Diabetes Standards of Care and Resources for Clinicians and Educators
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 the Centers for Disease Control and Prevention (CDC) guidelines (Immunization Schedule for Health Care Professionals).Exit Disclaimer: You Are Leaving www.ihs.gov Providers should consult these guidelines as needed for individual patient circumstances.
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 Exit Disclaimer: You Are Leaving www.ihs.gov 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).
The following three vaccines are recommended to protect against pneumococcal disease in adults ages 19 and older (see CDC Recommended Adult Immunization Schedule): Exit Disclaimer: You Are Leaving www.ihs.gov
- 20-valent pneumococcal conjugate vaccine (PCV20, Prevnar 20)
- 15-valent pneumococcal conjugate vaccine (PCV15, Vaxneuvance)
- 23-valent pneumococcal polysaccharide vaccine (PPSV23, Pneumovax)
Recommendations for persons with diabetes who have never received a pneumococcal vaccine or whose vaccination status is unknown:
- Administer one dose of PCV20 or PCV15 to adults with diabetes aged 19 years or older
- If PCV15 is used, it should be followed by a dose of PPSV23 ≥ 1 year later.
Note: A minimum interval of 8 weeks following PCV15 administration may be considered for PPSV23 injection in patients with immunocompromising conditions.
Recommendations for persons with diabetes who have previously received PCV13 or PPSV23:
- Administer PCV20 or PCV15 in adults with diabetes 19 or older who have previously received PPSV23 only, at least 1 year from their PPSV23 dose.
- Administer PPSV23 to those who have previously received PCV13 only. PPSV23 vaccination should be given at least 1 year after their last PCV13 injection and at least one dose should be given after age 65. If PPSV23 is not available, PCV20 may be offered.
- Consider additional vaccination for adults with diabetes who have previously received both PCV13 and PPSV23.
- Recommend no further vaccination if PPSV23 was given at age 65 or older.
- Administer additional PPSV23 at age 65 or older if PPSV23 vaccination was given before age 65 (at least 5 years after their last PPSV23 dose).
- Consider additional PPSV23 doses before age 65 for adults with immunocompromising or other specific conditions: Pneumococcal Vaccine Timing for Adults. [PDF] Exit Disclaimer: You Are Leaving www.ihs.gov
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, PreHevbrio, 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:Exit Disclaimer: You Are Leaving www.ihs.gov
- 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 Exit Disclaimer: You Are Leaving www.ihs.gov guidance from Immunize.org).
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). Exit Disclaimer: You Are Leaving www.ihs.gov
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IHS Immunization Program Manager
Division of Epidemiology and Disease Prevention
(Originally presented on 06/29/22.)