Vaccination in diabetes and morbidly obese

Sense and sensibility C. Mathieu

Endocrinology UZ Leuven

Advice Superior Health Council

• Diabetes Mellitus – Children < 16 years Influenza (annually) – Adults and adolescents > 16 years Influenza (annually)

• Metabolic conditions, including morbid obesity (BMI>35) Influenza (annually)

HGR nR. 8561

Questions

• Are patients with diabetes/obesity more susceptible to viral infections?

• Is there higher morbidity/mortality in patients with diabetes/obesity in case of viral infections, eg. influenza

Diabetes and infections: is there a link?

Casqueiro et al. Indian Journal of Endocrinology and Metabolism 2012

Diabetes and infections: is there a link?

Questions

• Are patients with diabetes/obesity more susceptible to viral infections? Not clearly

• Is there higher morbidity/mortality in patients with diabetes/obesity in case of viral infections, eg. influenza

Diabetes and influenza, not a desirable combination

• … potential of loosing glycemic control • … increased risk of complications of

influenza, ICU admission and death

Allard et al. Diabetes Care 2010

Diabetes and mortality in pandemic A/H1N1

Chowell PLoS ONE 2012

Obesity and influenza, not a desirable combination

Outcome Event rate per 1000 person-years ORa (95% CI)

Respiratory hospitalizations resulting in admission to an Intensive care unit (2002/2003 through 2007/2008 influenza seasons only)

0.67

<18.5 (underweight) 1.64 3.27 (0.76–14.15)

18.5–24.9 (normal weight) 0.29 1.00

25–29.9 (overweight) 0.75 2.21 (0.98–4.96)

30–34.9 (obese class I) 0.83 1.88 (0.72–4.94)

≥35 (obese class II or III) 2.78 3.23 (1.24–8.45)

Kwong et al. Clin Infect Dis 2011

Effectivity of influenza vaccination in diabetes?

Annual influenza vaccination in patients with (type 2)

diabetes lowers the risk of severe complications, hospitalisatioin and mortality with more than 50%

< 65 y: NNT to avoid 1 hospitalisation/death ± 70 ≥ 65 y: NNT to avoid 1 hospitalisation/death ± 130

YES

Standpunt VDV griepvaccinatie bij diabetes

• Iedereen die door leeftijd of ziekte meer risico loopt op complicaties, heeft baat bij jaarlijkse griepvaccinatie

• Griepvaccinatie bij diabetes is doeltreffend • Dus: griepvaccinatie voor IEDEREEN MET DIABETES,

jong of oud, diabetescomplicaties of niet, op insuline/incretinemimetica of behandeling met orale medicatie

• Bevraging diabetesconventiecentra 2008: 80% diabetologen volgt dit standpunt, echter 40% niet overtuigd van nut vaccinatie kinderen/adolescenten (T1)

• Positieve trend vaccinatie < 65 j diabetici laatste jaren (griepcampagne?)

2. Pneumokoccal vaccination and diabetes?

• “Immunization against influenza and pneumococcal disease is an important part of preventive services for many chronic diseases such as diabetes.”

ADA. Diab Care 2004

Risk for pneumococcal infections is increased in diabetes

RRdiabetes (adjusted): 3.4

Kyaw et al. J Infect Dis 2005.

Mortality upon pneumococcal infection in diabetes??

Cohortstudy Denmark (Thomsen, Diab Care 2004)

After correcting for age, gender, comorbidity: RR mortality = 0.6 vs non-diabetics

Cost-effectiveness vaccination?

Rozenbaum et al. BMJ 2012.

3. Hepatitis B vaccination and diabetes?

Kirkman & Schaffner. Diab Care 2012.

ACIP Recommendations 2011

• ACIP recommended that all previously unvaccinated adults aged 19 through 59 years with diabetes mellitus (type 1 and type 2) be vaccinated against hepatitis B as soon as possible after a diagnosis of diabetes is made (recommendation category A).

• Data on the risk for hepatitis B among adults aged ≥60 years are less robust. Therefore, ACIP recommended that unvaccinated adults aged ≥60 years with diabetes may be vaccinated at the discretion of the treating clinician after assessing their risk and the likelihood of an adequate immune response to vaccination (recommendation category B).

Hepatitis B risk in residential homes

WISE Recommendations to ensure the safety of injections in diabetes

K. Strauss, WISE Consensus Group. Diabetes & Metabolism 2012

EU Directive Needle Sharps (2010/32/EU)

Conclusions • ADA:

– Influenza vaccination Annually – Pneumococcal vaccination /5years – Hepatitis vaccination yes

• HGR: – Influenza vaccination Annually

= Diabetes =BMI >35 =BMI <18.5