Understanding the Importance of Pneumococcal Disease Prevention in Patients With Diabetes

JULY 23, 2018
TIMOTHY FLYNN, PHARMD, AND CONCHETTA LESSER, PHARMD, BCACP
As autumn approaches, so does the annual flu season. In community pharmacies across the country, pharmacists are also anticipating the advent of the influenza vaccination season. Many patients with diabetes already know they need a flu shot but are unaware of other recommended vaccinations. According to the CDC’s 2017 National Diabetes Statistics Report, the prevalence of influenza vaccination was higher than that for pneumococcal disease (61.6% vs 52.6%).1 Although pharmacists focus on administering the appropriate influenza vaccine to each patient, they should also consider other vaccinations from which patients may benefit, including the 2 available pneumococcal vaccines: pneumococcal conjugate vaccine (PCV13, Prevnar 13) and the pneumococcal polysaccharide vaccine (PPSV23, Pneumovax 23).2,3

RATES AND RISK FACTORS FOR INFECTION IN PATIENTS WITH DIABETES
Patients with diabetes mellitus have been specifically identified as an at-risk group for increased susceptibility to infection and poorer outcomes.4 Not only does diabetes mellitus increase the risk of contracting pneumococcal pneumonia, but patients with diabetes are more likely to be hospitalized, have a longer hospital stay, and die from complications.5,6 Patients with diabetes are at greater risk of infection, and abnormalities in the host defense mechanisms, including deficiencies in antibody response, cell-mediated immunity, leukocyte function, and colonization rates, may all contribute to this increase in risk.7 In patients with diabetes, rates of invasive pneumococcal disease (IPD) are 3.5 times higher and have associated costs of more than 3 times that of healthy adults.8 Poor glycemic control (higher glycated hemoglobin) has been associated with an increased risk of community- acquired pneumonia (CAP) and hospitalization.This underscores the importance of maintaining good glycemic control to prevent complications from pneumococcal pneumonia. 

Streptococcus pneumoniae is the most common cause of CAP and has over 90 bacterial subtypes. The 10 most common subtypes account for 62% of IPD manifesting as bacteremia and bacterial meningitis.10 Pneumococcal disease caused by S pneumoniae kills over 10,000 people each year.11 In 2015, a total of 3350 US adults aged 18 to 64 years died because of IPD. In this demographic, those with underlying health conditions, such as chronic heart disease, chronic lung disease, chronic liver disease, and diabetes, are at increased risk for pneumococcal disease and poorer outcomes. It is also worth noting, from an economic burden perspective, that hospitalizations and outpatient visits in 2004 attributed to S pneumoniae-related infection in those aged 18 to 64 years cost approximately $4 billion in direct medical costs and productivity loss.

The Advisory Committee on Immunization Practices (ACIP) recommends that patients with diabetes receive the PPSV23 once between 2 and 64 years of age. At age 65, everyone should receive a dose of the PCV13 with a follow-up dose of PPSV23 1 year later. PPSV23 and PCV13 should be separated by at least 1 year and there should be at least a 5-year interval between PPSV23 vaccinations.9

Immunization against S pneumoniae in patients with diabetes has proved to decrease the risk of pneumococcal infection.12 The Office of Disease Prevention and Health Promotion, a division of the US Department of Health & Human Services, publishes Healthy People, a set of science-based, 10-year national objectives for improving the health of all Americans. Healthy People 2020 aims to achieve at least 60% immunization coverage in high-risk adults aged 19 to 64 years and at least 90% immunization coverage for those over 65 by the year 2020.8 In 2015, the rate of pneumococcal vaccination for high-risk patients (including patients with diabetes) aged 19 to 64 years was 23%, and the rate of pneumococcal vaccination in adults 65 and older was 63%, both of which are far below the Healthy People 2020 goals.13 See table 1 and table 2 for pneumococcal vaccine recommendations.12
 
 

STRATEGIES FOR INCREASING VACCINATION RATES
A multitude of factors likely contribute to missed opportunities for vaccine coverage at our pharmacies, including not offering routine screenings, not making a strong recommendation, and not keeping up-to-date with current ACIP guidelines. Research indicates that most adults believe vaccines are important and are likely to get them if recommended by a health care professional, such as a pharmacist.14 This emphasizes the role of the pharmacist and that a pharmacist’s strong recommendation to a patient is a critical factor in determining whether a patient will receive a vaccine. The pharmacist can further increase the percentage of patients receiving vaccinations by tailoring recommendations to the individual. This includes sharing information on why vaccination is the right decision, explaining the risks of not getting vaccinated, and addressing any questions or concerns. 

Confusion over which pneumococcal vaccine to recommend is another common barrier to vaccination, especially when the patient reports having received one in the past. Contacting the primary care provider or asking the patient probing questions such as “When did you receive your last vaccination?” and “Why did you receive the vaccination?” can help to determine which vaccine was previously administered and allow the pharmacist to confidently recommend the appropriate vaccine. Some states have an immunization registry that can be accessed by pharmacists and used to verify which vaccines have been administered to the patient. When a determination cannot be made about immunization status, the patient should be treated as vaccine naive and vaccinated according to ACIP recommendations.

Keeping up-to-date with current ACIP guidelines, providing routine screenings, and giving a strong recommendation for indi- cated vaccinations will help pharmacists ensure that their patients with diabetes avoid these preventable infectious diseases.

REFERENCES
1. CDC. National diabetes statistics report, 2017. https://www.cdc.gov/dia- betes/pdfs/data/statistics/national-diabetes-statistics-report.pdf. Published 2017. Updated February 24, 2018. Accessed June 28, 2018.
2. Prevnar (pneumococcal conjugate vaccine) [prescribing information]. Wyeth Pharmaceuticals Inc; 2017. http://labeling.pfizer.com/showlabeling.aspx?id=501. Accessed June 20, 2018.
3. Pneumovax (pneumococcal polysaccharide vaccine) [prescribing information]. Whitehouse Station, NJ: Merck Pharmaceuticals; 2011. http://www.merck.com/ product/usa/pi_circulars/p/pneumovax_23/pneumovax_pi.pdf. Accessed June 20, 2018.
4. Suaya, JA. Jiang Q, Scott DA, et al. Post hoc analysis of the efficacy of the 13-valent pneumococcal conjugate vaccine against vaccine-type community-ac- quired pneumonia in at-risk older adults. Vaccine. 2018;36(11):1477-1483. doi: 10.1016/j.vaccine.2018.01.049.
5. Somnath P. Influenza and pneumonia vaccination in diabetic patients.US Pharm. 2018; 43(4):45-45.
6. Torres A, Blasi F, Dartois N, Akova M. Which individuals are at increased risk of pneumococcal disease and why? Impact of COPD, asthma, smoking, diabetes, and/or chronic heart disease on community-acquired pneumonia and invasive pneumococcal disease. Thorax. 2015;70(10):984-989. doi: 10.1136/ thoraxjnl-2015-206780.
7. Alcusky MJ, Pawasuaskas J. Adherence to guidelines for hepatitis B, pneu- mococcal, and influenza vaccination in patients with diabetes. Clin Diabetes.2015;33(3):116-122. doi: 10.2337/diaclin.33.3.116.
8. Petigara T, Zhang D. Pneumococcal vaccine coverage in adults aged 19-64 years, newly diagnosed with chronic conditions in the US. Am J Prev Med.2018;54(5):620-636. doi: 10.1016/j.amepre.2018.01.033.
9. CDC. Recommended immunization schedule for children and adolescents aged 18 years or younger, United States, 2018. CDC website. cdc.gov/vaccines/sched- ules/hcp/child-adolescent.html. Accessed June 28, 2018.
10. Pneumococcal Vaccines (PCV13 and PPSV23). Immunization Action Coalition website. immunize.org/askexperts/experts_pneumococcal_vaccines. asp. Updated February 1, 2018. Accessed June 6, 2018.
11. Diabetes and pneumonia: get the facts. DiabetesEd.net website. diabetesed. net/page/files/pneumonia-pt-handout-2012.pdf. Accessed June 28, 2018.
12. Smith SA, Poland, GA. Use of influenza and pneumococcal vaccines in people with diabetes. Diabetes Care. 2000;23(1):95-108.
13. Williams WW, Lu P, O’Halloran A, et al. Surveillance of vaccination coverage among adult populations-United States, 2015. MMWR Surveill Summ. 2017;66(11
suppl):1-28. doi: 10.15585/mmwr.ss6611a1.
14. CDC. Vaccine recommendation: a series on standards for adult immunization practice. CDC website. cdc.gov/vaccines/hcp/adults/downloads/standards-im- mz-practice-recommendation.pdf. Updated May 2016. Accessed June 28, 2018.

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