Blog entry written on: ‘Asthma and COVID-19: a review of evidence on risks and management considerations’ (bmjebm-2020-111506)
Authors: Jamie Hartmann-Boyce, James Gunnell, Jonny Drake, Afolarin Otunla, Jana Suklan, Ella Schofield, Jade Kinton, Matt Inada-Kim, F D Richard Hobbs, Paddy Dennison
Not all reasonable assumptions prove true. At the beginning of the COVID-19 pandemic all people with asthma were considered at higher risk of severe infection – in other words, they were vulnerable. COVID-19 is a respiratory illness, and people with asthma tend to be at higher risk of respiratory infections more generally.
However, in our recent review, “Asthma and COVID-19: a review of evidence on risks and management considerations 10.1136/bmjebm-2020-111506”, we found that though some studies suggest asthma is indeed a risk factor, others show the opposite, or show no relationship. This could be genuine, or because of problems with the studies, or could reflect differences in asthma severity in the populations studied, as risk appears higher in people with more severe asthma.
Despite this uncertainty, not identifying asthma as a vulnerability at the outset of the pandemic could have been viewed as violation of the precautionary principle. But months into the pandemic, with the evidence still unclear for people with milder forms of asthma, we need to recognise that harm from this pandemic is not just from acute infection. Labelling someone as “vulnerable” comes with side effects which are difficult to quantify, but present none-the-less.
Because of pre-existing conditions, some people are making difficult choices, and turning down opportunities. Since I’ve been working on rapid reviews of the evidence on long-term conditions and COVID-19, people living with asthma and diabetes have reached out to me asking what they should do. Should a doctor return to work? Should an undergraduate leave university? Should a child return to school? I’m not a clinician and those aren’t decisions I can advise on, but as someone with type 1 diabetes who also falls into this “clinically vulnerable” category, I can relate. The hard decisions people with pre-existing conditions have made and will continue to make in this pandemic will have ripple effects. I don’t want to imagine a scenario where people with long-term conditions are perpetually anxious to engage in the world around them – and those around them are missing out on all they contribute.
I hope that when we apply the precautionary principle to risk stratification in COVID-19, we are thinking not just about the harms of infection, but the potential unintended impacts of labelling someone as ‘vulnerable’. And I hope we do something to mitigate these impacts, which will vary based on individual context and societal factors, and will intersect with the profound health inequalities this pandemic has, once again, highlighted. Health inequalities in COVID-19 are related to existing inequalities in chronic diseases; as such inequalities have an important role in determining who is clinically vulnerable in the first place.
As well as vulnerability to infection, all people with long-term conditions are vulnerable in another way – to disruptions to the healthcare systems that keep us alive. Fortunately, these disruptions can be managed and mitigated. Unfortunately, they are often not. Universal healthcare (for me, the NHS) means that even if I’m not seeing my GP as much, I’m still accessing essential medications. In other parts of the world if people with long-term conditions lose their jobs due to the COVID-19 recession – or because they have to care for children during school closures – they may also lose their healthcare. Losing jobs can mean losing inhalers, losing insulin. We can be vulnerable to diseases, and we can be vulnerable to systems. Science is doing all it can to fight this disease. Let’s focus on fixing the systems while we’re at it.
Jamie Hartmann-Boyce, Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford
Conflicts of interest: none to declare
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