Why People With Chronic Lung Conditions Need Influenza Vaccination

It is common for people to catch influenza (better known as the flu). However, certain high risk groups have a higher likelihood of developing serious complications after the infection[1].

One such group comprises people with chronic lung conditions. For these individuals, something as natural as breathing can be quite a struggle on a day-to-day basis. If they acquire influenza, their breathing difficulty may worsen. This could be due to exacerbation of underlying lung conditions or development of secondary complications, such as pneumonia [2].

Clearly, it is important to prevent influenza among people with lung conditions. This has led various medical bodies worldwide and in Malaysia to recommend annual influenza vaccination[2],[3] for this vulnerable group.

In a general population, annual influenza vaccination has been shown to be about 60% effective in preventing influenza infection [4]. Additionally, vaccinated adults are 37% less likely to be admitted into the ICU compared to unvaccinated adults. Risk of mortality is also 52-79% lower in those who are vaccinated than those who are not[5]. Influenza vaccination can confer even more significant protective effects in those with lung conditions.


About half a million Malaysians suffer from moderate to severe chronic obstructive pulmonary disease (COPD)[6] that is characterised by persistent limitation of airflow [7]. Common forms of COPD include emphysema (due to destruction of lung tissue), and chronic bronchitis (secondary to long-term inflammation of the airways)[7].

Typically, COPD patients may present with shortness of breath, wheezing, chest tightness, and chronic cough with sputum production [7]. However, this condition is often only diagnosed after about half of the lung function is impaired [8]. At this stage, performing daily chores requires tremendous effort which severely impairs quality of life, with 23% of patients unable to work while 42% only able to perform limited amount of work or activities [9].

Influenza is a serious threat to people with COPD. Influenza accounts for up to 1-in-10 admissions to hospital [10]. Adding to the concern, patients who are hospitalised with acute COPD exacerbation are 3 times more likely to die if they have influenza [11].

Influenza vaccination has been shown to reduce the rate of hospitalisation by half among individuals with chronic lung diseases and lower the mortality risk by 70% [3]. Based on these findings, the Clinical Practice Guidelines for the Management of COPD (2nd edition) recommends that COPD patients be vaccinated annually to protect against influenza-associated complications and aggravated COPD symptoms[3].


Asthma is one of the most common chronic respiratory conditions in the world [12]. In Malaysia, about 7.1% of children and 4.5% of adults have asthma [13]. They typically experience recurring episodes of wheezing, chest tightness, shortness of breath, and cough [12].These symptoms can be attributed to the presence of narrowed airways as a result of inflammation, excessive mucus production and constriction of sensitised airways [12].

For asthmatic individuals, acute exacerbation of symptoms (asthma attack) is a main concern. They can be triggered by a host of factors, such as dusts, animal dander and pollen [14]. Influenza is also one of the triggers to watch as it can lead to severe complications[14].

Infected asthmatic children have been found to receive twice as many antibiotics (to treat asthma) and were more likely to visit the hospital compared with those without asthma [15]. Moreover, the risk of asthma treatment failure will increase by 24.9% if influenza is present [16].

Influenza infection can render asthmatic adults to be more susceptible to bronchoconstriction and prolonged decline in lung function [17]. Asthma attacks induced by influenza are associated with higher rate of hospitalisation and death, particularly in the elderly [17].

Recognising the danger that influenza poses, the US Centers for Disease Control and Prevention recommend annual influenza vaccination for asthmatic children aged 6 months and older as well as for adults, even if their asthma is not severe or their symptoms are controlled[2].


Caring for someone with a chronic lung condition can be challenging as one needs to be constantly vigilant and ready to act in the event of an episode. As such, family members and carers would do well to learn more about influenza and actively encourage influenza vaccination for the patient as well as for themselves [18]. This would go a long way towards preventing the spread of influenza in the house, while averting the cost and anguish associated with its complications.

The role of family members in advocating influenza vaccination is very important. At present, some 33-42% of high-risk individuals do not vaccinate against influenza. Some believe they can resist the infection[19] whereas others often mistake the disease for the common cold. During the 2009 H1N1 influenza outbreak, 41% of Malaysian adults believed that it was just a mild disease and there was no need to be vaccinated[20]. This misperception persists to this day.

Conversely, studies have shown that personal encouragement can make a big difference. Advice from healthcare professionals and family members have been shown to increase vaccination coverage by 25-48%[19]. Change can come from caring, indeed.

[1]CDC (2018). People at High Risk of Developing Flu-Related Complications. Retrieved from https://www.cdc.gov/flu/about/disease/high_risk.htm
[2]CDC (2017). Adults With Chronic Conditions: Get Vaccinated. Retrieved from https://www.cdc.gov/features/vaccineschronicconditions/index.html
[3]3. Ministry of Health Malaysia (2009). CPG Management of Chronic Obstructive Pulmonary Disease 2nd Edition, p21. Retrieved from www.acadmed.org.my
[4]CDC (2017). Vaccine Effectiveness – How Well Does the Flu Vaccine Work? Retrieved from https://www.cdc.gov/flu/about/qa/vaccineeffect.htm
[5]Arriola et al (2017). Influenza Vaccination Modifies Disease Severity Among Community-dwelling Adults Hospitalized With Influenza. Infectious Diseases Society of America.2017;65(8):1289–97
[6]Regional COPD Working Group (2003). COPD Prevalence in 12 Asia-Pacific Countries and Regions: Projections Cased on the COPD Prevalence Estimation Model. Respirology 8(2):192-198
[7]COPD Foundation (2018). What is COPD? Retrieved from https://www.copdfoundation.org/What-is-COPD/Understanding-COPD/What-is-COPD.aspx
[8]Cleveland Clinic (2015). Emphysema. Retrieved from https://my.clevelandclinic.org/health/diseases/9370-emphysema
[9]Lim et al (2015). Impact of Chronic Obstructive Pulmonary Disease in the Asia-Pacific Region: the EPIC Asia Population-based Survey. Asia Pacific Family Medicine. 14(4):DOI 10.1186/s12930-015-0020-9
[10]Qureshi et al (2014). Chronic Obstructive Pulmonary Disease Exacerbations: Latest Evidence and Clinical Implications. Therapeutic Advances in Chronic Disease. 5(5):212-227
[11]Koul et al (2014). Contribution of Influenza to Acute Exacerbations of Chronic Obstructive Pulmonary Disease in Kahsmir, India, 2010-2012. Influenza and Other Respiratory Viruses 9(1):40-42
[12]WHO (2017). Asthma. Retrieved from http://www.who.int/news-room/fact-sheets/detail/asthma
[13]13. Ministry of Health (2006). National Health and Morbidity Survey III. pp28,31. Retrieved from http://iku.moh.gov.my/images/IKU/Document/REPORT/2006/ExecutiveSummary.pdf.
[14] McErlean et al (2010). Viral Diversity in Asthma. Immunology Allergy Clinic North America. Nov 30(4): 481-495
[15] National Foundation for Infectious Diseases (2006). Influenza and Children with Asthma. Retrieved from http://www.nfid.org/Content-Conversion/pdf/fluasthmamono.pdf
[16] Merckx et al (2018). Respiratory Viruses and Treatment Failure in Children With Asthma Exacerbation. Pediatrics. 142(1):e20174105
[17] Watanabe et al (2005). Prevention of Asthma Exacerbation with Vaccination Against Influenza in Winter Season. Allergology International. 54(2):305-309
[18] Yeung et al (2016). Factors Associated with the Uptake of Seasonal Influenza Vaccination in Adults: A Systematic Review. Journal of Public Health. 38(4):746-753
[19] Kroneman et al (2006). Influenza Vaccination Coverage and Reasons to Refrain among High-Risk Persons in Four European Countries. Vaccine. 24(5):622-628
[20] Wong et al (2010). Factors Influencing the Uptake of 2009 H1N1 Influenza Vaccine in Multiethnic Asian Population. Vaccine. 17(28):499-505

SPMY.IFLU.18.09.0215 (09/18)