Asthma and Susceptibility to COVID-19 in Australian Children During Alpha, Delta and Omicron Waves of the COVID-19 Pandemic.

Purpose: Earlier coronavirus-19 (COVID-19) pandemic reports did not implicate increased disease burden in asthmatics while subsequent findings have been inconsistent. To date, the impact of COVID-19 on childhood asthma remains undetermined and is further complicated with ongoing emergence of new variants. This study aimed to investigate association between asthma and COVID-19 for children in New South Wales (NSW), Australia and compare its differences across four major outbreaks from alpha, delta and omicron variants/subvariants. Methods: This is a retrospective cross-sectional study of all children aged ≤17 years old who sought care for COVID-19 at Sydney Children's Hospitals Network (SCHN) between 1 January 2020 and 31 May 2022. Results: Of the 18,932 children with polymerase chain reaction (PCR) confirmed COVID-19 who attended SCHN, 60% received their care during delta wave, and 5.41% (n = 913) had prior diagnosis of asthma. Among children with COVID-19, the odds of having asthma were lower during alpha (aOR = 0.43; 95% CI, 0.19-0.83) and delta wave (aOR = 0.84; 95% CI, 0.73-0.96), but were higher during omicron wave (aOR = 1.56; 95% CI, 1.23-1.95). Length of hospital stay (LOS) for asthmatic children were increased by 0.55 days and 1.17 days during delta and the second omicron wave, respectively. Intensive care and mechanical ventilation requirements were not significantly different between asthmatic and non-asthmatic children. Eleven deaths were reported but none had asthma. Conclusion: Although children with asthma were more susceptible to COVID-19 infections during omicron waves compared to that of alpha or delta waves, they were not at greater risk of COVID-19 severity at any stage of the outbreak regardless of the predominant SARS-CoV-2 variants/subvariants.

Impact of integrated care coordination on pediatric asthma hospital presentations.

Introduction: Frequent asthma attacks in children result in unscheduled hospital presentations. Patient centered care coordination can reduce asthma hospital presentations. In 2016, The Sydney Children's Hospitals Network launched the Asthma Follow up Integrated Care Initiative with the aim to reduce pediatric asthma emergency department (ED) presentations by 50% through developing and testing an integrated model of care led by care coordinators (CCs). Methods: The integrated model of care was developed by a multidisciplinary team at Sydney Children's Hospital Randwick (SCH,R) and implemented in two phases: Phase I and Phase II. Children aged 2-16 years who presented ≥4 times to the ED of the SCH,R in the preceding 12 months were enrolled in Phase I and those who had ≥4 ED presentations and ≥1 hospital admissions with asthma attack were enrolled in Phase II. Phase I included a suite of interventions delivered by CCs including encouraging parents/carers to schedule follow-up visits with GP post-discharge, ensuring parents/carers are provided with standard asthma resource pack, offering referrals to asthma education sessions, sending a letter to the child's GP advising of the child's recent hospital presentation and coordinating asthma education webinar for GPs. In addition, in Phase II CCs sent text messages to parents/carers reminding them to follow-up with the child's GP. We compared the change in ED visits and hospital admissions at baseline (6 months pre-enrolment) and at 6-and 12-months post-enrolment in the program. Results: During December 2016-January 2021, 160 children (99 in Phase I and 61 in Phase II) were enrolled. Compared to baseline at 6- and 12-months post-enrolment, the proportion of children requiring ≥1 asthma ED presentations reduced by 43 and 61% in Phase I and 41 and 66% in Phase II. Similarly, the proportion of children requiring ≥1 asthma hospital admissions at 6- and 12-months post-enrolment reduced by 40 and 47% in Phase I and 62 and 69% in Phase II. Conclusion: Our results support that care coordinator led integrated model of asthma care which enables integration of acute and primary care services and provides families with asthma resources and education can reduce asthma hospital presentations in children.

Impact of lockdowns on paediatric asthma hospital presentations over three waves of COVID-19 pandemic.

Public health measures to mitigate the COVID-19 pandemic have altered health care for chronic conditions. The impact of the COVID-19 pandemic on paediatric asthma, the most common chronic respiratory cause of childhood hospitalisation, in Australia, remains unknown. In a multicentre study, we examined the impact of three waves of COVID-19 on paediatric asthma in New South Wales Australia. Time series analysis was performed to determine trends in asthma hospital presentations in children aged 2-17 years before (2015-2019) and during the COVID-19 pandemic (2020-2021) using emergency department and hospital admission datasets from two large tertiary paediatric hospitals.In this first report from Australia, we observed a significant decrease in asthma hospital presentations during lockdown periods including April (68.85%), May (69.46%), December (49.00%) of 2020 and August (66.59%) of 2021 compared to pre-pandemic predictions.The decrease in asthma hospital presentations coincided with the lockdown periods during first, second and third waves of the COVID-19 pandemic and was potentially due to reduced transmission of other common respiratory viruses from restricted movement.

Telehealth application of an ultrasonic home spirometer.

OBJECTIVE: To investigate the validity and home use of a personal ultrasonic spirometer. METHODS: Supervised spirometry was performed using laboratory equipment and a personal ultrasonic spirometer. In addition, the ability of children to perform acceptable spirometry during supervised telehealth appointments at home was assessed. RESULTS: 59 children completed spirometry on both devices. There was high between-device intraclass correlation coefficient (ICC) for forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC): ICC 0.991 (95% CI 0.985 to 0.995) and 0.989 (95% CI 0.981 to 0.993), respectively. Bland-Altman analysis revealed mean bias and limits of agreement of -0.01 (-0.22 to 0.24) L for FEV1 and -0.02 (-0.30 to 0.33) L for FVC. 125 of 140 (89%) supervised telehealth spirometry sessions were acceptable. CONCLUSION: There was excellent reliability in between-device measurements; however, the limits of agreement were wide. Therefore, caution is needed if the device is used interchangeably with laboratory equipment. High success rates of telehealth spirometry sessions indicate the device is suitable for this application.

Development and validation of a risk score to identify children at risk of life-threatening asthma.

OBJECTIVE: To develop and validate a prediction risk score for identification of children at risk of developing life-threatening asthma (LTA). METHODS: Our study utilized existing medical records and retrospective analysis to develop and validate a risk score. The study population included children aged 2-17 years, admitted with a primary diagnosis of asthma, to Sydney Children's Hospital between 2011-2016. Children admitted in the intensive care unit with asthma at risk of LTA (cases) and those admitted into general ward (comparison group), were randomly divided into a derivation and a validation cohort. Candidate predictors from derivation cohort were selected through multivariable regression, which were used to estimate each child's risk of developing LTA in the validation cohort. Predictive performance of the risk score was evaluated by the area under the receiver operating characteristic curve (AUROC) and Hosmer-Lemeshow goodness-of-fit test. RESULTS: The study population comprised of 1171 children; 586 in the derivation and 585 in the validation cohort. Four independent candidate variables from derivation cohort (age at admission, socioeconomic status, a family history of asthma/atopy and previous asthma hospitalizations) were retained in the predictive model (AUROC 0.759; 95% CI, 0.694-0.823), with a sensitivity of 78.5% and specificity of 46.6%. CONCLUSIONS: Our risk algorithm based on routinely collected clinical data may be used to develop a user-friendly risk score for early identification and monitoring of children at risk of developing LTA.

Assessment of Variation in Care Following Hospital Discharge for Children with Acute Asthma.

PURPOSE: To evaluate potential variation in care management pathways following hospital discharge for children with asthma in New South Wales, Australia. METHODS: A cross-sectional web-based survey was conducted in emergency departments (EDs) and paediatric units of public hospitals with more than five paediatric beds within New South Wales, Australia, between July 2018 and March 2019. Nursing and medical staff in EDs and paediatric units who had cared for children aged under 18 years with asthma in the preceding 12 months were invited to participate in this study. Outcome measures included use of clinical practice guidelines and asthma action plan (AAP); advice on post-hospitalization follow-up; provision of asthma education for parents/carers; availability of community-based asthma services; communication with schools/childcare services. RESULTS: A total of 502 participants (236 nursing and 266 medical staff, response rate=22%) from 37 hospitals were included. Overall, the use of AAP was not universal (median=90%; IQR=81-96%) with significant difference across local health districts (LHDs) (88.6%, 95% CI=85.4-91.3) and between EDs and paediatric wards (p=9.4×10-9); and a range of asthma clinical practice guidelines were used. Post-hospitalization follow-up within 2-3 days was recommended by 70% of the respondents, but only 8% reported that hospitals had a system in place to ensure follow-up compliance. Formal asthma education sessions (27% respondents) were seldom provided to parents/carers during hospital stays, especially in EDs (14% respondents). Less than 50% of the respondents were aware of any asthma community services for children and only 4% reported that schools/childcare services were notified about the child's hospital admission for an asthma flare up. CONCLUSION: There are marked variations in the post-hospitalization asthma care and community management for children in NSW. An integrated standardized model of care may improve health outcomes in children with asthma.

Community-based interventions for childhood asthma using comprehensive approaches: a systematic review and meta-analysis.

OBJECTIVE: We conducted a systematic review and meta-analysis to determine the effectiveness of comprehensive community-based interventions with ≥ 2 components in improving asthma outcomes in children. METHODS: A systematic search of Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Excerpta Medica Database (EMBASE), Cochrane Library and hand search of reference collections were conducted to identify any research articles published in English between 2000 and 2019. All studies reporting community-based asthma interventions with ≥ 2 components (e.g., asthma self-management education, home environmental assessment or care coordination etc.) for children aged ≤ 18 years were included. Meta-analyses were performed using random-effects model to estimate pooled odds ratio (OR) with 95% confidence intervals (CIs). RESULTS: Of the 2352 studies identified, 21 studies were included in the final analysis: 19 pre-post interventions, one randomised controlled trial (RCT) and one retrospective study. Comprehensive asthma programs with multicomponent interventions were associated with significant reduction in asthma-related Emergency Department (ED) visits (OR = 0.26; 95% CI 0.20-0.35), hospitalizations (OR = 0.24; 95% CI 0.15-0.38), number of days (mean difference = - 2.58; 95% CI - 3.00 to - 2.17) and nights with asthma symptoms (mean difference = - 2.14; 95% CI - 2.94 to - 1.34), use of short-acting asthma medications/bronchodilators (BD) (OR = 0.28; 95% CI 0.16-0.51), and increase use of asthma action plan (AAP) (OR = 8.87; 95% CI 3.85-20.45). CONCLUSION: Community-based asthma care using more comprehensive approaches may improve childhood asthma management and reduce asthma related health care utilization.

Role of technology in improving knowledge and confidence in asthma management in school staff.

Objective: To investigate the effectiveness of technology enabled learning in improving asthma first aid knowledge and self-confidence in providing asthma first aid to children in staff within a school setting. Study Design: A prospective randomized parallel study using a pre and post test design was conducted across Metropolitan schools of New South Wales (NSW), Australia. School staff in selected schools were randomly assigned to receive first aid asthma management training via a self-directed multimedia eBook learning resource or standard face-to-face training. Staff completed a 14 item validated Asthma First Aid Knowledge Questionnaire and a 4 item, 10-point Likert-scale asthma management self-confidence questionnaire immediately pre and post training. Results: 148 school staff from 46 schools were recruited with a total of 59 (78%) staff completing the eBook training and 62 (86%) completing face-to-face training. The mean asthma first aid knowledge score and self-confidence score in managing asthma increased significantly (p < 0.0001) in the eBook training group post training. There was no significant difference in the increase in the mean scores post training between the eBook and face-to-face training groups (p = 0.11). Conclusion: Asthma management knowledge and self-confidence increased in school staff following the eBook training. In school settings where human resources for health education are limited, technology enabled learning may be substituted to provide a self-directed approach to asthma first aid management training.