Research has shown that patients with diabetes are more prone to getting various types of infections, which in turn can increase their risk for hospitalizations. According to Cecilia C. Low Wang, MD, FACP, it can be challenging for clinicians to ensure that their patients with diabetes are up to date with vaccinations against common infections. “Oftentimes, clinicians are busy focusing on the management of diabetes and disease-related complications,” she says. “Prevention efforts like immunizations can sometimes take a backseat to other diabetes care issues.”
Influenza & Pneumonia
The American Diabetes Association, the CDC, and other groups have developed recommendations to guide clinicians on the vaccinations that should be administered to patients with diabetes. Influenza and pneumococcal vaccines are recommended for all individuals with diabetes (Table 1). The flu is among the most common infections in diabetics and has been linked to high morbidity and mortality as well as an increase in hospitalizations. Published data have shown that the influenza vaccine helps reduce diabetes-related hospital admissions by nearly 80% during flu epidemics. Studies have also shown that people with diabetes appear to be at higher risk for pneumococcal infection and nosocomial bacteremia, which has a mortality rate that has been reportedly as high as 50%.
“The flu and pneumonia are preventable infectious diseases,” says Dr. Low Wang. “Safe and effective vaccines are available and can greatly reduce the risk of serious complications from these infections.” The American Diabetes Association notes in its annual Standards of Medical Care in Diabetes that there is sufficient evidence to support that people with diabetes have appropriate serological and clinical responses to the influenza and pneumococcal vaccines.
Most individuals with diabetes should receive the pneumococcal polysaccharide (PPSV23) form of the pneumococcal vaccine, but this is contraindicated during pregnancy. A second dose of PPSV23 is required if the first dose was administered prior to the age of 65 and at least 5 years since the first dose.
Late in 2012, the Advisory Committee on Immu-nization Practices of the CDC recommended that all previously unvaccinated adults with diabetes between the ages of 19 and 59 be vaccinated against hepatitis B virus (HBV) as soon as possible after they are diagnosed with diabetes. The CDC also recommends that HBV vaccination be considered for those older than 60 after assessing risk and the likelihood of an adequate immune response. The age differentiation stems from CDC economic models. These models suggested that vaccinating adults with diabetes between the ages of 19 and 59 would cost an estimated $75,000 per quality-adjusted life-year saved. Cost per quality-adjusted life-year saved increased significantly at older ages. Also, the immune response to the HBV vaccine declines with age, and there are competing causes of mortality in older adults to consider (Table 2).
According to the CDC, at least 29 outbreaks of HBV have been reported in long-term care facilities and hospitals, with the majority of cases involving adults with diabetes who received assisted blood glucose monitoring. In these cases, this monitoring was done by a healthcare professional with responsibility for more than one patient. Studies show that the risk of acute HBV infection is about twice as high among adults with diabetes aged 23 and older when compared with adults who do not have diabetes. This finding occurred despite the exclusion of people with HBV-related risk behaviors. Furthermore, there is some evidence that diabetes imparts a higher HBV case fatality rate.
“HBV is highly transmissible and stable for long periods of time on surfaces like lancing devices and blood glucose meters, even when no blood is visible,” says Dr. Low Wang. “Insulin pens are another potential source for HBV infection. As a result, patients should be instructed not to share these devices with other individuals.” Beyond HBV infection, Dr. Low Wang says other vaccinations that are recommended for the general population should also be provided to patients with diabetes. These include common vaccinations, such as measles, mumps, and rubella; meningococcal disease; tetanus, diphtheria, and whooping cough; varicella; zoster; hepatitis A; and HPV (Table 3).
“Clinicians need to be vigilant about vaccinations when treating patients with diabetes,” Dr. Low Wang says. “Protocols should be in place to ensure that recommended vaccinations are accounted for in a checklist for comprehensive diabetes care,” she says. “Records should be updated on what vaccinations patients have completed as well as the ones that need to be administered. Clinicians should also refer back to vaccine recommendations from the American Diabetes Association and the CDC in case changes are made. The key is to keep immunizations in mind when treating patients with diabetes. This is an important part of care that should not be overlooked.”
American Diabetes Association. Standards of Medical Care in Diabetes—2014. Diabetes Care. 2014;37:S14-S80.
Centers for Disease Control and Prevention. Use of hepatitis B vaccination for adults with diabetes mellitus: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 2012;60:1709-1711. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6050a4.htm.
Immunization Action Coalition. Vaccinations for Adults with Diabetes. Available at: http://www.immunize.org/catg.d/p4043.pdf.
Smith SA, Poland GA. Use of influenza and pneumococcal vaccines in people with diabetes. Diabetes Care. 2000;23:95-108.
Colquhoun AJ, Nicholson KG, Botha JL, Raymond NT. Effectiveness of influenza vaccine in reducing hospital admissions in people with diabetes. Epidemiol Infect. 1997;119:335-341.
Bridges CB, Fukuda K, Uyeki TM, Cox NJ, Singleton JA; Centers for Disease Control and Prevention, Advisory Committee on Immunization Practices. Prevention and control of influenza. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2002;51(RR-3):1-31.