Decreased COPD Exacerbation Rates During the COVID-19 Pandemic

Incidence rates of infectious diseases have fallen since the start of the COVID-19 pandemic. This trend was also observed in Germany in 2020. A fall was seen primarily in travel associated diseases, gastrointestinal tract infections, measles, Haemophilus infections, and flu (1).

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are associated with a poor prognosis and disease progression. In this setting, infections play an important role. Viral infections—for example rhinovirus, influenza, and parainfluenza—may trigger 30–60% of all acute exacerbations. The most commonly occurring bacterial pathogens are Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, and Pseudomonas aeruginosa (2). Preventing exacerbations is one of the most important objectives in treating chronic obstructive pulmonary disease (COPD).

During the COVID pandemic, a range of behavioral measures were imposed so as to prevent the spread of the virus. Independently of their effectiveness, these measures were suitable for preventing other infections transmitted by the respiratory route too. Initial reports found a reduction in AECOPD rates of 50%.

Alsallakh et al analyzed data from the Welsh and Scottish health services. The weekly number of hospital admissions for COPD (ICD-10: J43/44) and COPD specific death rates in the first 30 weeks of 2020 were compared with the five preceding years. The authors reported a reduction in hospital admissions of 52% in Scotland and 40% in Wales without any change in death rates (3). Similarly, in 11 hospitals in the US state of Maryland, hospital admissions for AECOPD fell by 54.8% (4). Data collection from Slovenia showed a reduction in severe exacerbations by 48% and of moderate events of 34% (5). These data did not differentiate between AECOPD events in ambulatory or in hospitalized patients and therefore cannot answer the question of whether solely hospital admission numbers were reduced or whether it was rather a general reduction in AECOPD rates owing to preventive measures. Similarly, effects on the seasonally raised exacerbation rate cannot be concluded.

Method and results

To answer this question we analyzed anonymized data from a large health insurance fund with 4.5 million members (AOK Saxony and Thuringia). Between 2016 and 2021 data of 516 591 patients with AECOPD (including J44.0 or J44.1; ICD-10) were collected. 466 841 patients were treated outside the hospital and 49 750 as inpatients. From 2016 to 2019, an average of 81 628 outpatients and 9378 hospital inpatients with AECOPD were counted. In 2020 the number of patients receiving outpatient care for AECOPD fell by 9.7% (73/702) and in 2021 by 18.4% (66/629) (Figure).

Figure

Numbers of patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) in 2016–2021

Hospital admissions because of AECOPD fell in 2020 by 27.6% (6791) and in 2021 by 41.9% (5447). The AECOPD risk was reduced from 3/100 (0.28%) in 2016–2019 to 2/1000 (0.18%) in 2020 and 1/1000 (0.12%) in 2021.

The seasonal rise in patients with AECOPD in the first quarter of each year, which was particularly pronounced in 2018 due to a flu pandemic, was not detectable in 2021. The number of inpatient exacerbations was found to be notably more reduced than that of outpatient exacerbations.

Additionally we examined data from inpatients with AECOPD in three hospitals providing basic care (Emden/Aurich/Norden, Lower Saxony) and one university hospital (Leipzig, Saxony). Hospital. The number of admissions owing to AECOPD in was reduced by 28% in 2020 (n=733) and by 37% in 2021 (n=633). In the prior period of 2016–2019, a yearly average of 1008 patients were admitted as inpatients.

Discussion

These numbers confirm results published previously and demonstrate a general fall in the number of patients with AECOPD in the outpatient setting and more so in inpatient settings. In addition, seasonal exacerbation rates were almost leveled during the pandemic. Unfortunately we could not extract disease specific death rates from this data source. It is possible that the preventive measures implemented to avoid COVID-19 infections are responsible for the changes in exacerbation rates. These include in particular:

• Wearing masks/face coverings
• Minimizing social contacts
• Social/spatial distancing
• Improved hand hygiene
• Vaccinations.

Since most exacerbations of COPD are due to infections, we suspect that the reduced number of exacerbations as well as the leveled seasonal peaks point to the avoidance of infections during the pandemic. One recommendation from this situation may be the continuation of preventive measures for patients at higher risk of AECOPD

As most exacerbations of COPD are due to infections, we suspect that these events and the seasonal rise were affected by preventive measures. The recommendation that should be concluded from this is that patients at higher risk of AECOPD should take preventive measures. These may include masks for crowded spaces and adhering to a minimum distance e.g. during peaks of viral infections.

PD Dr. med. habil. Jens Bräunlich, Prof. Dr. med. Hubert Wirtz

Abteilung für Pneumologie, Universität Leipzig

Conflict of interest statement

The authors declare that no conflict of interest exists.

Manuscript received on 25 August 2022, revised version accepted on 8 November 2022.

Translated from the original German by Birte Twisselmann, PhD.

Cite this as:
Bräunlich J, Wirtz H: Decreased COPD exacerbation rates during the COVID-19 pandemic. Dtsch Arztebl Int 2023; 120: 115–6. DOI: 10.3238/arztebl.m2022.0376

References

1. Robert Koch-Institut: yearbook. www.rki.de/EN/Content/infections/epidemiology/inf_dis_Germany/yearbook/yearbook_summary_2020.html (last accessed on 9 November 2022).

2. Sethi S, Murphy TF: Infection in the pathogenesis and course of chronic obstructive pulmonary disease. NEJM 2008; 359: 2355–65

3. Alsallakh MA, Sivakumaran S, Kennedy S, et al.: Impact of COVID-19 lockdown on the incidence and mortality of acute exacerbations of chronic obstructive pulmonary disease: national interrupted time series analyses for Scotland and Wales. Bmc Med 2021; 19: 124

4. Dezman ZDW, Stryckman B, Zachrison KS, et al.: Masking for COVID-19 is associated with decreased emergency department utilization for non-COVID viral illnesses and respiratory conditions in Maryland. Am J Medicine 2021; 134: 1247–51

5. Sarc I, Dolinar AL, Morgan T, et al.: Mortality, seasonal variation, and susceptibility to acute exacerbation of COPD in the pandemic year: a nationwide population study. Ther Adv Respir Dis 2022; 16; doi:10.1177/17534666221081047