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. 2021 Nov 14;10(1):91–99.e12. doi: 10.1016/j.jaip.2021.10.067

COVID-19 Pandemic–Related Reductions in Pediatric Asthma Exacerbations Corresponded with an Overall Decrease in Respiratory Viral Infections

Samir Sayed a,∗,†, Avantika R Diwadkar b,∗,†, Jesse W Dudley c,∗,†, Janielle O’Brien d, Donald Dvorin d, Chén C Kenyon e,f, Blanca E Himes b,#,∗∗, David A Hill a,e,g,∗,#,∗, Sarah E Henrickson a,e,g,#,∗
PMCID: PMC8590625  PMID: 34785388

Abstract

Background

Respiratory viruses, air pollutants, and aeroallergens are all implicated in worsening pediatric asthma symptoms, but their relative contributions to asthma exacerbations are poorly understood. A significant decrease in asthma exacerbations has been observed during the coronavirus disease 2019 pandemic, providing a unique opportunity to study how major asthma triggers correlate with asthma activity.

Objective

To determine whether changes in respiratory viruses, air pollutants, and/or aeroallergens during the coronavirus disease 2019 pandemic were concomitant with decreased asthma exacerbations.

Methods

Health care utilization and respiratory viral testing data between January 1, 2015, and December 31, 2020, were extracted from the Children’s Hospital of Philadelphia Care Network’s electronic health record. Air pollution and allergen data were extracted from US Environmental Protection Agency public databases and a National Allergy Bureau–certified station, respectively. Pandemic data (2020) were compared with historical data.

Results

Recovery of in-person asthma encounters during phased reopening (June 6 to November 15, 2020) was uneven: primary care well and specialty encounters reached 94% and 74% of prepandemic levels, respectively, whereas primary care sick and hospital encounters reached 21% and 40% of prepandemic levels, respectively. During the pandemic, influenza A and influenza B decreased to negligible frequency when compared with prepandemic cases, whereas respiratory syncytial virus and rhinovirus infections decreased to low (though nonnegligible) prepandemic levels, as well. No changes in air pollution or aeroallergen levels relative to historical observations were noted.

Conclusions

Our results suggest that viral respiratory infections are a primary driver of pediatric asthma exacerbations. These findings have broad relevance to both clinical practice and the development of health policies aimed at reducing asthma morbidity.

Key words: Asthma, COVID-19, Respiratory virus, Pediatric to asthma, Aeroallergen, Pollution

Abbreviations used: CHOP, Children’s Hospital of Philadelphia; COVID-19, coronavirus disease 2019; ED, emergency department; ICS, inhaled corticosteroid; IFV-A, influenza A; IFV-B, influenza B; RSV, respiratory syncytial virus; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2

What is already known about this topic? Although respiratory viruses, air pollutants, and aeroallergens are implicated in worsening pediatric asthma symptoms, the interplay between these factors and asthma exacerbations is not well understood. Asthma exacerbations decreased significantly during the coronavirus disease 2019 pandemic, allowing for the investigation of these asthma triggers relative to asthma activity.

What does this article add to our knowledge? The sustained reductions in viral infections and acute asthma activity we observed during the coronavirus disease 2019 pandemic support a strong link between respiratory virus infections and pediatric asthma exacerbations.

How does this study impact current management guidelines? Our findings suggest that viral respiratory infections are a primary driver of pediatric asthma exacerbations and that preventive measures taken to control exposure to these viruses may help limit exacerbating asthma symptoms

Introduction

Symptoms of asthma, a common pediatric respiratory disease,1 worsen with exposure to respiratory viruses, air pollution, and aeroallergens.2 In addition, patients with asthma have more frequent, severe, and longer-lasting symptoms with respiratory viral infections than do people without asthma.3 , 4 Exposure to air pollutants, including particulate pollution (particulate matter with a diameter of less than 2.5 microns [PM2.5] and PM with diameter of less than 10 microns [PM10]), ozone, and nitrogen dioxide (NO2), has been associated with increased risk of asthma development, exacerbations, and hospitalizations.5, 6, 7, 8, 9 In children with atopic asthma, aeroallergens are also a cause of asthma exacerbations.10 , 11

Public health interventions to mitigate the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative virus of coronavirus disease 2019 (COVID-19), included social distancing, mask-wearing, and quarantining of sick or exposed individuals.12, 13, 14, 15 Although it was initially suspected that asthma might be a COVID-19 risk factor—a concern that may have increased preventive health behaviors among those with asthma16 , 17—subsequent studies showed that people with asthma who contract SARS-CoV-2 were at a lower risk for adverse outcomes.18 , 19 The institution and modulation of COVID-19–related public health measures offer a unique opportunity to study their effects on health outcomes beyond those directly infected, including asthma.20 , 21 Asthma symptoms and exacerbations decreased during the early stages of the COVID-19 pandemic,22, 23, 24, 25 along with factors that impact asthma, such as respiratory viral infections.23 , 26, 27, 28, 29 In a previous publication, we found that during the first 2 months following public health interventions in Philadelphia, in-person asthma visits and steroid prescriptions decreased by more than 80%, with a concomitant decrease in rhinovirus infections and no change in air pollution compared with historical data for the years 2015-2019.23 Given that public health measures changed throughout 2020 and health systems resumed more in-person services, we sought to determine whether the decreased patterns of asthma activity we initially observed were maintained throughout 2020, and whether levels of respiratory viral infections, air pollution, and aeroallergens mirrored asthma activity.

Methods

Study population and timeline

Patient-level demographic characteristics of our study population are presented in Table E1 in this article’s Online Repository at www.jaci-inpractice.org. We extracted asthma patient data corresponding to January 1-December 31 encounters for the years 2015 to 2020 from the Children’s Hospital of Philadelphia (CHOP) Care Network, which consists of 48 outpatient primary and specialty care clinical sites, 4 urgent care sites, 15 community hospital alliances, and a 557-bed quaternary care center in the greater Delaware River Valley area; the network has maintained the same number and type of providers during this time period. Asthma diagnosis was established on the basis of encounters having International Classification of Diseases, Tenth Revision code J45.nn. Public health measures during the COVID-19 pandemic in Philadelphia and surrounding counties were divided into phases. The prelockdown phase occurred from January 1 to March 17, 2020. The first lockdown occurred from March 18 to June 5, 2020, while the phased reopening consisted of an initial reopening between June 6 and June 26, 2020, and a further reopening between June 27 and November 15, 2020. The second lockdown was instituted on November 16 and lasted through January 4, 2021. A more thorough description of these time frames may be found in this article’s Online Repository at www.jaci-inpractice.org.

Variable selection

For each encounter, its type (ie, primary-well, primary-sick, specialty [Allergy and Pulmonary], emergency department [ED], inpatient, and intensive care unit) and date were extracted, along with the patient’s sex, race, ethnicity, date of birth, and payer type. Race was based on self- or parent/guardian-selection of 1 of the following categories: “white,” “Black,” “Asian or Pacific Islander,” or “Other.” Subjects without a race selection were coded as “Unknown.” Asthma-related drug prescription data for all outpatient asthma-related encounters (both primary and secondary diagnosis) and inpatient asthma-related encounters (primary diagnosis only) were obtained from CHOP prescription records (see Table E2 in this article’s Online Repository at www.jaci-inpractice.org). Outpatient encounters included primary-well, primary-sick, and specialty care outpatient visits, whereas hospital encounters included those in the ED, intensive care unit, or inpatient stays. Inhaled corticosteroid (ICS), leukotriene modifier, and ICS + long-acting β2-agonist drugs were considered asthma maintenance medications, whereas short-acting β-agonist, systemic steroid, anticholinergic, and ED/inpatient magnesium were considered acute management medications.

Viral infection data

Results for respiratory viral testing from CHOP ED and satellite sites for adenovirus, influenza A (IFV-A), influenza B (IFV-B), metapneumovirus, non–COVID-19 coronavirus, respiratory syncytial virus (RSV), rhinovirus, parainfluenza 1, parainfluenza 2, parainfluenza 3, and COVID-19 were extracted from CHOP’s Respiratory Virus Prevalence database (see Table E3 in this article’s Online Repository at www.jaci-inpractice.org). Four viruses most relevant to asthma exacerbations (IFV-A, IFV-B, RSV, and rhinovirus23 , 30), as well as COVID-19, were selected for further analysis. Data for the total weekly number of positive test results during 2020 and, separately, for 2015-2019 were obtained. Data for January 1 to March 31, 2021, were also obtained.

Air pollution data

Hourly PM2.5, PM10, ozone, and NO2 measures obtained at US Environmental Protection Agency monitoring sites in Philadelphia for the time period January 1 to December 31, 2020, were extracted from AirNow (an air quality data management system that reports real-time and forecast air quality estimates).31 Historical data from 2015 to 2019 for these pollutants were downloaded from Air Data (a US Environmental Protection Agency resource that provides quality-assured summary air pollution measures collected from outdoor regulatory monitors across the United States32). AirNow did not provide historical data for pollutants considered, and Air Data did not contain 2020 data, because its data are released months after the data are reported in AirNow. For regulatory monitors included in our study, AirNow and AirData measures were obtained at the same monitoring sites.

Aeroallergen data

Aeroallergen concentrations for trees, weed, mold, and grass pollen were measured per Burkard device guidelines at The Asthma Center, National Allergy Bureau–certified station in Mt Laurel, NJ, during the period March 17 to October 29, 2020.33 Station measures were reported as categorical variables based on historical concentrations: trees, weed, and grass pollen levels were categorized as not present, low concentration, moderate concentration, high concentration, and very high concentration for weekly average estimate ranges 0, 1 to 9, 10 to 29, 30 to 59, and 60+ particles/m3 of air, respectively; weed pollen was binned into the same levels according to weekly average ranges 0, 50 to 599, 600 to 999, 1000 to 2499, and 2500+ particles/m3 of air. Historical data for the time period 2015 to 2019 from this site were not available, but the ranges used are based on historical levels observed by the same National Allergy Bureau station that collected the 2020 data.

Data analysis

Summary statistics for rates of health care encounters and asthma-related medication prescriptions from 2020 were compared with those from 2015 to 2019. Comparisons were made between the prelockdown and the first lockdown period by comparing the average weekly encounter or medication prescription activity during the 8 weeks before and after the week of March 18, 2020. Comparisons were made between the phased-reopening time period and previous years by determining the “peak” weekly encounter or medication prescription activity, as defined as the highest 8-week moving average, between week 26 and 45 of 2020 or 2015-2019. Viral testing analysis was performed via 2 comparisons whereby summary statistics for historical data from 2015 to 2019 were compared with (1) 2020 data and (2) September 2020 to March 2021 data to cover the full influenza and RSV seasons expected for 2020-2021, which often span November to March. Weekly averages of PM2.5, PM10, ozone, and NO2 measures were calculated for the year 2020 and across the years 2015-2019. SD was calculated for historical data. Aeroallergen data were visualized according to categorical level for each week of 2020.

Data availability

The epidemiologic data supporting the conclusions of this article are available in the Zenodo repository (https://zenodo.org/record/5736294).

Ethical and regulatory oversight

The CHOP Institutional Review Board reviewed our study and determined it did not meet the definition of Human Subjects research.

Results

Before enacting COVID-19–related public health measures on March 18, 2020, in Philadelphia, pediatric asthma health care visit numbers and encounter types at CHOP were similar to 2015-2019 historical averages. Comparison of asthma encounters during the prelockdown to the first lockdown period showed that the average number of weekly outpatient encounters decreased to 12% of prepandemic levels (1069 encounters/wk vs 130 encounters/wk), with primary-well decreasing to 10% (351 vs 36 encounters/wk), specialty decreasing to 12% (455 vs 53 encounters/wk), and primary-sick decreasing to 16% (263 vs 41 encounters/wk) (Figure 1 , A). During this time period, the average number of weekly hospital encounters decreased to 20% of prepandemic levels (186 vs 37 encounters/wk; Figure 1, B). In the case of both outpatient and hospital encounters, weekly rates of historical data were at similar levels before and after the week of March 18.

Figure 1.

Figure 1

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Outpatient and hospital asthma encounters during 2020. (A) Weekly averages for outpatient asthma encounters from January 1 to December 31, 2020. Primary care well visits (Well), primary care acute care visits (Sick), and specialty care visits (Specialty; Allergy and Pulmonary) are shown. (B) Weekly averages for hospital asthma encounters from January 1 to December 31, 2020. ED, inpatient admissions (Inpatient), and pediatric intensive care unit (ICU) admissions are shown. Five-year historical averages (January 1-December 31, 2015-2019) with 1 SD from the mean are shown. Phases of Philadelphia COVID-19–related public health measures are shown.

During the phased reopening June 6 to November 15, there was a gradual return of nonacute asthma-related outpatient encounters to historical and prepandemic levels. Specifically, primary-well and specialty outpatient encounters rose to 94% (456 vs 486 encounters/wk) and 74% of historical levels (317 vs 429 encounters/wk), respectively (Figure 1, A). In contrast, primary-sick encounters increased to 21% of historical levels (66 vs 319 encounters/wk; Figure 1, A), and hospital encounters increased to 40% of historical levels (75 vs 188 encounters/wk; Figure 1, B).

Before enacting COVID-19–related public health measures, pediatric asthma prescription patterns at CHOP were similar to 2015-2019 historical averages. Comparison of CHOP prescription patterns during the prelockdown to the first lockdown period found that prescriptions for each asthma maintenance (Figure 2 , A) and acute management (Figure 2, B) medication decreased relative to their prepandemic levels: ICS to 59% (436 vs 258 prescriptions/wk), ICS + long-acting β2-agonist to 70% (98 vs 68 prescriptions/wk), leukotriene modifier to 63% (122 vs 77 prescriptions/wk), short-acting β-agonist to 46% (1146 vs 530 prescriptions/wk), systemic steroids to 36% (580 vs 211 prescriptions/wk), anticholinergic to 20% (129 vs 26 prescriptions/wk), and ED/inpatient magnesium to 38% (36 vs 14 prescriptions/wk). For each of these drug classes, their levels remained similar from January to June according to historical data. We did not observe an asthma medication shortage in Philadelphia during the early stages of the pandemic.

Figure 2.

Figure 2

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Asthma prescriptions during 2020. (A) Weekly averages for asthma maintenance medication prescriptions from January 1 to December 31, 2020. ICS, leukotriene modifiers (LTM), and ICS + long-acting β-agonist (ICS + LABA) prescriptions are shown. (B) Weekly averages for asthma acute management medication prescriptions from January 1 to December 31, 2020. Short-acting β-agonist (SABA), systemic steroid (SS), anticholinergic (AC), and magnesium (Mg) prescriptions are shown. Five-year historical averages (January 1-December 31, 2015-2019) with 1 SD from the mean are shown. Phases of Philadelphia COVID-19–related public health measures are shown.

When examining the phased reopening period, prescription patterns for all medications showed a recovery toward historical and prepandemic levels, but all remained lower through December 2020 (Figure 2). Specifically, short-acting β-agonist prescriptions were 61% of historical levels (761 vs 1240 prescriptions/wk), systemic steroid prescriptions were 58% of historical levels (338 vs 576 prescriptions/wk), anticholinergic prescriptions were 34% of historical levels (53 vs 153 prescriptions/wk), and ED/inpatient magnesium prescriptions were 66% of historical levels (23 vs 35 prescriptions/wk). In comparison, ICS prescriptions were 56% of historical levels (308 vs 551 prescriptions/wk), leukotriene modifier prescriptions were 65% of historical levels (97 vs 149 prescriptions/wk), and ICS + long-acting β2-agonist prescriptions were 84% of historical levels (85 vs 101 prescriptions/wk).

Testing for all viruses continued during 2020 though the number of non–COVID-19 tests performed decreased when compared with historical testing figures. During the prelockdown phase, an increase in the number of positive IFV-A and IFV-B test results was observed as compared with historical averages.23 In addition, both the number of positive RSV and positive rhinovirus test results decreased during this time period when compared with historical averages. Just as the first lockdown was instituted, the number of positive results for rhinovirus increased. However, this increase (as a percentage of total rhinovirus test results) was similar to the historical average (see Table E3). The weekly total positive test results for IFV-A, IFV-B, RSV, and rhinovirus during the first lockdown, phased reopening, and second lockdown were significantly lower than 2015-2019 historical averages even as the number of positive COVID-19 test results increased (Figure 3 ). When investigating seasonal trends, and focusing on months of peak viral transmission, the respiratory viral data from September 2020 to March 2021 showed that positive test results for IFV-A, IFV-B, and RSV were at or near zero when compared with their historical averages. Positive rhinovirus test results, while nonzero, also remained significantly lower than antecedent averages (Figure 4 ).

Figure 3.

Figure 3

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Viral respiratory testing data using deidentified institutional ED and satellite sites virology testing results for the period 2015 to 2020. Time series plots comparing historical average data (dark gray lines) and ±1 SD (light gray shaded areas) from 2015 to 2019 to 2020 data (dark blue lines) for total number of weekly positive IFN-A, IFV-B, RSV, rhinovirus, and COVID-19 test results, respectively. Phases of Philadelphia COVID-19–related public health measures are shown.

Figure 4.

Figure 4

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Viral respiratory testing data comparing September 2020 to March 2021 to historical data (2015-2019). Total number of weekly positive IFV-A, IFV-B, RSV, rhinovirus, and COVID-19 testing data (dark blue lines with blue markers) from the ED and satellite sites are compared with the 2015-2019 historical average (dark gray lines) ±SD (light gray shaded areas) during the same period. Weeks during which tests were not performed are without markers.

Air pollution and aeroallergen trends did not substantially change during the pandemic compared with historical or expected seasonal data,11 , 28 respectively (Figure 5 ). Although seasonal variability in daily average PM2.5, PM10, NO2, and ozone was observed, the variability was similar to historical trends across the years 2015-2019. Aeroallergen concentrations during most weeks of 2020 were not present or low concentration, with high concentration of weed pollen in September, very high concentration of tree pollen in March-May, high concentration to very high concentration of mold pollen in mid-March-October, and moderate concentration of grass pollen in May-June.

Figure 5.

Figure 5

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Levels of air pollutants and aeroallergens in Philadelphia during the COVID-19 pandemic. (A) Trend lines of weekly averages of daily NO2, ozone, PM10, and PM2.5 measures from 2020 and 2015-2019 sourced from AirNow and AirData, respectively, for the period January 1 to December 31 in Philadelphia. (B) Heatmap of weekly aeroallergen concentrations for tree, weed, mold, and grass pollen measured by a National Allergy Bureau–certified station near Philadelphia during the period March 17 to October 29, 2020. Phases of Philadelphia COVID-19–related public health measures are shown. ppb, Parts per billion.

Discussion

In addition to the devastating morbidity and mortality arising directly from COVID-19,29 , 30 , 34, 35, 36 there have been indirect negative effects on various health outcomes.20 , 21 , 26 , 28 In the case of asthma, however, COVID-19–related public health measures during the initial months of the pandemic reduced disease burden.23, 24, 25 , 27 , 37 , 38 As a continuation of our previous initial observations,23 the in-depth analyses of the effects of COVID-19–related public health measures on asthma activity over a longer period of time provide a unique opportunity to study the environmental triggers of asthma exacerbations. Our current results show that although the relaxation of COVID-19–related public health measures resulted in a recovery of nonacute asthma care to near prepandemic levels, there was a persistence of historically low acute asthma care that corresponded with low respiratory virus positivity until the end of 2020. The current study allows for the analysis of viral trends following deviations from public health interventions during the course of the study, as well as a closer look at the seasonality of the viruses when compared with historical averages due to the increased duration of the observation period. Allergen data during this span have also been included in the current analysis. In addition, analysis of well versus sick outpatient encounters was performed, as was a more detailed analysis of asthma medication prescriptions during this time frame.

The COVID-19 pandemic has resulted in a substantial decrease in respiratory viral infections,23 , 26 , 29 , 38 including influenza.23 , 28 , 39 , 40 Consistent with these reports, our results show that the number of positive virus test results decreased and remained lower than the historical average. Specifically, in the ED and satellite care centers between September 2020 and March 2021, when peaks in the number of IFV-A, IFV-B, and RSV infections were observed in previous years, no positive IFV-A, IFV-B, or RSV infections were identified. In addition, the number of positive cases of rhinovirus, a key virus linked to asthma exacerbations,41 , 42 remained lower than historical averages. These trends may not be solely due to behavioral responses or public health interventions, in that after the major US 2020 fall and winter holidays that were accompanied by ill-advised gatherings (eg, Thanksgiving, Christmas, and New Year’s Eve), the number of respiratory viruses, other than SARS-CoV-2, remained very low even as COVID-19 rates increased. Given the known role of respiratory viral infections as a trigger of asthma exacerbations, it is likely that the sustained decrease in respiratory virus levels strongly contributed to the decrease in asthma encounters in 2020.

Exposure to air pollution and aeroallergens contributes to asthma exacerbations.5, 6, 7, 8, 9, 10, 11 Consistent with our previous publication that studied the early phases of the pandemic,23 we did not observe changes to levels of air pollutants that diverged from historical trends; that is, seasonal variability in PM2.5, PM10, and ozone, which peaked during summer 2020, and NO2, which peaked during winter 2020, was consistent with 2015-2019 trends.43 , 44 Similarly, seasonal peaks were observed among aeroallergens from April to June and early September, according to pollen type,11 , 45 but these changes were consistent with historical trends. Previously, we explicitly confirmed that the seasonal decrease in levels of 4 air pollutants in the 2-month period following Philadelphia’s first lockdown period was not statistically significant when compared with historical trends via interrupted time series analysis.23 Here, having expanded the time period of observation, there were even fewer differences between pollution levels across 2020 compared with historical patterns, suggesting that the implementation and relaxation of COVID-19–related public health measures had little effect on levels of PM2.5, PM10, ozone, and NO2 in Philadelphia as measured with regulatory monitors. Similarly, COVID-19–related measures did not influence aeroallergen levels, as illustrated by our results for weed, tree, mold, and grass pollens, which followed expected seasonal trends. We note however that our data have limitations. First, the US Environmental Protection Agency data used comprised monitoring sites that sparsely cover the greater Philadelphia region and do not account for all pollutants that may have changed as a result of public health measures. Second, our aeroallergen data were sourced from a single monitoring site and did not have detailed historical measures available (only ranges). Third, public health interventions may have altered the outdoor pollution and aeroallergen exposure profiles of children due to increased usage of masks, decreased outdoor activity and commuting, and school closures.46 , 47 Given the complex behavioral, environmental, and biological issues relevant to fully understanding the effects of public health interventions on asthma studies, capturing individual-level data is necessary to more fully quantify changes in children’s exposure profiles, as well as to distinguish the impact of these changes on atopic versus nonatopic children with asthma.48

The recovery of nonacute asthma care during the reopening phases suggests that people were willing and able to access health care during this time. Thus, reduced access was not a major driver of the persistently low acute outpatient and inpatient asthma encounters. The persistently decreased prescription levels of maintenance and acute management medications during phases in which routine asthma care encounters were recovering further support that a decrease in asthma exacerbations and symptoms occurred. However, it is possible that fear of coming to the pediatrician’s office or hospital, out of concern for increased SARS-CoV-2 infection risk, drove some of the effect on acute asthma care that we observed. There are additional limitations to our study. Our results showing a substantial decrease in the number of asthma exacerbations along with extremely low levels of respiratory viral infections reflect a single pediatric health care network and may not generalize to other populations. Using an International Classification of Diseases, Tenth Revision classification of asthma may potentially miss asthma admissions that were coded primarily as COVID-19–related. Nevertheless, the observed trends of a decrease in weekly positive respiratory virus test results during the first lockdown, phased reopening, and second lockdown, together with the decrease in acute asthma episodes during the same time frame, suggest that limiting routes through which respiratory viruses are communicable likely substantially decreased asthma exacerbations.

Although the restrictive COVID-19 public health interventions would not be feasible or acceptable long-term given their detrimental consequences on other aspects of health,49, 50, 51 the insights gained during this period may foster greater awareness for the importance of practicing effective strategies to reduce exacerbations. Continued education of patients with asthma and their parents to encourage handwashing, provide anticipatory guidance about travel, adhere to asthma action plans as children return to school,52 consider voluntary masking during respiratory viral seasons in certain settings (eg, large indoor gatherings or while traveling), and follow other Centers for Disease Control and Prevention guidelines to reduce viral transmission53 , 54 could effectively curb asthma exacerbations. As the COVID-19 pandemic subsides and related public health measures are reduced, continued studies of the relationship between viral infection rates and asthma are needed to identify the most effective and acceptable long-term strategies that will maintain reduced asthma exacerbations.

Footnotes

This work was supported by the National Institutes of Health (grant no. K08DK116668 to D.A.H., grant nos. R01HL133433, R01HL141992, and P30ES013508 to B.E.H., grant no. K08AI135091 to S.E.H., and grant no. K23HL136842 to C.C.K.), the American College of Allergy, Asthma and Immunology (D.A.H.), the American Academy of Allergy, Asthma & Immunology (D.A.H.), the American Partnership for Eosinophilic Disorders (D.A.H.), the Burroughs Wellcome Fund (S.E.H.), and Children’s Hospital of Philadelphia Research Institute Developmental Awards (D.A.H., S.E.H., and C.C.K.). The content of this work is the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Conflicts of interest: The authors declare that they have no relevant conflicts of interest.

Online Repository

Table E1.

Demographic characteristics of subjects with asthma by time period and encounter type

Characteristic Cohort (n)
2015-2019
 January 1-December 31, 2020
All (88,039) Outpatient Inpatient Video All (28,157)
Sex, n (%)
 Male 50,281 (57) 13,996 (57) 1739 (57) 2804 (58) 16,160 (57)
 Female 37,756 (43) 10,392 (43) 1290 (43) 2017 (42) 11,997 (43)
Race, n (%)
 Asian/Pacific Islander 2926 (3) 824 (3) 73 (2) 140 (3) 934 (3)
 Black 33,495 (38) 8995 (37) 2117 (70) 1328 (28) 10,690 (38)
 White 38,943 (44) 10,881 (45) 461 (15) 2558 (53) 12,282 (44)
 Other 12,204 (14) 3537 (15) 373 (12) 757 (16) 4082 (14)
 Unknown 471 (1) 151 (1) 5 (0) 38 (1) 169 (1)
Ethnicity, n (%)
 Non-Hispanic/Latino 79,886 (91) 21,875 (90) 2717 (90) 4231 (88) 25,209 (90)
 Hispanic/Latino 7452 (8) 2330 (10) 305 (10) 538 (11) 2737 (10)
 Unknown 701 (1) 183 (1) 7 (0) 52 (1) 211 (1)
Birth year, n (%)
 Before 2000 6979 (8) 183 (1) 6 (0) 74 (2) 237 (1)
 2000-2004 18,668 (21) 3677 (15) 281 (9) 665 (14) 4189 (15)
 2005-2009 25,468 (29) 7564 (31) 591 (20) 1224 (25) 8468 (30)
 2010-2014 26,448 (30) 7932 (33) 963 (32) 1572 (33) 9168 (33)
 2015 or later 10,476 (12) 5032 (21) 1188 (39) 1286 (27) 6095 (22)
Payer type, n (%)
 Non-Medicaid 49,551 (56) 13,069 (54) 762 (25) 2865 (59) 14,842 (53)
 Medicaid 38,488 (44) 11,319 (46) 2267 (75) 1956 (41) 13,315 (47)
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ICU, Intensive care unit.

Outpatient (Primary-Well, Primary-Sick, Specialty); Inpatient (ED, Inpatient, ICU); Video (Primary-Video, Specialty-Video).

Table E2.

Asthma medication classes

Medication ID no. Name Class
61180 Decadron IJ Systemic steroid
61181 Decadron IV Systemic steroid
61183 Decadron OR Systemic steroid
132559 Dex Combo 8-4 mg/mL IJ SUSP Systemic steroid
132710 Dex Combo IJ Systemic steroid
132560 Dex LA 16 16 mg/mL IJ SUSP Systemic steroid
132711 Dex LA 16 IJ Systemic steroid
132561 Dex LA 8 8 mg/mL IJ SUSP Systemic steroid
132712 Dex LA 8 IJ Systemic steroid
130359 Dexameth SOD PHOS-BUPIV-LIDO Systemic steroid
90302 Dexamethasone (glucocorticosteroids) Systemic steroid
61547 Dexamethasone (PAK) OR Systemic steroid
200200162 Dexamethasone 0.1 mg/mL (D5W) injection custom Systemic steroid
200200163 Dexamethasone 0.1 mg/mL (NSS) injection custom Systemic steroid
2762 Dexamethasone 0.5 mg OR TABS Systemic steroid
200200499 Dexamethasone 0.5 mg OR TABS (CHEMO) Systemic Steroid
2759 Dexamethasone 0.5 mg/5 mL OR ELIX Systemic Steroid
2760 Dexamethasone 0.5 mg/5 mL OR SOLN Systemic steroid
2763 Dexamethasone 0.75 mg OR TABS Systemic steroid
2764 Dexamethasone 1 mg OR TABS Systemic steroid
200201009 Dexamethasone 1 mg OR TABS (CHEMO) Systemic steroid
200200164 Dexamethasone 1 mg/mL (D5W) injection custom Systemic steroid
200200874 Dexamethasone 1 mg/mL (NSS) injection custom Systemic steroid
21292 Dexamethasone 1 mg/mL OR CONC Systemic steroid
200200501 Dexamethasone 1 mg/mL OR CONC (CHEMO) Systemic steroid
135377 Dexamethasone 1.5 mg OR TBPK Systemic steroid
135378 Dexamethasone 1.5 mg OR TBPK Systemic steroid
135379 Dexamethasone 1.5 mg OR TBPK Systemic steroid
2765 Dexamethasone 1.5 mg OR TABS Systemic steroid
200200502 Dexamethasone 1.5 mg OR TABS (CHEMO) Systemic steroid
2766 Dexamethasone 2 mg OR TABS Systemic steroid
200201008 Dexamethasone 2 mg OR TABS (CHEMO) Systemic steroid
2767 Dexamethasone 4 mg OR TABS Systemic steroid
200200503 Dexamethasone 4 mg OR TABS (CHEMO) Systemic steroid
200200504 Dexamethasone 4 mg/mL (undiluted) injection (CHEMO) custom Systemic steroid
200200165 Dexamethasone 4 mg/mL (undiluted) injection custom Systemic steroid
2768 Dexamethasone 6 mg OR TABS Systemic steroid
200200505 Dexamethasone 6 mg OR TABS (CHEMO) Systemic steroid
132777 Dexamethasone ACE & SOD PHOS Systemic steroid
132551 Dexamethasone ACE & SOD PHOS 8-4 mg/mL IJ SUSP Systemic steroid
132713 Dexamethasone ACE & SOD PHOS IJ Systemic steroid
90303 Dexamethasone acetate Systemic steroid
29197 Dexamethasone acetate 16 mg/mL IJ SUSP Systemic steroid
2769 Dexamethasone acetate 8 mg/mL IJ SUSP Systemic steroid
61549 Dexamethasone acetate IJ Systemic steroid
2770 Dexamethasone acetate POWD Systemic steroid
27267 Dexamethasone base POWD Systemic steroid
200200166 Dexamethasone injection custom orderable Systemic steroid
200200506 Dexamethasone injection custom orderable (CHEMO) Systemic steroid
2758 Dexamethasone intensol 1 mg/mL OR CONC Systemic steroid
61551 Dexamethasone intensol OR Systemic steroid
61554 Dexamethasone OR Systemic steroid
18270 Dexamethasone POWD Systemic steroid
130355 Dexamethasone SOD PHOS & BUPIV Systemic steroid
130356 Dexamethasone SOD PHOS-LIDO Systemic steroid
121371 Dexamethasone SOD phosphate PF 10 mg/mL IJ SOLN Systemic steroid
121730 Dexamethasone SOD phosphate PF IJ Systemic steroid
200201236 Dexamethasone sodium phosphate (CHEMO) 4 mg/mL IJ SOLN Systemic steroid
90304 Dexamethasone sodium phosphate (glucocorticosteroids) Systemic steroid
2771 Dexamethasone sodium phosphate 10 mg/mL IJ SOLN Systemic steroid
200201160 Dexamethasone sodium phosphate 10 mg/mL IJ SOLN (CHEMO) Systemic steroid
128185 Dexamethasone sodium phosphate 100 mg/10 mL IJ SOLN Systemic steroid
128184 Dexamethasone sodium phosphate 120 mg/30 mL IJ SOLN Systemic steroid
128183 Dexamethasone sodium phosphate 20 mg/5 mL IJ SOLN Systemic steroid
2772 Dexamethasone sodium phosphate 4 mg/mL IJ SOLN Systemic steroid
200201065 Dexamethasone sodium phosphate 4 mg/mL INH SOLN CUSTOM Systemic steroid
61557 Dexamethasone sodium phosphate IJ Systemic steroid
61558 Dexamethasone sodium phosphate IV Systemic steroid
2776 Dexamethasone sodium phosphate POWD Systemic steroid
135753 Dexpak 10 day 1.5 mg OR TBPK Systemic steroid
97925 Dexpak 10 day OR Systemic steroid
135749 Dexpak 13 day 1.5 mg OR TBPK Systemic steroid
61586 Dexpak 13 day OR Systemic steroid
135755 Dexpak 6 day 1.5 mg OR TBPK Systemic steroid
100127 Dexpak 6 day OR Systemic steroid
130145 Doubledex 10 mg/mL IJ KIT Systemic steroid
130264 Doubledex IJ Systemic steroid
70802 Medrol (PAK) OR Systemic steroid
17892 Medrol 16 mg OR TABS Systemic steroid
5790 Medrol 2 mg OR TABS Systemic steroid
5792 Medrol 32 mg OR TABS Systemic steroid
17891 Medrol 4 mg OR TABS Systemic steroid
135742 Medrol 4 mg OR TBPK Systemic steroid
5793 Medrol 8 mg OR TABS Systemic steroid
70803 Medrol OR Systemic steroid
71141 Methylpred 40 IJ Systemic steroid
130360 Methylprednisol & BUPIV & LIDO Systemic steroid
90309 Methylprednisolone Systemic steroid
128079 Methylprednisolone & lidocaine IJ Systemic steroid
200200507 Methylprednisolone (CHEMO) injection custom orderable Systemic steroid
71143 Methylprednisolone (PAK) OR Systemic steroid
5957 Methylprednisolone 16 mg OR TABS Systemic steroid
12408 Methylprednisolone 2 mg OR TABS Systemic steroid
12410 Methylprednisolone 32 mg OR TABS Systemic steroid
5958 Methylprednisolone 4 mg OR TABS Systemic steroid
135372 Methylprednisolone 4 mg OR TBPK Systemic steroid
12411 Methylprednisolone 8 mg OR TABS Systemic steroid
128116 Methylprednisolone ACE-LIDO Systemic steroid
132562 Methylprednisolone ACE-LIDO 40-10 mg/mL IJ SUSP Systemic steroid
132542 Methylprednisolone ACE-LIDO 80-10 mg/mL IJ SUSP Systemic steroid
132732 Methylprednisolone ACE-LIDO IJ Systemic steroid
90310 Methylprednisolone acetate Systemic steroid
132539 Methylprednisolone acetate 100 mg/mL IJ SUSP Systemic steroid
5959 Methylprednisolone acetate 20 mg/mL IJ SUSP Systemic steroid
5960 Methylprednisolone acetate 40 mg/mL IJ SUSP Systemic steroid
200201903 Methylprednisolone acetate 40 mg/mL IJ SUSP (IR use only) C∗ Systemic steroid
5961 Methylprednisolone acetate 80 mg/mL IJ SUSP Systemic steroid
71145 Methylprednisolone acetate IJ Systemic steroid
121372 Methylprednisolone acetate PF 40 mg/mL IJ SUSP Systemic steroid
121373 Methylprednisolone acetate PF 80 mg/mL IJ SUSP Systemic steroid
121778 Methylprednisolone acetate PF IJ Systemic steroid
20399 Methylprednisolone acetate POWD Systemic steroid
200200293 Methylprednisolone injection custom orderable Systemic steroid
71147 Methylprednisolone OR Systemic steroid
20398 Methylprednisolone POWD Systemic steroid
200200508 Methylprednisolone sodium SUCC (CHEMO) 1 mg/mL (NSS) INJECT∗ Systemic steroid
200200509 Methylprednisolone sodium SUCC (CHEMO) 1000 mg IJ SOLR Systemic steroid
200200510 Methylprednisolone sodium SUCC (CHEMO) 125 mg IJ SOLR Systemic steroid
200201004 Methylprednisolone sodium SUCC (CHEMO) 125 mg/mL (SWFI) INJ∗ Systemic steroid
200200511 Methylprednisolone sodium SUCC (CHEMO) 40 mg IJ SOLR Systemic steroid
200201002 Methylprednisolone sodium SUCC (CHEMO) 40 mg/mL (SWFI) INJE∗ Systemic steroid
90311 Methylprednisolone sodium SUCC (glucocorticosteroids) Systemic steroid
52078 Methylprednisolone sodium SUCC 1 g IJ SOLR Systemic steroid
200200294 Methylprednisolone sodium SUCC 1 mg/mL (NSS) injection CUST∗ Systemic steroid
12412 Methylprednisolone sodium SUCC 1000 mg IJ SOLR Systemic steroid
12413 Methylprednisolone sodium SUCC 125 mg IJ SOLR Systemic steroid
200201001 Methylprednisolone sodium SUCC 125 mg/mL (SWFI) injection C∗ Systemic steroid
12414 Methylprednisolone sodium SUCC 2000 mg IJ SOLR Systemic steroid
12415 Methylprednisolone sodium SUCC 40 mg IJ SOLR Systemic steroid
200200999 Methylprednisolone sodium SUCC 40 mg/mL (SWFI) injection CU∗ Systemic steroid
12416 Methylprednisolone sodium SUCC 500 mg IJ SOLR Systemic steroid
71149 Methylprednisolone sodium SUCC IJ Systemic steroid
89026 Millipred 10 mg/5 mL OR SOLN Systemic steroid
97492 Millipred 5 mg OR TABS Systemic steroid
135762 Millipred DP 12-day 5 mg OR TBPK Systemic steroid
111603 Millipred DP 12-day OR Systemic steroid
135756 Millipred DP 5 mg OR TBPK Systemic steroid
135757 Millipred DP 5 mg OR TBPK Systemic steroid
100265 Millipred DP OR Systemic steroid
89183 Millipred OR Systemic steroid
33929 Orapred 15 mg/5 mL OR SOLN Systemic steroid
51263 Orapred ODT 10 mg OR TBDP Systemic steroid
50493 Orapred ODT 15 mg OR TBDP Systemic steroid
51264 Orapred ODT 30 mg OR TBDP Systemic steroid
73649 Orapred ODT OR Systemic steroid
73650 Orapred OR Systemic steroid
97196 Pediapred 6.7 (5 base) mg/5 mL OR SOLN Systemic steroid
74412 Pediapred OR Systemic steroid
90312 Prednisolone Systemic steroid
100776 Prednisolone 15 mg/5 mL OR SOLN Systemic steroid
13018 Prednisolone 15 mg/5 mL OR SYRP Systemic steroid
135373 Prednisolone 5 mg OR TBPK Systemic steroid
135374 Prednisolone 5 mg OR TBPK Systemic steroid
7711 Prednisolone 5 mg OR TABS Systemic steroid
90313 Prednisolone acetate (glucocorticosteroids) Systemic steroid
108953 Prednisolone acetate 16.7 (15 base) mg/5 mL OR SUSP Systemic steroid
75589 Prednisolone acetate IJ Systemic steroid
109427 Prednisolone acetate OR Systemic steroid
7716 Prednisolone acetate POWD Systemic steroid
20923 Prednisolone anhydrous POWD Systemic steroid
75593 Prednisolone OR Systemic steroid
7712 Prednisolone POWD Systemic steroid
75595 Prednisolone SOD phosphate OR Systemic steroid
90314 Prednisolone sodium phosphate (glucocorticosteroids) Systemic steroid
51252 Prednisolone sodium phosphate 10 mg OR TBDP Systemic steroid
89025 Prednisolone sodium phosphate 10 mg/5 mL OR SOLN Systemic steroid
50481 Prednisolone sodium phosphate 15 mg OR TBDP Systemic steroid
200201856 Prednisolone sodium phosphate 15 mg/5 mL (SWISH & SPIT) OR S∗ Systemic steroid
33930 Prednisolone sodium phosphate 15 mg/5 mL OR SOLN Systemic steroid
200200533 Prednisolone sodium phosphate 15 mg/5 mL OR SOLN (CHEMO) CUS∗ Systemic steroid
97477 Prednisolone sodium phosphate 20 mg/5 mL OR SOLN Systemic steroid
121526 Prednisolone sodium phosphate 25 mg/5 mL OR SOLN Systemic steroid
51253 Prednisolone sodium phosphate 30 mg OR TBDP Systemic steroid
96082 Prednisolone sodium phosphate 6.7 (5 base) mg/5 mL OR SOLN Systemic steroid
75598 Prednisolone sodium phosphate OR Systemic steroid
20439 Prednisolone sodium phosphate POWD Systemic steroid
90315 Prednisone Systemic steroid
75601 Prednisone (PAK) OR Systemic steroid
200200351 Prednisone 0.5 mg/mL OR SOL CUSTOM Systemic steroid
7721 Prednisone 1 mg OR TABS Systemic steroid
200200492 Prednisone 1 mg OR TABS (CHEMO) CUSTOM Systemic steroid
120527 Prednisone 1 mg OR TBEC Systemic steroid
135431 Prednisone 10 mg OR TBPK Systemic steroid
135432 Prednisone 10 mg OR TBPK Systemic steroid
7722 Prednisone 10 mg OR TABS Systemic steroid
200200493 Prednisone 10 mg OR TABS (CHEMO) CUSTOM Systemic steroid
120528 Prednisone 2 mg OR TBEC Systemic steroid
7723 Prednisone 2.5 mg OR TABS Systemic steroid
200200494 Prednisone 2.5 mg OR TABS (CHEMO) CUSTOM Systemic steroid
7724 Prednisone 20 mg OR TABS Systemic steroid
200200495 Prednisone 20 mg OR TABS (CHEMO) CUSTOM Systemic steroid
135375 Prednisone 5 mg OR TBPK Systemic steroid
135376 Prednisone 5 mg OR TBPK Systemic steroid
7725 Prednisone 5 mg OR TABS Systemic steroid
200200496 Prednisone 5 mg OR TABS (CHEMO) CUSTOM Systemic steroid
120529 Prednisone 5 mg OR TBEC Systemic steroid
7720 Prednisone 5 mg/5 mL OR SOLN Systemic steroid
7718 Prednisone 5 mg/mL OR CONC Systemic steroid
7726 Prednisone 50 mg OR TABS Systemic steroid
22674 Prednisone intensol 5 mg/mL OR CONC Systemic steroid
75602 Prednisone intensol OR Systemic steroid
75603 Prednisone OR Systemic steroid
7727 Prednisone POWD Systemic steroid
7732 Prelone 15 mg/5 mL OR SYRP Systemic steroid
75620 Prelone OR Systemic steroid
8767 Solu-Medrol 1000 mg IJ SOLR Systemic steroid
8768 Solu-Medrol 125 mg IJ SOLR Systemic steroid
8769 Solu-Medrol 2 g IJ SOLR Systemic steroid
8770 Solu-Medrol 40 mg IJ SOLR Systemic steroid
8771 Solu-Medrol 500 mg IJ SOLR Systemic steroid
79793 Solu-Medrol IJ Systemic steroid
79797 Solurex IJ Systemic steroid
79798 Solurex LA IJ Systemic steroid
80064 Sterapred 12 day OR Systemic steroid
80065 Sterapred DS 12 day OR Systemic steroid
80066 Sterapred DS OR Systemic steroid
80067 Sterapred OR Systemic steroid
36549 Accuneb 0.63 mg/3 mL INH NEBU β-agonist
36550 Accuneb 1.25 mg/3 mL INH NEBU β-agonist
53821 Accuneb IN β-agonist
54377 Airet IN β-agonist
91225 Albuterol β-agonist
54543 Albuterol IN β-agonist
20261 Albuterol POWD β-agonist
91226 Albuterol sulfate β-agonist
311 Albuterol sulfate (2.5 mg/3 mL) 0.083% INH NEBU β-agonist
312 Albuterol sulfate (5 mg/mL) 0.5% INH NEBU β-agonist
200200745 Albuterol sulfate (5 mg/mL) 0.5% NEB continuous custom β-agonist
36541 Albuterol sulfate 0.63 mg/3 mL INH NEBU β-agonist
36542 Albuterol sulfate 1.25 mg/3 mL INH NEBU β-agonist
132129 Albuterol sulfate 108 (90 base) μg/ACT INH AEPB β-agonist
315 Albuterol sulfate 2 mg OR TABS β-agonist
314 Albuterol sulfate 2 mg/5 mL OR SYRP β-agonist
316 Albuterol sulfate 4 mg OR TABS β-agonist
39219 Albuterol sulfate ER 4 mg OR TB12 β-agonist
39220 Albuterol sulfate ER 8 mg OR TB12 β-agonist
123418 Albuterol sulfate ER OR β-agonist
21155 Albuterol sulfate HFA 108 (90 base) μg/ACT INH AERS β-agonist
200200995 Albuterol sulfate HFA 108 (90 base) μg/ACT INH AERS (ED HOM∗) β-agonist
200200994 Albuterol sulfate HFA 108 (90 base) μg/ACT INH AERS (OR USE∗) β-agonist
98773 Albuterol sulfate HFA INH β-agonist
54545 Albuterol sulfate INH β-agonist
54546 Albuterol sulfate OR β-agonist
317 Albuterol sulfate POWD β-agonist
2002001992 Albuterol sulfate variable dose for pyxis β-agonist
91234 Levalbuterol HCL (sympathomimetics) β-agonist
37337 Levalbuterol HCL 0.31 mg/3 mL INH NEBU β-agonist
29159 Levalbuterol HCL 0.63 mg/3 mL INH NEBU β-agonist
44604 Levalbuterol HCL 1.25 mg/0.5 mL INH NEBU β-agonist
29160 Levalbuterol HCL 1.25 mg/3 mL INH NEBU β-agonist
69516 Levalbuterol HCL INH β-agonist
91235 Levalbuterol tartrate β-agonist
49020 Levalbuterol tartrate 45 μg/ACT INH AERO β-agonist
69517 Levalbuterol tartrate INH β-agonist
50377 Proair HFA 108 (90 base) μg/ACT INH AERS β-agonist
75956 Proair HFA IN β-agonist
132126 Proair respiclick 108 (90 base) μg/ACT INH AEPB β-agonist
132374 Proair respiclick INH β-agonist
21277 Proventil HFA 108 (90 base) μg/ACT INH AERS β-agonist
76250 Proventil HFA INH β-agonist
76251 Proventil INH β-agonist
76252 Proventil OR β-agonist
200200406 Terbutaline 0.1% nebulization SOLN custom β-agonist
91239 Terbutaline sulfate β-agonist
200200937 Terbutaline sulfate 0.1 mg/mL IJ SOLN custom β-agonist
13430 Terbutaline sulfate 1 mg/mL IJ SOLN β-agonist
200201165 Terbutaline sulfate 1 mg/mL IJ SOLN (SC use only) β-agonist
200200407 Terbutaline sulfate 1 mg/mL SUSP custom β-agonist
13432 Terbutaline sulfate 2.5 mg OR TABS β-agonist
13433 Terbutaline sulfate 5 mg OR TABS β-agonist
81143 Terbutaline sulfate IJ β-agonist
200200938 Terbutaline sulfate injection custom orderable β-agonist
81144 Terbutaline sulfate OR β-agonist
20433 Terbutaline sulfate POWD β-agonist
37396 Xopenex 0.31 mg/3 mL INH NEBU β-agonist
29270 Xopenex 0.63 mg/3 mL INH NEBU β-agonist
29271 Xopenex 1.25 mg/3 mL INH NEBU β-agonist
44598 Xopenex concentrate 1.25 mg/0.5 mL INH NEBU β-agonist
83997 Xopenex concentrate INH β-agonist
49017 Xopenex HFA 45 μg/ACT INH AERO β-agonist
83998 Xopenex HFA INH β-agonist
83999 Xopenex INH β-agonist
54262 Aerobid INH ICS
54263 Aerobid-M INH ICS
127561 Aerospan 80 μg/ACT INH AERS ICS
127718 Aerospan INH ICS
96592 Alvesco 160 μg/ACT INH AERS ICS
96591 Alvesco 80 μg/ACT INH AERS ICS
97729 Alvesco INH ICS
130919 Arnuity ellipta 100 μg/ACT INH AEPB ICS
130920 Arnuity ellipta 200 μg/ACT INH AEPB ICS
130972 Arnuity ellipta IN ICS
47449 Asmanex 120 metered doses 220 μg/INH INH AEPB ICS
55726 Asmanex 120 metered doses IN ICS
47450 Asmanex 14 metered doses 220 μg/INH INH AEPB ICS
55727 Asmanex 14 metered doses INH ICS
89591 Asmanex 30 metered doses 110 μg/INH INH AEPB ICS
47447 Asmanex 30 metered doses 220 μg/INH INH AEPB ICS
55728 Asmanex 30 metered doses INH ICS
47448 Asmanex 60 metered doses 220 μg/INH INH AEPB ICS
55729 Asmanex 60 metered doses INH ICS
111284 Asmanex 7 metered doses 110 μg/INH INH AEPB ICS
111529 Asmanex 7 metered doses INH ICS
130881 Asmanex HFA 100 μg/ACT INH AERO ICS
130893 Asmanex HFA 200 μg/ACT INH AERO ICS
130973 Asmanex HFA INH ICS
56112 Azmacort INH ICS
91254 Beclomethasone dipropionate (steroid inhalants) ICS
33588 Beclomethasone dipropionate 40 μg/ACT INH AERS ICS
33589 Beclomethasone dipropionate 80 μg/ACT INH AERS ICS
56626 Beclomethasone dipropionate INH ICS
56627 Beclovent INH ICS
91255 Budesonide (steroid inhalants) ICS
33341 Budesonide 0.25 mg/2 mL INH SUSP ICS
33342 Budesonide 0.5 mg/2 mL INH SUSP ICS
200201034 Budesonide 0.5 mg/2 mL NEB for PO use ICS
85108 Budesonide 1 mg/2 mL INH SUSP ICS
98957 Budesonide 180 μg/ACT INH AEPB ICS
98956 Budesonide 90 μg/ACT INH AEPB ICS
98788 Budesonide INH ICS
98448 Ciclesonide (steroid inhalants) ICS
96103 Ciclesonide 160 μg/ACT INH AERS ICS
96102 Ciclesonide 80 μg/ACT INH AERS ICS
97832 Ciclesonide INH ICS
98924 Flovent diskus 100 μg/BLIST INH AEPB ICS
98925 Flovent diskus 250 μg/BLIST INH AEPB ICS
53294 Flovent diskus 50 μg/BLIST INH AEPB ICS
64815 Flovent diskus INH ICS
46255 Flovent HFA 110 μg/ACT INH AERO ICS
46256 Flovent HFA 220 μg/ACT INH AERO ICS
46254 Flovent HFA 44 μg/ACT INH AERO ICS
64816 Flovent HFA INH ICS
64817 Flovent INH ICS
64818 Flovent rotadisk INH ICS
91256 Flunisolide (steroid inhalants) ICS
127699 Flunisolide HFA ICS
127438 Flunisolide HFA 80 μg/ACT INH AERS ICS
127758 Flunisolide HFA INH ICS
64856 Flunisolide INH ICS
20361 Flunisolide POWD ICS
131120 Fluticasone furoate (steroid inhalants) ICS
130716 Fluticasone furoate 100 μg/ACT INH AEPB ICS
130717 Fluticasone furoate 200 μg/ACT INH AEPB ICS
131018 Fluticasone furoate INH ICS
91257 Fluticasone propionate (INHAL) ICS
32750 Fluticasone propionate (INHAL) 100 μg/BLIST INH AEPB ICS
32751 Fluticasone propionate (INHAL) 250 μg/BLIST INH AEPB ICS
32749 Fluticasone propionate (INHAL) 50 μg/BLIST INH AEPB ICS
64934 Fluticasone propionate (INHAL) INH ICS
91258 Fluticasone propionate HFA ICS
46046 Fluticasone propionate HFA 110 μg/ACT INH AERO ICS
46047 Fluticasone propionate HFA 220 μg/ACT INH AERO ICS
46045 Fluticasone propionate HFA 44 μg/ACT INH AERO ICS
134419 Fluticasone propionate HFA INH ICS
91259 Mometasone furoate (steroid inhalants) ICS
130882 Mometasone furoate 100 μg/ACT INH AERO ICS
89590 Mometasone furoate 110 μg/INH INH AEPB ICS
130883 Mometasone furoate 200 μg/ACT INH AERO ICS
47345 Mometasone furoate 220 μg/INH INH AEPB ICS
71565 Mometasone furoate INH ICS
33535 Pulmicort 0.25 mg/2 mL INH SUSP ICS
33536 Pulmicort 0.5 mg/2 mL INH SUSP ICS
85111 Pulmicort 1 mg/2 mL INH SUSP ICS
99899 Pulmicort flexhaler 180 μg/ACT INH AEPB ICS
99900 Pulmicort flexhaler 90 μg/ACT INH AEPB ICS
76405 Pulmicort flexhaler INH ICS
76406 Pulmicort INH ICS
76407 Pulmicort turbuhaler INH ICS
33585 Qvar 40 μg/ACT INH AERS ICS
33586 Qvar 80 μg/ACT INH AERS ICS
76802 Qvar INH ICS
91260 Triamcinolone acetonide (steroid inhalants) ICS
85453 Triamcinolone acetonide INH ICS
83089 Vanceril double strength INH ICS
83090 Vanceril INH ICS
105585 Advair diskus 100-50 μg/dose INH AEPB ICS + LABA
105588 Advair diskus 250-50 μg/dose INH AEPB ICS + LABA
105589 Advair diskus 500-50 μg/dose INH AEPB ICS + LABA
54204 Advair diskus INH ICS + LABA
50623 Advair HFA 115-21 μg/ACT INH AERO ICS + LABA
50624 Advair HFA 230-21 μg/ACT INH AERO ICS + LABA
50622 Advair HFA 45-21 μg/ACT INH AERO ICS + LABA
54205 Advair HFA INH ICS + LABA
125719 Breo ellipta 100-25 μg/INH INH AEPB ICS + LABA
132901 Breo ellipta 200-25 μg/INH INH AEPB ICS + LABA
125944 Breo ellipta INH ICS + LABA
91246 Budesonide-formoterol fumarate ICS + LABA
53024 Budesonide-formoterol fumarate 160-4.5 μg/ACT INH AERO ICS + LABA
53023 Budesonide-formoterol fumarate 80-4.5 μg/ACT INH AERO ICS + LABA
57629 Budesonide-formoterol fumarate INH ICS + LABA
110610 Dulera 100-5 μg/ACT INH AERO ICS + LABA
110611 Dulera 200-5 μg/ACT INH AERO ICS + LABA
110811 Dulera INH ICS + LABA
126085 Fluticasone furoate-vilanterol ICS + LABA
125641 Fluticasone furoate-vilanterol 100-25 μg/INH INH AEPB ICS + LABA
132806 Fluticasone furoate-vilanterol 200-25 μg/INH INH AEPB ICS + LABA
125999 Fluticasone furoate-vilanterol IN ICS + LABA
91247 Fluticasone-salmeterol ICS + LABA
105249 Fluticasone-salmeterol 100-50 μg/dose INH AEPB ICS + LABA
50619 Fluticasone-salmeterol 115-21 μg/ACT INH AERO ICS + LABA
50620 Fluticasone-salmeterol 230-21 μg/ACT INH AERO ICS + LABA
105250 Fluticasone-salmeterol 250-50 μg/dose INH AEPB ICS + LABA
50618 FLuticasone-salmeterol 45-21 μg/ACT INH AERO ICS + LABA
105251 Fluticasone-salmeterol 500-50 μg/dose INH AEPB ICS + LABA
64938 Fluticasone-salmeterol INH ICS + LABA
111224 Mometasone furo-formoterol FUM ICS + LABA
110576 Mometasone furo-formoterol FUM 100-5 μg/ACT INH AERO ICS + LABA
110577 Mometasone furo-formoterol FUM 200-5 μg/ACT INH AERO ICS + LABA
110835 Mometasone furo-formoterol FUM IN ICS + LABA
53239 Symbicort 160-4.5 μg/ACT INH AERO ICS + LABA
53238 Symbicort 80-4.5 μg/ACT INH AERO ICS + LABA
80691 Symbicort INH ICS + LABA
128121 Umeclidinium-vilanterol ICS + LABA
127865 Umeclidinium-vilanterol 62.5-25 μg/INH INH AEPB ICS + LABA
128105 Umeclidinium-vilanterol INH ICS + LABA
30756 Accolate 10 mg OR TABS Leukotriene modulators
21303 Accolate 20 mg OR TABS Leukotriene modulators
53764 Accolate OR Leukotriene modulators
91262 Montelukast sodium (leukotriene modulators) Leukotriene modulators
26447 Montelukast sodium 10 mg OR TABS Leukotriene modulators
31645 Montelukast sodium 4 mg OR CHEW Leukotriene modulators
41211 Montelukast sodium 4 mg OR PKT Leukotriene modulators
26448 Montelukast sodium 5 mg OR CHEW Leukotriene modulators
71666 Montelukast sodium OR Leukotriene modulators
26454 Singulair 10 mg OR TABS Leukotriene modulators
31649 Singulair 4 mg OR CHEW Leukotriene modulators
41210 Singulair 4 mg OR PKT Leukotriene modulators
26451 Singulair 5 mg OR CHEW Leukotriene modulators
79047 Singulair OR Leukotriene modulators
91263 Zafirlukast Leukotriene modulators
30767 Zafirlukast 10 mg OR TABS Leukotriene modulators
21309 Zafirlukast 20 mg OR TABS Leukotriene modulators
84136 Zafirlukast OR Leukotriene modulators
91261 Zileuton Leukotriene modulators
22305 Zileuton 600 mg OR TABS Leukotriene modulators
85485 Zileuton ER 600 mg OR TB12 Leukotriene modulators
120894 Zileuton ER OR Leukotriene modulators
84194 Zileuton OR Leukotriene modulators
22304 Zyflo 600 mg OR TABS Leukotriene modulators
85530 Zyflo CR 600 mg OR TB12 Leukotriene modulators
85882 Zyflo CR OR Leukotriene modulators
84345 Zyflo OR Leukotriene modulators
134493 Mepolizumab Biologics
134274 Mepolizumab 100 mg SC SOLR Biologics
134437 Mepolizumab SC Biologics
134298 Nucala 100 mg SC SOLR Biologics
134446 Nucala SC Biologics
91264 Omalizumab Biologics
41330 Omalizumab 150 mg SC SOLR Biologics
73347 Omalizumab SC Biologics
41342 Xolair 150 mg SC SOLR Biologics
83995 Xolair SC Biologics
120900 Aclidinium bromide Anticholinergics
120515 Aclidinium bromide 400 μg/ACT INH AEPB Anticholinergics
120732 Aclidinium bromide INH Anticholinergics
46720 Atrovent HFA 17 μg/ACT INH AERS Anticholinergics
55931 Atrovent HFA IN Anticholinergics
55932 Atrovent IN Anticholinergics
134491 Glycopyrrolate (bronchodilators-anticholinergics) Anticholinergics
134424 Glycopyrrolate INH Anticholinergics
130918 Incruse ellipta 62.5 μg/INH INH AEPB Anticholinergics
131033 Incruse ellipta INH Anticholinergics
91220 Ipratropium bromide (bronchodilators-anticholinergics) Anticholinergics
14727 Ipratropium bromide 0.02% INH SOLN Anticholinergics
91221 Ipratropium bromide HFA Anticholinergics
46527 Ipratropium bromide HFA 17 μg/ACT INH AERS Anticholinergics
68438 Ipratropium bromide HFA INH Anticholinergics
68439 Ipratropium bromide IN Anticholinergics
20367 Ipratropium bromide POWD Anticholinergics
134455 Seebri neohaler INH Anticholinergics
43683 Spiriva handihaler 18 μg INH CAPS Anticholinergics
79945 Spiriva handihaler INH Anticholinergics
133764 Spiriva respimat 1.25 μg/ACT INH AERS Anticholinergics
130566 Spiriva respimat 2.5 μg/ACT INH AERS Anticholinergics
130663 Spiriva respimat INH Anticholinergics
91222 Tiotropium bromide monohydrate Anticholinergics
133714 Tiotropium bromide monohydrate 1.25 μg/ACT INH AERS Anticholinergics
43672 Tiotropium bromide monohydrate 18 μg INH CAPS Anticholinergics
130394 Tiotropium bromide monohydrate 2.5 μg/ACT INH AERS Anticholinergics
81562 Tiotropium bromide monohydrate INH Anticholinergics
120704 Tudorza pressair 400 μg/ACT INH AEPB Anticholinergics
120880 Tudorza pressair INH Anticholinergics
131119 Umeclidinium bromide Anticholinergics
130705 Umeclidinium bromide 62.5 μg/INH INH AEPB Anticholinergics
131098 Umeclidinium bromide INH Anticholinergics
91245 Ipratropium-albuterol Anticholinergics
97202 Ipratropium-albuterol 0.5-2.5 (3) mg/3 mL INH SOLN Anticholinergics
16477 Ipratropium-albuterol 18-103 μg/ACT INH AERO Anticholinergics
119838 Ipratropium-albuterol 20-100 μg/ACT INH AERS Anticholinergics
98087 Ipratropium-albuterol INH Anticholinergics
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AERS, AERO, Aerosolized; CAPS, capsule; CHEMO, chemotherapy; CONC, concentrate; CUST, custom; Dex, dexamethasone; D5W, dextrose 5% in water; ELIX, elixer; ER, extended release; HCL, hydrochloride; HFA, hydrofluoroalkane; IJ, IN, INJ, INJECT, injection; INH, INHAL, inhalation; LABA, long-acting β-agonist; LIDO, lidocaine; NEBU, NEB, nebulizer; NSS, normal saline solution; OR, oral; PAK, pack; PHOS, phosphage; PKT, packet; PO, per os (by mouth); POWD, powder; SC, subcutaneous; SOD, sodium; SOLN, SOL, solution; SUCC, succinate; SUSP, suspension; SWFI, sterile water for injection; SYRP, syrup; TABS, tablets; TBEC, enteric-coated tablet; TBPK, tablet pack.

Table E3.

Summary of virus-specific tests ordered and % of virus-specific positive test results

Virus Yearly averages (range)
Average 2015-2019
 2020
 2020 (Jan-Mar)
 2020 (Apr-Dec)
 2021 (Jan-Apr)
Total tests % positive test results Total tests % positive test results Total tests % positive test results Total tests % positive test results Total tests % positive test results
IFV-A 458 (19.8-1479) 7.24 (0-27.0) 1586 (1.00-5528) 7.19 (0-28.0) 4692 (3452- 5528) 21.6 (17.8- 28.0) 32.5 (1.00-123) 0 (0) 32.5 (2.00-56.0) 0 (0)
IFV-B 458 (19.8- 1479) 3.31 (0- 8.69) 1586 (0- 5528) 7.08 (0- 30.5) 4692 (3452- 5528) 20.4 (8.66- 30.5) 32.5 (1.00-123) 0.43 (0- 2.56) 32.5 (2.00-56.0) 0.64 (0- 2.56)
RSV 258 (40.2- 825) 12.7 (1.77- 38.0) 108 (17- 630) 4.69 (0- 26.1) 308 (136- 630) 16.5 (5.08- 26.1) 41.0 (17.0-126) 0.74 (0- 5.88) 32.0 (22.0-48.0) 3.39 (0- 9.38)
Rhinovirus 87.2 (39.0-129) 39.7 (24.6-56.1) 91.3 (17.0-577) 20.1 (7.69- 38.5) 244 (76.0- 577) 22.8 (16.3- 31.0) 40.3 (17.0-121) 19.2 (7.69- 38.5) 32.0 (22.0-48.0) 27.1 (9.09- 37.5)
COVID-19 2250 (1258- 4928) 5.29 (2.05- 11.5) 2250 (1258- 4928) 5.29 (2.05- 11.5) 2250 (1258- 4928) 5.29 (2.05- 11.5) 2148 (1501- 2648) 7.27 (5.40- 8.32)
Adenovirus 87.2 (39.0-129) 10.3 (5.56- 13.8) 91.3 (17.0-577) 3.85 (0- 11.6) 244 (76.0- 577) 9.00 (7.50- 11.6) 40.3 (17.0-121) 2.13 (0- 4.96) 32.0 (22.0-48.0) 5.40 (3.13- 7.69)
Non–COVID-19 coronavirus 87.2 (39.0-129) 3.40 (0.60- 9.06) 91.3 (17.0-577) 4.03 (0- 17.5) 244 (76.0- 577) 13.2 (10.4- 17.5) 40.3 (17.0-121) 0.95 (0- 5.26) 32.0 (22.0-48.0) 1.82 (0- 4.17)
Metapneumovirus 87.2 (39.0-129) 5.80 (0.30-12.2) 91.3 (17.0-577) 3.54 (0-11.8) 244 (76.0- 577) 11.5 (11.3- 11.8) 40.3 (17.0-121) 0.89 (0- 4.13) 32.0 (22.0-48.0) 0.52 (0- 2.08)
Parainfluenza 1 87.2 (39.0-129) 2.60 (0.37- 6.89) 91.3 (17.0-577) 0.36 (0- 2.50) 244 (76.0- 577) 1.45 (0.52- 2.50) 40.3 (17.0-121) 0 (0) 32.0 (22.0-48.0) 0 (0)
Parainfluenza 2 87.2 (39.0-129) 0.89 (0-2.74) 91.3 (17.0-577) 0.13 (0- 1.25) 244 (76.0- 577) 0.53 (0- 1.25) 40.3 (17.0-121) 0 (0) 32.0 (22.0-48.0) 0 (0)
Parainfluenza 3 87.2 (39.0-129) 6.09 (1.10- 17.8) 91.3 (17.0-577) 0.44 (0- 3.03) 244 (76.0- 577) 0.46 (0- 1.39) 40.3 (17.0-121) 0.43 (0- 3.03) 32.0 (22.0-48.0) 1.56 (0- 6.25)
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During the first lockdown that occurred from March 18 to June 5, 2020, social distancing measures were mandated, and schools, nonessential businesses, and dine-in restaurants/bars were closed. A phased reopening consisted of (1) an initial reopening between June 6 and June 26, 2020, when most businesses in Philadelphia county could remain open at limited capacity consistent with public health guidelines, and (2) an expanded reopening between June 27 and November 15, 2020, during which time restaurants could increase to 50% capacity for indoor dining and increased crowd capacity limits for indoor and outdoor events were allowed. November 16, 2020, marked the beginning of the second lockdown with restrictions that included no indoor dining at restaurants, capacity limits at retail stores and religious institutions, the closure of gyms, libraries, and certain entertainment businesses, telework for office workers unless not possible, no indoor gatherings, reduced size limits on outdoor gatherings, and no youth or school sports. This second lockdown was lifted January 4, 2021, though previously mandated social distancing and masking policies remained. In addition, although there was substantial variability in primary and secondary school opening, public Philadelphia county schools remained entirely virtual until March 8, 2021, when a phased reopening began with K-2 schools.

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Associated Data

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Data Availability Statement

The epidemiologic data supporting the conclusions of this article are available in the Zenodo repository (https://zenodo.org/record/5736294).

Articles from The Journal of Allergy and Clinical Immunology. in Practice are provided here courtesy of Elsevier

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