As seasonal influenza activity mounts during the winter, pharmacists become busier with immunization services, and providing such services has become an essential role.1 Influenza and pneumococcal immunization rates for patients with type 2 diabetes (T2D) are below desirable levels, according to the results of a MADIABTES follow-up study,2 but pharmacists can help by encouraging adherence and keeping the following factors in mind.

For one, influenza may lead to greater mortality from bacteremia, meningitis, or pneumonia; a higher incidence of hepatitis B infection; and hyperglycemia events.1,3 Given the risk factors, the CDC’s Advisory Committee on Immunization Practices recommends the following vaccinations: influenza; pneumococcal; hepatitis B (HBV); zoster; and tetanus, diphtheria, and pertussis (Tdap).4

INFLUENZA
During the 2017-2018 season, the influenza vaccination prevented an estimated 7.1 million influenza illnesses, 3.7 million influenza-associated medical visits, and 109,000 influenza-associated hospitalizations.5 A multiple logistic regression analysis performed in 1997 demonstrated that the vaccination in patients with diabetes reduced hospital admissions by 79% (95% CI, 19%-95%). An annual influenza vaccine is recommended for individuals with and without diabetes.

PNEUMOCOCCAL
Patients with diabetes are known to be more susceptible to pneumococcal infection and have a higher risk of mortality than individuals who do not have diabetes.6 Additional risk factors include age ≥65 years and cardiovascular, pulmonary, and renal disease. The CDC recommends 1 dose of 23-valent polysaccharide vaccine (PPSV23) for patients with diabetes aged 19 through 64 years.7 PPSV23 needs to be administered at least 1 year after 13-valent pneumococcal conjugate vaccine (PCV13). When both PCV13 and PPSV23 need to be administered, PCV13 is administered first.

HBV
Patients with diabetes are at higher risk of HBV infection mainly because of the use of a glucose meter, pen, or syringe without proper sanitation; improper sterilization of podiatry devices; and the sharing of fingerstick devices.8 Prevention of HBV is crucial, as 47% of patients with acute HBV in 2009 across the United States required hospitalization.9 The CDC recommends that all adults aged 19 through 59 years with diabetes be vaccinated against HBV as soon as they receive a diagnosis of diabetes.10 For patients ≥60 years, the decision may be at the discretion of the clinician, as data are not robust for this age group.

HERPES ZOSTER
Diabetes is considered a risk factor for herpes zoster and postherpetic neuralgia, which is known to be longer in duration and more severe in patients with diabetes.11,12

A meta-analysis of the results of 62 studies has shown that T2D is independently associated with an increased risk of herpes zoster infection (relative risk, 1.3; 95% CI). The CDC does not have a recommendation of zoster vaccination for individuals <50 years. Regardless of a history of diabetes or a previous vaccination history of the zoster vaccine live (ZVL), a recombinant zoster vaccine (RZV) is recommended for people ≥50 years. The ZVL may be reserved for individuals ≥60 years when RZV is not available. To date, no head-to-head clinical trial has compared the efficacy and safety of RZV and ZVL. However, the efficacy of RZV in the ZOE-50 study was 97.2% (95% CI) for subjects ≥50 years, whereas the efficacy of ZVL from the SPS study was 51% (95% CI) for subjects ≥60 years.13,14

TDAP AND TETANUS
The CDC does not have a separate recommendation of Tdap/tetanus (Td) immunization for patients with diabetes for 2019. It suggests administering a single dose of Tdap at age 11 to 12 years and a Td booster every 10 years after that. For adults who have never received Tdap, a single dose may be administered, with a Td every 10 years after that. The Tdap is also suggested for pregnant women between gestational weeks 27 and 36. An immediate postpartum Tdap may be considered for those who did not receive it during pregnancy.

CONCLUSION
Pharmacists are a resource for medication management and vaccinations. Therefore, pharmacists must understand the unique immunization considerations for patients with diabetes.

REFERENCES
  1. CDC. The flu season. cdc.gov/flu/about/season/flu-season.htm. Updated July 12, 2018. Accessed October 14, 2019
  2. Jiménez-Garcia R, Lopez-De-Andres A, Hernandez-Barrera V, et al. Influenza vaccination in people with type 2 diabetes, coverage, predictors of uptake, and perceptions. Result of the MADIABETES cohort a 7years follow up study. Vaccine. 2017;35(1):101-108. doi:10.1016/j.vaccine.2016.11.039.
  3. Wright PF. Influenza. In: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. eds. Harrison's Principles of Internal Medicine,20th ed. New York, NY: McGraw-Hill.
  4. 5 vaccines for people with diabetes. American Association of Diabetes Educators website. diabeteseducator.org/news/aade-blog/aade-blog-details/aade/2018/08/21/5-vaccines-for-people-with-diabetes. Published August 21, 2018. Accessed October 14, 2019.
  5. CDC. What are the benefits of flu vaccination? cdc.gov/flu/prevent/vaccine-benefits.htm. Updated January 24, 2019. Accessed October 14, 2019.
  6. Smith SA, Poland GA. Use of influenza and pneumococcal vaccines in people with diabetes. Diabetes Care. 2000;23(1): 95–108.
  7. CDC. Recommended adult immunization schedule for ages 19 years or older. cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf. Published 2019. Accessed October 14, 2019.
  8. CDC. Diabetes and hepatitis B. cdc.gov/hepatitis/populations/diabetes.htm. Updated August 23, 2019. Accessed October 14, 2019.
  9. CDC. Viral hepatitis surveillance - United States, 2009. cdc.gov/hepatitis/statistics/2009surveillance/index.htm. Updated August 30, 2011. Accessed November 15, 2019.
  10. CDC. Use of hepatitis B vaccination for adults with diabetes mellitus: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2011;60(50):1709-1711.
  11. Papagianni M, Metallidis S, Tziomalos K. Herpes zoster and diabetes mellitus: a review. Diabetes Ther. 2018;9(2):545-550. doi: 10.1007/s13300-018-0394-4. 
  12. Kawai K, Yawn BP. Risk factors for herpes zoster: a systematic review and meta-analysis. Mayo Clin, Proc. 2017;92:1806–1821. doi: 10.1016/j.mayocp.2017.10.009.
  13. Shingrix [prescribing information]. Triangle Park, NC: GlaxoSmithKline; 2017.  gsksource.com/pharma/content/dam/GlaxoSmithKline/US/en/Prescribing_Information/Shingrix/pdf/SHINGRIX.PDF. Accessed October 14, 2019.
  14. Zostavax [prescribing information]. Whitehouse Station, NJ: Merck & Co Inc; 2019.  merck.com/product/usa/pi_circulars/z/zostavax/zostavax_pi2.pdf. Accessed October 14, 2019.