Abstract
BACKGROUND: Chronic Obstructive Pulmonary Disease (COPD) is a long-standing respiratory illness marked by ongoing airflow obstruction and inflammation. It continues to be a major contributor to global disease, and death, with low- and middle-income countries (LMICs) experiencing a disproportionate impact. India, as one of the largest LMICs, plays a significant role in global COPD-related mortality and disability-adjusted life years (DALYs). In India, COPD continues to be underrecognized owing to limited spirometry availability, inconsistent diagnostic approaches, and weak surveillance systems. Previous prevalence estimates are both outdated and methodologically inconsistent, while the COVID-19 pandemic may have further shifted disease trends. This systematic review and meta-analysis seeks to bridge these gaps by delivering current, standardized, and comprehensive prevalence data. OBJECTIVE: To estimate the pooled prevalence of spirometry-confirmed COPD among Indian adults and identify key demographic and environmental correlates through a systematic review and meta-analysis of observational studies. METHODS: This systematic review and meta-analysis aimed to determine the prevalence of spirometry-confirmed COPD among Indian adults. The study was registered in PROSPERO (CRD420251140678) and conducted in accordance with PRISMA guidelines. Literature searches were carried out in PubMed, EMBASE, Scopus, and Web of Science up to June 9, 2025, using relevant MeSH terms and keywords on COPD, prevalence, and India. Eligible studies included observational designs reporting spirometry-based COPD prevalence in adults; studies relying on non-spirometry diagnosis, qualitative designs, interventions, or non-English publications were excluded. Three reviewers independently screened records, extracted study and population data, and evaluated methodological quality using the Joanna Briggs Institute (JBI) checklist. Pooled prevalence was calculated using a random-effects model. Heterogeneity was assessed with I(2) and Cochran’s Q, complemented by Baujat and Galbraith plots. Subgroup and sensitivity analyses examined variations by diagnostic criteria, demographics, and exposures, while publication bias was tested using funnel plots, Egger’s and Begg’s methods, and trim-and-fill analysis. RESULTS: Twenty-three studies comprising 27,319 Indian adults were included. The pooled prevalence of COPD was 13% (95% CI: 9%–18%), with substantial heterogeneity (I(2) = 99.8%). Higher prevalence was observed among smokers (37%), elderly adults (≥ 60 years: 27%), males (16%), and biomass fuel users (8%). Studies using GOLD criteria reported a higher prevalence (15%) than those using FEV₁/FVC < LLN (10%). Hospital-based studies showed a greater prevalence (27%) than community-based ones (12%). Regional variation was notable, with North India reporting the highest prevalence (19%) and West India the lowest (7%). Sensitivity analyses confirmed the robustness of findings; publication bias was minimal and did not significantly affect pooled estimates. CONCLUSION: COPD remains a significant and underrecognized public health challenge in India. As all included studies were appraised as good quality using the JBI tool, the evidence base is strong and supports reliable pooled estimates. Therefore, our conclusions emphasize the importance of routine spirometry-based screening, targeted interventions for high-risk groups, and integration of COPD surveillance into India’s NCD framework, while reinforcing gender-sensitive strategies and clean fuel initiatives as evidence-based measures to reduce disease burden and guide policy planning. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12890-026-04134-0.