Journal of Diabetology, June 2014; 2:5
http://www.journalofdiabetology.org/
Short Communication: Influenza and Pneumococcal vaccination in patients with diabetes 1
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* P.A. Koul , M.A. Bhat , S. Ali , S. Rahim , S.J. Ahmad , S. Ahmad , R. Yusuf , S.R. Masoodi
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Abstract Data for uptake of the recommended influenza and pneumococcal vaccination in patients with diabetes from developing countries are scarce. The aim of the study was to assess the uptake of influenza and pneumococcal vaccination in patients with diabetes. One thousand and five hundred patients with diabetes were approached; 1100 (685 female, age 5-90 years, median 50 years) consented for participation. Information regarding knowledge, beliefs and practices regarding vaccination was recorded by administering a predefined questionnaire. Only 99 (9%) and 97 (8.8%) of the 1100 patients had received influenza and pneumococcal vaccination respectively in the past 1-5 years. Vaccination rates were higher in males (15.9% versus 4.8% for influenza, p = 0.000 and 16.1% versus 4.5% ; p = 0.000 for Pneumococcus); and in those aged > 65 years (13.1% versus 7.96% , p = 0.017 for influenza; and 13.6% versus 7.6% , p = 0.012 for Pneumococcus). Reasons cited for non-participation included misperceptions about personal risk, vaccine efficacy and safety. Only 4 of the 28 physicians caring for the patients prescribed the vaccines regularly and the vaccination rates in their patients were significantly higher (p = 0.000). Poor vaccination rates in Northern Indian patients with diabetes call for intensive efforts to improve uptake. Key words: Vaccine, influenza, pneumococcus, Vaccination 1
Department of Internal Medicine and CDC/ICMR Multisite Influenza Surveillance Program for Influenza, SKIMS, Srinagar - India. 2
Department of Endocrinology SKIMS, Srinagar India *Corresponding author: (Current Details)
Parvaiz A Koul Department of Internal & Pulmonary Medicine Sheri-Kashmir Institute of Medical Sciences Soura, Srinagar - India E-mail:
[email protected] Introduction India is already home to 61.3 million subjects with diabetes and the number is predicted to reach 101.2 million by the year 2030 (1). Diabetes confers an increased risk of developing and dying from infectious diseases (2) with an enhanced susceptibility to morbidity, mortality and hospitalizations due to influenza and pneumococcal disease (2-4). Diabetes has been identified as one of the risk factors for H1N1 influenza and related complications (5,6). The Advisory Committee on Immunization Practices (ACIP) recommends
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influenza and pneumococcal vaccines for all individuals with diabetes (7,8). Influenza vaccination has been reported to facilitate a drop of up to 80% in influenza and pneumonia related hospitalizations in patients with diabetes (9) and up to 50% in influenza-related mortality (10). Influenza vaccination in a Taiwanese cohort was recently found to be associated with lower incidences of pneumonia or influenza and respiratory failure and reduced risk of morbidity, hospitalization, intensive care unit (ICU), admission, hospitalization cost and mortality (11). Despite these data, uptake rates of seasonal influenza vaccine among patients with diabetes vary widely from 43.5% to 67.6% (12,13) and those of pneumococcal vaccine being even lower from 16.1% to 43.5%. (14,15). Increasing age, chronic co-morbidity, increased frequency of physician visits, previous vaccination, male gender, increasing duration of diabetes and receipt of insulin therapy have been associated with higher uptake rates (15-18). We have demonstrated influenza as a cause of acute viral infections in our part of the world (19), but vaccination coverage is poor even in high risk groups like health care workers (20). Data for vaccination uptake in patients with diabetes in
Journal of Diabetology, June 2014; 2:5 developing countries is scant despite housing most of the patients with diabetes of the world. No data are available from India. The current survey was designed against this backdrop to assess the uptake of influenza and pneumococcal vaccinations in patients with diabetes in the Kashmir valley of the Indian subcontinent. Methods The study was conducted in the departments of Medicine and Endocrinology of the Sher-iKashmir Institute of Medical Sciences, a 650 bed tertiary care cum referral center in the summer capital of the Northern Indian state of Jammu & Kashmir. Kashmir is a temperate climate area in the more subtropical India and respiratory illnesses are common, of which influenza constitutes a substantial percentage (19). After informed consent, a convenience sample of 1500 patients with diabetes was approached for participation in a questionnaire based survey from December 2010 till March 2012. Of these 1100 (73%) consented to participate. The questionnaire was administered to record if the patients had received any vaccinations in the past 5 years, whether they had been advised vaccinations and the reasons for declining the vaccination if it had been medically advised. Available medical records of the patients were scrutinized for recording comorbidities as well as the physician recommendation for vaccination. Twenty-eight doctors caring for these patients were also interviewed regarding their knowledge, beliefs and practices regarding influenza and pneumococcal vaccination. The study was conducted following the Declaration of Helsinki and was approved by the Institute Ethics Committee. Statistical analysis was performed using Epi Info 7.0 employing Fisher’s exact, Chi-square and Student’s t-test, as appropriate. Odds ratio (OR) with 95% confidence intervals (95% CI) were calculated. A pvalue of < 0.05 was considered statistically significant. Findings: The participants included 685 females and 415 males with age ranging from 5 to 90 years (median 50 years) with 221 (20.1%) participants aged 65 (Page number not for citation purposes)
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http://www.journalofdiabetology.org/ years or more. The duration of diabetes ranged from 6 months to 25 years (median 5.5 years) and all but one had type 2 diabetes. Ninety-nine (9%) had received vaccination for influenza 1-2 times (median 1) in the last 5 years whereas 97 (8.8%) had received pneumococcal vaccination. Two patients had received only pneumococcal vaccination whereas 95 (8.6%) had received both pneumococcal as well as the influenza vaccination. Vaccination rates for influenza in patients aged 65 or more were higher (13.1% of 221) compared to those aged < 65 years (7.96% of 879; p = 0.017) (OR 1.75, 95% CI 1.1-2.8), whereas pneumococcal vaccination rates were 13.6% as against 7.6% (OR 1.84, 95% CI 1.13-2.98, p = 0.012) respectively. In males the vaccination rates for influenza were 15.9% compared to females (4.8%, p = 0.000) (OR 3.73, 95% CI 2.4-5.9), whereas for pneumococcal infection the respective vaccination rates were 16.1% and 4.5% (OR 4.06, 95% CI 2.556.5, p = 0.000). Vaccination status in various subgroups of patients is depicted in table 1. Presence of co-morbidity like chronic obstructive pulmonary disease (COPD) or chronic kidney disease (CKD) did not affect vaccination uptake; not exceeding 8% in any subgroup. Duration of diabetes also did not have any relation with the uptake of vaccination. Patients who had received pneumococcal vaccination were highly likely to receive influenza vaccination as well. Upon multivariate analysis recommend-dation of the doctor, male sex and age were positively associated with vaccination uptake. Nine hundred and thirty five (85%) participants were unaware that diabetes posed any additional risk for influenza or pneumonia and only 150 had been recommended vaccination by their treating physicians. The reasons cited for not getting vaccinated despite recommendation included disbelief about the efficacy of vaccine (n = 27), poor affordability (n=40), fear of side effects (n = 39) and inability to find time for vaccination (n = 40). Only 4 of the 28 physicians regularly prescribed vaccination to their patients; uptake in patients cared for by these doctors being significantly higher (62.7% compared to 0.3%, OR 529.97, 95% CI =
Journal of Diabetology, June 2014; 2:5 (162.9-1724.4), p = 0.000). However all the 28
http://www.journalofdiabetology.org/ doctors believed that influenza and
Table 1: Vaccination rates in different groups of patients Group
Total number
Vaccinated for Influenza n (%) 99 (9.0)
Total 1100 (100) Age < 65 years 879 (79.9) 70 (7.96) ≥ 65 year 221 (22.1) 29 (13.1) Sex Males 415 (37.7) 66 (15.9) Females 685 (62.3) 33 (4.8) Type of diabetes Type 1 1 (0.09) 0 (0) Type 2 1099 (99.01) 99 (9.01) Duration of diabetes < 5 years 538 (48.9) 42 (7.8) 5-10 years 393 (35.7) 39 (9.9) >10 years 169 (15.4) 18 (10.7) Has a doctor told you of the requirement of the vaccination? Yes 97 (8.8) 97 (100) No 1003 (91.2) 2 (0.2) Do you know of a requirement of vaccination? Yes 115 (10.5) 97 (84.3) No 985 (89.5) 2 (0.2) Co-morbidities Hypertension 718 (65.3) 30 (4.2) HCVD/CAD 130 (11.8) 11 (8.5) COPD 29 (2.6) 1 (3.5) Hypothyroidism 105 (9.5) 4 (3.8) Dyslipidemia 258 (23.5) 19 (7.4) Nephropathy/CKD 42 (3.8) 1 (2.4) Osteoporosis 43 (3.9) 2 (4.7) Stroke 15 (1.4) 0 (0.0) Rheumatoid arthritis 20 (1.8) 0 (0.0) Osteoarthritis 19 (1.7) 1 (5.3)
Vaccinated for Pneumococcus n (%) 97 (8.8)
Data presented as n (%, ), CAD= Coronary artery disease, HCVD=Hypertensive cardiovascular disease, Chronic obstructive pulmonary disease, CKD= Chronic kidney disease.
pneumococcal vaccination is a recommended guideline for patients with diabetes and diabetes is a high risk group for both influenza and pneumococcal disease. The vaccination rates as per our data are significantly low compared to the vaccination rates in other geographical locations. In comparison, Influenza vaccination coverage in patients with (Page number not for citation purposes)
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67 (7.6) 30 (9.05) 65 (15.7) 32 (4.7) 0 (0) 97 (8.8) 43 (7.99) 38 (9.67) 16 (9.5) 96 (98.9) 1 (0.1) 96 (83.5) 1 (0.1) 29 (4.0) 10 (7.7) 1 (3.5) 4 (3.8) 20 (7.8) 1 (2.4) 2 (4.7) 0 (0.0) 0 (0.0) 0 (0.0) COPD=
diabetes in the United State (US) was 28.2% in 200809 (21), whereas in a recent study from Australia, 47% and 31% of high-risk persons were immunized against influenza and pneumococcus respectively (22). In another recent Spanish survey, the coverage of influenza vaccination among adults with diabetes in 2010 was 65.0% compared with 41.2% for those
Journal of Diabetology, June 2014; 2:5 without diabetes with coverage being nearly steady from 2003 (23). Although benefits of influenza vaccination have been well documented in the western population (24) the data from developing countries are sparse. In a recent retrospective Taiwanese survey (25), the vaccinated cohort had a lower hospitalization rate compared to the non-vaccinated cohort (29.6 vs. 33.1 per 100 person-years, adjusted hazard ratio (HR) of 0.88). The vaccinated cohort was also less likely to be admitted to the intensive care unit (ICU) (0.58 vs. 2.05 per 100 person-year; adjusted HR 0.30 (95% CI 0.19 - 0.47)) and less likely to expire (3.13 vs. 7.96 per 100 person-year; adjusted HR 0.44 (95% CI 0.36 - 0.54)). Influenza vaccination also reduced the hospitalization cost by 1282.6 USD. Patients aged 65 years or more and those with male gender had a higher prevalence of vaccination in our study. Even as pneumococcal vaccination is recommended for any patient above 65 years of age, the vaccination rates were only 16%. The nearly 4 times higher prevalence of vaccination among males could reflect the gender inequality in healthcare in countries in the subcontinent. In societies where women are of a perceived lower status than men, gender inequities are often mirrored in terms of restrictions in education, economic and employment opportunities, health care and choices regarding marriage and reproductive health matters (26). Male gender along with higher age, presence of associated chronic conditions and physician visits in the last 2 weeks were positive predictors of vaccination uptake in another study too (23). Predictors of higher vaccination rates have included increasing age, nonHispanic origin, above the poverty line status and concomitant presence of high risk conditions like asthma or heart disease or being healthcare personnel (21). Poor self-reported health status was an independent predictor of pneumococcal vaccination status for people with asthma, diabetes or a cardiovascular condition; however it was only an independent predictor of influenza immunization status for people with diabetes (22). The general attitude and practices of the physician was a strong determinant (OR 529.97, 95% CI = (Page number not for citation purposes)
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http://www.journalofdiabetology.org/ (162.9-1724.4)) of the vaccination status of the patients in our study, with 4 physicians contributing to nearly all (except 3) of the vaccinated patients. A history of recent General Practitioner (GP) visit and recommendation by a GP were significant predictors of influenza vaccination in a recent Irish study (27). A recent survey of the practices of influenza vaccination among health care workers in Kashmir (21), demonstrated that only 4.4% of the 1421 healthcare workers had ever received influenza vaccination; most citing misperceptions about vaccine safety and efficacy as reasons for nonparticipation. Such perceptions among the practicing physicians are distinct impediments to the vaccination of patients. The current study is limited by a single center recruitment that may not entirely reflect the practices. However, we believe that the vaccination rates in such patients would be even lesser. This is however, subject to scientific scrutiny. Conclusion The poor vaccination uptake in patients with diabetes in Kashmir calls for intensive efforts aimed at increasing coverage by targeting patients, health care professionals as well as the vaccination delivery systems for an equitable and uniform vaccination. References 1.
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