Long-term impact of SARS-CoV-2 on recurrent COPD exacerbations

BACKGROUND: SARS-CoV-2 infection could increase the long-term risk of recurrent chronic obstructive pulmonary disease (COPD) exacerbations. This study investigated the long-term risk of COPD exacerbations following SARS-CoV-2 infection, with comparisons by hospitalisation status. METHODS: We conducted a retrospective cohort study using data from a large urban academic health system (March 2020-February 2025). The final cohort comprised of 2268 hospitalised and 1471 non-hospitalised COVID-19 patients with pre-existing COPD, each matched 1:1 by propensity score with non-COVID controls. Adjusted hazard ratios (aHRs) were estimated using Andersen-Gill models, and adjusted incidence rate ratios (aIRRs) using negative binomial models. Cumulative hazards were derived from Nelson-Aalen curves. Secondary analyses evaluated socioeconomic factors and multiple sensitivity analyses assessed robustness. FINDINGS: Among hospitalised patients, the incidence rate of COPD exacerbations was 35.7 per 100 person-years in the COVID-19 cohort, compared to 15.9 in controls (aIRR 1.81 [95% CI, 1.45-2.26]). Among non-hospitalised patients, rates were 13.7 vs 10.6 (aIRR 1.23 [0.88-1.73]). Hospitalised patients had a higher overall hazard of recurrent COPD exacerbations (aHR 1.69 [1.36-2.10]; p < 0.001), with risk persisting over four years post-infection. No significant difference was observed among non-hospitalised patients. Unmet social needs increased the risk by 53% among hospitalised patients, while Medicaid or Medicare coverage more than doubled the risk among non-hospitalised patients relative to private insurance. Findings were consistent across multiple sensitivity analyses. INTERPRETATION: COVID-19 hospitalisation was associated with a sustained increased risk of recurrent COPD exacerbations, underscoring the need for long-term pulmonary follow-up and targeted interventions in this high-risk population. FUNDING: None.