Asthma Disparities in the United States Narrowed During the COVID-19 Pandemic: Findings From a National Survey, 2019 to 2022
Authors: Adam Gaffney, David U. Himmelstein, Steffie Woolhandler
Journal: Annals of Internal Medicine (2023)

Letters19 December 2023Asthma Disparities in the United States Narrowed During the COVID-19 Pandemic: Findings From a National Survey, 2019 to 2022FREEAdam Gaffney, MD, MPH, David U. Himmelstein, MD, Steffie Woolhandler, MD, MPHAdam Gaffney, MD, MPHCambridge Health Alliance, Cambridge, Massachusetts; and Harvard Medical School, Boston, Massachusetts, David U. Himmelstein, MDHunter College, City University of New York, New York, New York; Cambridge Health Alliance, Cambridge, Massachusetts; and Harvard Medical School, Boston, Massachusetts, Steffie Woolhandler, MD, MPHHunter College, City University of New York, New York, New York; Cambridge Health Alliance, Cambridge, Massachusetts; and Harvard Medical School, Boston, MassachusettsAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M23-2100 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Background: The COVID-19 pandemic’s onset coincided with decreasing chronic airway disease exacerbations, attributed to reduced circulation of common respiratory viruses and possibly other disruptions (1, 2).Objective: To determine whether this decrease narrowed disparities in asthma morbidity nationwide.Methods: We analyzed adults (n = 120 698) and children (n = 30 708) in the 2019 to 2022 National Health Interview Survey (NHIS) (3).We examined 3 outcomes each year: 1) a current asthma diagnosis; and, among those ever diagnosed with asthma, 2) experiencing any asthma episode–attack or 3) asthma-related emergency department (ED) visit within the past year. We examined overall trends, and those for racial and ethnic groups with sufficient “n”: non-Hispanic White (n = 81 905 adults, n = 15 955 children), non-Hispanic Black (n = 12 956 adults, n = 3163 children), and Hispanic (n = 16 009 adults, n = 7577 children).We used unadjusted logistic regression to test linear time trends in the prevalence of each outcome, overall and for each race and ethnic group, and assessed trends in disparities with regressions that included indicators for year, race and ethnicity, year by race and ethnicity interaction, and several potential confounders (Table). We then calculated the adjusted percentage point (pp) differences in asthma outcomes among Black or Hispanic (relative to White) persons by survey year.Table. Unadjusted Asthma Trends and Adjusted Differences* in Predicted Probability of Asthma Outcomes Among Hispanic, Black, and White Persons by Survey Year and Age, 2019 to 2022Outcomes2019202020212022P Value for Trend†Adults Asthma prevalence White, %8.18.38.29.10.006 Hispanic, %6.97.45.87.20.82 Adjusted pp difference vs. White (95% CI)‡−1.5 (−2.6 to −0.5)−1.1 (−2.3 to 0.0)−2.6 (−3.6 to −1.7)−2.1 (−3.2 to −1.0)– Black, %10.410.910.610.10.66 Adjusted pp difference vs. White (95% CI)‡1.9 (0.5 to 3.4)1.7 (0.2 to 3.1)1.8 (0.4 to 3.2)0.6 (−0.9 to 2.0) Asthma attack White, %25.225.124.425.60.91 Hispanic, %22.724.121.726.10.38 Adjusted pp difference vs. White (95% CI)‡−3.5 (−8.3 to 1.2)−0.8 (−5.8 to 4.2)−3.6 (−8.2 to 1.0)−0.2 (−5.0 to 4.5)– Black, %29.326.023.922.10.029 Adjusted pp difference vs. White (95% CI)‡2.3 (−3.4 to 8.0)−0.2 (−5.7 to 5.4)−1.7 (−6.3 to 3.0)−5.8 (−10.5 to −1.1) Asthma ED visit White, %6.44.74.03.9<0.001 Hispanic, %9.010.97.111.00.71 Adjusted pp difference vs. White (95% CI)‡1.7 (−1.5 to 4.8) 6.2 (2.2 to 10.2)2.3 (−0.3 to 4.9)7.0 (4.0 to 10.0)– Black, %13.48.88.17.40.007 Adjusted pp difference vs. White (95% CI)‡5.2 (1.9 to 8.4)3.1 (0.3 to 5.8)2.8 (0.3 to 5.3)2.6 (0.4 to 4.9)–Children Asthma prevalence White, %5.75.25.75.80.77 Hispanic, %6.75.65.45.50.171 Adjusted pp difference vs. White (95% CI)§0.6 (−0.7 to 2.0)0.2 (−1.6 to 2.0)−0.5 (−1.9 to 0.8)−0.6 (−2.0 to 0.8)– Black, %13.58.912.511.20.60 Adjusted pp difference vs. White (95% CI)§6.7 (4.0 to 9.4)2.8 (0.2 to 5.4)6.1 (3.3 to 8.9)4.7 (1.7 to 7.7)– Asthma attack White, %30.127.926.339.80.066 Hispanic, %29.226.424.128.00.71 Adjusted pp difference vs. White (95% CI)§−4.7 (−13.3 to 3.9)−3.5 (−16.2 to 9.3)−6.1 (−15.4 to 3.2)−13.1 (−22.3 to −3.9)– Black, %36.125.526.930.30.39 Adjusted pp difference vs. White (95% CI)§2.2 (−8.2 to 12.6)−3.7 (−17.7 to 10.4)−3.7 (−14.2 to 6.9)−12.4 (−23.8 to −1.0)– Asthma ED visit White, %9.410.36.69.80.78 Hispanic, %24.19.212.612.50.036 Adjusted pp difference vs. White (95% CI)§12.3 (4.8 to 19.9)−1.5 (−9.2 to 6.2)4.7 (−2.0 to 11.4)3.9 (−4.1 to 11.9)– Black, %29.923.318.715.00.009 Adjusted pp difference vs. White (95% CI)§15.1 (6.8 to 23.4)12.3 (1.3 to 23.4)7.4 (−0.9 to 15.7)2.5 (−4.5 to 9.5)–ED = emergency department; pp = percentage point.* Adjusted percentage point differences represent the adjusted difference in predicted probability (multiplied by 100 to produce percentage point differences) of each asthma outcome for Hispanic (or Black) persons relative to White persons by survey year, estimated with multivariable logistic regressions and Stata’s margins commands. Coefficients for persons of other races and ethnicities not shown.† P value for trend is from univariate logistic regressions, treating year as a continuous predictor variable, performed separately for each of the 3 race and ethnic subgroups.‡ Adult analyses adjusted for age (18 to 24 y, 25 to 34 y, 35 to 44 y, 45 to 54 y, 55 to 64 y, ≥75 y; n = 301 of 120 698 with missing data); sex (male/female; n = 10 missing); family income as a percentage of the federal poverty level (<100%; 100% to 199%; 200% to 299%; 300% to 399%; 400% to 499%; ≥500%+); region (Northeast, Midwest, South, West); county of residence (large central metro, large fringe metro, medium and small metro, nonmetropolitan); interview quarter (Q1 to Q4); coverage status (uninsured vs. insured; n = 341 missing); smoking status (current every day smoker, current some day smoker, former smoker, never smoker; n = 2995 missing [“smoker, current status unknown,” or “unknown if ever smoked”]); year; race and ethnicity; and a year by race and ethnicity interaction. n for adjusted adult analyses: n = 116 965 (asthma prevalence); n = 16 063 (asthma attack in past 12 months); and n = 16 080 (asthma ED visit in past 12 months).§ Child analyses adjusted for age (0 to 4 y, 5 to 11 y, 12 to 17 y); sex (male/female; n = 13 of 30 708 missing); family income as a percentage of the federal poverty level (<100%; 100% to 199%; 200% to 299%; 300% to 399%; 400% to 499%; ≥500%); region (Northeast, Midwest, South, West); county of residence (large central metro, large fringe metro, medium and small metro, nonmetropolitan); interview quarter (Q1 to Q4); coverage status (uninsured vs. uninsured; n = 120 missing); year; race and ethnicity; and a year by race and ethnicity interaction. n for adjusted child analyses: n = 30 524 (asthma prevalence); n = 3192 (asthma attack in past 12 months); and n = 3192 (asthma ED visit in past 12 months). Download table Table. Unadjusted Asthma Trends and Adjusted Differences* in Predicted Probability of Asthma Outcomes Among Hispanic, Black, and White Persons by Survey Year and Age, 2019 to 2022We used Stata/SE 18, procedures appropriate for complex survey analysis, and NHIS-provided weights that allow national estimates. Our institutional review boards do not consider analyses of deidentified publicly available data human subjects research.Findings: For adults, asthma prevalence overall increased slightly from 8.0% in 2019 to 8.7% in 2022, driven by increases among White adults. Hispanic adults had the lowest and Black adults the highest prevalence throughout the study period (Figure), although the adjusted difference between Black versus White adults decreased over time (Table).Figure. Asthma trends among U.S. adults and U.S. children, overall and by race and ethnicity, 2019 to 2022.ED = emergency department. A. Asthma prevalence defined by an indicator for those with an affirmative response both to “Have you EVER been told by a doctor or other health professional that you had asthma?” and “Do you still have asthma?” versus those with a negative response to either question. Of n = 120 698 sample adults, n = 252 had missing data for this indicator due to “refused,” “not ascertained,” or “don’t know” responses, leaving n = 120 446 adults for analysis. B. Asthma attack defined by the question, “During the past 12 months, have you had an episode of asthma or an asthma attack?,” ascertained among those who ever had been diagnosed with asthma (n = 16 520). n = 32 had missing data (“refused,” “not ascertained,” or “don’t know”) for this outcome, leaving n = 16 488 for analysis. C. Asthma ED visit defined by the question, “During the past 12 months, have you had to visit an emergency room or urgent care center because of asthma?,” ascertained among those who ever had been diagnosed with asthma (n = 16 520). n = 14 had missing data (“refused,” “not ascertained,” or “don’t know”) for this outcome, leaving n = 16 506 for analysis. D. Asthma prevalence defined by an indicator for those with an affirmative response both to “Has a doctor or other health professional EVER told you that [sample child’s name] had asthma?” and “Does [sample child’s name] still have asthma?” versus those with a negative response to either question. Of n = 30 708 sample children, n = 59 had missing data for this indicator due to “refused,” “not ascertained,” or “don’t know” responses, leaving n = 30 649 children for analysis. E. Asthma attack defined by the question, “During the past 12 months, has [sample child] had an episode of asthma or an asthma attack?,” ascertained among those who ever had been diagnosed with asthma (n = 3207). n = 2 had missing data (“refused,” “not ascertained,” or “don’t know”) for this outcome, leaving n = 3205 for analysis. F. Asthma ED visit defined by the question, “During the past 12 months, did [sample child] have to visit an emergency room or urgent care center because of [his/her/their] asthma?,” ascertained among those who ever had been diagnosed with asthma (n = 3207). n = 1 had missing data (“refused,” “not ascertained,” or “don’t know”) for this outcome, leaving n = 3206 for analysis.* Indicates statistically significant trend from 2019 to 2022 (P < 0.050), tested with a univariate logistic regression treating year as a continuous variable. White and Black persons are non-Hispanic; Hispanic persons can be of any race. Note that “overall” analyses include persons of non-White, non-Black, and non-Hispanic race and ethnicity. Download figure Download PowerPoint The asthma attack rate overall remained stable (Figure), with comparable rates among White and Hispanic adults (Table). However, asthma attack rates decreased among Black adults, from 29.3% to 22.1%, with relative adjusted differences between Black and White adults going from +2.3 pp (95% CI, −3.4 to 8.0 pp) in 2019 to −5.8 pp (CI, −10.5 to −1.1 pp) in 2022.Overall, asthma ED visit rates decreased, primarily due to decreases among Black and White adults (Figure). The ED visit rates were consistently higher among Black versus White adults, although the adjusted difference narrowed over time, from a 5.2-pp difference (CI, 1.9 to 8.4 pp) in 2019 to 2.6 pp (CI, 0.4 to 4.9 pp) in 2022 (Table).For children, asthma prevalence was stable, but consistently highest among Black children (Figure; Table), despite a transient dip in 2020.Asthma attacks decreased slightly through 2021, then increased in 2022 (Figure), particularly among White children (vs. Hispanic and Black children), with an adjusted difference of −13.1 pp (CI, −22.3 to −3.9) and −12.4 pp (CI, −23.8 to −1.0 pp), respectively (Table).Asthma ED-visit rates overall decreased from 17.3% in 2019 to 12.1% in 2022, driven by decreases among Black and Hispanic, but not White, children (Figure). Black and Hispanic children had higher rates of ED visits prepandemic (adjusted difference, 15.1 pp [CI, 6.8 to 23.4 pp] and 12.3 pp [CI, 4.8 to 19.9], respectively). For Hispanic children, ED visits decreased quickly and became comparable with White children beginning in 2020, whereas ED visits for Black children decreased more gradually and became comparable by 2021.Discussion: Prepandemic, Black adults and children had the highest rates of asthma prevalence, attacks, and ED visits. Downward trends during the pandemic were seen for Black (relative to White) adults and children for asthma attack rates and ED visits. In contrast, asthma attack rates among White children increased in 2022 relative to Black and Hispanic children.The gradual decrease in ED visits and rebound of asthma attacks in 2022 after a small drop may be attributed to a decrease in the circulation of common respiratory viruses (1, 4, 5). Differential exposure to tobacco, allergens, pollution, COVID-19, or controller inhaler usage during the pandemic could also have affected asthma trends and deserve further study. Health care avoidance, which likely played a role in 2020, is less likely to explain reductions in subsequent years as care use rebounded.The narrowing asthma morbidity disparities through the pandemic suggest opportunities for mitigation, for example, improving environmental conditions or developing and equitably delivering vaccines against respiratory pathogens. However, other policies are needed to address the multitude of factors that drive both asthma pathogenesis and exacerbations.References1. Cookson W, Moffatt M, Rapeport G, et al. A pandemic lesson for global lung diseases: exacerbations are preventable. Am J Respir Crit Care Med. 2022;205:1271-1280. [PMID: 35192447] doi:10.1164/rccm.202110-2389CI CrossrefMedlineGoogle Scholar2. Ye D, Gates A, Radhakrishnan L, et al. Changes in asthma emergency department visits in the United States during the COVID-19 pandemic. J Asthma. 2023;60:1601-1607. [PMID: 36608267] doi:10.1080/02770903.2023.2165445 CrossrefMedlineGoogle Scholar3. Division of Health Interview Statistics, National Center for Health Statistics. National Health Interview Survey (NHIS) 2022 Survey Description. June 2023. Accessed at https://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/NHIS/2022/srvydesc-508.pdf on 2 August 2023. Google Scholar4. Ho T, Shahzad A, Jones A, et al. Examining the effect of the COVID-19 pandemic on community virus prevalence and healthcare utilisation reveals that peaks in asthma, COPD and respiratory tract infection occur with the re-emergence of rhino/enterovirus. Thorax. 2023;78:1248-1253. [PMID: 37423763] doi:10.1136/thorax-2022-219957 CrossrefMedlineGoogle Scholar5. So JY, O'Hara NN, Kenaa B, et al. Population decline in COPD admissions during the COVID-19 pandemic associated with lower burden of community respiratory viral infections. Am J Med. 2021;134:1252-1259.e3. [PMID: 34126098] doi:10.1016/j.amjmed.2021.05.008 CrossrefMedlineGoogle Scholar Comments 0 Comments Sign In to Submit A Comment Author, Article, and Disclosure InformationAuthors: Adam Gaffney, MD, MPH; David U. Himmelstein, MD; Steffie Woolhandler, MD, MPHAffiliations: Cambridge Health Alliance, Cambridge, Massachusetts; and Harvard Medical School, Boston, MassachusettsHunter College, City University of New York, New York, New York; Cambridge Health Alliance, Cambridge, Massachusetts; and Harvard Medical School, Boston, MassachusettsDisclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M23-2100.Reproducible Research Statement: Study protocol: Not available. Statistical code: Available from the corresponding author at agaffney@cha.harvard.edu. Data set: Publicly available at www.cdc.gov/nchs/nhis/data-questionnaires-documentation.htm.Corresponding Author: Adam Gaffney, MD, MPH, Harvard Medical School/Cambridge Health Alliance, 1493 Cambridge Street, Cambridge, MA 02139; e-mail, agaffney@cha.harvard.edu.This article was published at Annals.org on 19 December 2023. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Latest Keywords Asthma Children COVID-19 Pandemics Racial and ethnic issues ePublished: 19 December 2023 Copyright & PermissionsCopyright © 2023 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...