2008 Clinical Practice Guidelines - Canadian Diabetes Association

2008 CLINICAL PRACTICE GUIDELINES
S86
Influenza and Pneumococcal Immunization
Canadian Diabetes Association Clinical Practice Guidelines Expert Committee
The initial draft of this chapter was prepared by Vincent Woo MD FRCPC
KEY MESSAGES
• Studies in high-risk individuals, which included people
with diabetes, have shown that influenza vaccination
can reduce hospitalizations by approximately 40%.
• As people with diabetes are at least as susceptible to
pneumococcal infection as other people with chronic diseases,
the use of the pneumococcal vaccine is encouraged.
• A one-time pheumococcal revaccination is recommended
for individuals >65 years of age if the original vaccine
was administered when they were 5 years earlier.
INTRODUCTION
People with diabetes, especially those with renal and cardiac
complications, are at high risk for morbidity and mortality
from influenza and pneumococcal disease (1). Studies in
high-risk individuals, which included people with diabetes,
have shown that influenza vaccination can reduce hospitalizations
by about 40% (2). However, there are few randomized
controlled trials that have specifically evaluated the use and
benefit of influenza or pneumococcal immunization in people
with diabetes (1). Clinical practice recommendations for
people with diabetes must therefore be extrapolated from
recommendations for individuals at high risk of complications
associated with these infectious diseases (3-5).
INFLUENZA IMMUNIZATION IN ADULTS
The majority of studies on influenza immunization rely on
observational reports of increased death rates in people with
diabetes during influenza epidemics (6-9). One case-control
study of people with diabetes showed a 6-fold increased risk
of hospitalization during influenza outbreaks compared to
nonepidemic years (9).
A retrospective case-control study demonstrated the
effectiveness of influenza vaccination in reducing rates of
hospitalization of people with diabetes for influenza, pneumonia
or diabetes-related events during 2 influenza epidemics
in Leicestershire, England, United Kingdom (10).
The study detected a 79% reduction in hospitalization rates
during the 2 epidemics in people with diabetes who had been
immunized against influenza during the period immediately
preceding the epidemic. Another nested case-control study
in the Netherlands demonstrated that vaccination was associ-
ated with a 56% reduction in any complication, a 54% reduction
in hospitalizations and a 58% reduction in deaths in
people with type 2 diabetes (11).
PNEUMOCOCCAL IMMUNIZATION
IN ADULTS
Numerous studies have demonstrated the efficacy of immunization
in reducing pneumococcal bacteremia in the general
population (12-15).There is widespread acceptance that people
with diabetes are at least as susceptible to pneumococcal
infection as other people with chronic diseases (1), and therefore
the use of the pneumococcal vaccine is encouraged in this
population. A one-time revaccination is recommended for
individuals >65 years of age if the original vaccine was administered
when they were 5 years earlier.
RECOMMENDATIONS
1. People with diabetes should receive an annual influenza
vaccine to reduce the risk of complications associated
with influenza epidemics [Grade D, Consensus].
2. People with diabetes should be considered for vaccination
against pneumococcus [Grade D, Consensus].
RELATED WEBSITES
National Advisory Committee on Immunization. Canadian
Immunization Guide. 7th ed. Ottawa, ON: Canadian Medical
Association; 2006. Available at: http://www.phac-aspc.gc.
ca/publicat/cig-gci/index.html.Accessed September 1, 2008.
REFERENCES
1. Smith SA, Poland GA. Use of influenza and pneumococcal vaccines
in people with diabetes. Diabetes Care. 2000;23:95-108.
2. Nichol KL, Nordin J, Mullooly J, et al. Influenza vaccination
and reduction in hospitalizations for cardiac disease and stroke
among the elderly. N Engl J Med. 2003;348:1322-1332.
3. Casey JI. Host defense abnormalities in diabetic patients. In:
Rifkin H, Raskin P, eds. Diabetes Mellitus. Vol 5. Bowie, MD:
Robert J. Brady Company; 1981:219-223.
4. Heymann AD, Shapiro Y, Chodick G, et al. Reduced hospitalizations
and death associated with influenza vaccination among
patients with and without diabetes. Diabetes Care. 2004;27:
2581-2584.