Allergic conditions linked with more COVID-19 diagnoses, less mortality early in pandemic
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Key takeaways:
- Incidence of COVID-19 included 8.74 with and 6.23 without allergic conditions per 100 person-years.
- COVID-19 incidence was higher for patients with asthma compared with other allergic conditions.
Patients with allergic conditions had a greater risk for COVID-19 diagnosis but a lower risk for dying of the disease than patients without these conditions, according to a study published in Annals of Allergy, Asthma & Immunology.
However, patients with asthma had higher risks for hospitalization and mortality due to COVID-19 compared with patients with other allergic conditions, Chao Chen, PhD, senior manager, Regeneron Pharmaceuticals, and colleagues wrote.
The study used information from the geographically diverse Optum Clinformatics Data Mart health insurance claims database, including patients from all 50 U.S. states. To determine COVID-19 susceptibility, the researchers examined data from April 1 through Dec. 31, 2020.
This cohort of patients susceptible to COVID-19 included 1,273,231 patients with allergic conditions, including asthma (47.2%), atopic dermatitis (1.5%), allergic rhinitis (58.6%), food allergy (5.1%), anaphylaxis (4.1%) and eosinophilic esophagitis (0.9%).
The patients with asthma included 21% with severe asthma, and those with AD included 60% with severe AD. Also, 2,278,571 patients in the cohort did not have any allergic conditions.
COVID-19 incident rates included 8.74 per 100 person-years (95% CI, 8.68-8.8) for the allergic group and 6.23 per 100 person-years (95% CI, 6.2-6.27) for the nonallergic group.
Rates also included 9.83 per 100 person-years (95% CI, 9.62-10.04) for patients with severe asthma and 8.83 (95% CI, 8.72-8.93) for those with non-severe asthma.
Similarly, rates included 8.07 per 100 person years (95% CI, 7.47-8.71) for patients with severe AD and 7.3 per 100 person years (95% CI, 6.61-8.06) for those with non-severe AD.
Higher COVID-19 incidence persisted among patients with allergic conditions, with an adjusted incidence rate ratio (IRR) of 1.22 (95% CI, 1.21-1.24) compared with patients who did not have allergic conditions, after adjustments for prognostic variables.
The researchers categorized severe asthma’s effect on COVID-19 incidence as modest, compared with non-severe asthma, with an adjusted IRR of 1.12 (95% CI, 1.09-1.15). They also said that severe AD’s effect on susceptibility to COVID-19 was minimal, with an adjusted IRR of 1.05 (95% CI, 0.92-1.2).
The patients who developed COVID-19 included 261,076 with allergic conditions, including asthma (51.1%), AD (1.4%), allergic rhinitis (55.9%), food allergy (5.6%), anaphylaxis (3.9%) and EoE (0.9%).
Also, there were 1,098,135 patients who developed COVID-19 but who did not have any allergic conditions. The patients with asthma included 22.1% with severe asthma, and the patients with AD included 66.1% with severe AD.
The patients with allergic conditions had higher 30-day risks for a composite outcome including COVID-19 hospitalization or all-cause mortality, with an event risk of 15.2% (95% CI, 15.06%-15.34%), compared with those who did not have any allergic conditions, who had an event risk of 12.81% (95% CI, 12.75%-12.87%).
Specific event risks included 18.05% (95% CI, 17.82%-18.28%) for those with asthma and 12.45% (95% CI, 12.27%-12.63%) for those with non-asthma allergic conditions. Patients with severe asthma had the highest 30-day risk for the composite outcome at 19.95% (95% CI, 19.49%-20.4%).
Risks for the composite outcome persisted among patients with allergic conditions with a hazard ratio of 0.96 (95% CI, 0.95-0.98) compared with the patients who did not have allergic conditions after adjusting for prognostic variables.
Also, patients with asthma had higher risks for severe outcomes with an adjusted hazard ratio of 1.27 (95% CI, 1.25-1.3) compared with patients who had non-asthma allergic conditions. Severe asthma had an adjusted hazard ratio of 1.04 (95% CI, 1.01-1.08) for these risks compared with non-severe asthma as well.
Patients with AD may have had a slightly decreased risk for severe COVID-19 outcomes with an adjusted hazard ratio of 0.89 (95% CI, 0.8-0.98) compared with those who had non-AD allergic conditions, the researchers continued.
The 30-day event risks for all-cause mortality included 2.4% (95% CI, 2.34%-2.46%) for patients with allergic conditions and 2.47% (95% CI, 2.44%-2.49%) for those who did not have any allergic conditions.
Among the patients with allergic conditions, those with asthma had a 2.69% 30-day event risk (95% CI, 2.59%-2.78%) for all-cause mortality, and those with other allergic conditions had a 2.28% event risk (95% CI, 2.2%-2.37%). Patients with severe asthma had the highest event risk at 3.68% (95% CI, 3.47%-3.9%).
Adjustments for prognostic variables revealed a lower risk for mortality among the patients with allergic conditions with a hazard ratio of 0.8 (95% CI, 0.78-0.83) compared with those patients who did not have allergic conditions.
The researchers also classified the risks for mortality between patients with asthma and those with non-asthma allergic conditions as comparable, with an adjusted hazard ratio of 0.97 (95% CI, 0.92-1.02).
The difference between patients with severe and non-severe asthma was slight as well (aHR = 1.08; 95% CI, 1.01-1.16), the researchers added, with no substantial difference in 30-day mortality risk between patients with and without AD (aHR = 0.94; 95% CI, 0.74-1.19) in partially adjusted models.
Overall, the researchers characterized the impact of allergic conditions on 30-day hospitalization related to COVID-19 or all-cause mortality as minimal, but they did associate these conditions with reduced mortality.
The researchers hypothesized that these increases in COVID-19 diagnoses among patients with allergic conditions partly may be due to impaired epithelial barrier function and inadequate antiviral response. However, they continued, these patients also may be more proactive in seeking health care, and their physicians may be providing closer monitoring.
Also, the researchers hypothesized that the reduced mortality risks among patients with allergic conditions could be caused by preexisting skewed type 2 inflammation that counter-regulates the overreactive type 1 response that SARS-CoV-2 induces. More proactive engagement in health care may be a cause as well, they continued.
Perspective
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This study adds to the existing literature on the relationship between allergic conditions and COVID-19 infection, focusing on patients early in the pandemic (April to December 2020) with initial diagnosis of COVID-19 and comparing those with and without allergic conditions such as asthma, atopic dermatitis and allergic rhinitis, among others.
This has been an important area of discussion, as CDC guidelines continue to list asthma as a potentially high-risk condition for severe COVID-19 infection, whereas other studies suggested no increased risk in atopic conditions. This study showed that while patients with allergic conditions were diagnosed with COVID-19 infection more frequently, there was not a significant increase in hospitalization rate.
When looking at asthma vs. other allergic conditions, there was a slight increase in COVID-19-related hospitalization. These data are in line with prior reports but add to the existing literature and have the benefit of being a very large sample with representation of patients in all 50 states included in a large database.
Similar to the findings in this paper, I have not found that my patients with allergic conditions have worse clinical outcomes with COVID-19 infection. One caveat of this paper is that it reviews data from prior to the introduction of COVID-19 vaccines and newer variants. It only reflects 2020 infection rates. In clinical practice, we have certainly seen a decrease in the severity of infection in those who have been vaccinated as well as with subsequent variants.
It is important to discuss with patients how their underlying health conditions may affect their risk for infections and other disease processes. COVID-19 was a perfect example of trying to navigate this when little information was known, and research studies continue to help identify risk factors. Similar studies should try to identify how these risk factors change with the advent of vaccines and newer strains of COVID-19 virus.
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