Patients with COPD are at a much higher risk for health complications secondary to infection. The value of vaccination in COPD is clear and has been so for decades. Now, guidelines in the Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD) 2024 Report have also been updated to align with Centers for Disease Control and Prevention (CDC) recommendations regarding vaccinations for influenza, pneumococcal pneumonia, herpes zoster, respiratory syncytial virus (RSV), COVID-19, and tetanus, diphtheria, and pertussis (Tdap).
Pulmonology Advisor spoke with pulmonologist Antonio Anzueto, MD, professor of pulmonary/critical care medicine at University of Texas Health Sciences Center at San Antonio, to learn more about the importance of vaccinations for patients with COPD and pulmonologists’ role in promoting these vaccinations to patients. Notably, Dr Anzueto recently presented on this topic at the 2023 GOLD COPD Conference, held in Philadelphia.
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Vaccination Recommendations
People with stable COPD should receive all recommended vaccinations in line with their local guidelines, according to 2024 GOLD COPD guidelines. Guidance includes the following1:
- Influenza vaccination is recommended for all patients with COPD.
- COVID-19 vaccination is recommended (evidence level B; ie, supported by randomized controlled trials [RCTs] with important limitations or by a limited body of evidence).
- One dose of pneumococcal conjugated vaccine 20 (PCV20) or 1 dose of PCV15 followed by PPSV23 is recommended in people with COPD (evidence level B). Notably, pneumococcal vaccination has been demonstrated to decrease the incidence of community–acquired pneumonia and exacerbations in COPD patients (evidence level B).
- The CDC recommends the new RSV vaccine for those individuals older than 60 years of age or with chronic heart or lung disease (evidence level A; ie, supported by RCTs or rich body of high-quality evidence).
- The tetanus, diphtheria, and pertussis vaccine (Tdap) is recommended for patients with COPD who were not vaccinated earlier in life (evidence level B).
- The herpes zoster vaccine is recommended for patients with COPD aged 50 years and older (evidence level B).
Notably, vaccination among patients with COPD is recommended worldwide — not only by the CDC but also by its European equivalent, the European Center for Disease Prevention and Control (ECDC).
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Dr. Anzueto stressed the importance of vaccination in patients with all types of pulmonary disease, including asthma, bronchiectasis, and pulmonary fibrosis, as well as COPD. All such patients are at higher risk for increased morbidity and mortality secondary to infection.
On a related note, Dr Anzueto stressed the importance of vaccination in patients with all types of pulmonary disease, including asthma, bronchiectasis, and pulmonary fibrosis, as well as COPD. All such patients are at higher risk for increased morbidity and mortality secondary to infection.
Preventing Infections Is Critical in Those With COPD
“COPD puts patients at increased risk of viral infections, bacterial infections, and pneumonia. They are primed to have many problems,” said Dr Anzueto. “Prevention is very important. Anything we can do to prevent these processes is very important.”
For instance, in a large cohort study of US veterans, investigators assessed hospitalizations secondary to pneumococcal pneumonia in patients who received the pneumococcal vaccine compared with those who didn’t receive the vaccine. They found that the adjusted relative risk for pneumocococcal pneumonia hospitalizations in patients with COPD who had not been vaccinated was 8.02, compared with 3.87 among those who were vaccinated.2
“If a patient has COPD and develops pneumonia, the outcome will be worse compared with another individual who develops pneumonia,” stressed Dr Anzueto. “We have treatment for bacterial pneumonia but we don’t have treatment for viral pneumonia. The only measure we have is prevention. For COVID, it’s the same story.”
Bacterial pneumonia in patients with COPD can lead to acute respiratory failure, intensive care unit (ICU) admission, and ventilator support. According to Dr Anzueto, the chances of survival from bacterial pneumonia are about 50/50 — and even worse in patients with viral pneumonia. Moreover, the risk for morbidity and ICU hospitalization is currently at an all-time high with the “triple threat” of RSV, influenza, and COVID-19.
There is also some evidence suggesting that lack of vaccination for respiratory viruses that have vaccines may increase exacerbation-related hospitalizations in those with COPD. According to a study published in the European Respiratory Review, “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,” noted the study authors.3
Vaccination Rates in Patients With COPD
Not enough individuals with COPD are properly vaccinated, stressed authors of the European Respiratory Review article. “Despite long-standing recommendations to vaccinate patients with COPD, vaccination rates remain suboptimal in this population,” they noted.3
Vaccination rates are low among all patients — including those with chronic respiratory conditions, said Dr Anzueto, noting that this problem is universal and should be addressed.
Harvard researchers characterized the rates/determinants of pneumococcal vaccination in the US between 2011 and 2019 based on the Behavioral Risk Factor Surveillance System (BRFSS) conducted by the CDC. The researchers concluded that vaccination rates were low: only 62.9% of Americans ever reported receiving the vaccine, with women less likely to receive it than men. Moreover, White individuals were more likely to receive the vaccine vs non-Hispanic Black individuals and Hispanic individuals. Among respondents, vaccination rates were higher in those who completed high school or those with comorbidities such diabetes or coronary artery disease.4
Vaccination schedules are usually not a topic of conversation among adult patients, concedes Dr Anzueto.
“It’s kind of weird to be talking about vaccination in adults because this is traditionally a concern of pediatricians. In adults, we have to also give a combo of vaccines,” he said.
Dr Anzueto notes the importance of shifting the mindset of specialists who treat adult patients with pulmonary disease to focus on whether the patients’ vaccinations are up to date and to make every effort to ensure that preventive steps are taken.
Seasonal vaccines that are administered starting in October include influenza, COVID, and RSV. On the other hand, pneumococcal and herpes zoster vaccines can be given year-round. One issue with pneumococcal vaccines is the existence of 2 vaccine types, which makes dosing and coverage complicated for patients, providers, and payers. Recently, CDC approved PCV20, a 1-dose vaccine that can be administered every 3-5 years.
The importance of the herpes zoster vaccine in patients with COPD should not be underestimated by clinicians, added Dr Anzueto. Shingles can be markedly debilitating and result in painful neuropathy.
Overcoming Vaccine Hesitancy
Although there’s been some blowback regarding vaccination in recent years, patients with COPD are typically on board with getting vaccinated, says Dr Anzueto. Despite practicing in the more politically conservative environs of southern Texas, his patients are pretty enthusiastic about receiving preventive care in the form of vaccination, with only 1 in 20 refusing.
“COPD patients have no problem getting vaccines. Most patients will do it in the office. Having the pneumococcal vaccine available translates to usage. We aren’t seeing as much resistance as with COVID,” he said. “Having the pneumococcal vaccination available in the office is important. You can establish a relationship with them. It’s convenience and the fact that they trust you. I recommend this intervention.
As for the influenza, RSV, and COVID vaccines, Dr Anzueto recommends that his patients receive them at their local pharmacies. In his anecdotal experience, there is little resistance to receiving the COVID vaccine in combination with these other 2 vaccines.
Summing up
COPD patients experience worsened clinical outcomes when developing viral pneumonia, bacterial pneumonia, and herpes zoster. In cases of viral infection, the only effective intervention is preventive. The 2024 GOLD report recommends that all patients with COPD receive vaccinations in line with CDC recommendations. Offering vaccination in the office can improve vaccination rates. Patients can also be encouraged to receive vaccines at their local pharmacies.
Key measures to improve vaccination rates among COPD patients in the future include the importance of novel vaccine discovery targeted at an increased number of viruses and bacteria. Combination vaccines can also help increase adherence.5
