Disparities in asthma attacks, ED visits narrow for Black patients during pandemic
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Key takeaways:
- Overall asthma prevalence increased from 8% to 8.7% from 2019 to 2022.
- Asthma attacks decreased from 29.3% to 22.1% for Black adults.
- Overall ED visit rates fell from 17.3% to 12.1%.
There was a downward trend for asthma attacks and ED visits among Black adults and children relative to white patients during the COVID-19 pandemic, according to a letter published in Annals of Internal Medicine.
These decreases in disparities suggest opportunities for mitigation, Adam Gaffney, MD, MPH, assistant professor, Harvard Medical School and Cambridge Health Alliance, and colleagues wrote.
“Early in the pandemic, news reports began noting that rates of asthma exacerbations appeared to drop, abruptly and unexpectedly,” Gaffney told Healio. “Later studies in various locales and nations confirmed these observations, finding reductions both in asthma and COPD ED visits and hospitalizations that coincided with onset of the pandemic onset.”
Gaffney noted that many things changed during the pandemic, but previous research indicated that this reduction in obstructive lung disease mortality could be attributed to plummeting circulation of common respiratory viruses such as influenza, rhinovirus and RSV, which typically cause colds but can provoke serious exacerbations in patients with lung disease.
“While previous work has examined overall trends in airway disease exacerbations, we were interested in how this dynamic affected long-standing, well-described racial/ethnic disparities in the burden of asthma,” Gaffney said. “We wanted to know whether the overall fall in asthma exacerbations mitigated or potentially exacerbated these disparities.”
Study design, results
The researchers analyzed data from 120,698 adults and 30,708 children in the National Health Interview Survey from 2019 to 2022. These patients included 81,905 adults and 15,955 children identified as non-Hispanic white, 12,956 adults and 3,163 children identified as non-Hispanic Black, and 16,009 adults and 7,577 children identified as Hispanic.
Overall asthma prevalence rose from 8% to 8.7% among adults between 2019 and 2022. This slight uptick was driven by increases among white adults, the researchers said.
Throughout the study period, Hispanic adults had the lowest prevalence, and Black adults had the highest prevalence, the researchers continued, with a decrease in the adjusted difference between Black and white adults over time.
The overall asthma attack rate was stable through the study period, the researchers said, and rates of attacks among white and Hispanic adults were comparable.
Black adults experienced a decrease in asthma attack rates from 29.3% to 22.1%. The relative adjusted differences between Black and white adults fell from 2.3 percentage points (95% CI, –3.4 to 8) in 2019 to –5.8 percentage points (95% CI, –10.5 to –1.1) in 2022.
Primarily because of decreases among Black and white adults, the researchers said, overall asthma ED visit rates decreased as well. Black adults had consistently higher rates than white adults, the researchers added, but the adjusted difference fell from 5.2 percentage points (95% CI, 1.9-8.4) to 2.6 percentage points (95% CI, 0.4-4.9) from 2019 to 2022.
Asthma prevalence was stable among children, the researchers said. It was consistently highest among Black children, although there was a transient dip in 2020.
There was a slight decrease in asthma attacks through 2021 and then an increase in 2022, especially among white children compared with Hispanic and Black children.
Adjusted differences in asthma attacks included –13.1 percentage points (95% CI, –22.3 to –3.9) between white and Hispanic children and –12.4 percentage points (95% CI, –23.8 to –1) between white and Black children.
The overall rate of ED visits for asthma fell from 17.3% to 12.1% from 2019 to 2022, due to decreases among Black and Hispanic children.
Also, ED visit rates were higher for Black and Hispanic children before the pandemic, with adjusted differences of 15.1 percentage points (95% CI, 6.8-23.4) between Black and white children and 12.3 percentage points (95% CI, 4.8-19.9) between Hispanic and white children.
Beginning in 2020, ED visit rates decreased quickly for Hispanic children and were comparable with those for white children, the researchers said. Decreases in ED visits for Black children were more gradual and were not comparable with those for white children until 2021.
Conclusions, next steps
The researchers said that the gradual decrease in ED visits and the rebound of asthma attacks in 2022 could be due to decreases in commonly circulated respiratory viruses. Other factors may include differential exposure to tobacco, allergens, pollution, COVID-19 and controller inhaler usage.
“It was very notable just how sharp and sustained the reduction in ED visits for asthma, which usually means a serious exacerbation, was among both adults and children. However, this confirms previous studies,” Gaffney said.
The most original finding, Gaffney continued, was the narrowing in disparities observed among children in asthma ED visits.
“Before the pandemic, Black and Hispanic children had significantly higher rates of asthma ED visits than white children, even when accounting for things like differences in family income or health insurance,” he said.
But during the pandemic, those differences narrowed and indeed became insignificant, according to Gaffney.
“This observation strengthens the case that common respiratory viruses may be one driver of disparities in asthma morbidity among children, a mechanism that has not received enough attention to date,” he said.
Although reductions in health care usage probably impacted these trends in 2020, the researchers continued, they are a less likely explanation for these reductions later as usage rebounded.
These decreased disparities in asthma morbidity during the pandemic indicate potential for mitigation, the researchers suggested, such as improved environmental conditions, equitable delivery of vaccines against respiratory pathogens and other policies that address drivers of asthma pathogenesis and exacerbations.
“In conjunction with the existing body of research on this issue, our findings probably should increase awareness of the role that common respiratory viruses play in asthma morbidity,” Gaffney said. “Clinically, this highlights the importance of vaccination against respiratory pathogens.”
Also, Gaffney said, a multitude of policies is needed to stem disparities in asthma, which have many causes. For instance, he continued, addressing disparities in air quality is critical.
“Our findings additionally highlight policies that could mitigate the impact of common respiratory viruses — things like housing justice to address the problem of household crowding, investment to improve indoor air quality in places like schools or workplaces, and policies to achieve universal health care to improve the uptake of vaccines against viral pathogens,” he said. “More research is needed to develop novel vaccines against additional respiratory viruses, however.”
For more information:
Adam Gaffney, MD, MPH, can be reached at agaffney@challiance.org.
Perspective
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This is an interesting study that provides valuable epidemiologic insights into asthma prevalence and morbidity trends during the COVID-19 pandemic. It is very encouraging to see reductions in disparities for Black children and adults and Hispanic children in asthma-related ED visits. However, Hispanic adults did not experience comparable reductions during the years of the study. The causes of these observed trends remain unclear and warrant further study.
That the adjusted differences in predicted probability of asthma-related ED visits for Black children compared with White children are smaller than the unadjusted differences suggests that the factors the authors adjusted for (such as family income, region and insurance status) contribute to the observed disparities by race. This provides support for policies that reduce poverty and increase access to health insurance to improve health outcomes and reduce health disparities.
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