Influenza and Pneumococcal Immunization

Canadian Diabetes Association Clinical Practice Guidelines Expert Committee

Nadira Husein MD, FRCPC Vincent Woo MD, FRCPC

  • Key Messages
  • Recommendations
  • Figures
  • Full Text
  • References

Key Messages

  • Influenza immunization can reduce hospitalization rates by approximately 40% for those individuals deemed to be at high risk.
  • Pneumococcal immunization is desired in people with diabetes as they are considered as likely to be infected as those with other chronic diseases.
  • For those who are >65 years of age, a 1-time revaccination is recommended if the original vaccine was administered when they were <65 years of age with at least 5 years between administrations.


People with diabetes are considered to be at high risk for morbidity and mortality from influenza and pneumococcal disease (1,2). During recent influenza epidemics, diabetes was considered a significant risk factor for hospitalization (3). Influenza immunization is associated with up to a 40% risk reduction in mortality (2). Clinical recommendations for vaccination are derived from large cohort studies that included people with diabetes as trials specific to individuals with diabetes are currently lacking.

Influenza Immunization in Adults

Data regarding influenza morbidity and mortality in people with diabetes are based on retrospective analyses during influenza epidemics (3,4). A recent epidemiological analysis of pandemic influenza demonstrated that people with diabetes are more likely to be hospitalized or to require intensive care (5).

Over a period of 10 influenza seasons, influenza vaccination was shown to be effective in reducing both death and hospitalization from influenza and pneumonia in a cohort that included people with diabetes (6).

A Dutch case control study documented that the incidence of complications was 2 times higher in the unvaccinated group compared to the vaccinated group (7). The rates of hospitalization for influenza, pneumonia, other acute respiratory diseases, myocardial infarction, congestive heart failure, and stroke or diabetes events were reduced by 70%.

Pneumococcal Immunization in Adults

People with diabetes are at increased risk of hospitalization for pneumococcal disease (1,8). Prior pneumococcal vaccination is associated with a reduction in death and complications in hospitalized adults with community-acquired pneumonia (9). It is accepted that people with diabetes are at similar risk of developing pneumococcal disease as those with other chronic conditions (1), and, therefore, those with diabetes are encouraged to receive pneumococcal vaccination. Revaccination is recommended as a 1-time event for individuals >65 years of age if the original vaccine was given when they were <65 years of age and >5 years earlier.


  1. People with diabetes should receive an annual influenza immunization to reduce the risk of complications associated with influenza [Grade D, Consensus].
  2. Pneumococcal immunization should be offered to people with diabetes. A single dose is recommended for those >18 years of age. A 1-time revaccination is recommended for those >65 years of age (if the original vaccine was given when they were <65 years of age) with at least 5 years between administrations [Grade D, Consensus].

Related Websites

National Advisory Committee on Immunization. Canadian Immunization Guide. 7th ed. Ottawa, ON: Canadian Medical Association; 2006. Available at: Accessed November 2012.


  1. 1 L.M.A.J. Muller K.J. Gorter E. Hak Increased risk of common infections in patients with type 1 and type 2 diabetes mellitus Clin Infect Dis 41 2005 281 288
  2. 2 R.H.H. Groenwold A.W. Hoes E. Hak Impact of influenza vaccination on mortality risk among the elderly Eur Respir J 34 2009 56 62
  3. 3 S. Jain L. Kamimoto A.M. Bramley Hospitalized patients with 2009 H1Ni influenza in the United States, April-June 2009 N Engl Med 361 2009 1935 1944
  4. 4 A. Campbell R. Rodin R. Kropp Risk of severe outcomes among patients admitted to hospital with pandemic (H1N1) influenza CMAJ 182 2010 349 355
  5. 5 R. Allard C. Tremblay P. LeClerc T. Tannenbaum Diabetes and the severity of pandemic influenza A (H1N1) infection Diabetes Care 33 2010 1491 1493
  6. 6 K.L. Nichol J.D. Nordin D.B. Nelson Effectiveness of influenza vaccine in the community-dwelling elderly N Engl J Med 357 2007 1373 1381
  7. 7 I. Looijmans-Van Den Akker K.L. Nichol T.J.M. Verheij Clinical effectiveness of first and repeat influenza vaccination in adult and elderly diabetic patients Diabetes Care 29 2006 1771 1776
  8. 8 J. Kornum H.-H. Lervang R.W. Thomsen Diabetes, glycemic control, and risk of hospitalization with pneumonia Diabetes Care 31 2008 1541 1545
  9. 9 D. Fisman E. Abrutyn K. Spaude Prior pneumococcal vaccination is associated with reduced death, complications, and length of stay among hospitalized adults with community acquired pneumonia Clin Infect Dis 42 2006 1093 1101
Reproduced with permission from Canadian Journal of Diabetes © 2013 Canadian Diabetes Association. To cite this article, please refer to For citation.

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