Diabetes Standards of Care & Clinical Practice Resources
People with diabetes are more susceptible to infectious diseases, and they may experience more serious complications. Immunizations offer protection from infections and can reduce illness severity. These recommendations for non-pregnant people with diabetes are based on Centers for Disease Control and Prevention (CDC) guidelines (Immunization Schedule for Health Care Professionals). Providers should consult these guidelines as needed for individual patient circumstances.
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- Section 1 – Clinical Practice Recommendations: Immunizations
- Section 2 – Clinician and Educator Resources: Immunizations
- Section 3 – Patient Education Resources: Immunizations
Clinical Practice Recommendations
Seasonal influenza is responsible for many deaths, especially among individuals with chronic diseases. New vaccines are developed each year to combat new strains.Recommendations:
- Administer the influenza vaccine annually to all people with diabetes aged 6 months and older, except when the vaccine is contraindicated for a given individual. Use any influenza vaccine appropriate for that person’s age and health status (see CDC’s Information for Health Professionals for details on types of vaccines and doses).
- For people who contract influenza, use antiviral therapy early in the course of infection. Such treatment can reduce symptoms, shorten illness duration, and prevent serious complications. Oseltamivir (Tamiflu) is available on the Indian Health Service National Core Formulary.
Pneumococcus (Streptococcus pneumoniae) can cause serious illness, including pneumonia, sepsis, meningitis, and local infections (e.g., ear infections).
Two pneumococcal vaccines are available: pneumococcal 23-valent polysaccharide vaccine (Pneumovax 23) and pneumococcal 13-valent conjugate vaccine (Prevnar 13).
Pneumovax 23 is recommended for all people with diabetes aged 2 years and older and persons aged 65 years and older. Prevnar 13 is recommended for certain individuals based on age, other diseases and conditions, and pneumococcal strains in the community. For additional details, see Pneumococcal Vaccine Timing for Adults. [PDF]Recommendations:
- Administer one dose of Pneumovax 23 to children and adults with diabetes aged 2 to 64 years.
- Administer Pneumovax 23 to all adults aged 65 years and older, regardless of vaccination history, at least 5 years after their last Pneumovax 23 vaccination or 1 year after their last Prevnar 13 vaccination.
- Administer one dose of Prevnar 13 to immunocompromised individuals aged 19 years or older. These people include those with chronic kidney failure, nephrotic syndrome, or cancer as well as people treated with medications that suppress the immune system.
- Consider Prevnar 13 for individuals aged 65 years and older with chronic diseases, especially if PCV13 serotypes are common in the community. If a decision is made to give Prevnar 13, wait at least 1 year before giving Pneumovax 23.
People with diabetes have a higher risk of contracting hepatitis B. This virus can cause acute or chronic hepatitis, which can lead to liver failure or cirrhosis. The CDC recommends vaccination to prevent this infection in adults with diabetes.
Two types of hepatitis B vaccines are available in the United States:
- Two-dose vaccine (Heplisav-B)
- Three-dose vaccine (Engerix-B, Recombivax HB, or hepatitis A/B in Twinrix)
- Vaccinate adults with diabetes aged 18 to 59 years who have not received a complete hepatitis B vaccination series. Use these schedules for the vaccine from CDC’s Hepatitis B Questions and Answers for Health Professionals:
- Two-dose vaccine: Wait at least 1 month between the first and second dose.
- Three-dose vaccine: Give the second dose at least 1 month after the first dose, and give the third dose at least 6 months after the first dose.
- Complete the vaccination series with the same product, when feasible.
- Consider vaccinating adults with diabetes age 60 years and older if they have a higher risk of infection and have not received a complete hepatitis B vaccination series.
- Consider hepatitis B antibody testing for people who are not sure whether they have been vaccinated or finished the vaccination series. If a person has an antibody level lower than 10 mIU/mL, administer a single dose and repeat antibody testing 1-2 months later, or administer the entire vaccination series (see Hepatitis B guidance from the Immunization Action Coalition).
The CDC recommends routine tetanus and diphtheria (Td) or tetanus, diphtheria, and acellular pertussis (Tdap) vaccines for adults including people with diabetes.Recommendations:
- Give a single dose of Tdap to adults aged 19 years and older who have never received this vaccine, regardless of how long it has been since they last received a vaccine containing tetanus and diphtheria toxoid.
- Give the Td or Tdap booster every 10 years.
- Give the Td or Tdap vaccine for wound management if the individual’s last Td or Tdap vaccination was more than 5 years earlier.
Shingles is a painful, blistering skin rash that develops when the Varicella zoster (chickenpox) virus is reactivated in a nerve. Vaccination can prevent postherpetic neuralgia (persistent pain), which is the most common shingles complication and is more common in people older than 50 years.
The CDC recommends the two-dose recombinant herpes zoster vaccine (RZV; Shingrix).Recommendations:
- Give the two-dose Shingrix vaccine to all adults aged 50 years and older. Wait 2 to 6 months between doses.
- Give the two-dose Shingrix vaccine to people who have previously received the Zostavax vaccine. Give the first dose at least 2 months after the Zostavax vaccine (for details, see Shingles Vaccination Information for Healthcare Providers).
Clinician and Educator Resources
General Information on Immunizations:
Immunization Schedule for Health Care Professionals
Centers for Disease Control and Prevention (CDC)
Information for Health Professional
Indian Health Service
Use of 13-Valent Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal Polysaccharide Vaccine Among Adults Aged ?65 Years: Updated Recommendations of the Advisory Committee on Immunization Practices
Immunization Action Coalition
Tetanus, Diphtheria, and Pertussis:
Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis Vaccines: Updated Recommendation of the Advisory Committee on Immunization Practices – United States, 2019.
Shingles (Herpes zoster):
Recommendations of the Advisory Committee on Immunization Practices for Use of Herpes Zoster Vaccines