COVID-19, asthma, and return to school
Authors: Elissa M Abrams, Gráinne McGill, Sunil S Bhopal, Ian Sinha, Ricardo M Fernandes
Journal: The Lancet Respiratory Medicine (2020)

Social distancing and lockdown measures have included the suspension of children and young people's education for several weeks to months. Although the precise educational and societal effects of closing schools are unknown, they are likely to be substantial and will almost certainly have exacerbated inequalities. In countries in which society is reconfiguring to a new normal, the priority must be preparing for reopening schools because of the potential lifelong impact on children and young people. However, with this return to school rapidly approaching, there should be particular considerations regarding children and young people with asthma. There is an annual seasonal autumnal spike in asthma attacks in children and young people (the so-called September epidemic) due to colder weather, common viral infections, aeroallergen exposure, and reduced asthma medication compliance.1Sears MR Johnston NW Understanding the September asthma epidemic.J Allergy Clin Immunol. 2007; 120: 526-529Summary Full Text Full Text PDF PubMed Scopus (95) Google Scholar It is unclear where various countries will be with respect to ongoing community spread of COVID-19 in the autumn, but we anticipate constraints in ongoing health-care resource allocation in many parts of the world; for example, prioritisation of respiratory care in people with moderate to severe asthma, including limitation of exposure to aerosol generating procedures such as spirometry.2Searing DA Dutmer CM Fleischer DM et al.A Phased Approach to Resuming Suspended Allergy/Immunology Clinical Services.J Allergy Clin Immunol Pract. 2020; 8: 2125-2134Summary Full Text Full Text PDF PubMed Scopus (33) Google Scholar These constraints might reduce access and follow up for children and young people with milder asthma, who are at high risk of asthma exacerbations and emergency department visits. However, as stay at home orders have had a substantial impact on children and young people, including decreased vaccination rates, delayed management of health conditions, prolonged exposure to indoor home air pollutants, and impacts on mental health, it is possible that in some children and young people a return to school might improve overall asthma control.3SickKidsCOVID-19: Recommendations for School Reopening.https://www.sickkids.ca/PDFs/About-SickKids/81407-COVID19-Recommendations-for-School-Reopening-SickKids.pdfDate: June 17, 2020Date accessed: July 29, 2020Google Scholar It is important to reassure families that severe COVID-19 infection is rare in children and young people, irrespective of underlying asthma.4Bhopal S Bagaria J Bhopal R Children's mortality from COVID-19 compared with all-deaths and other relevant causes of death: epidemiological information for decision-making by parents, teachers, clinicians and policymakers.Public Health. 2020; (https://doi.org.10.1016/j.puhe.2020.05.047 published online May 20.)Crossref Scopus (36) Google Scholar Despite this, children and young people with asthma might be at high risk of missing out on education when schools reopen. Asthma can be confused with COVID-19 respiratory symptoms,5Abrams EM 't Jong GW Yang CL Asthma and COVID-19.CMAJ. 2020; 192: E551Crossref PubMed Scopus (55) Google Scholar and children and young people with cough and wheeze at school are at greater risk of being sent home. To minimise this disruption, rapid testing services, which are likely to be stretched, should be prioritised for children and young people wherever possible. Primary, secondary, and tertiary care services can also mitigate this problem by adhering to evidence-based approaches to childhood asthma. In particular, a focus on asthma control, risk stratification, and medication adherence will be essential, including ongoing review of inhaler technique and a personalised written asthma action plan, whether in-person or virtually.5Abrams EM 't Jong GW Yang CL Asthma and COVID-19.CMAJ. 2020; 192: E551Crossref PubMed Scopus (55) Google Scholar Prioritising less (or no) short-acting bronchodilator use, as recommended in the Global Initiative for Asthma (GINA) 2019 and 2020 strategy, and clear stepwise action plans might improve asthma control and management among people with mild asthma. An ongoing cycle of assess, adjust, and review, as recommended in the GINA guideline, is essential because a return to school this year might impact asthma in ways that are unpredictable at present. An appreciation of the effect of social determinants of health among families of children and young people with asthma, whether this be housing quality, adequately heated and ventilated homes, access to transportation, poverty, health literacy, access to medications, or access to health care,6Federico MJ McFarlane 2nd, AE Szefler SJ Abrams EM The impact of social determinants of health on children with asthma.J Allergy Clin Immunol Pract. 2020; 8: 1808-1814Summary Full Text Full Text PDF PubMed Scopus (87) Google Scholar will be important, since economic depression is anticipated to worsen.7Sinha I Bennett D Taylor-Robinson DC Children are being sidelined by covid-19.BMJ. 2020; 369m2061Crossref PubMed Scopus (26) Google Scholar Broad access to influenza vaccination will be an important public health strategy to further decrease risk, and particular effort must be made to educate families about the benefits of vaccinating children and young people with asthma. Little guidance exists on how to transition children and young people with asthma back to school and how to counsel their caregivers on mediation of risk. Although returning to school is of utmost importance for education and social development, mental health, and mitigation of food insecurity,8Sinha IP Lee AR Bennett D McGeehan L et al.Child poverty, food insecurity, and respiratory health during the COVID-19 pandemic.Lancet Respir Med. 2020; (published online June 29.)https://doi.org/10.1016/S2213-2600(20)30280-0Summary Full Text Full Text PDF Scopus (36) Google Scholar ensuring that those with asthma return to school safely will require diligence and ongoing monitoring. In addition to the broader public health recommendations (screening, physical distancing, mask wearing, and hand hygiene), specific recommendations might be especially salient for families of children and young people with asthma. For example, regular environmental cleaning is recommended to reduce the presence of severe acute respiratory syndrome coronavirus 2 on surfaces in schools,3SickKidsCOVID-19: Recommendations for School Reopening.https://www.sickkids.ca/PDFs/About-SickKids/81407-COVID19-Recommendations-for-School-Reopening-SickKids.pdfDate: June 17, 2020Date accessed: July 29, 2020Google Scholar but various household cleaning products have been associated with an increased risk of asthma and wheeze across all age groups.9Abrams EM Cleaning products and asthma risk: a potentially important public health concern.CMAJ. 2020; 192: E164-E165Crossref PubMed Scopus (10) Google Scholar Consequently, cleaning products used in schools should be free of organic compounds, irritants, or fragrances.9Abrams EM Cleaning products and asthma risk: a potentially important public health concern.CMAJ. 2020; 192: E164-E165Crossref PubMed Scopus (10) Google Scholar Improving classroom ventilation will be important overall,3SickKidsCOVID-19: Recommendations for School Reopening.https://www.sickkids.ca/PDFs/About-SickKids/81407-COVID19-Recommendations-for-School-Reopening-SickKids.pdfDate: June 17, 2020Date accessed: July 29, 2020Google Scholar but there is a fine balance between opening windows and maintaining thermal comfort, and care must be taken to reduce exposure to outdoor seasonal aeroallergens, such as mould or pollens, in children and young people with atopic asthma. Although large-scale studies are scarce, available data indicate that indoor air quality in schools is often poor, with pollutant concentrations frequently exceeding EU and WHO guideline values.10Annesi-Maesano I Baiz N Banerjee S Rudnai P Rive S Group S Indoor air quality and sources in schools and related health effects.J Toxicol Environ Health B Crit Rev. 2013; 16: 491-550Crossref PubMed Scopus (190) Google Scholar Indoor air quality monitors that measure carbon dioxide and humidity might be useful adjuncts. Schools could use strategies to reduce traffic pollution, including anti-idling policies at drop-off and pick-up times for those driving cars, encourage as many students as possible to arrive on foot or by bicycle, and arranging deliveries outside school hours. Those who work in health, school, and government should be mindful and considerate of the concerns of children with asthma and their parents. Urgent guidance, incorporating views of various stakeholders, including children and young people, is required to prepare families, physicians, and schools for reopening in the autumn. Formal health need assessments, weighing up the risks and benefits of school attendance for children with asthma, are required to properly inform such guidance moving forward. Involving schools in ongoing recognition of asthma symptoms will be essential. In the interim, focusing on asthma control and mediation of risk might allow children and young people with asthma—and all children—to return to school safely. EMA is a collaborator with the Institute for Health Metrics and Evaluation, is on the National Advisory Board for Food Allergy Canada, has received moderator fees from Novartis, and is on the National Food Allergy Action Plan Action Steering Team for Food Allergy Canada. IS and RMF are co-last authors. EMA reports moderator fees from Novartis, outside of the submitted work, and is a collaborator with the Institute for Health Metrics and Evaluation, is on the National Advisory Board for Food Allergy Canada, and is on the National Food Allergy Action Plan Action Steering Team for Food Allergy Canada. All other authors declare no competing interests.