Discussion
In this descriptive cross- sectional study, including 512 children who presented to the ED for asthma related symptoms during 3 time periods in two consecutive years, we demonstrated different patterns in ED visits and in hospitalizations during pre-lockdown, lockdown and post lockdown periods, compared with 2019.
There was no difference in the demographic data between the groups except for trend towards older age during 2020 compared with 2019. Male predominance, as can be expected among this pre-pubertal age group, was observed.13 The majority of our patients during all time periods were of Bedouin Arab descent, with a significant increase in their visits during lockdown. This could be explained by the low socioeconomic status of the Bedouin population in southern Israel, some which are living in large families with overcrowding, poor accommodations/housing conditions, and limited access to health care in some of the settlements14. In those areas, social distancing is more difficult to achieve and the exposure to outdoor allergens was probably not significantly reduced, even during the lockdown. The mildly lower heart rate and respiratory rate noticed in 2020 is clinically insignificant and could stem from the difference in patients age between 2019 and 2020, with an average of 1.5 years older in 2020. Since asthma severity parameters (hospitalization rate and LOS) were higher during 2020B, we can assume that this change in vital signs did not reflect milder cases, but probably proportionate to an older age. Treatment in the ED was similar between all time periods except for a significant drop in the use of NACL 0.9% inhalations during 2020B and 2020C. Since the COVID-19 outbreak, in accordance with the Israeli pediatric pulmonology society guidelines, there has been a shift from using small-volume nebulizers to metered-dose inhalers (MDIs) with valved-holding chambers for beta-agonist and anticholinergic inhalations in order to reduce the viral infection transmission by reducing the spread of aerosol mass by small-volume nebulizers.15,16
The accumulating evidence on the impact of COVID-19 pandemic on ED visits patterns, show a substantial decrease in the volume of patients presenting to the ED during the pandemic, throughout various disciplines and countries.17 Furthermore, there are increasing reports on higher hospital admission rates, indicating higher acuity patients, with increased morbidity and mortality due to delayed medical care in non-COVID-19 emergency conditions. 18-20
In this descriptive cross-sectional study, we compare three parallel time periods during two consecutive years, and show a significant decrease in pediatric asthma related ED visits during COVID-19 lockdown. Similar trends in asthma related ED visits were observed in different countries, and possible explanations were suggested by the different authors 11,21-24. Since the major triggers for asthma exacerbation in the pediatric population are viral infections, it was expected that social distancing measures during lockdown will decrease viral infections transmission, including Influenza virus, Rhinovirus and Respiratory syncytial virus (RSV)25, 26 . Another important trigger is outdoor exposure to pollen allergens and air pollution27, again substantially reduced due to minimal exposure during lockdown and the reduction of industrial work28. Reduced physical activity during lockdown was described in large questionnaires studies, along with an increase in children’s psychological and behavioral symptoms and elevated screen-time29-31. Socio-affective complications and insufficient physical activity were underscored as two of the main concerns, particularly among socio-economic deprived children32. As a result, a reduction in physical activities reduces the number of asthma exacerbations related to exercise induced bronchospasm (EIB) and exercise induced asthma (EIA). The fewer ED visits during lockdown can also result from better asthma control while the parents are at home, providing better adherence to anti asthmatic controllers therapy33. Although, this issue is most probably of limited effect, since most of the parents that participated in a telephone visit during lockdown, stated they stopped the preventive therapy as their child was feeling well. Another issue that should be discussed is the avoidance of approaching for medical care during lockdown, due to concerns of parents from increased exposure and the risk of COVID-19 transmission.
After lockdown, we demonstrated significant rise in number of ED visits, even in comparison to same time period during the previous year. We speculate this rise represents the return to routine activity with everyday exposure to classmates, outdoor pollen exposure, rise in air pollution and physical activity. This may resemble ”September pandemic”, when children returning to school after summer vacations with significant rise in asthma exacerbations8.
Alongside with a significant reduction in ED visits for asthma exacerbations during lockdown, higher hospitalization rates and longer LOS were observed, that may indicate more severe exacerbations predominate this period. This observation could be attributed to delay in presentation both due to reduced availability of community medical services during lockdown and transition towards telemedicine-based practice as well as the hesitation to come to the ED due to the fear to contract COVID-19. Our data indicated that hospitalization rate was 1.5 times higher during lockdown period compared to the previous year, in contrary to other publications that reported a reduction in the number of hospitalizations in the pediatric population during this period23,34. We believe this fact is related to different demographics between countries, with majority of Bedouin Arab population in our region. Another possible explanation for the higher admission rate and longer LOS seen during lockdown could be a lower threshold for admission at the ER and higher threshold for discharging the patient from the wards, in light of the reduced availability of community health care services and the concern of lack of proper follow-up in the community.
Our study has a few limitations. This is a single tertiary center experience, and therefore can be influenced, as mentioned, by the unique demographics in the region. Another limitation is the retrospective nature of our study, with all data drawn from electronic files. Some of the data that was documented in a hard copy, in extremely acute patients treated in the resuscitation room, may be missing in the electronic files (e.g. intravenous Magnesium Sulfate).
In conclusion , we report a new pattern of ED visits and hospital stay of children with asthma related symptoms, associated with the COVID-19 pandemic, that perhaps is not only confined to asthma. Pediatricians should be aware to this phenomenon at the community and hospital levels.