Since they see diabetic patients so often, community pharmacists who encourage vaccination can play a major role in boosting public health.
New research suggests that a large percentage of diabetic patients aren’t getting properly vaccinated, as recommended, for influenza, pneumococcal disease, and hepatitis B. A July study found that only 41 of 100 diabetic patients treated at a Rhode Island hospital had been vaccinated for influenza, and just 37 for pneumococcal disease. Despite guidelines released in 2011, none had received hepatitis B vaccination as recommended.
There is good news, however. The July study noted that while regulatory limitations exist, pharmacists in every state can now administer some or all vaccinations, and pharmacy interns can do so in 38 states. Since they see diabetic patients so often, community pharmacists who encourage vaccination can play a major role in boosting public health.
William Schaffner“There’s an incredible opportunity for pharmacists to provide an important preventive service to their patients. It’s a real add-on value,” said William Schaffner, MD, professor and chair of Preventive Medicine, Department of Health Policy, Vanderbilt University School of Medicine. “Pharmacists are welcome participants in the immunization neighborhood.”
Why worry so much about vaccinations for diabetic patients? “People with diabetes have a predilection for infections of various kinds,” Schaffner said, citing higher rates of skin infections, pneumonia, and influenza. “Among other things, the change in their metabolism impairs the way white blood cells can fight infections. That leads to an impaired immune and inflammatory response in people with diabetes.”
Three kinds of immunizations are especially recommended for diabetics. Here’s a look at each one.
The American Diabetes Association (ADA) recommends an annual influenza vaccination for all individuals ages six months or older. This is especially important to diabetic patients, and not just because of the risk of influenza, Schaffner said. “Flu’s primary complication is pneumonia, and the best way to prevent the pneumonia related to flu is not to get the flu. The best way not to get the flu is to be vaccinated against influenza.”
According to ADA, diabetic patients are three times more likely than other people to die when infected with flu and pneumonia.
Fortunately, diabetic patients often know that flu shots are recommended. “Most of the patients with diabetes that I work with are well aware of their need for an annual influenza vaccine,” said Miranda Wilhelm, PharmD, clinical assistant professor, Department of Pharmacy Practice, Southern Illinois University Edwardsville School of Pharmacy. “I rarely have patients with diabetes refuse my recommendation for an influenza vaccine.”
ADA recommends a pneumococcal vaccination - polysaccharide vaccine 23 (PPSV23) - in all patients with diabetes ages two or over.
For previously unvaccinated patients 65 or older, the association recommends pneumococcal conjugate vaccine 13 (PCV13), followed by PPSV23 6-12 months later. If they were previously vaccinated with PPSV23, they should receive a follow-up a year or later with PCV13.
Patients can be confused by the complicated recommendations, said Ginger Lemay, PharmD, CDOE, CVDOE, clinical assistant professor, University of Rhode Island College of Pharmacy. “We reinforce that PPSV23 is specifically recommended for all patients with diabetes one time between the ages of two and 64. Once they reach the age of 65, they should receive PCV13 followed by PPSV23 again 12 months later.”
According to Wilhelm, “One misconception that patients and pharmacists may have, related to pneumococcal vaccine, is when to administer both PCV13 and PPSV23. It is important to note that patients with diabetes are not considered immunocompromised and therefore would not need PCV13 before age 65 years based only on their diabetes status.”
Do patients understand that they should get these vaccinations? “It has been my experience that patients know they need a PPSV23 at 65 years of age. The CDC estimates that 59.7% of patients 65 years of age and older have received PPSV23,” Wilhelm said. But those at high risk under the age of 65 may not realize they should get vaccinated, she said.
In 2011, the Centers for Disease Control and Prevention (CDC) recommended that all people under 60 with diabetes obtain vaccination for hepatitis B as soon as possible following diagnosis. After the age of 60, physicians should make the call. The vaccination is give as a series of three shots over 6 months.
What prompted this recommendation? “When large databases were studied, it became clear that at every age group, diabetics had a higher rate of antibodies to hepatitis B,” said Schaffner. The higher rate of exposure appears to be associated with inadvertent use of contaminated needles in a healthcare setting, he said.
Indeed, the CDC reports that it has investigated multiple cases of hepatitis B outbreaks among diabetics who live in nursing homes, long-term-care facilities, and assisted-living facilities. The outbreaks are thought to have stemmed from transmission through improper cleaning and sterilization or multiple use of fingerstick devices, blood glucose meters, insulin pens, and syringes.
“It is important for patients with diabetes to be educated about not sharing lancet devices even with family members,” Wilhelm said.
According to the CDC, among diabetic patients ranging from 19 to 59 years of age, only an estimated 26.35% have received the hepatitis B vaccine. For patients ages 60 and over, the number is thought to be just 14%.
“In my experience, initially after the recommendation was made, because patients were not familiar with the recommendation they were a little hesitant to receive the vaccine,” said Wilhelm. “But the patients I have worked with were responsive after I described the rationale for the recommendation.”
Wilhelm recommended that pharmacists schedule the date for the second dose of the vaccine when patients get the first one. “Scheduling this appointment right away helps to keep the series on track and gets the patient protected from the disease as soon as possible,” she said.
How can pharmacists boost rates of vaccination among diabetic patients? If student pharmacists are allowed to give vaccinations in your state, enlist them, suggested Wilhelm. “In addition to helping the pharmacist, student pharmacists can assist with paperwork, billing procedures, and contacting the patients’ physicians to notify them of administration of the vaccine.”
Amanda ApplegateAs for reminders, “I advise every community pharmacist to bag-tag all diabetic prescriptions during flu-shot season,” said Amanda Applegate, PharmD, BCACP, pharmacy clinical services coordinator, Balls Food Stores. “Use that medication pickup time to emphasize the importance of getting immunized. Several of my patients with diabetes came back to me saying they got their first flu shot ever because of my recommendation!”
Bag-tagging can also help with pneumococcal vaccination, she said. “Set aside a couple of months during the year to ensure that you talk with all of your patients with diabetes between the ages of 18 and 64 about making sure they are informed about and have received the PPSV23 vaccination.”
Of course, some patients wrongly fear that vaccines are more dangerous than the illnesses they prevent. With them, Applegate said, she tries to be understanding but firm: “I sympathize with your concerns about vaccines, but I strongly recommend this vaccine to protect your health.”
Schaffner, the physician, urges healthcare providers to make definitive statements about vaccines. Don’t say: “It’s the season, you might want to think about getting a flu shot.” Do say: “Today is the day you’re getting your influenza vaccine.”
“There are innumerable studies that have indicated that vaccine acceptance almost invariably follows a firm statement made by a healthcare provider,” he said. “They listen carefully to what their provider says, and that includes pharmacists.”
Randy Dotinga is a medical writer based in San Diego.