Risks of infection, hospital and ICU admission, and death from COVID-19 in people with asthma: systematic review and meta-analyses

Objectives: To determine if and to what degree asthma may predispose to worse COVID-19 outcomes in order to inform treatment and prevention decisions, including shielding and vaccine prioritisation. Design: Systematic review and meta-analysis. Setting: Electronic databases were searched (October 2020) for clinical studies reporting at least one of the following stratified by asthma status: risk of infection with SARS-CoV-2; hospitalisation, intensive care unit (ICU) admission, or mortality with COVID-19. Participants: Adults and children who tested positive for or were suspected to have COVID-19. Main outcome measures: Main outcome measures were the following stratified by asthma status: risk of infection with SARS-CoV-2; hospitalisation, intensive care unit (ICU) admission, or mortality with COVID-19. We pooled odds ratios (ORs) and presented these with 95% confidence intervals (CIs). Certainty was assessed using GRADE. Results: 30 (n=112,420) studies were included (12 judged high quality, 15 medium, 3 low). Few provided indication of asthma severity. Point estimates indicated reduced risks in people with asthma for all outcomes, but in all cases the evidence was judged to be of very low certainty and 95% CIs all included no difference and the possibility of increased risk (death: OR 0·90, 95%CI 0·72-1·13, I2=58%; hospitalisation: OR 0·95, 95%CI 0·71-1·26; ICU admission: OR 0·96, 95%CI 0·75-1·24). Findings on hospitalisation are limited by substantial unexplained statistical heterogeneity. Within people with asthma, allergic asthma was associated with less COVID-19 risk and concurrent COPD was associated with increased risk. In some studies, corticosteroids were associated with increased risk, but this may reflect increased risk in people with more severe asthma. Conclusions: Though absence of evidence of a clear association between asthma and worse outcomes from COVID-19 should not be interpreted as evidence of absence, the data reviewed indicates that risks from COVID-19 in people with asthma, as a whole, may be less than originally anticipated.