The research was presented by Dr Lisa Steen Duus from Gentofte Hospital, Copenhagen, Denmark. She said: “Flu can be particularly serious for older people with chronic lung disease, such as asthma and COPD. They are more likely to develop complications, including pneumonia, worsening of their existing lung disease, and hospitalisation.

“Although high-dose flu vaccines are designed to produce a stronger immune response in older adults, there has been limited randomised evidence specifically showing whether they provide better protection against serious illness in people with chronic lung disease. We therefore wanted to investigate whether a high-dose vaccine could reduce hospitalisations in this particularly vulnerable group.”

The new research combines the results of two gold-standard randomised controlled trials comparing a high-dose flu vaccine with a standard-dose in people aged 65 and older. One trial ran in Denmark over three flu seasons (2022-23, 2023-24 and 2024-25) and one ran in Galicia, Spain over two flu seasons (2023-24 and 2024-25). Analysis of these trials has already shown that the high-dose vaccine is beneficial in older people overall [2].

In the new study, researchers looked specifically at trial participants who had a chronic lung disease, including asthma, bronchiectasis, bronchitis, chronic obstructive pulmonary disease (COPD), cystic fibrosis, emphysema, interstitial pulmonary disease, lung transplantation, respiratory tuberculosis and sarcoidosis. Between the two studies, this was 31,976 people, just under seven per cent of the total 466,320 trial participants.

Around half of the participants were randomly allocated to receive a standard dose of flu vaccine. The other half received a flu vaccine containing four times as much of the active ingredient that stimulates the immune response.

Researchers monitored the participants and recorded any who were hospitalised from 14 days after their vaccination until the following May when the flu season is largely over in Europe.

The high-dose flu vaccine reduced hospital admissions for flu or pneumonia by 8.8% compared with the standard-dose vaccine. The high-dose vaccine also reduced hospitalisations for several other conditions, including cardiorespiratory disease, and hospitalisation from any cause, compared to the standard-dose vaccine.

Dr Duus said: “For older people with chronic lung disease and their families, these findings provide reassurance that high-dose flu vaccination can offer better protection against serious illness requiring hospital treatment than a standard-dose vaccine.

“Being hospitalised creates a considerable burden on patients, families and healthcare systems, so even a modest reduction could have meaningful public health benefits. For that reason, these results support considering high-dose flu vaccines for older adults, including those with chronic lung disease, when developing vaccination recommendations.”

Professor Thomas Wilkinson, Chair of the European Respiratory Society’s Group on Respiratory Infections and Immunology and based at University of Southampton, UK, who was not involved in the research said: “A flu infection is unpleasant for anyone, but for some people it can be a serious health risk. Older people with lung disease have a greater risk of severe illness, hospitalisation and death from flu, which is why the European Respiratory Society recommends annual flu vaccination for this group.

“This research combines the results of two large and well-run studies comparing the standard-dose flu vaccine with a high-dose flu vaccine in people aged 65 and above. Researchers have looked specifically at people on the trial who had also been diagnosed with a lung disease, such as COPD or asthma. Their analysis shows that a high-dose flu vaccine could be even more beneficial in this group.”

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The study was led by Professor Chloe Bloom, Clinical Associate Professor in Respiratory Epidemiology at the National Heart & Lung Institute, Imperial College London, UK, and presented by Dr Bohee Lee.

Dr Bloom said: “GLP-1 receptor agonists are widely used to treat type 2 diabetes and obesity. Previous research suggests that they may have anti-inflammatory effects and may improve lung-related outcomes. However, asthma and COPD outcomes have not been included as outcomes in GLP-1 drug trials.

“We wanted to use real-world health records to investigate whether people with asthma or COPD who started GLP-1 receptor agonists had fewer acute respiratory attacks.”

Using UK electronic medical records, the researchers conducted four parallel studies that each looked at between 20,000 and 22,000 people who started taking any type of GLP-1 treatment or another type of diabetes medication called sulfonylureas.

They found that people with airways diseases like asthma and COPD who were prescribed GLP-1 therapies appeared to have fewer asthma attacks and COPD flare ups than similar people who were prescribed other diabetes medicines.

Bloom explains: “The effect was strongest with semaglutide especially in people with asthma, where use of semaglutide appears to be associated with nearly 40% reduction in asthma attacks. Semaglutide also led to a 20% reduction in COPD flare ups.”

She believes that for people with airways disease who are already eligible for GLP-1 receptor agonists because of obesity or type 2 diabetes, the results suggest these treatments may have additional respiratory benefits.

She explains: “The findings from this study are encouraging, but they should not change treatment decisions on their own. People with asthma or COPD should not start GLP-1 receptor agonists specifically for their lung condition outside current prescribing guidance. While the findings suggest that some people taking GLP-1 receptor agonists may experience fewer respiratory attacks, this needs confirmation in clinical trials.”

Dr Alexander Mathioudakis, Chair of the European Respiratory Society’s Group on Airway Pharmacology and Treatment and Senior Lecturer in Respiratory Medicine at the University of Manchester, UK, who was not involved in the research said: “Obesity and metabolic dysfunction are common in airways disease and are often under-recognised as problems that can and should be addressed.

“This is one of the largest real-world studies to investigate GLP-1 receptor agonists and airways disease, and one of the first to examine whether effects differ between individual GLP-1 receptor agonists.

“It highlights the need to consider metabolic health as part of respiratory care. It also supports the case for including respiratory outcomes, such as asthma attacks and COPD exacerbations, in future trials of metabolic therapies.

“We need clinical trials that include respiratory outcomes, such as asthma attacks, COPD exacerbations, lung function, symptoms and quality of life, to determine whether metabolic treatments could become part of a broader, more personalised approach to managing airways disease.”

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Researchers say their findings suggest that nicotine addiction remains a major health concern and that public health measures need to deter children and young people from all forms of nicotine, including vaping, cigarettes, shisha and nicotine pouches.

The first study is presented by Dr Charmaine Helk-Lim from the Ludwig Boltzmann Institute for Lung Health and Sigmund Freud Private University, Vienna, Austria [1]. It included 15,056 Austrian people aged between six and 82 years who were asked about their use of any tobacco products over the course of 12 years between 2012 and 2024.

Researchers found that, during that time, smoking fell from 24.2% to 16.3%. However, they found use of ‘alternative’ nicotine products, such as vaping, rose sharply over the same period from 0% to 17.2%. At the same time, the proportion of people using more than one tobacco or nicotine product, for example smoking and vaping, also increased from 5.2% to 18.3%. The average age when people started to smoke has gone down over the same period of time, from 20 years in people born in the 1930s to around 15 years in those born in the 2000s, and the proportion of under 18s who smoke has almost doubled from 2.6% to 5.0%.

Dr Helk-Lim said: “The decrease in smoking conceals a broader nicotine problem. The epidemic isn’t shrinking; it’s changing shape and reaching children younger than it used to. This appears to be a global pattern, not just an Austrian one, and it can create a false impression that today’s youth are safer from nicotine than in the past, when in reality many are being exposed earlier and through different products.

“Our advice for families is to talk with children about all nicotine products – vapes and heated tobacco included, not just cigarettes – and to start that conversation before the teenage years, since our data show many young people begin using these products by age 15 or 16. Those who start using tobacco early face a greater risk of long-term addiction meaning that quitting becomes harder later in life.”

Research by a second team, led by Professor Joan Hanafin, from the TobaccoFree Research Institute Ireland, was presented by Salome Sunday [2]. They examined smoking and vaping in 5,265 Irish 15- to 16-year-olds over three points in time: 2015, 2019 and 2024. This showed that the proportion of these children who smoke has gone from 13.9% in 2015 down to 11.7% in 2024, after a peak of 14.4% in 2019. The proportion who vape has gone from 10.1% in 2015 up to 15.7% in 2024, after a peak of 18.1% in 2019. This study also showed that a growing proportion of children said they had taken up vaping without prior use of cigarettes, increasing from 50.2% of vapers in 2015 to 76.2% in 2024.

Another study by the team from the TobaccoFree Research Institute Ireland, presented by Professor Luke Clancy, looked at smoking and vaping habits in a group of 3,380 young people, and how these changed as they grew older (from age 13 to 25) [3]. This showed that both smoking and vaping generally increased from adolescence into young adulthood, with current e-cigarette use at 38% by age 25 and current smoking at 25%. The people who were least likely to be smokers by the age of 25 were those who had never vaped.

Ms Sunday said: “Nicotine use among young people is changing rapidly. Although smoking in some age groups has declined over the long term, young people are increasingly using a wider range of nicotine products, leading to an overall increase in nicotine use and highlighting the need to monitor overall nicotine use rather than individual products alone.

“Our findings reinforce the need for prevention strategies and tobacco control policies that address both smoking and vaping, particularly given the growing number of adolescents who try nicotine first through vapes. The availability of new nicotine products will likely keep the prevalence of nicotine addiction at the current high levels or even higher.”

Dr Filippos Filippidis, Chair of the European Respiratory Society’s Tobacco Control Committee from Imperial College London, UK, who was not involved in the research said: “Nicotine is highly addictive and it has taken decades for research on the harms of cigarettes to translate into a long-term decline in smoking. E-cigarettes have only become widely available over the last ten to 15 years, but research has already shown that vaping is harmful to the lungs and cardiovascular health.

“These studies, looking at smoking and vaping in Austria and in Ireland, show how the gains we’ve made in terms of fewer people smoking could now be jeopardised by a rise in addiction that results from the use of e-cigarettes and other nicotine products, especially among children, teenagers and young adults. These studies also show a rise in ‘dual use’, which can complicate quitting efforts and implementation of tobacco control policies.

“If we want to protect the next generation from addiction and the potential harms of these products, we need policies and public health strategies that address all forms of nicotine.”

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“We found undisclosed harmful chemicals in products claiming to be free of them,” said Jenna Hua, PhD, MPH, senior author of the study and founder of the Million Marker Research Institute. “That means someone can carefully read ingredient lists, choose ‘clean’ products, and still end up exposed to the very chemicals they were trying to avoid. The label can’t protect you when it doesn’t show what’s really in the bottle.”

The researchers tested 113 personal care and cleaning products across 12 categories. On average, each product contained 51 detected chemicals, more than three times the average of 16 ingredients listed on the label. Overall, 98% of products contained at least one unlabeled chemical, and 85% contained at least one unlabeled chemical with known or suspected health hazards. The specific brands and items will be revealed in an upcoming report.

These undisclosed chemicals included endocrine-disrupting compounds such as phthalates and parabens, fragrance chemicals, silicone contaminants, and butylated hydroxytoluene (BHT). Previous research has linked some of these chemicals to infertility, miscarriage, breast cancer, obesity, diabetes, allergies, and other health problems. Others are classified as potential carcinogens, endocrine disruptors, reproductive or developmental toxicants, or skin sensitizers.

Undisclosed harmful chemicals were found across product categories, price points, company sizes, and marketing claims. Products advertised as “natural,” “non-toxic,” or “organic” frequently contained undisclosed chemicals linked to health harm.

More than one-quarter of the products contained chemicals that contradicted claims made on labels or company websites. Researchers found synthetic chemicals in some products marketed as “100% natural,” as well as fragrance, phthalates, parabens, silicones, or oxybenzone in products claiming to be specifically free of those substances. Some products labeled “hypoallergenic” contained known allergens or sensitizers.

The researchers note that this does not necessarily mean manufacturers intentionally added these chemicals. Contaminants can enter products through raw materials, processing equipment, chemical reactions, storage or packaging. Changes in suppliers may also alter a product’s chemical composition without a corresponding change to its label.

The study used nontargeted analysis, an advanced laboratory method that can screen for thousands of chemicals without relying on a predefined list of substances. Researchers detected 3,141 chemical signals and identified 303 compounds with confirmed, probable, or tentative confidence.

Most product safety ratings and certifications programs rely heavily on disclosed ingredient lists. According to the authors, that approach can miss contaminants, impurities, breakdown products, and chemicals introduced during manufacturing or packaging. The researchers recommend making nontargeted analysis of finished, packaged products a standard part of product safety and quality control, alongside existing checks such as stability, microbial, and preservative testing.

The authors also argue that current U.S. oversight remains too dependent on ingredient disclosure and manufacturer reporting. Although the 2022 Modernization of Cosmetics Regulation Act expanded the U.S. Food and Drug Administration’s authority over cosmetics, routine testing of finished products for undisclosed chemical contaminants is still generally not required.

“People shouldn’t need a chemistry lab to know what they’re bringing into their homes or putting on their skin,” Hua said. “The next generation of product safety must look beyond the label and test what is actually there.”

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“While the risk is still low to the general public, we are seeing a virus with a high fatality rate transmitting person-to-person,” said Milton, whose research has shown how viruses such as COVID and the flu are transmitted in exhaled breath and has demonstrated the efficacy of masks for prevention.

“WHO should change its default response – the starting point should not be to downplay the risk of airborne transmission until it is definitively proven. ”

Milton worked with a group of international experts: Trisha Greenhalg at University of Oxford, David N. Fisman at University of Toronto, Amanda Kvalsvig at University of Otago, Lidia Morawska at Queensland University of Technology and Jonathan M. Samet at Colorado School of Public Health.

The group writes: “The starting point should be the immediate adoption of precautionary measures to reduce airborne transmission, such as respirator use by healthcare workers, [infected people] and their close contacts.” They also recommend WHO include guidelines on improving ventilation, avoiding unfiltered air recirculation and use of portable HEPA (high efficiency particulate air) filtration in all enclosed quarantine and transport settings.”

The group also provided more detail to the BMJ article in this substack.

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In the first randomised controlled trial to investigate the use of a 2-in-1 inhaler as the sole reliever therapy for children aged 5 to 15, an international team found the combined treatment to be more effective than salbutamol, the current standard for asthma symptom relief in children, with no additional safety concerns.

The results show that using a single 2-in-1 anti-inflammatory reliever inhaler – which combines the inhaled corticosteroid (ICS) budesonide and the fast-acting bronchodilator formoterol – reduced children’s asthma attacks by an average of 45%, compared to the widely-used salbutamol inhaler.

Asthma attacks in children may be life-threatening and reducing their frequency and severity is a public health priority.

The 2-in-1 budesonide-formoterol inhaler is widely recommended as the preferred reliever treatment for adults, but children are still usually prescribed salbutamol.

Researchers say the findings, published today in The Lancet, provide the evidence needed to bring children’s global asthma guidelines into line with adults’, which could benefit millions of children around the world with mild-to-moderate asthma.

The CARE study (Children’s Anti-inflammatory REliever) was designed and led by the Medical Research Institute of New Zealand (MRINZ), in collaboration with Imperial College London, University of Otago Wellington, Starship Children’s Hospital, and the University of Auckland. It recruited 360 children across New Zealand who were then randomly assigned to receive either budesonide-formoterol or salbutamol for on-demand symptom relief.

The trial lasted a year and the budesonide-formoterol reliever resulted in a lower rate of asthma attacks than salbutamol reliever, with rates of 0.23 versus 0.41 per participant per year. This means that for every 100 children with mild asthma who are switched from salbutamol to a 2-in-1 budesonide-formoterol inhaler, there would be 18 fewer asthma attacks per year. Importantly, the study also confirmed the safety of the combined-inhaler approach, with no significant differences in children’s growth, lung function, or asthma control between the two groups.

Dr Lee Hatter, lead author of the study and Senior Clinical Research Fellow at the MRINZ, said: “This is a key step in addressing the evidence gap that exists between asthma management in adults and children. For the first time, we have demonstrated that the budesonide-formoterol 2-in-1 inhaler, used as needed for symptom relief, can significantly reduce asthma attacks in children with mild asthma. This evidence-based treatment could lead to improved asthma outcomes for children worldwide.”

Professor Richard Beasley, Director of MRINZ and senior author of the study, said: “Implementing these findings could be transformative for asthma management on a global scale. The evidence that budesonide-formoterol is more effective than salbutamol in preventing asthma attacks in children with mild asthma has the potential to redefine the global standard of asthma management.”

The burden of asthma in the estimated 113 million children and adolescents with asthma worldwide is substantial. The latest study builds on previous studies in adults led by MRINZ researchers (see detail in Notes, below) which shaped international asthma treatment guidelines. These findings contributed to the recommended use of the 2-in-1 ICS–formoterol reliever inhaler as the preferred reliever treatment for adults with asthma around the world.

The incorporation of findings from the CARE study into global asthma treatment strategies could help reduce disparities in care and ensure that more children access effective, evidence-based treatments.

The researchers say that global health organisations have long advocated for child-targeted asthma interventions, and their findings provide crucial evidence to support those efforts.

However, the authors acknowledge some limitations of the clinical trial. It was undertaken during the COVID-19 pandemic, during which stringent public health measures and fewer circulating respiratory viruses contributed to the lower than predicted rate of severe asthma attacks. The authors also acknowledge the challenges with the identification of asthma attacks in children, and the potential bias with the lack of blinding of the randomised treatments. They say though that the study’s findings are generalisable to clinical practice due to its pragmatic, real-world design.

Professor Andrew Bush, from Imperial College London, senior respiratory paediatrician and co-author of the CARE study, said: “Having an asthma attack can be very scary for children and their parents. I’m so pleased that we’ve been able to prove that an inhaler that significantly reduces attacks – already a game-changer for adults – is safe for children with mild asthma too. We believe this will transform asthma care worldwide and are excited to be building on this work with the CARE UK study.”

Professor Helen Reddel, Chair of the Science Committee of the Global Initiative for Asthma (GINA), commented on the global significance of the study, saying that it fills a critically important gap for asthma management globally. Professor Reddel said: “Asthma attacks have a profound impact on children’s physical, social and emotional development and their prevention is a high priority for asthma care. It is in childhood, too, that lifelong habits are established, particularly reliance on traditional medications like salbutamol that only relieve symptoms and don’t prevent asthma attacks.”

Professor Bob Hancox, Medical Director of the New Zealand Asthma and Respiratory Foundation, said: “This is a very important study for children with mild asthma. We have known for some time that 2-in-1 budesonide/formoterol inhalers are better than the traditional reliever treatment in adults, but this had not been tested in children. This research shows that this 2-in-1 inhaler is effective and safe for children as young as 5. This information will help to reduce the burden of asthma for many children, and both they and their families will breathe easier because of it.”

The study was made possible by the generous support of the Health Research Council of New Zealand, Cure Kids (New Zealand), and the Barbara Basham Medical Charitable Trust managed by Perpetual Guardian. Symbicort Rapihalers for the trial were provided by AstraZeneca.

Budesonide-formoterol versus salbutamol as reliever therapy in children with mild asthma (CARE): a 52-week, open-label, multicentre, superiority, randomised controlled trial is published in The Lancet; https://doi.org/10.1016/S0140-6736(25)00861-X

Post-embargo link here: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(25)00861-X/fulltext

Study key points:

1. The CARE study is the first randomised controlled trial comparing ICS–formoterol anti-inflammatory reliever inhaler treatment with salbutamol reliever inhaler treatment, in children aged five to 15 years with asthma.
2. Budesonide-formoterol demonstrated a significant reduction in asthma attacks, with a 45% decrease in the rate of attacks compared to salbutamol (0.23 vs 0.41 attacks per participant per year; relative rate 0.55, 95% CI 0.35–0.86, p=0.01).
3. These findings are consistent with established benefits seen in adults, where ICS–formoterol has become the preferred reliever treatment for asthma management.
4. The study found no safety concerns regarding the use of a combined inhaled steroid treatment in children, with no adverse effects on growth or lung function.
5. This study provides compelling evidence that switching from a salbutamol reliever inhaler to a budesonide-formoterol reliever inhaler can help prevent asthma attacks in children with mild asthma as young as five, which could lead to a potential shift in asthma treatment globally.

Previous evidence from MRINZ Adult Clinical Trials of anti-inflammatory reliever therapy:

1. https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(13)70007-9/abstract
2. https://www.nejm.org/doi/full/10.1056/NEJMoa1901963

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)31948-8/abstract

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The study analysed data from almost 500 patients hospitalised with COVID-19 across six countries. Patients who inhaled heparin were half as likely to require ventilation and had a significantly lower risk of dying compared with those receiving standard care.

Heparin, a drug traditionally injected to treat blood clots, was tested in this study in an inhaled form, targeting the lungs directly. As well as acting as an anticoagulant, heparin has anti-inflammatory and pan-antiviral properties. Earlier research results showed breathing and oxygen levels improved in COVID-19 patients after they inhaled a course of heparin.

The researchers believe the drug could also be useful in fighting other serious respiratory infections such as pneumonia.

Professor Clive Page, Emeritus Professor of Pharmacology at King’s who co-led the international study with ANU’s Professor van Haren, said: “Inhaled heparin is anti-viral, anti-inflammatory and anti-coagulant. There’s no other drug that has that unique combination. We know it’s only a matter of time until the next pandemic, and there are still COVID-19 patients who get very sick. This is a great weapon to have up our sleeve.”

While the findings highlight the potential of inhaled heparin, further development is required before the treatment can be routinely adopted. The researchers believe the drug could also be useful in fighting other serious respiratory infections such as pneumonia, which can be caused by a range of viruses and bacteria.

According to Professor van Haren, the drug would also be helpful for those with a compromised immune system, such as cancer patients, when they experience a respiratory infection.

Professor Frank van Haren, lead author, ANU and Director of the Intensive Care Unit at the St George Hospital in Sydney, said: “It doesn’t matter what kind of respiratory infection the patient is dealing with, the drug – when inhaled – will stop it from infecting the patient and from damaging the lungs. We’re aiming to conduct another trial in Europe to confirm its effectiveness in fighting other common respiratory infections such as influenza and RSV. And because it’s inexpensive, it’s much more accessible for those from low-income countries”

The researchers are now also developing an improved formulation of heparin, specifically designed to be given by inhalation.

The research is published in eClinicalMedicine and simultaneously presented of at the European Respiratory Society (ERS) International Congress in Amsterdam on Sunday 28 September, the leading annual gathering for respiratory research.

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The international research team used an electronic health database in the United States, TriNetX, to investigate the link between COVID-19 and so-called type-2 inflammatory diseases, a group of chronic conditions in which the immune system overreacts to allergens or infections.

The researchers compared 973,794 people who had had COVID-19 with 691,270 people who had been vaccinated against the SARS-CoV-2 virus and 4,388,409 healthy controls with no documented infection or vaccination.

Inflammation in the airways

The results are presented in The Journal of Allergy and Clinical Immunology. People who had had COVID-19 had a 66 per cent higher risk of developing asthma, a 74 per cent higher risk of chronic sinusitis and a 27 per cent higher risk of hay fever compared with healthy controls. However, no increased risk was seen for the skin disease atopic eczema or for eosinophilic oesophagitis, an inflammation of the oesophagus.

“Our results suggest that COVID-19 can trigger type-2 inflammation in the airways, but not in other organs,” says Philip Curman, a physician and researcher at the Department of Medical Epidemiology and Biostatistics at Karolinska Institutet, Sweden, who led the research.

Vaccination against the virus had the opposite effect. The risk of asthma was 32 per cent lower among vaccinated individuals compared with healthy unvaccinated individuals. The risk of sinusitis and hay fever was also slightly lower.

More than twice the risk

When people who had had COVID-19 were compared with vaccinated individuals, an even clearer effect was seen. Infected individuals had more than twice the risk of developing asthma or chronic sinusitis and a 40 per cent higher risk of developing hay fever compared with those who had been vaccinated.

“It is interesting to see that vaccination not only protects against the infection itself, but also appears to provide good protection against certain respiratory complications,” says Philip Curman.

The study is retrospective, i.e. based on data that has already been collected. This means that the researchers cannot draw any firm conclusions about causal links. Another limitation is that some infections may have gone undiagnosed, especially if they were detected through self-testing.

The research was conducted in close collaboration with the University of Lübeck and the Lübeck Institute of Experimental Dermatology in Germany, the Technical University of Madrid in Spain and Bar-Ilan University in Israel. It was mainly funded by the German Research Foundation (Deutsche Forschungsgemeinschaft), Region Stockholm and Karolinska Institutet. Two researchers received travel grants from TriNetX, which provides the database used in the study, and one of the authors is employed by the company.

Publication: “COVID-19 infection raises respiratory type-2 inflammatory disease risk, whereas vaccination is protective”, Henning Olbrich, Sophie L Preuß, Khalaf Kridin, Gema Hernandez, Diamant Thaçi, Ralf J Ludwig, Philip Curman, The Journal of Allergy and Clinical Immunology, online 12 August 2025, doi: 10.1016/j.jaci.2025.07.030.

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Led by Darlene Bhavnani, Ph.D., MPH, an infectious disease epidemiologist in Dell Med’s Department of Population Health, the study — published in The Journal of Allergy and Clinical Immunology — found that children in under-resourced communities face sharply higher rates of asthma flare-ups tied to viral infections during the first weeks of school.

“Every parent knows the start of the school year can bring colds and sniffles,” Bhavnani said. “But for kids with asthma, those viral infections can quickly turn dangerous — and our research shows the risk isn’t equal. Children in more disadvantaged neighborhoods are bearing an uneven share of this burden.”

Using health data from Texas’ four largest cities between 2016 and 2019, Bhavnani and her team analyzed emergency department visit rates across 3,000 neighborhoods before and after children went back to school. As expected, asthma-related ER visits surged when children went back to school each year — but the increase was significantly greater in neighborhoods with higher levels of poverty and social vulnerability. This suggests that living in a disadvantaged area may raise a child’s risk of viral infections that often trigger asthma emergencies, Bhavnani said.

The study also points to why these flare-ups are worse in some neighborhoods: factors such as crowded classrooms, environmental stress, and limited access to sick leave among caregivers can make it easier for viruses to spread — and harder for kids with asthma to recover.

“Back-to-school season shouldn’t mean a trip to the ER,” Bhavnani said. “We need to focus not just on managing asthma, but on the environments kids are returning to and their risk of viral infections — in homes, schools and neighborhoods.”

For parents of children with asthma, Bhavnani encourages proactive planning as the school year begins:

• Talk to your child’s doctor about updating their asthma action plan.

• Make sure teachers and school nurses know your child’s triggers and medications.

• Advocate for cleaner air and healthier school environments in your neighborhood.

“This study reinforces what many families already feel,” Bhavnani said. “Health risks don’t stop at the clinic door — they start at home, at school and across our neighborhoods. By understanding those risks, we can start to fix them.”

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Eosinophilic asthma is characterized by high levels of eosinophils, a type of white blood cell involved in the body’s immune response. While eosinophils typically help fight infections, in eosinophilic asthma, they accumulate in the lungs and airways, causing chronic inflammation, swelling and damage to the respiratory system.

Eosinophilic asthma is driven by type 2 (T2) inflammation, an immune response involving cytokines that promote the production and activation of eosinophils. Because of this, therapies targeting T2 inflammation are used to reduce eosinophil levels and prevent asthma flare-ups.

But even with targeted therapies against T2 inflammation, some children still experience asthma attacks. This suggests that other inflammatory pathways also play a role in exacerbations, said Rajesh Kumar, MD, Interim Division Head of Allergy and Immunology at Ann & Robert H. Lurie Children’s Hospital of Chicago, who was a co-author of the paper.

In the study, scientists analyzed data from a previous clinical trial studying respiratory illnesses in children with eosinophilic asthma living in low-income urban areas across nine U.S. cities. Investigators compared the effects of mepolizumab—a biologic therapy that targets T2 inflammation—with a placebo over a 52-week period.

While mepolizumab significantly reduced the expression of eosinophil-associated T2 inflammation during asthma flare-ups, exacerbations still occurred.

“The previous trial raised questions about what happens when you take away some of the allergic inflammation using a biologic drug, and why is it that some children experience exacerbations and some don’t?” Dr. Kumar said. “Different types of inflammation–allergic and different types of nonallergic inflammation–interact with exacerbations, both viral and non-viral. We wanted a more precise way of understanding what’s driving some of the exacerbations in kids.”

By employing RNA sequencing of nasal samples collected during 176 episodes of acute respiratory illness, investigators identified three distinct inflammatory drivers of asthma exacerbations. The first were epithelial inflammatory pathways, which were increased in children receiving mepolizumab, regardless of viral infection. The second was macrophage-driven inflammation, which was specifically linked to viral respiratory illnesses, and the third involved mucus hypersecretion and cellular stress responses, which were elevated in both treatment and placebo groups during flare-ups.

“We found that children who still exacerbated on the drug had less of this allergic type of inflammation, but they had other residual epithelial pathways which were driving some of that inflammatory response that was involved in exacerbation,” Dr. Kumar said.

The study highlights the complexity of asthma in children and underscores the need for more personalized treatment strategies, Dr. Kumar said.

“There are multiple different types of inflammatory responses that are involved in exacerbations, and they’re driving exacerbations differentially based on whether patients have a virus or are taking drugs to block different parts of the inflammatory response,” Dr. Kumar said.

As asthma continues to affect children in urban communities disproportionately, the insights from the study could pave the way for precision interventions for children based on the type of inflammation driving their asthma, and lead to improved quality of life for young patients, Dr. Kumar said.

“This study gives us a better understanding of what results in persistent exacerbations and opens up the potential for new therapies or combinations of therapies based upon that.”

The study was supported by a National Institutes of Health grant (UM1AI11427).

Ann & Robert H. Lurie Children’s Hospital of Chicago is a nonprofit organization committed to providing access to exceptional care for every child. It is the only independent, research-driven children’s hospital in Illinois and one of less than 35 nationally. This is where the top doctors go to train, practice pediatric medicine, teach, advocate, research and stay up to date on the latest treatments. Exclusively focused on children, all Lurie Children’s resources are devoted to serving their needs. Research at Lurie Children’s is conducted through Stanley Manne Children’s Research Institute, which is focused on improving child health, transforming pediatric medicine and ensuring healthier futures through the relentless pursuit of knowledge. Lurie Children’s is the pediatric training ground for Northwestern University Feinberg School of Medicine. It is ranked as one of the nation’s top children’s hospitals by U.S. News & World Report.

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The study was published in the journal Health Expectations (Wiley) and conducted by full Professor Francesco Pagnini of the Department of Psychology at the Università Cattolica and colleagues.

Professor Pagnini explains: “this study was developed in response to the difficulties reported by patients in managing asthma. Patients helped identify key areas of concern, and their perspectives influenced the choice of outcomes and tools”. Although direct involvement in recruitment and dissemination was limited due to the pandemic, the design and focus of the study were guided by patient priorities, with potential applications in clinical consultations and future co-designed interventions.

BACKGROUND

After receiving a diagnosis, people often develop expectations about how their condition will evolve, Professor Pagnini explains. This cognitive framework, known as “illness expectations” (IE), comprises future-oriented beliefs about the course of the disease and its symptoms. In chronic conditions such as asthma, IEs can play a crucial role in determining patient-reported outcomes and also variations in clinical markers indicative of disease progression. “In this study, we empirically assessed the impact of IEs on asthma symptoms and respiratory function in patients,” Pagnini affirms.

THE STUDY

‘We involved a group of 310 people diagnosed with asthma who were followed for a period of 6 months, with three assessment points, measuring the level of asthma control with the Asthma Control Test (ACT), while respiratory function was assessed through forced expiratory volume in 1 second (FEV1) using spirometry,’ he explains. At the beginning of the study, we assessed each person’s IE using the validated Illness Expectation Test (IET), which captures both explicit (conscious) and implicit (unconscious) expectations.

It emerged that people with more negative explicit IE about their asthma reported worse symptoms over time. Explicit IE about symptom progression was also associated with changes in lung function, with more negative expectations predicting greater decline in respiratory performance, the professor adds.

These findings suggest that IE may be significantly associated with asthma outcomes, highlighting their potential relevance in understanding patient experiences and symptom perception. “In experiments with patients affected by other diseases, such as multiple sclerosis, we obtained similar results”, the expert continues.

The hypothesis suggested to explain these results is that, as with the placebo effect, what happens is that if I have an idea about the world and the future that awaits me, that idea will prevail, largely influencing behaviour and thus, for example, modifying adherence to therapies and clinical recommendations, he concludes.

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There was no increase in asthma attacks for women taking the combined oestrogen and progesterone contraceptive pill.

The researchers say their finding could be an important step towards understanding why women are more likely to have severe asthma than men.

The study was led by Dr Chloe Bloom, a clinical senior lecturer in respiratory epidemiology at the National Heart and Lung Institute, Imperial College London, UK, and funded by Asthma + Lung UK. She said: “Asthma is common in women, and unfortunately, women are twice as likely to die from asthma as men. To help prevent these deaths, we need a better understanding of why women are at greater risk.

“One theory is that sex hormones play a major role. But studying their effects can be tricky. For example, it’s often hard to know exactly when someone has reached puberty or menopause. Instead, we can study women who take sex hormone medications like the contraceptive pill, because we know exactly when they started and stopped using them.”

The researchers used the UK’s Clinical Practice Research Datalink to study a group of 261,827 women aged between 18 and 50 who had been diagnosed with asthma. They compared women who had never used the contraceptive pill with women who started taking either the combined or progesterone-only pill. They gathered data on whether the women experienced any asthma attacks – meaning they were either prescribed oral steroids for asthma, they visited the hospital emergency department for asthma or they died of asthma – between 2004 and 2020.

“We found that the combined pill did not affect whether women had asthma attacks. But some women who took the progesterone-only pill had more asthma attacks. These included women under 35 years old, those who used fewer asthma medications, like inhaled or oral steroids, and those with higher levels of inflammation linked to asthma in their blood,” Dr Bloom explained.

The risk of asthma attacks in women under 35 was around 39% higher in those taking the progesterone-only pill; in women taking fewer asthma treatments, the risk was around 20% higher; and in women with eosinophilic asthma (where sufferers have high levels of blood cells called eosinophils that cause inflammation) the risk was around 24% higher.

Dr Bloom said: “Our study is the first to look at a large group of women over time with such detailed data on both their contraceptive pill use and their medical history. We also used a special type of study design that mimics the methods of a clinical trial, but applied to real-world health data. This approach helped us identify which groups of women might be more at risk of asthma attacks while using the pill.

“Asthma is common in women of reproductive age, many of whom are taking the pill. This study helps women and healthcare professionals make more informed decisions about which contraceptive pill might be best for them. The findings also add another piece to the puzzle of why women may be more likely to have severe asthma than men.

“This is an area that hasn’t been studied much. Most research has focused on oestrogen and testosterone, not progesterone. Our study is one of the first to show that progesterone may play an important role. We’re now calling for more research into how progesterone affects asthma, including how it might interact with asthma medications like steroids.”

The researchers are continuing to study the effects of sex hormones on asthma by looking at the possible effects of hormone replacement therapy and at the impact of pregnancy.

Professor Apostolos Bossios is head of the European Respiratory Society’s group on airway diseases, asthma, COPD, and chronic cough, based at Karolinska University Hospital, Stockholm, Sweden, and was not involved in the research. He said: “We know that women are more likely to have asthma and to suffer more severe asthma. We need much more research to understand why asthma is worse for women than men so we can begin to reduce the risk. This major study in an important step towards that aim.

“Women with asthma who are taking the combined pill, or considering it, should speak to their doctor about their contraception options and their asthma symptoms. Whichever contraception they use, it’s vital that women with asthma use their preventer inhalers and any other prescribed treatments regularly.”

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