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Data availability The datasets used are publicly available from the National Vital Statistics System

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The course of the disease is featured and frequently aggravated by intermittent exacerbations, acute changes in the airway microbiome, for example by introduction of a new strain of a respiratory pathogen, lead to larger inflammatory responses, which present clinically as exacerbations of COPD [80], so changes in the composition and activity of the microbiome may be implicated in their appearances