Vaccinations in people with type 2 diabetes mellitus… are more pokes needed?

We are in the clutches of the icy hands of winter with a symphony of coughing and sneezing all around. I realise that the COVID-19 vaccines and how they were rolled out has created suspicion and reluctance in individuals when we suggest more vaccinations. Nonetheless, we cannot ignore the years of research that other vaccinations have behind them. In addition, I have seen the benefit in the general well-being of my clients with type 2 diabetes who have been vaccinated as recommended. In this blog, I therefore want to focus on the benefit of vaccinations in people with type 2 diabetes.

^‍Type 2 diabetes is well known to affect overall longevity through a significant increase in cardiovascular disease risk.¹ The other causes of mortality and morbidity sometimes take a backseat to the more sinister cardiovascular issues. However locally, lower respiratory tract infections, tuberculosis (TB) and diarrhoeal diseases are amongst the top ten causes of death in people with type 2 diabetes.² The World Health Organisation (WHO) also adds lower respiratory tract infections and chronic lung disease as part of the top ten causes of deaths in people with diabetes. It is therefore a worthwhile endeavour to discuss and possibly convince our clients to take the necessary vaccinations.^‍‍

Pneumococcal Infections

Pneumococcal infections have long been recognised to be a cause of mortality in hospitalised patients with the case fatality for invasive pneumococcal disease remaining at around 12%. People with suboptimal glycaemic management (HbA1c >9%) have a 60% increased risk of hospitalisation. Unfortunately, even people with optimal glycaemic management (HbA1c <7%) have a 22% increased risk for admission to hospital. This adverse relationship is most likely due to changes in the individual’s defence system which renders them more susceptible to the pneumococcus bacteria. In South Africa, serotypes 8, 3, 19A, 12F, 4 and 19F are the commonest 6 serotypes causing pneumococcal disease in persons >5 years. Currently, two types of pneumococcal polysaccharide vaccines (PCV13 and PPV23) cover different serotypes. The 2017 South African guidelines recommended PCV13 vaccination use in all adults > 50 years, and adults >65 years who are pneumococcal vaccine naïve should receive PCV13 followed by PPV23 one year later.

Influenza

Influenza is estimated to cause between 10 000 and 30 000 deaths annually and people with diabetes are at a 6-times higher risk of being hospitalised.⁶ There is also a risk of precipitating cardiovascular incidents in people with type 2 diabetes.⁷ The influenza vaccination is recommended for all persons older than 6 months. This is a yearly vaccination, as the strains circulating in the community change due to antigenic drift and thus the vaccinations have to be updated. The best time to get vaccinated in South Africa is between March and June, and some medical aid funders are even paying for the vaccinations yearly.

Other Vaccinations
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^‍Other vaccinations include that for shingles (herpes zoster) as people with diabetes are susceptible to zoster resurgence due to immune suppression. This painful complication can be prevented with the vaccination. Guidelines also recommend vaccination for hepatitis B infection if this hasn’t been received as a child. Vaccinations have been a pet subject for many conspiracy theorists. This irresponsible populist opinion should not detract the health care provider from counselling their clients and offering them the necessary vaccinations. These vaccinations have been studied extensively and have proven benefit. Prevention is better than cure… so what’s a few more jabs?!

References^‍

1. The Emerging Risk Factors Collaboration (2011). Diabetes Mellitus, Fasting Glucose, and Risk of Cause-Specific Death. N Engl J Med; 364:829-41. DOI: 10.1056/NEJMoa1008862
2. Statistics South Africa (2021). TB tops leading causes of death in SA in 2018. Available from: http://www.statssa.gov.za/?p=14435
3. Feikin DR, Schuchat A, Kolczak M, et al. (2000). Mortality from invasive pneumococcal pneumonia in the era of antibiotic resistance, 1995 – 1997. Am J Public Health; 90: 223–229.
4. Kornum JB, Thomsen RW, Riis A, Lervang HH, Schønheyder HC, Sørensen HT. (2008). Diabetes, glycemic control, and risk of hospitalization with pneumonia: A population-based case-control study. Diabetes Care; 31:1541-5.
5. Boyles TH, Brink A, Calligaro GL, et al. (2017). South African guideline for the management of community-acquired pneumonia in adults. J Thorac Dis; 9:1469-502. 10.21037/jtd.2017.05.31
6. Smith SA, Poland GA. (2000). Use of influenza and pneumococcal vaccines in people with diabetes. Diabetes Care. 23(1):95-108. DOI: 10.2337/diacare.23.1.95.
7. Warren-Gash C, Smeeth L, Hayward AC (2009). Influenza as a trigger for acute myocardial infarction or death from cardiovascular disease: a systematic review. Lancet Infect Dis. 9(10):601-10. DOI: 10.1016/S1473-3099(09)70233-6.