Corticosteroid use and COVID-19

Today (30th March 2020), we noticed a sharp increase in the number of visitors to a particular page of the Aspergillus Website.

The page is called ‘Medications that Weaken Your Immune System and Fungal Infections (CDC)’. We know that many people are worried and struggling to understand if and how their susceptibility to infection with SARS-CoV-2 (COVID-19) is changed by their existing medications.

It is worth noting that the article on the Aspergillus Website is written with specific reference to how medicines, such as corticosteroids and TNF (tumor necrosis factor) inhibitors, increase the risk of fungal infections. It is not written about bacterial or viral infections.

Many medications for asthma, which lots of people have in addition to allergic aspergillosis, contain corticosteroids that are inhaled. Currently, there is no evidence that people who use inhaled corticosteroids are at an increased risk of contracting COVID-19.

The Centre for Evidence-Based Medicine in Oxford has published a useful article on this subject that points out that a COVID-19 infection in an asthmatic may trigger an asthma attack, and it is of greater benefit to the patient to prevent or control that attack than it would be to stop inhaled corticosteroids in an attempt to decrease the risk of  COVID-19 infection. There is even a hint that some types of asthma medication can inhibit coronavirus infection, but the evidence is not based on COVID-19.

Many of our more severe aspergillosis patients also take oral corticosteroids to try to control their breathlessness. During flare-ups, the dose can get quite high for a short time. Needless to say, it is critically important that these patients complete the increased dose as prescribed by their doctor. Patients on long term maintenance steroids must not reduce their dose as this will not offer additional protection against COVID-19. Maintaining good control of your condition is very important in reducing risk of complications. For patients on long term steroids shielding is also particularly important.

Overall, people with chronic (long-term) respiratory diseases, such as asthma, chronic obstructive pulmonary disease (COPD), emphysema, bronchitis or CPA are considered at increased risk of severe illness from coronavirus (COVID-19) regardless of corticosteroid use. These people should closely follow the guidance on social distancing available from Public Heath England.

Covert infections and the spread of coronavirus

Yesterday, the Prime Minister introduced strict limitations on when and how we can move about and live our lives. He said we should leave our homes only if absolutely necessary. Why is this so important?

The Scientific Journal, Nature, has published an interesting and informative article about the proportion of people with mild or no symptoms of COVID-19 who could be spreading the virus and this information highlights why limiting our movements can help to reduce the spread of coronavirus.

The first important question is how many people are contracting this virus but are experiencing few or no symptoms? It is thought that the number may be quite high because there have been many community acquired infections where the patient has no links to known COVID-19 cases and has not travelled to any area with a large outbreak.

Those people with few or no symptoms may be totally unaware they have the virus and continue to behave as normal. The article calls COVID-19 infections of this sort ‘covert infections’.

Understanding the covert infection rate is crucial if we are to slow the spread of the virus and prevent new outbreaks.

One study that the article reports on looked at 565 Japanese citizens who were all evacuated from Wuhan in February. They were regularly monitored and tested. 13 were infected but 4 (31%) had no symptoms.

The Diamond Princess cruise ship, which was quarantined with 3711 people on board, was another opportunity to study covert infections. There were 700 infections on the ship and 18% of those showed no symptoms. The authors of this study pointed out though that the average age of the people on the cruise ship was relatively high and this could have affected the data because older people tend to experience worse symptoms than younger people.

Finally, there is a suggestion that children may experience mild or no symptoms in 56% of cases.

All of this data show just how important it is to enforce extreme social distancing measures if we are to stop the virus from spreading.

Take a look at the article, it’s available for free on the Nature website.

Asthma and Covid 19 – research findings

An article published in the European Journal of Allergy and Clinical Immunology has described the symptoms and the allergy status of patients with Covid-19.

The study looked at 140 people in Wuhan who were hospitalised because of Covid-19. They were categorised as non-severe (82) or severe (58) on admission, around 70% of the patients were over 50 years old but the age range was 25-87 years old.

The most commonly experienced symptoms were fever (92%), followed by cough (75%), fatigue (75%), and chest tightness or shortness of breath (37%).

64% of the patients had a co-morbidity. The most common of which were chronic diseases such as hypertension (30%) and diabetes (12%). Only two patients had COPD and two had chronic urticaria (an allergic condition of the skin).

No other allergic conditions were reported, including asthma and allergic rhinitis.

This suggests that asthma, allergic disease and COPD are not likely to be prominent risk factors for COVID‐19.

A more recent report, published on 7th March 2020 in the Journal of Global Antimicrobial Resistance, reviewed the currently available literature published in English of microbiologically confirmed infections. It reviewed 225 available studies and seems to support the suggestion that chronic pulmonary diseases such as COPD, asthma and bronchiectasis are less common co-morbidities in people with Covid-19. Cardiovascular, digestive and endocrine system diseases were more commonly reported.

These are just two studies. We still don’t know exactly what the risk factors are. As the scientific community learns more about Covid-19 a more precise picture will emerge. More studies are needed.

In the meantime, government advice is for everyone aged 70 and over, regardless of medical conditions, to follow social distancing measures. Full guidance on the social distancing measures we should all be taking to reduce social interaction between people in order to reduce the transmission of coronavirus is available on gov.uk. This includes information for people with pre-existing health conditions including asthma and COPD. Please read it and follow it.

The full paper in the European Journal of allergy and Clinical Immunology can be read on the Aspergillus Website.

The full report from March 2020, published in the Journal of Global Antimicrobial Resistance can also be read on the Aspergillus Website.

Aspergillus fumigatus and azole resistance in the hospital: Surveillance from flower beds to corridors.

A research team in France have undertaken a screen on indoor air, soil and dust in and around hospitals to look for azole resistant Aspergillus in the environment of the University Hospital of Besançon.

The authors noted that the numbers of azole resistant Aspergillus fumigatus strains that were being isolated from patients, especially cystic fibrosis patients, was increasing. The study was designed to test the air in the hospital to discover if azole resistant A. fumigatus was brought to the hospital from rural environments by prevailing winds. They also wanted to see if plants, trees and flowerbeds around the hospital played a role.

The researchers found 83 azole resistant A. fumigatus isolates.

  • 1 from the air of the intensive care unit
  • 16 from the main corridors
  • 59 from pots of tulips imported from the Netherlands
  • 5 from the soil of trees grown in pots.

No samples of azole resistant A. fumigatus were found from an external sensor, suggesting that the resistant strains collected were not carried into the hospital on prevailing winds.

The tulips may be the main source but the authors are careful to note that to confirm this, genetic analysis would be needed to link isolates found in flower beds to isolates found in the hospital or strains isolated from patients.

In the University Hospital of Besançon, the decision has been made to stop planting bulbs. The results demonstrate a need for increasing vigilance on the surveillance of resistant strains.

The full paper is available on the Aspergillus Website.

A bed of tulips
Soil samples were tested from an outdoor relaxation area planted with tulips and from flower beds in other parts of the hospital.

Mycobacterium and Aspergillus can be co-isolated but are not often responsible for co-infections.

Aspergillus and Mycobacterium are often seen together in respiratory samples such as sputum. This is known as ‘concomitant isolation’. The relevance of this in terms of infection, disease progression or the effect on other pre-existing conditions such as bronchiectasis, COPD or asthma, is poorly understood at the moment. There’s even debate over whether isolating both organisms from the same sample means that one or both are causing infection or just simply that they are both living in the individual without causing a problem.

A new study from researchers in France has attempted to understand how often concomitant isolation occurs and to better understand what this means for patients and their clinical outcomes.

The study looked back at 1384 patients in a hospital near to Paris who has positive cultures for Aspergillus (896) and Mycobacterium (488), over a 3 month period.

50 patients had at least one positive culture for both Mycobacterium and Aspergillus. The most commonly isolated Aspergillus species was Aspergillus fumigatus (33). Seven patients in the study had pulmonary aspergillosis. One third were immunocompromised and 92% had an underlying lung disease such as bronchiectasis.

Classification of lung infection or colonization by Mycobacterium spp. and Aspergillus spp. co-isolated in respiratory samples of 50 patients.

The authors looked at data from blood samples, microbiology and scans to distinguish colonisation from infection. They concluded that while cases of the two organisms causing infections at the same time was rare, it is very important to perform all available tests and follow ups and discuss cases of co-infection or co-colonisation at multi-disciplinary team meetings to ensure that the best therapeutic decisions are made. This is especially important because development of chronic aspergillosis can worsen outcomes for patients already infected with Mycobacterium. Early diagnosis of CPA for patients with Mycobacterium is crucial.

In addition, the authors note that chronic lung conditions such as bronchiectasis might increase the likelihood of co-colonisation and so more work is needed to understand how the two organisms interact with each other in the lung.

More studies are also needed to see if these results are the same in other health care centres and hospitals and to see what differences, if any, are seen in patients colonised or infected by just one organism as well as both.

Read the full paper over on the Aspergillus website.

1 2 3