Rationale: Vitamin D insufficiency (a serum 25(OH)D <30 ng/ml) has been associated with severe asthma exacerbations, but this could be explained by underlying racial ancestry or disease severity. Little is known about vitamin D and asthma in Puerto Ricans. Objectives: To examine whether vitamin D insufficiency is associated with severe asthma exacerbations in Puerto Rican children, independently of racial ancestry, atopy, and time outdoors. Methods: A cross-sectional study was conducted of 560 children ages 6–14 years with (n = 287) and without (n = 273) asthma in San Juan, Puerto Rico. We measured plasma vitamin D and estimated the percentage of African racial ancestry among participants using genome-wide genotypic data. We tested whether vitamin D insufficiency is associated with severe asthma exacerbations, lung function, or atopy (greater than or equal to one positive IgE to allergens) using logistic or linear regression. Multivariate models were adjusted for African ancestry, time outdoors, atopy, and other covariates. Measurements and Main Results: Vitamin D insufficiency was common in children with (44%) and without (47%) asthma. In multivariate analyses, vitamin D insufficiency was associated with higher odds of greater than or equal to one severe asthma exacerbation in the prior year (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.5–4.9; P = 0.001) and atopy, and a lower FEV1/FVC in cases. After stratification by atopy, the magnitude of the association between vitamin D insufficiency and severe exacerbations was greater in nonatopic (OR, 6.2; 95% CI, 2–21.6; P = 0.002) than in atopic (OR, 2; 95% CI, 1–4.1; P = 0.04) cases. Conclusions: Vitamin D insufficiency is associated with severe asthma exacerbations in Puerto Rican children, independently of racial ancestry, atopy, or markers of disease severity or control.

The Coronavirus infectious disease 2019 (COVID-19) pandemic has disproportionally impacted historically disadvantaged populations, with infection and mortality rates among Black and Latinx Americans far exceeding the proportion of the population that these groups represent. We, as researchers, educators, and critical care and pulmonary providers on the frontline of care for all individuals, believe it is important to reflect on the root causes for these striking disparities. Moreover, recent incidences of structural violence highlight the need to recognize the critical role of racism in causing and perpetuating health disparities. Without attention to the underlying causes, it is difficult to enact equitable action. Applying the World Health Organization Conceptual Framework for Action, we examine the social and structural determinants of health (SDOH) that contributed to disparities in the care and outcomes of patients with COVID-19. Applying this lens, we identify three potential critical targets for action: 1) increased exposure due to occupation and/or living circumstances that make social distancing and self-isolation more difficult, 2) limited access to accurate, up to date information regarding the health risks of COVID-19, and 3) limited and differential access to healthcare services, including coronavirus testing and care. In this perspective, we focus on action steps that we, as members of the American Thoracic Society, should take to actively change the status quo and influence policies that address root causes. This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/).

As of 2018, an estimated 5.5 million children in the US had asthma, a major cause of health care utilization and costs.¹ In 2018, asthma exacerbations led to more than 546 000 emergency department (ED) visits and 80 000 hospitalizations.¹

Vitamin D deficiency and asthma are common conditions that share risk factors such as African American ethnicity, inner-city residence, and obesity. This review provides a critical examination of current experimental and epidemiologic evidence of a causal association between vitamin D status and asthma or asthma morbidity, including potential protective mechanisms such as antiviral effects and enhanced steroid responsiveness. Because most published epidemiologic studies of vitamin D and asthma or asthma morbidity are observational, a recommendation for or against vitamin D supplementation as preventive or secondary treatment for asthma is not advisable and must await results of ongoing clinical trials. Should these trials confirm a beneficial effect of vitamin D, others will be needed to assess the role of vitamin D supplementation to prevent or treat asthma in different groups such as infants, children of school age, and ethnic minorities.