Condition Hard to Differentiate From Novel Coronavirus Infection

In one weekend at the beginning of February, more than 950 veterans received COVID-19 vaccines at the Salisbury, NC, VAMC’s Mass COVID-19 Vaccination Event. Now, the facility has opened vaccines for all veterans 65 and older as well as younger veterans with national Centers for Disease Control and Prevention (CDC)-defined high-risk conditions and their caregivers. Photo from Salisbury, NC, Facebook page.

SALISBURY, NC — There’s some good news for veterans with chronic obstructive pulmonary disease. After a year of anxiety over COVID-19, all veterans who receive care through the VA and have a diagnosis of COPD are eligible for immunization in a growing number of VA facilities.

More than 14% of veterans have COPD, a prevalence rate nearly one-third higher than seen in the general population. VA research indicates that the higher rate of respiratory diseases in veterans may be attributed to exposure to potentially toxic respiratory irritants during deployments, including burn pits, pesticides and other hazardous chemicals, and dust. Smoking, which is more common in servicemembers and veterans, is the primary cause of COPD.

The Salisbury VA Health Care System was one of the first to expand eligibility. The facility moved to Phase 1C in late January, making all veterans 65 and older as well as younger veterans with national Centers for Disease Control and Prevention-defined high-risk conditions and their caregivers eligible for the vaccine. Those conditions include COPD, cancer, chronic kidney disease, Down syndrome, heart conditions, pregnancy, sickle cell disease, smoking, obesity, organ transplant-related immunocompromise and Type 2 diabetes.

“We know that patients that have had those medical conditions …. have a greater risk of having an adverse outcome, should they contract the disease,” J. David Waller, MD, deputy chief of staff for the VA North Florida/South Georgia, told News4 JAX. “[W]e just want to try and protect as many of those people as we can.”

With the help of two mass vaccination events that immunized more than 1,000 veterans each, Salisbury reached the milestone of 10,000 veterans vaccinated on Feb. 13. Two weeks later, Salisbury opened vaccines to all veterans, even as the VA facilities in Charlotte and Kernersville, NC, stayed at Stage 1C. Veterans with COPD and other high-risk conditions who typically receive care at the other North Carolina locations were invited to schedule a vaccination appointment in Salisbury.

The VA announced in early February that all facilities could move to 1C. In addition to high-risk patients, the VA included veterans employed as essential workers to those eligible two weeks later. Still, many locations continue to work through their lists of highest priority veterans—those in long-term care facilities, VA healthcare workers and veterans over age 75.

The high number of older patients and veterans with multiple comorbidities means that many veterans with COPD who are eligible to receive their shots through the VA might find it faster to receive their vaccines through local vaccine clinics run by their state or their employer. If they have one of those options before they can get immunized at the VA, they should take it.

“We want to encourage veterans to get the COVID vaccine as soon as it becomes available to them,” said Sophia Califano, MD, chief consultant for preventive medicine at the National Center for Health Promotion and Disease Prevention. “We believe this is the best path forward and the best way to protect you and your family.”


The vaccines offer an opportunity to relax the heightened vigilance adopted by many individuals with COPD and other respiratory illnesses and alleviate the anxiety that a COVID-19 infection could go undetected for too long. As veterans with COPD frequently experience many of the symptoms common to COVID-19 including coughing, shortness of breath and chest tightness, determining whether recurrent symptoms indicate an infection with SARS-CoV-2 can be challenging—and critical.

A January report by the Global Strategy for the Diagnosis Management, and Prevention of COPD (GOLD) Science Committee concluded that, while studies regarding increased risk of contracting COVID-19 for individuals with COPD have shown mixed results, the positive association between COPD and serious illness or death in those who become infected is quite clear. The GOLD report authors included Antonio Anzueto, MD, PhD, of the division of pulmonary/critical care medicine at the South Texas Veterans Health Care System and professor of medicine at the University of Texas Health Graduate School of Biomedical Sciences, both in San Antonio, TX.1

The GOLD Report followed a study in the Journal of Allergy and Clinical Immunology that research that failed to differentiate asthma from COPD could have understated the risk of negative outcomes from COVID-19. “In distinguishing asthma within chronic respiratory disease categorization, we found that a comorbid diagnosis of COPD was a strong risk factor for hospitalization, and the only comorbidity that remained statistically significant after correction for multiple comparisons,” the authors wrote.2

Comorbidities appear to be a key contributor to more serious illness with COVID-19, VA researchers led by George Ioannou, BMBCh, of VA Puget Sound Health System in Seattle determined. While they did not find a strong association between COPD and hospitalization and death, unlike previous studies, they did find that a high burden of comorbidities nearly doubled mortality on an adjusted basis. Explaining the difference in their results in an analysis of more than 88,000 veterans tested for COVID-19 from earlier reports, including not detecting an increased risk for serious illness or death associated with COPD, they suggested that differences might be attributed to the choice of confounders for which various teams adjusted and “the attenuation of racial/ethnic disparities in access to care in the VA system relative to the private sector.”3

Many veterans with COPD have taken the warnings to minimize their risk of COVID-19 infection to heart. For those that have been locked down for more than a year now, knowing that they are eligible for the vaccine is a tremendous relief. Waiting for their turn to get the shots while others who are older or sicker get theirs, while understandable, remains frustrating.

As a veterans’ organization, the American Legion can take a broader view than the individual high-risk veterans eager to ease up on pandemic restrictions. “The American Legion has the utmost confidence in VA to balance the vaccine rollout, while prioritizing the most vulnerable veterans and health-care providers,” said Mario Marquez, director of The American Legion’s Veteran Affairs & Rehabilitation Division. “VA has assured us they will provide this balance with site-specific resources, needs, availability and local status of the pandemic.”


  1. Halpin DMG, Criner GJ, Papi A, Singh D, Anzueto A, Martinez FJ, Agusti AA, Vogelmeier CF. Global Initiative for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease. The 2020 GOLD Science Committee Report on COVID-19 and Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med. 2021 Jan 1;203(1):24-36. doi: 10.1164/rccm.202009-3533SO. PMID: 33146552; PMCID: PMC7781116.
  2. Wang L, Foer D, Bates DW, Boyce JA, Zhou L. Risk factors for hospitalization, intensive care, and mortality among patients with asthma and COVID-19. J Allergy Clin Immunol. 2020;146(4):808-812. doi:10.1016/j.jaci.2020.07.018
  3. Ioannou GN, Locke E, Green P, et al. Risk Factors for Hospitalization, Mechanical Ventilation, or Death Among 10 131 US Veterans With SARS-CoV-2 Infection. JAMA Netw Open. 2020;3(9):e2022310. doi:10.1001/jamanetworkopen.2020.22310