risk of SARS-CoV-2 infection or on the course of COVID-19 is currently weak—predominantly in highly selected populations, such as hospitalised patients with severe disease—and is constantly evolving.
A Comment published in The Lancet suggested that steroids might be harmful in patients with COVID-19, but stressed that available data are limited. The data do not relate to patients with asthma and should not result in a change in management. The AAAAI and several lung disease organisations reiterated that patients should remain on their current medications because experiencing an exacerbation event and the need for hospitalisation, in those who become poorly controlled, could actually increase patient exposure and the risk of infection. Data are scarce for patients with severe asthma, so any additional guidance for this group is welcome, especially ahead of the forthcoming allergy season. NICE has provided COVID-specific rapid guidance for severe asthma, with five areas for consideration: communicating with patients and minimising risk, investigations, treatment, equipment, and modifications to usual care. Furthermore, the NHS has provided a guide for the management of respiratory patients during the pandemic.
Ahead of World Asthma Day, it is easy to overlook the substantial progress that has been made in asthma management in these challenging times. Personalised medicine now plays a large part in asthma care, and concepts such as treatable traits have been folded into patient management. Although the current focus is quite rightly on the pandemic, funders should ensure that there is continued investment for future research and treatment efforts, especially given that support for respiratory diseases has traditionally been underfunded for multifactorial reasons, not least the blame culture that is associated with smoking as a major risk factor for many CRDs and lung cancer. Data related to smoking and risk of SARS-CoV-2 infection has been somewhat contradictory, but the association between smoking and an increased risk of respiratory disease is clear. Research efforts to control smoking, and monitor e-cigarette use in light of the recent EVALI cases, should therefore be safeguarded so that they can be kickstarted again once this pandemic has passed. President Trump's withdrawal of funding to WHO in a knee-jerk reaction during an unprecedented time of global crisis—an action that has quite rightly been described as a “crime against humanity”—should prompt worldwide condemnation. As a result of this decision, vital research to tackle smoking and CRDs is likely to be impacted.
The world will look very different in a year's time, but positives can be noted: the spirit of international collaboration and breaking down of geographical barriers, widespread sharing of data, and the global appreciation of dedicated health-care workers and frontline staff. These aspects will inform the core discussions on this forthcoming, and the next, World Asthma Day.
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