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CME / ABIM MOC / CE

Can Asthma Control Predict COVID-19 Related Pediatric Hospitalizations?

  • Authors: News Author: Heidi Splete; CME Author: Laurie Barclay, MD
  • CME / ABIM MOC / CE Released: 1/14/2022
  • Valid for credit through: 1/14/2023
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

    Pharmacists - 0.25 Knowledge-based ACPE (0.025 CEUs)

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for infectious disease clinicians, pulmonologists, internists, family medicine/primary care clinicians, pediatricians, critical care medicine clinicians, nurses, pharmacists, and other members of the healthcare team for pediatric patients with asthma who may be at risk for hospitalization from COVID-19.

The goal of this activity is to describe markers for increased risk for serious COVID-19 outcomes among children with asthma, according to a national incidence cohort study of all children aged 5 to 17 years in Scotland who were enrolled in the linked dataset of Early Pandemic Evaluation and Enhanced Surveillance of COVID-19 (EAVE II).

Upon completion of this activity, participants will:

  • Describe markers for increased risk for serious COVID-19 outcomes among children with asthma, according to a Scottish national incidence cohort study of children enrolled in EAVE II
  • Determine clinical and public health markers for increased risk for serious COVID-19 outcomes among children with asthma, according to a Scottish national incidence cohort study of children enrolled in EAVE II
  • Outline implications for the healthcare team


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News Author

  • Heidi Splete

    Freelance writer, Medscape

    Disclosures

    Disclosure: Heidi Splete has disclosed no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC

    Disclosures

    Disclosure: Laurie Barclay, MD, has disclosed the following relevant financial relationships:
    Own stock, stock options, or bonds from the following ineligible company(ies): AbbVie

Editor/Nurse Planner

  • Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP

    Associate Director, Accreditation and Compliance
    Medscape, LLC

    Disclosures

    Disclosure: Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP, has disclosed no relevant financial relationships.

CME Reviewer

  • Esther Nyarko, PharmD

    Director, Accreditation and Compliance
    Medscape, LLC

    Disclosures

    Disclosure: Esther Nyarko, PharmD, has disclosed no relevant financial relationships.


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CME / ABIM MOC / CE

Can Asthma Control Predict COVID-19 Related Pediatric Hospitalizations?

Authors: News Author: Heidi Splete; CME Author: Laurie Barclay, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 1/14/2022

Valid for credit through: 1/14/2023

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Note: The information on the coronavirus outbreak is continually evolving. The content within this activity serves as a historical reference to the information that was available at the time of this publication. We continue to add to the collection of activities on this subject as new information becomes available. It is the policy of Medscape Education to avoid the mention of brand names or specific manufacturers in accredited educational activities. However, manufacturer names related to COVID-19 vaccines may be provided in this activity to promote clarity. The use of manufacturer names should not be viewed as an endorsement by Medscape of any specific product or manufacturer.

Clinical Context

Given uncertainty about benefit-risk ratio of COVID-19 vaccines in children and concerns about limited vaccine supplies in many countries, policies for vaccinating children have differed markedly. Identifying which school-aged children should be prioritized for vaccination has important implications for vaccine delivery worldwide.

Study Synopsis and Perspective

Children and adolescents with poorly controlled asthma were 3 to 6 times more likely to be hospitalized with COVID-19, according to data from a national study of more than 750,000 children in Scotland.

Although the majority of COVID-19 cases in children have been mild, some children require hospitalization, wrote Ting Shi, PhD, of the University of Edinburgh (Scotland) and colleagues.

Vaccination policies to potentially reduce infection and hospitalization of children remain inconsistent, the researchers said. Identifying which school-age children would derive the greatest benefit from vaccination "could help to reduce the risk for infection and consequently the need for children to have time off school; and might also reduce the risk of spread of SARS-CoV-2 within schools and households," but the potential benefits of vaccination for children with asthma, in particular, have not been well studied, they wrote.

The United Kingdom's Joint Commission on Vaccination and Immunisation commissioned research on the rates of hospitalization among children with poorly controlled asthma. In a national incidence cohort study published in The Lancet Respiratory Medicine, the researchers reviewed data from all children aged 5 to 17 years in Scotland who were enrolled in the linked dataset of Early Pandemic Evaluation and Enhanced Surveillance of COVID-19 (EAVE II). The total number of children in the dataset was 752,867, and 63,463 (8.4%) of these had diagnosed asthma. Among the children with asthma, 4339 (6.8%) had confirmed COVID-19 between March 1, 2020 and July 27, 2021. A total of 67 infected children were hospitalized. Of the 689,404 children without asthma, 40,231 (5.8%) had confirmed COVID-19, and 382 (0.9%) of these children were hospitalized.

Overall, hospital admission rates for COVID-19 were significantly higher among children with asthma compared with children without asthma (adjusted HR [aHR] = 1.49), and the rates increased among children with poorly controlled asthma.

The researchers used previous hospital admission for asthma as a measure of uncontrolled asthma and found that hospitalization was at least 6 times as likely for children with poorly controlled asthma compared with children with no asthma (aHR = 6.4), although children with well-controlled asthma also had an increased risk for hospitalization compared with children with no asthma (aHR = 1.36).

When the researchers used oral corticosteroid (OCS) prescriptions as an indicator of uncontrolled asthma, the aHR ratios were as follows: 3.38 for children with prescribed OCS courses of 3 or more, 3.53 for 2 OCS courses; 1.52 for 1 OCS course; and 1.34 for no OCS courses compared with children with no asthma.

These hazard ratios remained significant after controlling for factors including age, sex, socioeconomic status, comorbidity, and previous hospital admission, the researchers wrote.

In an age-based analysis, results were similar for children aged 12 to 17 years, but in children aged 5 to 11 years, the hospitalization risk decreased for children with one course of corticosteroids and reached the highest rate for children with three or more courses rather than two courses.

The study findings were limited by several factors, including the relatively small numbers of COVID-19 hospitalizations, intensive care unit (ICU) admissions, and deaths in children with asthma, the researchers noted. Other limitations include potential changes in asthma control over the study period, and lack of data on certain confounders such as tobacco use, unsuitable housing, and ethnicity, they noted; however, the results were strengthened by the use of a large, national dataset, and access to electronic health records, they said.

The findings reflect data from previous studies suggesting increased risk for hospitalization for patients with respiratory illness who develop COVID-19, the researchers wrote.

The results emphasize the importance of good asthma control to protect children from severe COVID-19, and careful monitoring of children with poorly controlled asthma who do become infected, they added.

"The findings from this linkage of multiple data sources have helped inform the prioritization of school-aged children with poorly controlled asthma for vaccines," they concluded.

Findings Support Value of Vaccination for Children With Asthma

"Pediatricians see many children who suffer from asthma, and although one could assume that these children would have more serious consequences from contracting COVID-19, the current study examines a large database in a way not possible in the United States to address the severity question," said Suzanne C. Boulter, MD, of the Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.

"The authors used prior hospitalization rate or two prescriptions for [OCS] as markers of asthma severity prior to the onset of COVID-19 in Scotland, and they collected retrospective data for 16 months of the pandemic through July of 2021, showing a significant increase in hospitalization for those children," she said.

Boulter added that she was not surprised by this finding, given the impact of COVID-19 on the respiratory system.

"Pediatricians have found significant challenges from some groups of parents when discussing the indications and need for vaccination in their patients," said Dr. Boulter. "Having this data on the increased risk of morbidity and mortality in children with asthma might help parents who are uncertain about the risk/benefit ratio of the vaccine make their decision."

Boulter said she hoped that additional studies will yield ongoing information about hospitalization rates for COVID-19 regarding asthma and other diagnoses affecting children in the United States and worldwide.

"It would also be important to see a breakdown of ethnic factors and adverse childhood experiences and how they relate to hospitalization and death from COVID-19," Boulter said.

"The results of this study are not surprising, as we have known for a long time that children with severe asthma are more susceptible to severe respiratory viruses," Francis E. Rushton, MD, a pediatrician in Beaufort, South Carolina, said in an interview, "but the study is still important, as it helps us determine which children are most urgently in need of protection from COVID-19 in any of its forms."

In particular, the current study underlines the importance of vaccinating children with unstable asthma, Rushton said.

Going forward, "it would be interesting to do additional studies looking at other markers for poor asthma control that could guide our vaccine efforts so that they are focused on those most at risk," he added.

The study was supported by the UK Research and Innovation (Medical Research Council), Research and Innovation Industrial Strategy Challenge Fund, Health Data Research UK, and the Scottish Government. Lead author Shi had no financial conflicts to disclose. Rushton and Boulter had no financial conflicts to disclose, but each serves on the Editorial Advisory Board of Pediatric News.

Lancet Respiratory Medicine. Published online November 30, 2021[1]

Study Highlights

  • This national incident cohort study included all 752,867children in Scotland aged 5 to 17 years enrolled in the linked EAVE II dataset between March 1, 2020 and July 27, 2021, of whom 63,463 (8.4%) had clinician-diagnosed and -recorded asthma.
  • Of these, 4339 (6.8%) had reverse-transcriptase polymerase chain reaction-confirmed SARS-CoV-2 infection, including 67 (1.5%) hospitalized with COVID-19.
  • Among the 689,404 children without asthma, 40,231 (5.8%) had confirmed SARS-CoV-2 infections, including 382 (0.9%) hospitalized with COVID-19.
  • Cox proportional hazard models were adjusted for age, sex, socioeconomic status, comorbidity, and previous hospitalization.
  • Rates of COVID-19 hospitalization were higher in children with poorly controlled asthma than in children with well-controlled or no asthma, overall and when limited to COVID-19 hospitalization with hospital stay > 1 day or with previous positive test.
  • When defining uncontrolled asthma by previous asthma hospitalization within the past 2 years, aHR was 6.4 (95% CI: 3.27, 12.53) for poorly controlled asthma and 1.36 (95% CI: 1.02, 1.8) for well-controlled asthma vs no asthma.
  • When defining uncontrolled asthma by prescribed OCS courses, aHR was 3.38 (95% CI: 1.84, 6.21) for children with ≥ 3; 3.53 (95% CI: 1.87, 6.67) for 2; 1.52 (95% CI: 0.9, 2.57) for 1, and 1.34 (95% CI: 0.98, 1.82) for children with no prescribed course vs children without asthma.
  • Results were similar for children aged 12 to 17 years, but in children aged 5 to 11 years, hospitalization risk decreased for children with one corticosteroid course and was highest for children with ≥ 3 courses vs two courses.
  • The investigators concluded that even after adjustment for demographics, comorbidity, and previous hospitalization, school-aged children with markers of uncontrolled asthma (previous recent hospitalization or ≥ 2 OCS courses) are at markedly increased risk for COVID-19 hospitalization and should be prioritized for vaccinations.
  • This would translate into 9124 children across Scotland and an estimated 109,448 across the United Kingdom.
  • Although aHR was elevated, overall risk for COVID-19 hospitalization was low (1 in 380 children with poorly controlled asthma).
  • This is the first national study evaluating risk for COVID-19 hospitalization among children aged 5 to 17 years with markers of uncontrolled asthma.
  • The findings have been used to inform decisions on which children aged 12 to 15 years should be prioritized for COVID-19 vaccination.
  • Extending the offer of vaccination to younger children should be considered.
  • The findings also highlight the importance of maintaining good asthma control and of careful monitoring of children with poorly controlled asthma if they develop SARS-CoV-2 infection, as these could help protect children from developing more severe COVID-19.
  • As vaccines in children and youths are being given and planned worldwide, policymakers can use these findings and other public health surveillance data to inform decisions on vaccination priorities among school-aged children with asthma.
  • This is particularly important given potentially limited vaccine supplies and lower absolute risk for serious COVID-19 in children.
  • As COVID-19 typically affects children less severely than adults, study limitations include small absolute numbers of COVID-19 hospitalizations, ICU admissions, and deaths in children with asthma, precluding further assessment of more severe outcomes.

Clinical Implications

  • School-aged children with uncontrolled asthma are at markedly increased risk for COVID-19 hospitalization.
  • These children should be prioritized for vaccinations.
  • Implications for the Healthcare Team: Maintaining good asthma control and carefully monitoring children with uncontrolled asthma if they develop SARS-CoV-2 infection could help protect children from more severe COVID-19.

 

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