Influenza vaccine for patients with chronic obstructive pulmonary disease

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Abstract
Influenza vaccinations are currently recommended in the care of people with COPD, but these recommendations are based largely on evidence from observational studies with very few randomised controlled trials (RCTs) reported. Influenza infection causes excess morbidity and mortality in COPD patients but there is also the potential for influenza vaccination to cause adverse effects or not to be cost effective. To evaluate the evidence from RCTs for a treatment effect of influenza vaccination in COPD subjects. Outcomes of interest were exacerbation rates, hospitalisations, mortality, lung function and adverse effects. We searched the Cochrane Airways Group Specialised Register of trials, and reference lists of articles. References were also provided by a number of drug companies we contacted. The latest search was carried out in May 2010. RCTs that compared live or inactivated virus vaccines with placebo, either alone or with another vaccine in persons with COPD. Studies of people with asthma were excluded. Two reviewers extracted data. All entries were double checked. Study authors and drug companies were contacted for missing information. Eleven trials were included but only six of these were specifically performed in COPD patients. The others were conducted on elderly and high‐risk individuals, some of whom had chronic lung disease. Inactivated vaccine in COPD patients resulted in a significant reduction in the total number of exacerbations per vaccinated subject compared with those who received placebo (weighted mean difference (WMD) ‐0.37, 95% confidence interval ‐0.64 to ‐0.11, P = 0.006). This was due to the reduction in "late" exacerbations occurring after three or four weeks (WMD ‐0.39, 95% CI ‐0.61 to ‐0.18, P = 0.0004). In Howells 1961, the number of patients experiencing late exacerbations was also significantly less (odds ratio 0.13, 95% CI 0.04 to 0.45, P = 0.002). Both Howells 1961 and Wongsurakiat 2004 found that inactivated influenza vaccination reduced influenza ‐related respiratory infections (WMD 0.19, 95% CI 0.07 to 0.48, P = 0.0005). In both COPD patient and in elderly patients (only a minority of whom had COPD), there was a significant increase in the occurrence of local adverse reactions in vaccinees, but the effects were generally mild and transient. There was no evidence of an effect of intranasal live attenuated virus when this was added to inactivated intramuscular vaccination. The studies are too small to have detected any effect on mortality. An updated search conducted in September 2001did not yield any further studies. A search in 2003 yielded two further reports of the same eligible study Gorse 2003. A search in 2004 yielded two reports of the another eligible study Wongsurakiat 2004. The author informed us of another report of the same study Wongsurakiat 2004/2. An update search in May 2010 did not identify any new studies for consideration. It appears, from the limited number of studies performed, that inactivated vaccine reduces exacerbations in COPD patients. The size of effect was similar to that seen in large observational studies, and was due to a reduction in exacerbations occurring three or more weeks after vaccination, and due to influenza. There is a mild increase in transient local adverse effects with vaccination, but no evidence of an increase in early exacerbations. 對慢性阻塞性肺病(COPD)患者施打流感疫苗 對於慢性阻塞性肺病患者的照顧，目前建議接種流感疫苗，但是這些建議主要是根據觀察性研究證據，很少來自於隨機對照試驗的報告。慢性阻塞性肺病患者一旦感染流行性感冒，將造成罹病率和死亡率增加；然而流感疫苗接種可能造成副作用，或不符合成本效益。 有關慢性阻塞性肺病患者接受流感疫苗接種的效果，評估來自於隨機對照試驗的證據。重要結果有：發病率、住院率、死亡率、肺功能和副作用等。 搜尋Cochrane Airways Group Specialised Register資料庫，以及文章的參考目錄清單。同時聯絡一些藥廠提供參考資料。最後一次搜尋時間是2007年5月。 在慢性阻塞性肺病患者身上，比較活性或去活性病毒疫苗和安慰劑的隨機對照試驗－單獨接種或與另一種疫苗同時接種。排除那些納入氣喘病患的研究。 兩位審查員擷取數據。所有輸入資料都經過雙重檢驗。短缺的資料則連絡研究作者和藥廠。 共納入十一個試驗，但只有六個特別針對慢性阻塞性肺病患者。其他試驗對象為老年人和高危險群，其中有些是慢性阻塞性肺病患者。與安慰劑相比，慢性阻塞性肺病病患接受去活性疫苗者，其個人發作總次數明顯減少(加權平均差[WMD] 0.37，95% 信賴區間0.64到0.11，P = 0.006)。這是因為三到四週後的晚期發作減少(加權平均差0.39，95% 信賴區間0.61到0.18，P = 0.0004)。Howells氏1961年的 報告，經驗晚期發作的病人數也明顯減少(危險對比值 [OR] 0.13，95%信賴區間0.04到0.45，P = 0.002)。Howells氏在1961年和Wongsurakiat氏於2004年的報告都發現：去活性流感疫苗接種可以減少流感相關的呼吸道感染(加權平均差0.19，95% 信賴區間0.07到0.48，P = 0.0005)。在慢性阻塞性肺病病患和老年病患(只有一小部分有慢性阻塞性肺病)中，注射疫苗的局部不良反應明顯增加，但通常是輕度和暫時性的。沒有證據顯示：在去活性肌肉注射疫苗外，加上鼻內減毒活性病毒的效果；這些研究太小以至於無法偵測到對死亡率的影響。2001年9月的更新搜尋並沒有找到任何進一步的研究。2003 年的搜尋找到新的研究－Gorse氏2003年的兩篇報告。2004年的搜尋又找到Wongsurakiat氏2004年研究的兩篇報告。該作者通知我們同一個還有另一篇報告Wongsurakiat...

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