Prevalence of Influenza Vaccination in Chronic Obstructive Pulmonary Disease Patients and Impact on the Risk of Severe Exacerbations

Prevalence and disparities in influenza vaccination among patients with COPD: A French nationwide population study

INTRODUCTION

Despite concordant international recommendations, many surveys found disappointing rates of influenza vaccination in at-risk populations, ranging from 23% in overall COPD population to more than 70% in more severe COPD subjects. Therefore, we assessed the proportion of French COPD patients non-vaccinated for influenza and their clinical and socio-demographic factors.

MATERIEL AND METHODS

This was a national retrospective study based on the French health insurance database. We identified "diagnosed COPD", defined as subjects hospitalized at least once in 2017 with a principal or associated diagnosis of COPD, and "suspected COPD" as those who were prescribed at least thrice long-acting bronchodilators (LAB), after exclusion of patients with a principal diagnosis or secondary associated diagnosis of asthma or cystic fibrosis, patients deceased before the influenza season and patients hospitalized in long-term or in palliative care unit. Multivariate logistic regression was used to assess the association between patients' characteristics and the lack of influenza vaccination.

RESULTS

From the national database, 1 474 396 subjects were identified as "suspected COPD" of whom 528 114 were excluded because of previous diagnosis of asthma or cystic fibrosis, and 350 566 as "diagnosed COPD". Among the 1 296 848 patients included, 646 687 patients (53.3%) were vaccinated against influenza. Non-vaccinated subjects were significantly younger (62.1 vs 71.6 years old), more often women (47.9% vs 43.1%) and had fewer comorbidities assessed by Charlson's index (3.0 ± 2.2 vs 4.3 ± 2.1). Lack of vaccination was also associated with a lower LAB usage. Also, non-vaccinated subjects neither had severe exacerbation during the study period. Besides there was a significant heterogeneity in vaccination rate by geographic region, from 47% to 57%. In multivariate analysis, variables independently associated with the lack of influenza vaccination were female gender, younger age, fewer comorbidities and lower socio-economic level.

CONCLUSIONS

This study using the French exhaustive health insurance database shows that influenza vaccination among COPD patients remains dramatically low and must become a high-priority public-health strategy.

Immune Dysregulation in Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is a disease whose incidence increase with age and is characterised by chronic inflammation and significant immune dysregulation. Inhalation of toxic substances cause oxidative stress in the lung tissue as well as airway inflammation, under the recruitment of chemokines, immune cells gathered and are activated to play a defensive role. However, persistent inflammation damages the immune system and leads to immune dysregulation, which is mainly manifested in the reduction of the body's immune response to antigens, and immune cells function are impaired, further destroy the respiratory defensive system, leading to recurrent lower respiratory infections and progressive exacerbation of the disease, thus immune dysregulation play an important role in the pathogenesis of COPD. This review summarizes the changes of innate and adaptive immune-related cells during the pathogenesis of COPD, aiming to control COPD airway inflammation and improve lung tissue remodelling by regulating immune dysregulation, for further reducing the risk of COPD progression and opening new avenues of therapeutic intervention in COPD.

The role of vaccination in COPD: influenza, SARS-CoV-2, pneumococcus, pertussis, RSV and varicella zoster virus

Exacerbations of COPD are associated with worsening of the airflow obstruction, hospitalisation, reduced quality of life, disease progression and death. At least 70% of COPD exacerbations are infectious in origin, with respiratory viruses identified in approximately 30% of cases. Despite long-standing recommendations to vaccinate patients with COPD, vaccination rates remain suboptimal in this population.Streptococcus pneumoniae is one of the leading morbidity and mortality causes of lower respiratory tract infections. The Food and Drug Administration recently approved pneumococcal conjugate vaccines that showed strong immunogenicity against all 20 included serotypes. Influenza is the second most common virus linked to severe acute exacerbations of COPD. The variable vaccine efficacy across virus subtypes and the impaired immune response are significant drawbacks in the influenza vaccination strategy. High-dose and adjuvant vaccines are new approaches to tackle these problems. Respiratory syncytial virus is another virus known to cause acute exacerbations of COPD. The vaccine candidate RSVPreF3 is the first authorised for the prevention of RSV in adults ≥60 years and might help to reduce acute exacerbations of COPD. The 2023 Global Initiative for Chronic Lung Disease report recommends zoster vaccination to protect against shingles for people with COPD over 50 years.

Clinical Management of COPD in the Real World: Can Studies Reveal Errors in Management and Pathways to Improve Patient Care?

Real world data comprise information on health care that is derived from multiple sources outside typical clinical research settings. This review focuses on what real world evidence tells us about problems with the diagnosis of chronic obstructive pulmonary disease (COPD), problems with the initial and follow-up pharmacological and non-pharmacological management, problems with the management of exacerbations and problems with palliative care. Data from real world studies show errors in the management of COPD with delays to diagnosis, lack of confirmation of the diagnosis with spirometry, lack of holistic assessment, lack of attention to smoking cessation, variable adherence to management guidelines, delayed implementation of appropriate interventions, under-recognition of patients at higher risk of adverse outcomes, high hospitalisation rates for exacerbations and poor implementation of palliative care. Understanding that these problems exist and considering how and why they occur is fundamental to developing solutions to improve the diagnosis and management of patients with COPD.

Greek Guidelines for the Management of COPD, a Proposal of a Holistic Approach Based on the needs of the Greek Community

Despite that COPD remains one of the most common respiratory diseases worldwide, it can be managed effectively with certain treatments and, more importantly, be prevented by the early implementation of various measures. The pathology and pathophysiology of this disease continue to be studied, with new pharmacological and invasive therapies emerging. In this consensus paper, the Working Group of the Hellenic Thoracic Society aimed to consolidate the up-to-date information and new advances in the treatment of COPD. Local and international data on its prevalence are presented, with revised strategies on the diagnostic approach and the evaluation of risk assessment and disease severity classification. Emphasis is placed on the management and therapy of patients with COPD, covering both common principles, specialized modalities, and algorithms to distinguish between home care and the need for hospitalization. Although pharmacological treatment is commonly recognized in COPD, an integrative approach of pulmonary rehabilitation, physical activity, patient education, and self-assessment should be encountered for a comprehensive treatment, prevention of exacerbations, and increased quality of life in patients.

Effectiveness of influenza and pneumococcal vaccines on chronic obstructive pulmonary disease exacerbations

BACKGROUND AND OBJECTIVE

Single-study evidence of separate and combined effectiveness of influenza and pneumococcal vaccination in patients with chronic obstructive pulmonary disease (COPD) is limited. To fill this gap, we studied the effectiveness of trivalent seasonal influenza vaccine (TIV) and 23-valent pneumococcal polysaccharide vaccine (PPSV23), separately and together, at preventing adverse COPD outcomes.

METHODS

Our study used a self-controlled, before-and-after cohort design to assess the effectiveness of TIV and PPSV23 in COPD patients. Patients were recruited from hospitals in Tangshan City, Hebei Province, China. Subjects self-selected into one of the three vaccination schedules: TIV group, PPSV23 group and TIV&PPSV23 group. We used a physician-completed, medical record-verified questionnaire to obtain data on acute exacerbations of COPD (AECOPD), pneumonia and related hospitalization. Vaccine effectiveness was determined by comparing COPD outcomes before and after vaccination, controlling for potential confounding using Cox regression.

RESULTS

We recruited 474 COPD patients, of whom 109 received TIV, 69 received PPSV23 and 296 received TIV and PPSV23. Overall effectiveness for preventing AECOPD, pneumonia and related hospitalization were respectively 70%, 59% and 58% in the TIV group; 54%, 53% and 46% in the PPSV23 group; and 72%, 73% and 69% in the TIV&PPSV23 group. The vaccine effectiveness without COVID-19 non-pharmaceutical intervention period were 84%, 77% and 88% in the TIV group; 63%, 74% and 66% in the PPSV23 group; and 82%, 83% and 91% in the TIV&PPSV23 group.

CONCLUSION

Influenza vaccination and PPSV23 vaccination, separately and together, can effectively reduce the risk of AECOPD, pneumonia and related hospitalization. Effectiveness for preventing AECOPD was the greatest.

Trends in Influenza Vaccination Rates in Participants With Airflow Limitation: The Korea National Health and Nutrition Examination Survey 2007-2018

Background

Influenza vaccination is strongly recommended for people with chronic lung diseases, including chronic obstructive pulmonary disease, to reduce risk of exacerbation. We assess the influenza vaccination rate and its related factors in participants with airflow limitation (AFL) using nationally representative data in Korea.

Methods

We conducted a cross-sectional study from the Korea National Health and Nutrition Examination Survey from 2007 to 2018. Individuals ≥ 40 years who underwent spirometry and had identifiable information on influenza vaccination status were included.

Results

Overall influenza vaccination coverage was 61.2% in participants with AFL and 41.8% in participants without AFL. Age had a significant impact on the yearly vaccination rate in participants with AFL. Over the 10 years of study period, while the yearly vaccination rate steadily increased from 58.3 to 61.9% in elderly participants (≥65 years) with AFL (p for trend = 0.117), the yearly vaccination rate decreased from 41.5% to 30.8% in younger participants (<65 years) (p for trend = 0.038). In multivariable analyses, younger age [adjusted odds ratio (OR) for unvaccinated = 0.88, 95% confidence interval (CI) = 0.87-0.90], male (adjusted OR = 1.64; 95% CI = 1.23-2.19), and current smokers (adjusted OR = 1.42, 95% CI = 1.01-2.00) were associated with increased odds of being unvaccinated.

Conclusions

The vaccination rate in participants with AFL affected by age. Younger age, male sex, and current smoking were associated with unvaccinated status. More attention and targeted interventions are required to improve the influenza vaccination rate in those with AFL.

Chronic obstructive pulmonary disease and influenza vaccination effect in preventing outpatient and inpatient influenza cases

Evidence of influenza vaccine effectiveness in preventing confirmed influenza among persons diagnosed with chronic obstructive pulmonary disease (COPD) is scarce. We assessed the average effect of influenza vaccination in the current and prior seasons in preventing laboratory-confirmed influenza in COPD patients. We carried out a pooled test-negative case–control design in COPD patients hospitalized or presented to primary healthcare centres with influenza-like illness who were tested for influenza in 2015/2016 to 2019/2020 seasons in Navarre, Spain. Influenza vaccination status in the current and 5 prior seasons was compared between confirmed-influenza cases and test-negative controls. Vaccination effect was compared between target patients for vaccination with and without COPD. Out of 1761 COPD patients tested, 542 (31%) were confirmed for influenza and 1219 were test-negative controls. Average effect for current-season vaccination in preventing influenza was 40% (95% CI 20–54%), and for vaccination in prior seasons only was 24% (95% CI –10 to 47%). Point estimates seemed higher in preventing outpatient cases (60% and 58%, respectively) than inpatient cases (37% and 19%, respectively), but differences were no statistically significant. Influenza vaccination effect was similar in target population with and without COPD (p = 0.339). Influenza vaccination coverage in control patients with COPD was 68.3%. A 13.7% of the influenza cases in patients with COPD could be prevented by extending the influenza vaccine coverage. Average effect of current-season influenza vaccination was moderate to prevent influenza in COPD persons. The increase of influenza vaccination coverage can still prevent COPD exacerbations.

Time Trends (2012-2020), Sex Differences and Predictors for Influenza Vaccination Uptake among Individuals with Chronic Obstructive Pulmonary Disease in Spain

(1) Background: To analyze time trends, sex differences, and factors associated with influenza vaccination uptake among individuals with COPD in Spain, 2012−2020. (2) Methods: A cross-sectional study based on data from the European Health Surveys for Spain, 2020 (EHSS2020) and 2014 and from the Spanish National Health Interview Surveys for 2017 and 2012. (3) Results: The study included 65,447 participants. Prevalence of COPD was 5.9% (n = 3855). Overall, the influenza vaccination uptake among COPD patients was 57.8% versus 28.6% for those without COPD (p < 0.001). Men with COPD reported higher uptake than women in all the surveys studied. Neither the crude nor the multivariable analysis showed a significant variation change overtime for people with COPD. However, among those aged <65 years, crude uptake decreased from 2012 to 2020 (39.4% vs. 33.3%; p = 0.039). Over the entire period, men were vaccinated significantly more than women (OR 1.28; 95% CI 1.12−1.47). Among COPD participants, included in the EHSS2020, independent predictors of vaccine uptake included being male, higher age, reporting no current smoking and suffering cancer or heart disease. (4) Conclusions: In COPD patients, the influenza vaccination uptake is below desirable levels and did not improve from 2012 to 2020. Sex differences are found, with consistent and constant lower uptake among women with COPD. The observed lower uptake among COPD women and patients with unhealthy lifestyle requires increased attention.

The Current Status of Vaccine Uptake and the Impact of COVID-19 on Intention to Vaccination in Patients with COPD in Beijing

Background

SARS-CoV-2 tends to cause more severe disease in patients with COPD once they are infected. We aimed to investigate the rates of influenza, pneumococcal and COVID-19 vaccination uptake in patients with COPD and to determine whether the COVID-19 pandemic and widespread vaccination against COVID-19 had any impact on the intention to accept influenza vaccines in these patients.

Methods

We conducted a multi-center and cross-sectional survey in seven tertiary hospitals in Beijing and consecutively recruited outpatients with COPD from June 1st to July 30th, 2021. The survey included patient’s clinical characteristics, uptake of influenza, pneumococcal and COVID-19 vaccination, vaccine knowledge, attitude towards vaccines, and the change of intention to receive influenza vaccination after COVID-19 epidemic and COVID-19 vaccination in Beijing.

Results

A total of 264 patients were enrolled. The rate of COVID-19 vaccination during the study period was 39.0%. The rates of influenza vaccination in the past season and pneumococcal vaccination in the past year were 22.7% and 5.7%, respectively. Of the patients who had not received COVID-19 vaccination (n = 161), only 16.2% reported that COVID-19 vaccination was recommended by clinicians, while 23.5% had no knowledge regarding COVID-19 vaccination. About 51.1% of the patients reported that their intention to receive influenza vaccination was influenced by the COVID-19 pandemic. COVID-19 vaccination was independently associated with a positive change in intention to receive influenza vaccination.

Conclusion

The coverage rate of COVID-19 vaccination among patients with COPD in Beijing was 39.0%, and that of influenza and pneumococcal vaccination was very low. The COVID-19 pandemic and the COVID-19 vaccination campaign showed a significant, positive impact on patients with COPD in terms of influenza vaccination. Improving awareness of the effectiveness and safety of vaccines among both healthcare professionals and patients could increase vaccination coverage in patients with COPD.

The traditional herbal formulation, Jianpiyifei II, reduces pulmonary inflammation induced by influenza A virus and cigarette smoke in mice

Chronic obstructive pulmonary disease (COPD) is a worldwide chronic inflammatory lung disease, and influenza A virus (IAV) infection is a common cause of acute exacerbations of COPD (AECOPD). Therefore, targeting viral infections represents a promising strategy to prevent the occurrence and development of inflammatory flare ups in AECOPD. Jianpiyifei II (JPYFII) is a traditional herbal medicine used in China to treat patients with COPD, and its clinical indications are not well understood. However, investigation of the anti-inflammatory effects and underlying mechanism using an animal model of smoking have been reported in a previous study by our group. In addition, some included herbs, such as Radix astragali and Radix aupleuri, were reported to exhibit antiviral effects. Therefore, the aim of the present study was to investigate whether JPYFII formulation relieved acute inflammation by clearing the IAV in a mouse model that was exposed to cigarette smoke experimentally. JPYFII formulation treatment during smoke exposure and IAV infection significantly reduced the number of cells observed in bronchoalveolar lavage fluid (BALF), expression of proinflammatory cytokines, chemokines, superoxide production, and viral load in IAV-infected and smoke-exposed mice. However, JPYFII formulation treatment during smoke exposure alone did not reduce the number of cells in BALF or the expression of Il-6, Tnf-a, and Il-1β. The results demonstrated that JPYFII formulation exerted an antiviral effect and reduced the exacerbation of lung inflammation in cigarette smoke (CS)-exposed mice infected with IAV. Our results suggested that JPYFII formulation could potentially be used to treat patients with AECOPD associated with IAV infection.

Effects of influenza vaccination on clinical outcomes of chronic obstructive pulmonary disease: A systematic review and meta-analysis

PURPOSE

Influenza is a threat to patients with chronic obstructive pulmonary disease (COPD), influenza vaccination help to reduce incidence of influenza infection, however, whether it is beneficial to COPD patients in clinical outcomes lacks for evidence due to limited studies and participations.

METHODS

We searched PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI) and China Science and Technology Journal Database (CSTJ) to retrieve eligible studies regardless of study design published before August 2020, and conducted meta-analysis with odds ratio (OR) and mean difference (MD). The quality of included studies and pooled evidences were assessed. Narrative summaries were provided where data were insufficient for meta-analysis.

RESULTS

2831 COPD patients were included, the pooled results showed that influenza vaccination reduced the exacerbations (P = 0.0001) and trends of hospitalizations (P = 0.09) in COPD patients. Further subgroup analysis showed that the reduction of exacerbations and hospitalizations were significant in patients with FEV₁<50 % predicted (P = 0.01 and P < 0.0001 respectively), but not in those with FEV₁≥50 % predicted (P = 0.23 and P = 0.76 respectively). No significant effect of influenza vaccination on all-cause mortality was observed.

CONCLUSIONS

Our findings support a protective role of influenza vaccination in COPD patients, a yearly influenza vaccination should be strongly recommended for all COPD patients, especially those with severe airflow limitation, to reduce possible influenza infection, and thus associated exacerbations and hospitalizations.

[Incidence of severe exacerbation in patients diagnosed with diabetes and chronic obstructive pulmonary disease: Cohort study]

Objetivo

Estimar en una cohorte de pacientes diagnosticados de EPOC y diabetes la incidencia de hospitalizaciones por exacerbación grave de la EPOC y sus factores asociados.

Diseño

Estudio prospectivo de cohorte.

Emplazamiento

Centros de Atención Primaria de Lleida ciudad (en total 7 centros).

Participantes

Se estudiaron 761 pacientes codiagnosticados de EPOC y diabetes. Los criterios de inclusión fueron pacientes de ambos sexos, igual o mayores de 40 años, residentes en el área geográfica de Lleida ciudad, con el diagnóstico de EPOC según los criterios de la guía GOLD, con espirometría reciente y una fracción FEV₁/FVC < 0,7; diagnosticados de DM2 según la guía de la International Diabetes Federation. Los criterios de exclusión fueron padecer alguna enfermedad física o psíquica grave.

Mediciones principales

Las variables del estudio fueron: el sexo, la edad, su área básica de salud en Lleida, índice de masa corporal, perímetro de cintura, hábito tabáquico y enólico, hipertensión arterial, insuficiencia cardiaca, insuficiencia renal crónica, FEV₁, FEV₁/FVC, categorización GOLD, HbA1c. Se registró la vacuna antigripal y antineumocócica. La variable dependiente fue la exacerbación grave. En el análisis estadístico la asociación de la variable dependiente con las variables independientes se determinó mediante el cálculo de la hazard ratio (HR) con el intervalo de confianza del 95%. La HR se estimó de forma ajustada mediante modelos de regresión de Cox no condicional.

Resultados

La incidencia de hospitalización por exacerbación grave de la EPOC fue del 9,98%; se objetivó un aumento del riesgo de exacerbación grave en pacientes diagnosticados de insuficiencia cardiaca (HR = 2,27; p = 0,002), y con una menor fracción de FEV₁/FVC. La vacuna antigripal y antineumocócica presentaron un papel protector débil sin ser estadísticamente significativa.

Conclusión

Se documenta una incidencia de exacerbaciones elevada en los pacientes codiagnosticados de EPOC y DM2. La insuficiencia cardiaca y una menor fracción FEV₁/FVC podrían aumentar el riesgo de exacerbación.

Prevalence of influenza and pneumococcal vaccination in chronic obstructive pulmonary disease patients in association with the occurrence of acute exacerbations

Background

Based on current evidence, vaccination is recommended against the influenza virus and pneumococcus to avoid serious acute exacerbations in patients with chronic obstructive pulmonary disease (COPD), but the rate of their vaccination coverage is still suboptimal. To determine the prevalence and effectiveness of influenza and pneumococcal vaccination in COPD patients, and to prove its hypothetical association with the decreasing number of acute exacerbations.

Methods

We conducted a retrospective, population-based cohort study. Influenza and pneumococcal vaccination history were collected from 250 patients selected by simple random sampling from all COPD patients in Budapest at the Department of Pulmonary Rehabilitation of the National Koranyi Institute of Pulmonology between 01 January 2019 and 01 June 2019. Inclusion criteria were the following: age 40 years and diagnosis of COPD. Odds ratios (ORs) were evaluated based on the occurrence of acute exacerbations during the preceding year.

Results

The average age was 66.62 (±8.34) years, 67.30 (±8.54) for males, and 66.09 (±8.16) for females. Man:woman ratio: 43.6%:56.4% in total. Overall prevalence of influenza vaccination was 23.6%, and the pneumococcal vaccination rate was 10.8% among COPD patients. Influenza and pneumococcal vaccination showed a significant protective effect and reduced the occurrence of exacerbations in the following year, influenza vaccination OR: 2.11 (95% CI: 0.88-5.02), pneumococcal vaccination OR: 1.06 (95% CI: 0.84-1.34), when taking both vaccination: OR: 2.37 (95% CI: 1.39-4.08).

Conclusions

We found association between influenza and pneumococcal vaccination and the reduced risk of hospitalization due to exacerbations in the ensuing year. The prevalence of vaccination is significantly below the optimal level.

Smoking Cessation/Vaccinations

More than one-third of patients with chronic obstructive pulmonary disease (COPD) continue to smoke cigarettes despite knowing they have the disease. This behavior has a negative impact on prognosis and progression, as repeated injury enhances the pathobiological mechanisms responsible for the disease. A combination of counseling plus pharmacotherapy is the most effective cessation treatment of smokers with COPD, and varenicline seems to be the most effective pharmacologic intervention. Preventing exacerbations in patients with COPD is a major goal of treatment, and vaccination against influenza and pneumococcus is an effective preventive strategy to achieve this goal.

Prevalence of Seasonal Influenza Vaccination in Chronic Obstructive Pulmonary Disease (COPD) Patients in the Balearic Islands (Spain) and Its Effect on COPD Exacerbations: A Population-Based Retrospective Cohort Study

To determine the prevalence of influenza vaccination in chronic obstructive pulmonary disease (COPD) patients and its effect on COPD exacerbations, we conducted a retrospective population-based cohort study analyzing real-life data. We included all registered COPD patients ≥40 years old using respiratory medication during the study period (2012-2013). Influenza vaccination during the 2012/2013 campaign was the parameter studied. Moderate and severe exacerbations during 2013 were the dependent outcome variables. Logistic regression adjusting for age, gender, concomitant asthma diagnosis, COPD severity, smoking status, number of moderate and severe exacerbations the previous year, and comorbidities was performed, and 59.6% of the patients received seasonal influenza vaccination. The percentage of patients with exacerbations was higher among those vaccinated. Influenza vaccination had a statistically significantly negative (non-protective) crude effect favoring the risk of severe exacerbations: OR: 1.20 (95% CI; 1.05-1.37). This association diminished and lost statistical significance after adjustment: aOR: 0.93 (95% CI; 0.74-1.18). The protective effect in the analysis restricted to the epidemic period was not significant: aOR: 0.82 (95% CI; 0.58-1.16). We concluded that prevalence of influenza vaccination was suboptimal. In contrast with most of the available evidence, our results did not support a protective effect of influenza vaccination on the risk of admission for COPD exacerbation.

Susceptibility to frequent exacerbation in COPD patients: Impact of the exacerbations history, vaccinations and comorbidities?

INTRODUCTION

Exacerbations are key events in the natural history of COPD, but our understanding of their longitudinal determinants remains unclear. We used data from a large observational study to test the hypothesis that vaccination status and comorbidities could be associated with the occurrence of exacerbations profile.

METHODS

Diagnosed COPD patients have been included by their pulmonologists, with up to 3 years of follow-up. Data were analyzed using the KmL method designed to cluster longitudinal data and receiver operating characteristic curve analysis to determine the best threshold to allocate patients to identified clusters.

RESULTS

932 COPD patients were included since January 2014, 446 patients (65.68% males, 35.59% current smokers) were followed over a period of 3 years with complete data. 239(28.15%) patients reported two or more exacerbations in the year before enrolment (frequent exacerbations). Among them 142(16.68%) also had frequent exacerbations in the first year of the study, and 69(8.10%) who remained frequent exacerbators in the second year. Based on our hypothesis, we were able to determine four phenotypes: A (infrequent), B (frequent in underweight patients), C (transient), and D (frequent in obese patients). Frequent exacerbators had more airflow limitation and symptoms. Irrespective of cut-offs set to define the optimal number of clusters, a history of exacerbations OR: 3.72[2.53-5.49], presence of anxiety OR: 2.03[1.24-3.31] and absence of the annual influenza vaccination OR: 1.97[1.20-3.24] remained associated with the frequent exacerbator phenotypes.

CONCLUSIONS

The most important determinants of frequent exacerbations are a history of exacerbations, anxiety and unvaccinated against influenza.

Influenza vaccination rate and its association with chronic diseases in China: Results of a national cross-sectional study

INTRODUCTION

Influenza vaccination is the most effective way to prevent influenza. Few studies on its rate were reported throughout China and for populations with chronic diseases. An estimation of the rates in China was accomplished.

METHODS

All data were from a national cross-sectional survey of a sample representing the population aged 40 years or older in mainland China in 2014-15. A total of 74,484 individuals with complete self-reported influenza vaccination status were analyzed in 2018-19.

RESULTS

The overall influenza vaccination rate was 2.4% (95% CI 1.4-3.3) with 1.7% (95% CI 1.2-2.2) for the age group 40-59 years and 3.8% (95% CI 1.6-5.9) for the group ≥60 years. The rate was 4.0% (95% CI 2.0-5.9) among people with a chronic disease. People with asthma and people with emphysema had the highest rates (7.1%, 95% CI 3.2-11.0 and 6.6%, 95% CI 3.6-9.7) while people with chronic obstructive pulmonary disease (COPD) and people with chronic bronchitis had the lower rates (3.6%, 95% CI 2.0-5.2 and 4.8%, 95% CI 2.6-7.0). The rate was the highest among former smokers (3.3%, 95% CI 2.3-4.4) compared to current smokers (1.8%, 95% CI 0.9-2.7) and never smokers (2.5%, 95% CI 1.4-3.6). People living with finance-reimbursed vaccination policy, a positive factor for vaccination, had a higher vaccination rate (11.5%, 95% CI 10.8-12.2) (p < 0.05). People with older age, higher education level, occupation of professionals or technical personnel, living in rural areas or Northern China, former/never smoking were more likely to be vaccinated (p < 0.05).

CONCLUSIONS

The influenza vaccination rate is low among adults aged ≥40 years, those ≥60 years and those with chronic diseases in China. Reimbursement policy targeting the elderly should be implemented widely and strategies towards patients with chronic diseases need urgent attention to increase the influenza vaccination coverage.

Effectiveness of Influenza Vaccination on Hospitalizations and Risk Factors for Severe Outcomes in Hospitalized Patients With COPD

BACKGROUND

The effectiveness of influenza vaccination in reducing influenza-related hospitalizations among patients with COPD is not well described, and influenza vaccination uptake remains suboptimal.

METHODS

Data were analyzed from a national, prospective, multicenter cohort study including patients with COPD, hospitalized with any acute respiratory illness or exacerbation between 2011 and 2015. All patients underwent nasopharyngeal swab screening with polymerase chain reaction (PCR) testing for influenza. The primary outcome was an influenza-related hospitalization. We identified influenza-positive cases and negative control subjects and used multivariable logistic regression with a standard test-negative design to estimate the vaccine effectiveness for preventing influenza-related hospitalizations.

RESULTS

Among 4,755 hospitalized patients with COPD, 4,198 (88.3%) patients with known vaccination status were analyzed. The adjusted analysis showed a 38% reduction in influenza-related hospitalizations in vaccinated vs unvaccinated individuals. Influenza-positive patients (n = 1,833 [38.5%]) experienced higher crude mortality (9.7% vs 7.9%; P = .047) and critical illness (17.2% vs 12.1%; P < .001) compared with influenza-negative patients. Risk factors for mortality in influenza-positive patients included age > 75 years (OR, 3.7 [95% CI, 0.4-30.3]), cardiac comorbidity (OR, 2.0 [95% CI, 1.3-3.2]), residence in long-term care (OR, 2.6 [95% CI, 1.5-4.5]), and home oxygen use (OR, 2.9 [95% CI, 1.6-5.1]).

CONCLUSIONS

Influenza vaccination significantly reduced influenza-related hospitalization among patients with COPD. Initiatives to increase vaccination uptake and early use of antiviral agents among patients with COPD could reduce influenza-related hospitalization and critical illness and improve health-care costs in this vulnerable population.

TRIAL REGISTRY

ClinicalTrials.govNo.:NCT01517191; URL www.clinicaltrials.gov.

The efficacy of a flipping education program on improving self-management in patients with chronic obstructive pulmonary disease: a randomized controlled trial

Purpose: Self-management is widely used among patients with a chronic disease to control their condition. However, the self-management programs are less distinctive for patients with chronic obstructive pulmonary disease (COPD) than those with other chronic diseases. This study examines the efficacy of a flipping education program on improving self-management in patients with COPD.

Patients and methods: A single-blinded, randomized controlled trial was conducted at a medical center in northern Taiwan from January 2015 to May 2016. Sixty participants were randomized to an experimental group and a control group. The self-management program with flipped teaching, customized action plans, and scheduled telephone interviews was implemented in the experimental group for three months. Conventional patient education was implemented in the control group. Disease knowledge, self-efficacy, the patient’s activation level, and the impact of COPD were assessed at baseline, 1 month, and 3 months after the intervention. SPSS 22.0 was used for data analysis.

Results: The results showed that the patients who received the flipping education program of self-management had statistically significant improvements in their disease knowledge (p<0.05), self-efficacy (p<0.01), and activation levels (p<0.01) from baseline to the 1 month and 3 months follow-up compared to the control group.

Conclusion: The findings supported that flipped teaching could be applied to patient education in adults and that a nurse case manager can feasibly use this flipping education program of self-management to motivate and support patients with COPD to acquire self-management skills, carry out their action plans, and help them achieve beneficial behaviors in their daily lives.

Pulmonary complications of influenza infection: a targeted narrative review

Severe influenza infection represents a leading cause of global morbidity and mortality. Several clinical syndromes that involve a number of organs may be associated with Influenza infection. However, lower respiratory complications remain the most common and serious sequel of influenza infection. These include influenza pneumonia, superinfection with bacteria and fungi, exacerbation of underlying lung disease and ARDS. This review analyzes the available literature on the epidemiology and clinical considerations of these conditions. It also provides an overview of the effects of type of influenza, antiviral therapy, vaccination and other therapies on the outcome of these complications.

Immunization status in chronic obstructive pulmonary disease: A multicenter study from Turkey

OBJECTIVE:

The purpose of this study is to detect the prevalence and the factors associated with influenza and pneumococcal vaccination and outcomes of vaccination during 2013–2014 season in patients with chronic obstructive pulmonary disease (COPD) in Turkey.

METHODS:

This was a multicenter retrospective cohort study performed in 53 different centers in Turkey.

RESULTS:

During the study period, 4968 patients were included. COPD was staged as GOLD 1-2-3-4 in 9.0%, 42.8%, 35.0%, and 13.2% of the patients, respectively. Influenza vaccination rate in the previous year was 37.9%; and pneumococcus vaccination rate, at least once during in a life time, was 13.3%. Patients with older age, higher level of education, more severe COPD, and comorbidities, ex-smokers, and patients residing in urban areas had higher rates of influenza vaccination. Multivariate logistic regression analysis showed that advanced age, higher education levels, presence of comorbidities, higher COPD stages, and exacerbation rates were associated with both influenza and pneumococcal vaccination. The number of annual physician/outpatient visits and hospitalizations due to COPD exacerbation was 2.73 ± 2.85 and 0.92 ± 1.58 per year, respectively. Patients with older age, lower education levels, more severe COPD, comorbid diseases, and lower body mass index and patients who are male and are residing in rural areas and vaccinated for influenza had significantly higher rates of COPD exacerbation.

CONCLUSIONS:

The rates of influenza and pneumococcal vaccination in COPD patients were quite low, and the number of annual physician/outpatient visits and hospitalizations due to COPD exacerbation was high in Turkey. Advanced age, higher education levels, comorbidities, and higher COPD stages were associated with both influenza and pneumococcal vaccination.

Impact of a homeopathic medication on upper respiratory tract infections in COPD patients: Results of an observational, prospective study (EPOXILO)

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a progressive lung disorder in which airflow is obstructed. Viral or bacterial upper respiratory tract infections (URTIs) may lead to exacerbations. Homeopathic medication administration to COPD patients during the influenza-exposure period may help to reduce the frequency of common URTIs.

METHODS

This prospective, observational, multicenter study was carried out in Cantabria, Spain. Patients with COPD were divided into two groups: group 1 received conventional treatment + homeopathic medication (diluted and dynamized extract of duck liver and heart; Boiron) (OG); group 2 received conventional treatment only (CG). The primary endpoint was the number of URTIs between the 4-5 months follow up (mean 4.72 ± 0.96) from basal to last visit. Secondary endpoints included the duration of URTIs, number and duration of COPD exacerbations, use of COPD drugs, changes in quality of life (QoL), compliance, and adverse events (AEs).

RESULTS

219 patients were analyzed (OG = 109, CG = 110). There was a significant reduction in mean number of URTIs during the follow-up period in OG compared to CG (0.514 ± 0.722 vs. 1.037 ± 1.519, respectively; p = 0.014). Logistic regression analysis showed a 3.3-times higher probability of suffering ≥2 URTI episodes in CG (p = 0.003, n = 72). OG patients having ≥1 URTI also had a significant reduction in mean URTI duration per episode (3.57 ± 2.44 days OG vs. 5.22 ± 4.17 days CG; p = 0.012). There was no significant difference in mean number of exacerbations, mean duration of exacerbations, or QoL between OG and CG. There was a greater decrease in proportion of patients using corticosteroids for exacerbations between baseline and visit 2 in OG compared to CG (22.1% vs. 7.5% fewer respectively, p = 0.005). Exacerbator phenotype patients had a significant decrease in number of URTIs (0.54 ± 0.72 vs. 1.31 ± 1.81; p = 0.011), and fewer COPD exacerbations (0.9 ± 1.3 vs. 1.5 ± 1.7; p = 0.037) in OG vs. CG, respectively.

CONCLUSIONS

Homeopathic medication use during the influenza-exposure period may have a beneficial impact at reducing URTIs' number and duration in COPD patients and at reducing the number of COPD exacerbations in patients with the exacerbator phenotype. Further studies are needed to confirm the effects observed in this study.

Patterns and management of chronic obstructive pulmonary disease in urban and rural China: a community-based survey of 25 000 adults across 10 regions

Introduction

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death worldwide, with COPD deaths in China accounting for one-third of all such deaths. However, there is limited available evidence on the management of COPD in China.

Methods

A random sample of 25 011 participants in the China Kadoorie Biobank, aged 38–87 years, from 10 regions in China was surveyed in 2013–2014. Data were collected using interviewer-administered questionnaires on the diagnosis (‘doctor-diagnosed’ or ‘symptoms-based’) and management of COPD (including use of medication and other healthcare resources), awareness of diagnosis and severity of symptoms in COPD cases.

Results

Overall, 6.3% of the study population were identified as COPD cases (doctor-diagnosed cases: 4.8% and symptom-based cases: 2.4%). The proportion having COPD was higher in men than in women (7.9% vs 5.3%) and varied by about threefold (3.7%–10.0%) across the 10 regions. Among those with COPD, 54% sought medical advice during the last 12 months, but <10% reported having received treatment for COPD. The rates of hospitalisation for COPD, use of oxygen therapy at home and influenza or pneumococcal vaccinations in the previous year were 15%, 3% and 4%, respectively. Of those with COPD, half had moderate or severe respiratory symptoms, and over 80% had limited understanding of their disease and need for treatment.

Conclusion

Despite a high prevalence of COPD in China and its substantial impact on activities of daily living, knowledge about COPD and its management were limited.

Seasonal influenza vaccination in patients with COPD: a systematic literature review

BACKGROUND

Influenza is a frequent cause of exacerbations of chronic obstructive pulmonary disease (COPD). Exacerbations are associated with worsening of the airflow obstruction, hospitalisation, reduced quality of life, disease progression, death, and ultimately, substantial healthcare-related costs. Despite longstanding recommendations to vaccinate vulnerable high-risk groups against seasonal influenza, including patients with COPD, vaccination rates remain sub-optimal in this population.

METHODS

We conducted a systematic review to summarise current evidence from randomised controlled trials (RCTs) and observational studies on the immunogenicity, safety, efficacy, and effectiveness of seasonal influenza vaccination in patients with COPD. The selection of relevant articles was based on a three-step selection procedure according to predefined inclusion and exclusion criteria. The search yielded 650 unique hits of which 48 eligible articles were screened in full-text.

RESULTS

Seventeen articles describing 13 different studies were found to be pertinent to this review. Results of four RCTs and one observational study demonstrate that seasonal influenza vaccination is immunogenic in patients with COPD. Two studies assessed the occurrence of COPD exacerbations 14 days after influenza vaccination and found no evidence of an increased risk of exacerbation. Three RCTs showed no significant difference in the occurrence of systemic effects between groups receiving influenza vaccine or placebo. Six out of seven studies on vaccine efficacy or effectiveness indicated long-term benefits of seasonal influenza vaccination, such as reduced number of exacerbations, reduced hospitalisations and outpatient visits, and decreased all-cause and respiratory mortality.

CONCLUSIONS

Additional large and well-designed observational studies would contribute to understanding the impact of disease severity and patient characteristics on the response to influenza vaccination. Overall, the evidence supports a positive benefit-risk ratio for seasonal influenza vaccination in patients with COPD, and supports current vaccination recommendations in this population.

Adherence to GOLD Guidelines in the Inpatient COPD Population

PURPOSE

The Global Initiative for Chronic Obstructive Lung Disease guidelines provide recommendations to manage chronic obstructive lung disease (COPD) exacerbations. This study assessed the management of inpatient COPD exacerbations at an urban teaching hospital.

METHODS

A retrospective cohort analysis of adults admitted between December 2010 and August 2012 with a COPD exacerbation was conducted. Patient demographics, length of stay (LOS), Charlson comorbidity score, inpatient pulmonary medications, and 30-day readmission were collected. Descriptive statistics characterized guideline adherence and readmission.

RESULTS

94 patients were included with median LOS of 3 days (interquartile range [IQR]: 1-5 days) and median Charlson comorbidity score of 6 (IQR: 5-8). All patients received an inhaled short-acting beta agonist, and 52 (55.3%) also received an inhaled short-acting anticholinergic. Seventy-eight (83%) received systemic corticosteroids, of which 3 received guideline-recommended doses. Sixty-four (68.1%) received antibiotics for a pulmonary indication, of which 71.9% received appropriate antibiotics per indication. Of the 94 patients, 2 were managed in complete adherence with GOLD recommendations. A total of 24 (25.5%) patients were readmitted within 30 days of discharge, 9 of these for COPD.

CONCLUSION

COPD exacerbation treatment deviated from GOLD recommendations. This provides opportunities for further optimization of treatment of COPD exacerbations.

Independent effect of prior exacerbation frequency and disease severity on the risk of future exacerbations of COPD: a retrospective cohort study

Few studies have researched the independent effect of COPD severity on the risk of future exacerbations adjusted by previous exacerbation frequency. We aimed to analyse the independent effect of COPD severity on the risk of exacerbations in the following year, and whether this effect was stronger or not than the effect of a previous history of exacerbations. We conducted a retrospective population-based cohort study including 900 patients with confirmed COPD. Exacerbation frequency was observed for the previous year and for the following year. Patients were defined as ‘Frequent Exacerbator’ (FE) phenotype if they suffered ⩾2 exacerbations in a year, and were categorised according to the severity of COPD (GOLD Grades 1–4). Odds ratios (ORs) were estimated by logistic regression adjusting for age, gender, smoking status, severity of COPD and being FE in the previous year. The main predictor of being FE among all grades of COPD severity was a history of frequent exacerbations in the previous year: adjusted OR 4.97; 95% confidence interval (CI) (3.54–6.97). COPD severity was associated with a higher risk of being FE: Crude OR GOLD Grade 4 3.86; 95% CI (1.50–9.93). However, this association diminished after adjusting for being FE in the previous year: adjusted OR 2.08; 95% CI (0.75–5.82). Our results support that a history of frequent exacerbations in the previous year is the most important independent predictor of exacerbations in the following year, also among the most severe COPD patients. Severity of COPD would be associated with a higher risk of exacerbations, but this effect would be partly determined by the exacerbations suffered in the previous year.