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Influenza vaccination in adults with type 2 diabetes can significantly reduce the occurrence of flu complications, hospitalizations, and mortality in those patients, according to recent research.1
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The findings were based on data from the Prevention of Influenza, Surveillance, and Management (PRISMA) study, a primary-care–based, nested case-control investigation of the cost-effectiveness of a Dutch flu vaccine campaign. The authors examined the PRISMA records of 9,238 patients with diabetes, noting that past research has offered "conflicting evidence regarding potential benefits" of vaccination for such patients.
Hypothesizing that this uncertainty had contributed to low levels of influenza vaccination among people with diabetes, a population at high risk for infection and flu complications such as lower respiratory tract infections and diabetes dysregulation, Ingrid Looijmans-Van den Akker, MD, and colleagues at the Julius Center for Health Sciences and Primary Health Care in Utrecht, the Netherlands, examined the relationship between vaccination for influenza and hospitalization and death from any cause during the 1999–2000 influenza A epidemic. They found vaccination was associated with a 56% reduction in any complication, a 54% reduction in hospitalizations, and a 58% reduction in deaths.
In response to the study, John Buse, MD, PhD, vice president, medicine and science, of the American Diabetes Association (ADA), observes that, while the Dutch researchers' concerns about low "influenza vaccine uptake" may not reflect conditions in the U.S., the study has value for this country's clinicians.
"ADA has a long-standing recommendation that patients with diabetes should get flu vaccine on an annual basis, and this study provides some evidence that there are consequences to not getting flu vaccine," Buse says.
DOES LIVE VIRUS MATTER?
In heeding the diabetes care and public health drumbeats about flu vaccination, patients with type 2 may not be aware that reviewing their personal medical conditions before taking a vaccine is good practice. The ubiquity of retail vaccination fairs and needle-free vaccine options, such as MedImmune's FluMist, may make a clinician's counsel regarding flu vaccines especially useful.
"Live attenuated viruses are contraindicated in patients who have decreased immune response," says endocrinologist Susan E. Spratt, MD, assistant professor and clinical director of the endocrine division at Duke University Medical Center in Durham, N.C. "Anyone with diabetes is immunosuppressed to some extent."
Indeed, the Centers for Disease Control and Prevention (CDC) and manufacturers of the live-virus vaccine warn against using live, attenuated influenza vaccine in people with metabolic disorders such as type 2 diabetes.
But Buse suggests that the motivation behind such warnings is not a research-based concern about safety but caution generated by the dearth of clinical studies of the possible effects of attenuated virus vaccines on patients with serious health conditions.
Such caution is easier to exercise when good inactive virus vaccines are available. If inactive virus vaccine options were limited for some reason, Buse says, "I believe that for the average patient with diabetes, there are greater consequences to not taking the vaccine" than might result from taking an attenuated vaccine.
ANTIVIRALS AS ADJUNCT THERAPIES
Designed to reduce the severity of flu symptoms and effects in patients who do catch a seasonal virus, antiviral drugs may be valuable tools in flu prevention and treatment for diabetes patients. These drugs must be started within days of onset of symptoms in order to be effective. Antivirals also may provide a measure of protection for those vaccinated late in the season while they wait for immunity to develop or for those unable or unwilling to get a vaccination who likely will encounter significant social exposure to the virus.2
For the 2006–2007 season, the CDC has identified three trivalent vaccine strains, among which both A and B strains are represented. Of the four licensed antiviral agents available in the U.S., only oseltamivir (Tamiflu, Roche), taken as a liquid or capsule, and the inhaled zanamivir (Relenza, GlaxoSmithKline) are recommended for treatment of influenza A strains. The CDC has documented the continued resistance of influenza A to the antivirals amantadine and rimantadine; accordingly, it recommends that these agents not be prescribed for the treatment of flu symptoms.
Potential for confounding symptoms of bacterial or other illness should be considered. Laboratory testing may be indicated for accurate identification and treatment of influenza strains, whether by means of antivirals or other protocols.3
COUNSELING FOR COMPLIANCE
Overcoming patient indifference or reticence about flu vaccination remains a challenge for health care providers. Patient concerns may have some foundation. For example, some adverse events are possible after influenza vaccination, though they may be relatively mild and short-lived.
"Complications from the vaccine include soreness or redness at the site of the shot, fever, or arthralgias [pains in the joints]," Spratt says. "In rare cases, anaphylaxis or a rare neuromuscular disorder such as Guillain-Barré can occur." Also, patients may not know that flu vaccination is contraindicated for anyone with severe egg allergy.
In general, patients may feel more confident when clinicians place both the concerns and benefits of flu inoculation in the context of their personal medical history.
With the U.S. Food and Drug Administration's fast-tracked approval in October 2006 of Flu Laval, GlaxoSmithKline's newest vaccine against seasonal influenza, five approved flu vaccines are available in the U.S.
Though this may seem an embarrassment of riches, especially in contrast to the 2004 flu season supply crisis, clinicians should give special attention to immunization practices and patient counseling, as not all available vaccines are indicated for patients with chronic illnesses such as diabetes and heart disease. Also, some patients may choose to visit immunization fairs in retail and work environments, where vaccination counseling specific to their medical needs is less likely.
Buse advises care providers to be sure reluctant patients understand that the annual flu vaccine is recommended for people with diabetes because their chance of getting seriously ill is greater than that of the general population.
"In a patient with diabetes, it's somewhat more likely that instead
of just feeling miserable and missing 5 days of work they could end up in the
hospital for three or four or five of those days because of issues with
keeping the blood glucose down and keeping hydrated," Buse says.
Footnotes
Get the CDC's latest seasonal influenza news at www.cdc.gov/flu/whatsnew.htm.
Find flu season patient education materials, practice guidelines, bulletins, multilingual fact sheets, and more at www.cdc.gov/flu.
And for more information on vaccine distribution and availability, see the CDC's influenza vaccine supply questions and answers at www.cdc.gov/flu/about/qa/vaxprioritygroups.htm.
References
2. Smith NM, Bresee JS, Shay DK, et al.: Prevention and control of influenza: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 55:1–42, 2006. Available online at www.cdc.gov/mmwr/preview/mmwrhtml/rr5510a1.htm. Accessed November 13, 2006.
3. Centers for Disease Control and Prevention: Lab diagnosis of influenza. Available online at www.cdc.gov/flu/professionals/labdiagnosis.htm. Accessed November 13, 2006.
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