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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 30  |  Issue : 2  |  Page : 66-70

Response of influenza vaccine in chronic obstructive pulmonary disease patients


1 Department of Pulmonary Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, New Delhi, India
2 Department of Biostatistics, Vallabhbhai Patel Chest Institute, University of Delhi, New Delhi, India

Date of Web Publication5-Dec-2016

Correspondence Address:
S N Gaur
Department of Pulmonary Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, New Delhi - 110 007
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-6691.195213

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  Abstract 

Background: Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide. The World health Organization has suggested that elderly individuals with chronic lung disease to be targeted for immunization. In spite of all these recommendations, influenza vaccine is underused, especially in developing countries. Objective: This study aims to study the effect of influenza vaccine in patients with COPD in reducing acute exacerbations, emergency visits, sputum quantity, hospital admission, and Intensive Care Unit (ICU) admission in a 2-year period. Materials and Methods: Twenty-five patients of COPD were selected based on their forced expiratory volume in 1 s as having mild, moderate, severe, and very severe COPD. These patients were followed and evaluated for 2 years, 1 year before vaccination, and 1 year after vaccination. The parameters studied are, the number of acute episodes, emergency visits, hospital admission, ICU admissions, sputum quantity, and chest X-rays were evaluated before and after 1 year of vaccination. Results: The vaccine showed a significant decrease in all the parameters (P < 0.001), except for chest X-rays and ICU admission. The overall effectiveness of influenza vaccine was found to be 63.12%. Conclusions: Influenza vaccine is safe and effective among moderate, severe, and very severe COPD patients. It has also been found very effective in severe COPD patients associated with comorbidities.

Keywords: Chronic obstructive pulmonary disease, effectiveness, influenza vaccine


How to cite this article:
Gaur S N, Begum G, Bhati G, Rehman M. Response of influenza vaccine in chronic obstructive pulmonary disease patients. Indian J Allergy Asthma Immunol 2016;30:66-70

How to cite this URL:
Gaur S N, Begum G, Bhati G, Rehman M. Response of influenza vaccine in chronic obstructive pulmonary disease patients. Indian J Allergy Asthma Immunol [serial online] 2016 [cited 2017 Mar 25];30:66-70. Available from: http://www.ijaai.in/text.asp?2016/30/2/66/195213


  Introduction Top


Chronic obstructive pulmonary disease (COPD) is a common preventable and treatable disease characterized by persistent airflow limitation that is usually progressive and associated with enhanced chronic inflammatory response in airways and lungs to noxious particles or gasses. Exacerbations and comorbidities contribute to overall severity in individual patients. It is a leading cause of mortality and morbidity worldwide. [1] As the disease progresses, exacerbations can occur several times per year, and may require hospital admission. These exacerbations can take several weeks to resolve, during which time considerable morbidity can occur and result in significant health care costs. Infection with influenza is an important cause of excess mortality and morbidity in COPD. Although influenza is not really related to excess mortality in the young patients, it can play an important role in causing exacerbations, especially in epidemic seasons. [2] Seasonal influenza outbreaks represent a major public health challenge. The virus causes 3-5 million cases of severe disease each year and is responsible for up to 1 million deaths annually. [3],[4] Patients with COPD are at an increased risk for respiratory illness-related hospitalization during influenza outbreaks irrespective of age and degree of morbidity. Morbidity measures traditionally include physician visits, emergency department visits, and hospitalizations. Although COPD databases for these outcome parameters are less readily available and usually less reliable than mortality databases, the limited data available indicate that morbidity due to COPD increases with age. [5],[6] Patients with COPD are frequently exposed to human rhinovirus, as well as to Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis. These infectious agents are responsible for exacerbations increasing morbidity and mortality in COPD patients. [7] The most effective way to prevent infection by the influenza virus and its potentially severe complications is immunization. Vaccination is safe and well-tolerated and can prevent up to 70-90% of influenza-specific illness in healthy adults. This study has been carried out to study the effect of influenza vaccine in patients of COPD in reducing acute exacerbations, emergency visits, sputum quantity, hospital admission, and Intensive Care Unit (ICU) admission. It also includes smokers and never smokers' females with biomass fuel exposure. Infections caused by influenza virus play a major role in the exacerbation of COPD patients. Guidelines for annual influenza vaccination in persons with COPD are largely based on observational studies. [8] Studies have reported that the influenza vaccine reduces mortality outcomes in those with chronic lung disease. [9] Studies have also reported that influenza vaccine is safe in COPD patients and reduces exacerbations, OPD visits, hospitalization, and mechanical ventilation. At present, guidelines for management of COPD recommend annual influenza vaccination in every patient with COPD. [10] The objective of this study is to see the effectiveness of influenza vaccine in terms of acute episodes, emergency visits, hospital admission, and ICU admission in patients of COPD. Further, Sputum quantity and chest X-rays were also evaluated.


  Materials and Methods Top


Study design and demographics

A cross-sectional study from tertiary care hospital (Vallabhbhai Patel Chest Institute, Delhi) was done which enrolled 25 COPD patients for 2 years (pre- and post-vaccination). There were twenty-two males and three females with confirmed diagnosis of COPD, postbronchodilator value of forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) <0.7, <200 ml, and 12% increase in FEV1 or FVC after bronchodilator. There were 6, 12, and 7 patients in moderate, severe, and very severe COPD, respectively. None of them was in the mild category of COPD. All patients of age >45 years with no previous history of vaccination of influenza were selected. Patients with a history of recent myocardial infarction and egg allergy were excluded from this study.

Influenza vaccination

All patients, 22 males who were ex-smokers and females who were never smokers but had a history of biomass fuel exposure and patients having comorbid disease were evaluated for the study. All patients were on regular treatment and was counseled and advised for smoking cessation and correct inhaler technique in each visit. Acute exacerbation was managed with short course of oral steroids for 7 days and severe cases were managed in hospital admission with antibiotics. All patients were vaccinated with influenza vaccine (split virion, inactivated), 0.5 ml intramuscular injection in deltoid. Every patient received one dose of injection.

Statistical analysis

The results were presented as median value of the all the parameters and significance difference between pre- and post-vaccination were tested by Wilcoxon sign rank test. P < 0.05 is considered as statistically significant. The analysis was carried using SPSS Statistical Programme.


  Results Top


A total of 27 patients of COPD who attended outpatient department (OPD) were evaluated. The exclusion criteria were egg allergy and recent myocardial infarction. One of the patients had myocardial infarction and was excluded from the study, and one patient was lost to follow-up in the OPD. None of the patients was allergic to eggs. Hence, finally, twenty-five patients were selected for the study. Eighteen of them had a comorbid disease which included hypertension, cor pulmonale, gastroesophageal reflux disease, diabetes, and hypothyroidism.

Baseline characteristics of all patients are presented in [Table 1].
Table 1: Baseline characteristics of the 25 study subjects

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Vaccine effectiveness

The comparison of the total acute episodes, emergency visits, sputum quantity, hospitalization, and ICU admission of the COPD patients before 1 year of vaccination and after 1 year of vaccination was studied. Out of 25 patients, four patients had no previous hospital admission in the hospital before vaccination and after vaccination two of them had hospital admission. Four patients had ICU admission prior to vaccination and in the postvaccination period, two of them had ICU admission. The total number of acute episodes and emergency visits was 175 and 172 respectively in pre-vaccination of 1 year which reduced to 63 and 55 in the postvaccination period. Similarly, a total number of hospital admission and ICU admission was 52 and 6 respectively in the prevaccination period, and it was reduced to 18 and 2 in the postvaccination period. Influenza vaccination showed 64% decrease in the acute episodes after vaccination. There was 68.02% decrease in emergency visits, 65.38% decrease in hospital admission. There was 66.67% decrease in ICU admission which was not significant. Sputum quantity was decreased 42.86% in the postvaccination period. [Table 2] describes the various parameters in detail. Chest X-rays of the patients did not show any significant change in the postvaccination period. Overall effectiveness of influenza vaccine was found to be 63.12%. [Figure 1] shows the bar graph comparing the data in pre- and post-vaccination period. Hence, influenza vaccine was found to be effective in smoker and those exposed to biomass fuel exposure and also the COPD patients with comorbidities. Menon et al. 2008 had also compared total episodes of Acute Respiratory Infections (ARI) and acute exacerbations of COPD, OPD visits, hospitalization, and mechanical ventilation pre- and post-vaccination and there was a significant reduction in postvaccination period. The effectiveness of influenza vaccine was 60%, 60%, and 75% for mild, moderate, and severe COPD, respectively. [10] P. J. Poole et al. 2000 showed vaccine effectiveness (expressed as 1 - rate vaccine group/rate control group) in this study was 44% for all exacerbations and 91% for late exacerbations. The authors of the study concluded that protection did not develop until at least 3 weeks after immunization. [11] Ting et al. 2011 reported that influenza vaccine is safe in COPD patients and does not cause an increase in exacerbations. [12]
Figure 1: Bar graph comparing different entities before and after vaccination in chronic obstructive pulmonary disease

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Table 2: Episodes and severity (median) of acute respiratory infection in all patients with chronic obstructive pulmonary disease

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  Discussion Top


COPD is a major cause of chronic morbidity and mortality worldwide; many people suffer from this disease for years and die prematurely from it or its complications. [1] In fact, by 2020, the World health Organization predicts that COPD will become the third leading cause of death and the fifth leading cause of disability worldwide. [13] In 1990, COPD was the twelfth leading cause of disability-adjusted life years (DALY) lost in the world, responsible for 2.1% of the total. According to the projections, COPD will be the seventh leading cause of DALYs lost worldwide in 2030. [14] Influenza viruses are a major cause of mortality and serious morbidity in the elderly individuals, particularly in patients with COPD. [15] A novel influenza A (H 1 N 1 ) virus emerged in mid-April 2009 and spread rapidly among humans worldwide. [16],[17] The highly conserved nature of 2009A/H 1 N 1 virus seen during the first wave of pandemic is in agreement with circulating 2009A/H 1 N 1 viruses across the world. Sixteen months after the first pandemic viruses were isolated from Mexico and United States in April 2009, the virus is still antigenically homogeneous. However, as the hemagglutinin (HA) continues to circulate in the human population, its HA antigenic sites are likely be targeted by antibody-mediated selection pressure, which may affect antigenicity or virulence as this virus evolves. HA variation may also be driven by neuraminidase inhibitor use as well as antibody-mediated selection. HA mutations affecting enzymatic activity may appear in viruses that generate neuraminidase inhibitor resistance mutations. [18]

There are three types of influenza viruses A, B, C. Human influenza A and B viruses cause seasonal epidemics of disease almost every winter in the United States current subtypes of influenza A viruses found in people are influenza A (H 1 N 1 ) and influenza A (H 3 N 2 ) viruses. [11] Influenza vaccination can reduce illness and death in COPD patients. [19] Vaccines containing killed or live inactivated viruses are recommended as they are more effective in elderly patients with COPD. [20]

Influenza vaccine has proved to be effective in preventing hospital admissions and deaths in populations of elderly people. [13],[21],[22],[23],[24] Influenza vaccination is therefore currently recommended for people with chronic pulmonary disorders. [13] A few studies on the other hand, have documented that there is no reduction in the incidence rate of influenza-associated respiratory morbidity in patients with COPD. [14],[15] The naturally occurring influenza virus strain often varies from year to year, and although the vaccine strain frequently matches the epidemic strain, occasionally it does not. As a result vaccine, efficacy is expected to vary according to the match between the epidemic and vaccine strains. [16] Vaccines that are available now are effective only against the infecting strains of virus that have hemagglutinins, the vaccine may provide partial protection. A major change in the viral agglutinins results in a lack of protection from the vaccine. The prevention of acute respiratory infection was used as index of efficacy of influenza vaccination in some studies. [25],[26] This study has used the criteria of acute episodes, emergency visits, hospital, and ICU admission to evaluate the effectiveness of influenza vaccine.

  1. Virus used to make the vaccine is grown in allantoic fluid, and contraindications to vaccination include hypersensitivity to eggs, polymyxin, or neomycin. [27] Patients with egg allergy were not included in this study. Several studies have assessed the efficacy and cost-effectiveness of influenza vaccine and have reported favorable outcome especially in the elderly population. [22],[28],[29] Various studies have been done to show the safety of influenza vaccine. [30],[31] Patients in this study did not show any immediate or late reaction after vaccination. There were no local or systemic side effects in these patients. Influenza vaccine is safe and effective. Recent studies have also been done to determine the overall prevalence of influenza vaccine and was found to be 62.7%. [32] Some studies showed that efficacy of influenza vaccination had been documented to range from 32% to 45%. [9],[33],[34],[35] Few studies, on the other hand, showed that influenza vaccine had no protective effect in preventing hospital admission, respiratory failure, mortality in older men, and asthmatics. [36],[37] This study has shown the benefits of influenza vaccination on reducing the acute episodes, emergency visits, hospital admission, ICU admissions, and sputum quantity among the diagnosed COPD patients those who were ex-smokers and among nonsmoker's females before and after vaccination. Overall effectiveness of vaccine was found to be 63.12%. Thus, influenza vaccine was found to be safe and effective in this study.



  Conclusions Top


Influenza vaccine is safe and effective among moderate, severe, and very severe COPD patients. It has also been found very effective in severe COPD patients associated with comorbidities.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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