Just one week after Massachusetts closed schools and day cares in March, Boston Children's Hospital saw a drastic change in asthma-related visits to the emergency room: They were down 80% from the prior two months.
For two more months, during the state's stay-at-home order, they stayed that way. When the order began lifting in late May, the ER was seeing 82% and 87% fewer asthma emergency visits compared with 2018 and 2019, according to a recent study published in the journal Annals of the American Thoracic Society.
Dr. Tregony Simoneau, a pediatric pulmonologist and lead author of the study, says she expected a drop-off similar to those seen during summer breaks, but "the sustained nature of it and the dramatic drop were surprising."
The study's authors suggest emergency room avoidance wasn't solely responsible for the decline, but that pandemic-driven changes in individual, community and environmental circumstances are likely at play.
While the overall number of ER visits went down for patients between the ages of 2 and 22 after the shutdown, the decline was much steeper for the proportion of asthma-related visits in contrast to other types of pediatric emergencies. This held true when compared to the two months before the shutdown and the same time periods in 2018 and 2019, and across ethnicities.
What about the children who did require care for asthma emergencies? There was no increase in the share who required hospitalization, suggesting most cases that made it to the ER weren't any worse than usual.
Dr. Alan Schroeder, a pediatric critical care doctor at Stanford's Lucile Packard Children's Hospital, says he has seen a similar trend with pediatric asthma during California's stay-at-home orders early in the pandemic, and in the months since.
Like the Boston researchers, he believes the results likely reflect environmental and behavioral changes — ones that might be sustainable in a post-pandemic world.
Here are some of the factors identified by the researchers:
Better medication adherence
The Centers for Disease Control and Prevention estimates only 54% of children who take asthma medications use them as prescribed, which can lead to more frequent, and severe, asthma attacks. Throughout the COVID-19 crisis, Simoneau says she has noticed patients and families refilling controller inhalers and rescue inhalers earlier and more often, and reporting better adherence to daily medications.
Though it can't be determined if the change is due to fear of hospitals in the pandemic, health talk in the media or other factors (like spending more time at home), the study authors suggest medication adherence could be a big contributor to how long the ER visits were able to stay so low, as medications are able to maintain better control of symptoms over time.
Schroeder, too, has witnessed "a prevailing sense of trying to do everything you can at home to avoid being hospitalized," adding that "if that meant more parents encouraging their kids to [use] their inhaler, it wouldn't be surprising as one of the mechanisms at play here."
Access to telemedicine
Telemedicine, also believed to help with medication adherence for adolescents, has had a much bigger role in the delivery of health care while people in the U.S. have sheltered in place.
The convenience and availability of virtual visits means patients and parents can reach doctors earlier in the course of symptoms, and more often. By providing a platform for better at-home management of asthma symptoms, telemedicine could help fend off emergencies.
Public health measures such as hand-washing, social distancing, disinfecting surfaces and staying home when sick are far more common in pandemic life, Schroeder points out. And doctors have seen fewer infections with common viruses in the past 10 months — infections that can be lethal for children who have asthma.
"These [measures] work. We've not seen the type of transmissible infections that we would normally be seeing — RSV, rhinovirus, influenza, metapneumovirus. In trying to prevent the transmission of COVID-19, we've also prevented the transmission of these other seasonal viruses that cause asthma exacerbations," Schroeder says.
Simoneau credits these hygiene habits with keeping asthma emergency rates at Boston Children's lower going into winter in comparison to previous years, noting only a "slight increase" in the fall.
Environmental and other factors
The study authors also cited environmental reasons: improved air quality as more Americans worked from home and had less contact with outdoor allergens such as pollen and dust on playgrounds, many of which have been off-limits during the COVID-19 crisis.
The researchers additionally suspected the lack of participation in school sports, which are known to trigger exercise-induced asthma, both indoors and outdoors.
Whether these factors are sustainable, pandemic-driven lifestyle changes have brought the pediatric community closer to solving a problem that has long plagued them: how to better protect children with asthma and save lives.
"It's really an opportunity to do a deeper dive into understanding more about which element has had the greatest contribution to the drop in emergency room visits," Simoneau says. "This is something we, as both clinicians and researchers, have been struggling with for quite some time, and yet this pandemic was quite effective in showing us what works. We just have to tease apart the things that could be really useful for the future."
And while the value of mask-wearing in non-pandemic times is another question for the future, it's not stopping Simoneau's young patients from stepping up to do the right thing now — never mind the contentious debate over mask-wearing among grown-ups.
"Over time, and with some practice, they're able to wear them," she says of the kids she treats. "Most of our patients are doing quite well with it."
Kristen Kendrick is a board-certified family physician in Washington, D.C., and a health and media fellow at NPR and Georgetown University School of Medicine.