PNEUMOCOCCAL VACCINE AND DIABETES

India is the world leader in diabetes. People with diabetes are more prone infections. Pneumococcal infections are a common cause of morbidity and mortality, and people with diabetes are more prone to develop pneumococcal infections. With the availability of the pneumococcal vaccine, most international organizations now recommend that people with diabetes should be vaccinated against pneumococcal disease.  The two major types of diabetes are type-1 (insulin-dependent) diabetes mellitus, which is due to destruction of insulin producing cells in the pancreatic islets, and type-2 (noninsulin-dependent) diabetes mellitus, which is characterized by insulin resistance, often associated with other features such as obesity, hypertension, dyslipidemia, and accelerated arteriosclerosis.

Patients with diabetes have higher risk for bacterial and viral infections. The most common infections are preventable bacterial infections of the skin, the urinary tract, and the respiratory tract. Apart from the morbidity associated with the long term complications of Diabetes infections with influenza and pneumococcus contribute to the overall morbidity and mortality in diabetes patients.

Diabetes mellitus has been identified as an independent risk factor for developing respiratory tract infections. Streptococcus pneumoniae remains the major cause of pneumonia in spite of widespread vaccination. Apart from pneumonia and its complications, viz., empyema and lung abscess, the pneumococcus also causes other clinical syndromes such as sinusitis, otitis media, tracheobronchitis, bacteremia, meningitis and peritonitis, some of which have high case fatality rates. Diabetes is a well-known risk factor for pneumococcal infection.

Diabetic patients have a normal response to pneumococcal vaccination, and vaccination is a cost-effective preventive strategy. Immunization with Pneumococcal Polysaccharide Vaccine (PPV, which includes 23 purified capsular polysaccharide antigens representing 85-90% of the serotypes of S. pneumoniae) in diabetic patients significantly reduces morbidity and mortality related to pneumococcal disease.  The 23 valent PPV (PPV23) can be given as a subcutaneous or intramuscular injection (preferably in the deltoid muscle or lateral mid thigh).  The antibody response after a single dose of PPV begins 7-10 days after vaccination

During influenza outbreaks, pneumococcal vaccines may be useful in preventing secondary pneumococcal infections. CDC's Advisory Committee on Immunization Practices (ACIP) recommends a single dose of PPSV23 for all people 65 years and older and for persons 2-64 years of age with certain high-risk conditions. The vaccine is generally safe, but mild local side effects may be seen. Injection site reactions consisting of pain, soreness, erythema, warmth, local indurations occur. Fever is the most common side effect.

Indian Recommendations

The Geriatric Society of India recommends the use of PPV for

persons aged 50 years and above and

Persons aged 2 years or above with certain underlying medical conditions such as diabetes.

Revaccination

A one-time revaccination is recommended by the ADA and ACIP for individuals >64 years of age, previously immunized when they were <65 years of age, if the vaccine was administered >5 years ago.

Should All Diabetic Patients Receive Pneumococcal Vaccination?

Diabetes is in itself a risk factor for invasive pneumococcal infection. In addition, there exist a substantial number of diabetic patients who have other co-morbidities like renal complications, coronary artery disease, COPD, chronic liver disease, malignancies, etc. For this subset of diabetic patients, pneumococcal vaccination should be recommended on priority by virtue of being at more risk than those with diabetes alone. The final decision lies with the treating physician as invasive pneumococcal infection is not so common in India.