Adult Vaccination Part 1: Patients with Diabetes Mellitus

[[{"type":"media","view_mode":"media_crop","fid":"52917","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_4252226375750","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"6575","media_crop_rotate":"0","media_crop_scale_h":"229","media_crop_scale_w":"250","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"font-size: 13.008px; height: 150px; width: 164px; float: right;","title":" ","typeof":"foaf:Image"}}]]Primary care physicians understand well why persons with diabetes are a category unto themselves. This unique status holds true across maladies including infections. Infections wreak havoc with glucose control and can result in ketoacidosis, hyperosmolar syndrome, hospitalization, and even death. Persons with diabetes are prone to certain viral infections as well. Two particularly troublesome agents-hepatitis B and pneumococcus-and their consequences are preventable through vaccination.

Let’s start with a closer look at hepatitis B vaccination in individuals with diabetes.

ANSWER AND DISCUSSION »

Answer: A

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The sooner after the diagnosis of diabetes an individual is vaccinated against hepatitis B the better. Although the study on which this question is based looked at the absence of other typical risk factors for acquiring hepatitis B, there is more to the story. The study investigated 29 hepatitis B outbreaks in patients with diabetes. Twenty-five out of 29 were a consequence of contaminated blood glucose monitors.¹ Protecting diabetics against hepatitis B infections by vaccination is an important primary care responsibility. Preventing hepatitis B in the study’s at-risk cohort (ages 20-59) saved $75,100 per every quality adjusted life year.¹

Regarding the incorrect statements, hepatitis B mortality is higher in diabetic individuals, although the difference does not achieve statistical significance (B).¹ Among persons with diabetes aged 20-40 years, more than 90% will get a protective response to the 3 vaccine series, and individuals aged 41-59 years experience an 80% conversion (C).¹ Why does the age stop at 59 years? Data on the risk of hepatitis B in diabetics older than age 60 are less impressive than those on individuals aged 20-59 years (D).¹ Vaccination in this older age group is at the discretion of the physician.

NEXT QUESTION »

[[{"type":"media","view_mode":"media_crop","fid":"52919","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_290168476764","media_crop_h":"214","media_crop_image_style":"-1","media_crop_instance":"6577","media_crop_rotate":"0","media_crop_scale_h":"135","media_crop_scale_w":"200","media_crop_w":"318","media_crop_x":"32","media_crop_y":"4","style":"font-size: 13.008px; float: right; width: 149px; height: 100px;","title":" ","typeof":"foaf:Image"}}]]Pneumococcal disease in adults (invasive pneumococcal disease [IPD] and community-acquired pneumonia [CAP]), is a global problem and can be particularly virulent in individuals with diabetes and other chronic diseases such as asthma, COPD, and chronic heart disease. Chronic disease places affected persons at risk of IPD all year round, not only during the winter, as is the case with seasonal influenza. Patients with diabetes and other chronic conditions, therefore, are candidates for vaccination at “the earliest opportunity at any time of the year.”²

The greatest risk of IPD and CAP in patients with diabetes is among those age <64 years and particularly in patients age ≤40 with or without comorbidities.²

ANSWER AND DISCUSSION »

Answer: B

The risk in this Danish study² was threefold higher in those with diabetes, with the relative risk decreasing with age. The risk of being hospitalized for pneumonia was also greater among study patients with no additional comorbidities and among those with longer duration of diabetes and/or poor glycemic control, as reflected by A1C levels.² In a US study, higher A1C levels in diabetes patients were associated with an increasing risk of CAP. It is thought that the increased risk of IPD in patients with diabetes may be a result of the impact of sustained hyperglycemia on immune and/or pulmonary function.²

ANSWER AND DISCUSSION »

Answer: True

Diabetes is an independent risk factor (OR: 1.67) for the development of bacteremia in patients with pneumococcal pneumonia; bacteremia, in turn, is associated with significantly increased mortality versus non-bacteremic pneumonia (OR: 2.57).²

ANSWER AND DISCUSSION »

Answer: A

[[{"type":"media","view_mode":"media_crop","fid":"52920","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_5659735677369","media_crop_h":"203","media_crop_image_style":"-1","media_crop_instance":"6578","media_crop_rotate":"0","media_crop_scale_h":"116","media_crop_scale_w":"200","media_crop_w":"350","media_crop_x":"0","media_crop_y":"35","style":"font-size: 13.008px; float: right; width: 198px; height: 100px;","title":" ","typeof":"foaf:Image"}}]]Current guidelines recommend only PPSV23, not additional PCV13, in both persons with diabetes and those with asthma who are younger than age 65 (options B and C). Despite the serious risk factors for infection in patients with diabetes, IPD is more lethal in persons with asthma than with diabetes.³

ANSWER AND DISCUSSION »

Answer: G

Data are from a study reported in July 2016 that analyzed patient records from 300 primary-care practices in England that are part of a Clinical Practice Research Datalink. They identified 124,503 patients with type 2 diabetes and followed them for 7 flu seasons between 2003–2004 and 2009–2010.⁴

CONTINUE TO ADULT VACCINATION PART II. OLDER ADULTS

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References:

1. Centers for Disease Control and Prevention (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 Dec 23;60:1709-11.

2. 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 Oct; 70(10): 984–989.

3. Kwak BO, Choung JT, Park YM. The association between asthma and invasive pneumococcal disease: a nationwide study in Korea. J Korean Med. Sci. 2015;30:60-65.

4. Wise J. Flu vaccination reduces hospital admissions for cardiovascular disease in people with diabetes, study shows. BMJ. 2016; 354:i4130doi.