Evidence backing the long-held belief that viruses play a key role in respiratory disease exacerbations has sparked debate over how patients may be kept safe from viral transmission when society opens up again after lockdowns.

While respiratory physicians have been advising patients to reduce their viral exposure for years, a study led by respiratory physician Dr James Chalmers, Chair of Respiratory Research at the University of Dundee, UK, has now confirmed this association by showing a 48% reduction in reported bronchiectasis exacerbations over the lockdown period. During this period, circulating virus levels were low as a result of social isolation and mask-wearing interventions, he notes.

A particular strength of the study, published in the American Journal of Respiratory and Critical Care Medicine, was that the researchers had access to two years of baseline data, in which exacerbation rates were relatively similar, with 2.08 per patient per year in 2018/19 and 2.01 in 2019/20. Compared to this, they found that the rate of exacerbations had dropped significantly to 1.12 per patient year in 2020/21.

Similarly, the number of patients who experienced no annual exacerbations jumped from 22.4% in 2018/19 and 25.6% in 2019/20 to 52.3% in 2020/21, while the proportion of patients experiencing a hospitalisation due to severe exacerbation fell to 8.8% from 14.3% and 16.3% in the two prior years, respectively, further highlighting the impact of pandemic related interventions.

The question now is how to replicate these benefits in a re-opened society, without bringing the negative impact of social isolation, the study authors note

“This research shows an effect but doesn’t tell us how we can recreate this effect in future – it’s very difficult,” Professor Chalmers told the limbic.

“Lockdowns are very harmful to society and to patients with chronic diseases, through reduced access to care and services, lack of social support and many other issues. We can’t replicate lockdown conditions forever, but perhaps this research tells us that viral transmission is an important source of exacerbation and doing simple things like hand hygiene and not visiting relatives when they are unwell will help to protect patients in future.”

Social responsibility

Respiratory consultant Professor Adam Hill, Chair of the British Thoracic Society’s bronchiectasis guideline group said that everyone had a responsibility to stay at home when ill to help reduce the number of circulating viruses and protect those more vulnerable to them. “I think we have been very poor as a society in doing that. I think we commonly go to work with colds and go out when we’re not feeling well, and that needs to culturally change.”

“My hope is that one of the positives from the COVID pandemic is that society realises that if you’ve got a cold, you should be staying at home and not infecting others. If we can’t even get that message right after the pandemic then we’ve lost everything,” he told the limbic.

However, Professor Hill also urged caution in how the study’s findings are acted on. “What I would not want to see happening is that patients end up being hermits. A lot of my patients are terrified of going outside, they’re quite happy to isolate in their own house, but it is not healthy for people to get socially isolated. The key message [for respiratory patients] is that yes it’s important to avoid viruses, but it doesn’t mean to say you can’t go out.”

In an editorial referencing Professor Chalmer’s research, US respiratory physician Professor Mark Metersky, from the University of Connecticut School of Medicine, said funding should now be made available for research to verify the benefit of social distancing and mask wearing in a non-pandemic setting and how to employ such behaviours with minimal disruption to patients.

“The evidence is overwhelmingly clear that mask-wearing and physical distancing implemented in response to the COVID-19 pandemic have prevented morbidity and mortality related to numerous respiratory viruses in patients,” he wrote.

“This demonstrates a potentially highly effective tool to prevent disease and economic disruption related to highly incident respiratory viruses even after the COVID-19 pandemic is over,” he added.