World Immunisation Week, celebrated in the last week of April, aims to highlight the collective action needed to promote the use of vaccines to protect people of all ages against disease. The goal of World Immunisation Week is for more people, and their communities, to be protected from vaccine-preventable diseases. 

Immunisation is highly effective in reducing morbidity and mortality caused by vaccine-preventable diseases. Childhood vaccination for diphtheria was introduced in Australia in 1932 and use of vaccines to prevent tetanus, pertussis (whooping cough) and poliomyelitis became widespread in the 1950s.  This was followed by vaccines for measles, mumps and rubella in the 1960s and in more recent years, vaccines have been introduced for hepatitis B, pneumococcal disease, influenza and COVID-19.   

This article aims to summarise the importance of vaccines for protecting against disease for people living with diabetes. 

Influenza 

Everyone living with diabetes should be highly encouraged to get the annual influenza (flu) vaccine to reduce their risk of getting the flu. People living with diabetes, even when their diabetes is well-managed (blood glucose levels are largely sitting in the safe target ranges), are at high risk of serious flu complications. The flu can make chronic health problems, such as diabetes, worse. This is because diabetes may make the immune system less able to fight infections. In addition, illness can make it harder to manage blood glucose levels, leaving blood glucose levels to climb. 

The annual influenza vaccine is recommended for everyone aged six months and older. It is free under the National Immunisation Program (NIP) for children aged six months to five years and adults 65 years and over, as well as pregnant women, Aboriginal and Torres Strait Islander people, and people with certain medical conditions such as diabetes. 

Annual vaccination should ideally occur before the onset of each flu season, which usually occurs from June to September in most parts of Australia. The flu vaccination program will commence in April, providing protection before the peak of the expected season. If you do get sick over winter it is important to follow sick day guidance. 

COVID-19 and diabetes 

COVID-19 is a respiratory illness caused by a new virus SARS-CoV-2. Symptoms can include fatigue, fever, coughing, sore throat and shortness of breath. The virus can spread from person to person, but good hygiene can help to prevent infection. The COVID-19 vaccinations are safe and have been approved by the Therapeutic Goods Administration’s (TGA) rigorous testing process. All vaccines currently approved by the TGA (AstraZeneca, Pfizer, Moderna and Novavax) are suitable for use in adults living with diabetes. 

It is important that as many Australians as possible get vaccinated. This is the best path forward in the fight against the Covid-19 virus. 

Recommended vaccinations for people living with type 2 diabetes

The Royal Australian College of General Practitioners (RACGP) general practice management of type 2 diabetes recommends the following vaccinations for people living with type 2 diabetes: 

• Influenza – annual vaccination is recommended for people with chronic conditions, including diabetes, that require regular medical follow-up or have required hospitalisation in the past year 
• Diphtheria, tetanus, pertussis – for all adults aged 65 years and over if they have not had one in the previous 10 years 
• Hepatitis B – consider for travellers to hepatitis B-endemic areas 
• Herpes zoster – consider for ages 70–79 years (available for free in this age group under the National Immunisation Program)  
• Pneumococcus – diabetes is considered a ‘Category B’ condition for increased risk of invasive pneumococcal disease. It is recommended that all adults with type 2 diabetes receive three lifetime doses of the 23-valent pneumococcal polysaccharide vaccine (23vPPV), as follows: 
  • first dose at around age 18 years, or at time of diagnosis of type 2 diabetes  
  • second dose 5 – 10 years later  
  • third dose at least five years later or at age 65 years, whichever is later 

It has been nearly three years since the first case of the new coronavirus (SARS-CoV-2) was detected. At first there were fears that people with diabetes may be at greater risk of getting COVID-19, but this does not seem to be the case.

However, having diabetes and hyperglycaemia (high blood glucose levels) are risk factors for a more severe COVID-19 infection. Why is this so?

Are diabetes and COVID-19 connected?

There does seems to be a connection between diabetes and COVID-19. Diabetes is a risk factor for getting more severe COVID-19, but new evidence now suggests that COVID-19 may actually trigger the development of diabetes.

People with diabetes may get more severe COVID-19 because high blood glucose levels can increase the risk of infections. It could also be that the infection itself can affect your immune system.

Some people believe that inflammation caused by the virus can bring about insulin resistance, which is linked to type 2 diabetes.

A group of researchers found that a particular protein, called angiotensin-converting enzyme 2, or ACE2, may play a role. ACE2 is produced in your kidneys, intestines, heart, blood vessels, lungs and pancreas. ACE2  makes it easier for the coronavirus to enter your body as one of the spikes of the coronavirus binds to ACE2. This is particularly the case in the new Omicron variant.

When there is a sudden sharp rise in your blood glucose levels your body may become more sensitive to this ACE2 and this can make it even easier for the coronavirus to enter your cells.

Although COVID-19 enters your body through the lungs, it can easily spread throughout your body once it is connected to this ACE2. As your pancreas is one of the organs in which ACE2 is made it is possible that it damages the islet cells in the pancreas that are responsible for making insulin.

Perhaps the immune system accidentally attacks insulin-producing cells as it is attacking something else in the same area, for example COVID-19. It could be that COVID-19 is causing some people’s immune system to do just that.

The rising levels of diabetes could also be linked to the impact of the pandemic restrictions. Some people have delayed seeking medical care out of fear of infection with COVID-19. For others it could be relating to changes in physical activity levels or food choices.

As COVID-19 is so new, there is a lot that we still need to learn about how it interacts with the immune system and how it affects different organs.

COVID-19 treatment can cause hyperglycaemia

A steroid medication called Dexamethasone is often used to treat people with severe COVID-19 who need oxygen treatment. Dexamethasone can cause insulin resistance and hyperglycaemia, even in people who do not have diabetes. It can also cause people with diabetes to need more insulin than usual to lower their blood glucose to target levels.

Some people with diabetes who get COVID-19 may develop ketoacidosis or hyperosmolarity.

Ketoacidosis is a serious condition that can happen when the level of ketones in the blood is too high. The liver makes ketones by breaking down fat. It does this when there is not enough insulin in the body to allow the use of glucose for energy. The ketones enter your bloodstream and this makes the blood too acidic. Ketones in large amounts are toxic for your body.

Hyperosmolarity is a condition in which the blood has a high concentration of glucose, salt and other materials. These pull water out of the body’s other organs, leading to severe dehydration.

Both ketoacidosis and hyperosmolarity are treated with intravenous fluids (a ‘drip’) and high doses of insulin. Some people who take tablets for their diabetes may need insulin treatment instead during this time.

COVID-19 and the development of diabetes

Research from around the world has shown larger numbers than expected of new cases of diabetes in people who had COVID-19. But many of these studies are done in ways that make it hard to compare the findings and draw conclusions. For example, some studies only looked at children, others only at adults.

It seems that the chance of developing diabetes is highest in the first four weeks after getting COVID-19. It appears that the risk of developing diabetes, for people who did not have diabetes before COVID-19, is not increased long-term. The risk seems to remain high for 5-12 weeks after COVID-19 and then it decreases.

It is possible that a COVID-19 infection brings existing diabetes to light. Perhaps because people with COVID-19 are more likely to see their doctor and get health checks that can pick up diabetes.

Researchers are also considering if COVID-19 could be causing a new type of diabetes.

Type 2 diabetes develops slowly over time. Even type 1 diabetes can take months or years to come to light. So, it will be some time before anyone can say with certainty if COVID-19 is leading to an increase in diabetes.

Next steps

Scientist are working hard to find answers. To help them do this, they have built a database of new cases of diabetes in people with COVID-19.

The CoviDiab registry allows doctors from around the globe to upload de-identified information about people with COVID-19 and high blood glucose levels, who were not diagnosed with diabetes previously.

The registry also records information about medications that were used to treat COVID-19, in case the diabetes is an unknown side effect, also known as an adverse event.

Over time, the data will provide answers to many questions around COVID-19 and diabetes. In the meantime, if you or someone you know suspect diabetes seek medical attention immediately. A blood test can show if your blood glucose level is high and whether any further action is needed.

If you have questions or concerns about diabetes call the NDSS Helpline on 1800 637 700 to speak with a diabetes educator.

By Carolien Koreneff, CDE-RN, FADEA

While there is no doubt that exercise plays an important role in maintaining good health, you might be wondering if exercising after COVID-19 or the flu is appropriate.

Everyone wants a speedy recovery when they are unwell, but sometimes it can be tricky to know when it’s okay to power on with your exercise routine or when to take a few days off. COVID-19 and the flu can present as a mild respiratory disease, but may also cause severe illness. While exercise is very important for recovery from these illnesses, it must be done gradually and safely.

Symptoms

I like to use the “above the neck rule” when navigating symptoms. This means that if you are experiencing mild symptoms above your neck, such as sneezing, a mild cough, a headache or a stuffy nose, it’s likely that it’s okay to engage in light to moderate intensity exercise. Alternatively, if you have symptoms below your neck, such as a fever, chest pain, chronic fatigue, nausea, or diarrhoea, then it is wise to err on the side of caution and skip exercise until you feel better. These are all signs that your body needs to rest and recuperate.

Resuming exercise

When you resume exercise after illness, return to familiar light activities first and slowly increase the duration. It’s likely that you will have reduced energy, so shorter bouts of exercise are a great way to still keep active, even if it is at a lower level of exertion than you are used to. Start with 10 or 15 minutes initially and monitor your recovery. Once you have no, or very mild, symptoms you can begin increasing the frequency, duration and intensity of your exercise sessions. If you are returning to resistance training, start with bodyweight exercises and keep the repetitions low. It is important to pay careful attention to your recovery in this post-viral period so not to overdo it.

Keep an eye on blood glucose levels

In addition to modifying your exercise program, it’s also important to be aware of the changes to blood glucose levels, in response to illness and during the recovery period. When you have diabetes, illness and infection can increase your blood glucose levels, so you may need to make some changes to your diabetes management to help prevent fluctuations. It is recommended that all people living with diabetes have a sick day management plan so you can act at the earliest sign of illness and monitor your recovery. This may include checking your blood glucose levels more often and adjusting your medication, with the support of your doctor and credentialled diabetes educator.

Remember, if you’re unsure whether you should be exercising or not, always check with your doctor. An accredited exercise physiologist can also help you progress and regress an exercise program during times of illness and as you recover from COVID-19 and the flu.

By Hayley Nicholson, Exercise Physiologist and Credentialled Diabetes Educator

Medications that reduce the severity of COVID-19 are now available on the Pharmaceutical Benefits Scheme (PBS).

Oral anti-viral medications, Paxlovid and Lagevrio, can now be prescribed by doctors or authorised nurse practitioners to people living with any type of diabetes who use medication to manage their condition and have another condition. Other conditions include heart or kidney disease or obesity.

People living in residential aged care and all people aged 70 and over are also eligible even if they have no risk factors.

The medications can be prescribed for:

• People 50 years of age or older, with two additional risk factors for developing severe COVID-19
• People 30 years of age or older identifying as Aboriginal or Torres Strait Islander, with two additional risk factors for developing severe disease
• People 18 years of age or older, who are moderately to severely immunocompromised.

The medicines must be started as soon as possible after a diagnosis of COVID-19. If you have developed COVID-19 please speak to your health team about accessing these medicines immediately.

It is important to note anti-viral medicines are not intended to be used as substitutes for getting vaccinated against COVID-19. Diabetes Australia continues to recommend people get vaccinated and boosted in line with the latest advice from the Australian Technical Advisory Group on Immunisation.

A winter or fourth booster of the Covid vaccine is now available and free to all people in Australia managing their diabetes with medication following advocacy by Diabetes Australia.

The Australian Technical Advisory Group on Immunisation (ATAGI) is advising the winter COVID-19 dose can be administered at the same time as the influenza vaccine.

Diabetes Australia Group CEO Justine Cain wrote to ATAGI on May 16 urging it to expand availability of fourth booster doses of Covid-19 vaccine to Australians living with diabetes. People with diabetes are at greater risk of becoming severely ill or being hospitalised if they contract Covid-19 or the flu.

“People living with diabetes need the same access to these vaccines as those living with other chronic conditions. We were grateful that the latest update from ATAGI addressed these concerns,” Ms Cain said.

ATAGI has recommended a Covid-19 booster at least four months after the previous booster dose or four months after a previous Covid-19 infection.

You are eligible for a fourth booster if you meet the below criteria:

·  Adults aged 65 years and older

·  Residents 16 years and older of aged care or disability care facilities

·  People aged 16 years and older who are severely immunocompromised (as defined in the ATAGI statement on use of a 3rd primary dose of COVID-19 vaccine)

·  Aboriginal and Torres Strait Islander adults aged 50 years and older.

The expanded criteria now applies to people aged 16-64 years who have a medical condition that increases the risk of severe Covid-19 illness, including diabetes.

Also included are people with disability with significant or complex health needs or multiple comorbidities which increase the risk of poor outcomes from Covid-19.

For more information, click here

The Royal Australian College of General Practitioners (RACGP) and Consumer Health Forum (CHF) are urging Australians to prepare for a potential resurgence of influenza (flu) and get vaccinated early.

The pandemic has led to decreased exposure to the influenza virus and lower influenza vaccine coverage compared to previous years. But with an end to lockdowns and state and international borders reopening, a resurgence of influenza is expected in 2022, prompting warnings of a potentially monster flu season ahead.

Annual vaccination should ideally occur before the onset of each influenza season, which usually occurs from June to September in most parts of Australia. The influenza vaccination program will commence in April, providing protection before the peak of the expected season. 

The annual Influenza vaccine is recommended for everyone aged six months or older. It’s free under the National Immunisation Program (NIP) for children aged 6-months to 5-years and adults 65 years and over, as well as pregnant women, Aboriginal and Torres Strait Islander people, and people with certain medical conditions.

RACGP President Professor Karen Price urged Australians to prepare for the influenza season.

“GPs are concerned about this year’s flu season because Australians haven’t been exposed to the virus for the past two years like we were in the years before the pandemic.” she said.

“Children born since the start of the pandemic are likely to have had no exposure to the influenza virus in their lifetime, meaning it’s now more important than ever to ensure they are protected.

“Flu is something to be taken seriously – in 2019, just before the pandemic, there were 953 influenza related deaths in Australia. And we are already starting to see cases in some parts of the country.

“Australia has among the highest vaccination rates in the world. And our response to COVID shows prevention really is much better than cure; our high COVID vaccination rates are why we’ve done so well. Now it’s time to protect yourself against influenza, it’s another jab for sure, but it’s a win for you and your community.

“Getting your flu vaccine as soon as it becomes available in April gives you protection before the expected peak of the influenza season.

“Remember, the vaccine rolls out across the country from April. Most practices will only open bookings when they receive stock, and your practice may notify you when this happens.

“So, I encourage everyone to be proactive and prepare for influenza season. Check your practice’s website and have a chat with your GP or nurse at your next visit to see when the vaccine is available, and book in for your jab when you can.

“And if you do call your practice, remember our receptionists have been under a great deal of pressure during the pandemic and clinics are busier than usual, so please be patient and understanding.

“It’s also important to keep up the great hygiene practices we’ve learned during the pandemic, including hand washing, coughing into your elbow, and wearing a face mask and staying at home if you’re sick. Because all these measures help protect us from the flu, as well as winter colds.”

Consumers Health Forum CEO, Ms Leanne Wells said that Australians should continue to follow health advice as winter approaches and the flu season emerges.

“Australians have taken up vaccination at record rates to protect themselves against the COVID-19 virus, and due to this, the worst predictions of severe illness and death have not happened,” said Ms Wells.

“We encourage people to continue keeping up with vaccinations to protect themselves and their families from severe effects of the flu and any future outbreaks of COVID-19.

“Vaccines are rigorously tested for safety before being offered to the public in Australia, so the chances of any complications from them are very small, compared to the risks of severe illness from the flu or COVID-19.

“If you have questions about vaccination, you should talk to a trusted medical expert. Your GP will be able to advise you on when to get your next vaccination,” she said.

Diabetes Australia Group CEO Justine Cain urged all Australians living with diabetes to make an appointment to get their flu vaccine as soon as possible.

“Flu is a highly infectious disease that can make anyone sick, but people living with all types of diabetes are at a much higher risk of developing serious health complications than people without diabetes,” Ms Cain said.

“For some people living with diabetes flu can even be life-threatening so please get your flu vaccine, schedule your COVID booster and keep yourself healthy this flu season.

“Don’t delay – book your flu vaccine today.” 

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Media contacts

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Media Adviser
0428 122 357
media@racgp.org.au

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About the RACGP

The Royal Australian College of General Practitioners (RACGP) is the peak representative organisation for general practice, the backbone of Australia’s health system. We set the standards for general practice, facilitate lifelong learning for GPs, connect the general practice community, and advocate for better health and wellbeing for all Australians.

Visit www.racgp.org.au. To unsubscribe from RACGP media releases, click here.

About CHF

The Consumers Health Forum of Australia (CHF) is the national peak body representing the interests of Australian healthcare consumers. CHF works to achieve safe, quality, timely healthcare for all Australians, supported by accessible health information and systems.

Visit www.CHF.org.au. Follow on Twitter @CHFofAustralia  Facebook  and Linked In

About Diabetes Australia

Diabetes Australia is the national organisation supporting all people living with or at risk of diabetes. We put people first. We work in collaboration with member organisations, consumers, health professionals, researchers and the community. For more information visit: www.diabetesaustralia.com.au

With workplace changes, we are now receiving calls about returns to workplaces, exclusions from workplaces, and health and safety policies.

Not all of them are as clear-cut, and an important thing to remember is that these are new circumstances for everybody, so communication is important.

Trends we are noticing include:

Health concerns

Some workplaces are treating their employees with diabetes differently, but because of health concerns.

The risk of severe COVID for people living with diabetes has been well publicised. Some employers are insisting that people with existing conditions obtain medical certification before returning to the workplace.

This is not necessarily discrimination. It may be in line with industry or company health and safety regulations.

However, if these directives are causing disadvantage (reduced income or hours for people with diabetes but not other employees), compared to difference (work from home with the same entitlements as colleagues), then they could fulfil the criteria for discrimination.

Different responses

Different industries, different companies and even different offices have had varied responses to the pandemic. Some have returned to physical workspaces when not in lockdown, others still concentrate on working from home, and many others are in-between.

Many companies are still finding the balance as remote working has become normalised.

If a person living with diabetes needs to maintain the increased flexibility of working from home for at least some of the working hours, then they should file a written request to their manager.  This should be responded to in 21 days.  This is the grounds for a negotiation between employer and employee, not an entitlement to flexibility.

It also applies to employees who have been in the company for more than 12 months, and are not casual.   More information about this is available from the Fair Work Ombudsman.

Other aspects including workplace payments, government directives, social distancing and health policies can affect these decisions, so the best first step is to talk to your manager.

A brief history of vaccines

It is estimated that vaccinations against common diseases now save 57 million lives every year worldwide. This is almost the same as saving the entire population of Italy, annually. Humans have been living with diseases throughout history. As far back as 1200 BC we see evidence of influenza being described in Babylon. Since then, humans have been documenting disease outbreaks around the world, with the latest being COVID-19.

Dr Jenner and smallpox

In the 1700s, smallpox was wide-spread with high death rates. During this time, a doctor in England, Edward Jenner, noticed that cowpox, an illness in cattle and usually mild, could be spread from a cow to humans via sores on the cow. During an infection, dairy workers get sores on their hands and spread the infection to other parts of their body. The cowpox virus belongs to the family of viruses that also includes smallpox.

Jenner tested the idea that an infection with cowpox could protect a person from smallpox. On May 14, 1796, Jenner inoculated an 8-year-old boy with some matter taken from a cowpox sore on the hand of milkmaid. The boy suffered a local reaction and felt poorly for several days, but made a full recovery. Two months later, Jenner deliberately infected the same boy with matter taken from a fresh human smallpox sore, in an attempt to show the protection from cowpox. The 8-year-old boy did not develop smallpox.

Jenner next demonstrated that cowpox matter transferred in a human chain, from one person to the next, provided protection from smallpox. Initially, Jenner was ignored, but this changed when a colleague of Jenner’s demonstrated that vaccination with cowpox material prevented future smallpox infections. From that point on, the word spread quickly about how to protect people from smallpox.

Mass vaccination

The first mass vaccination programs began in the early 1900s. Today, in Australia we have the National Immunisation Program (NIP). This program is aimed at giving all Australians an opportunity to be vaccinated against the most common diseases in Australia. The program literally begins from birth, with a vaccination against hepatitis B. By school age, most children are now immunised against diphtheria, tetanus, whooping cough (pertussis), hepatitis B, polio, haemophilus influenzae type B (Hib), rotavirus, pneumococcal, measles, mumps, rubella, meningococcal C and chickenpox. In high school, children are also immunised against human papilloma virus (HPV), a leading cause of cervical cancer.

During their life, people will need booster shots of some vaccines every 10 years to maintain their immunity. This includes diphtheria, tetanus and whooping cough.

Some of us will also have a yearly flu shot to keep us protected against the ever-changing influenza virus. For those 70-80 years of age, there are vaccines against shingles. This is for people who were never vaccinated against chickenpox as to develop shingles, you must have first been infected with chickenpox.

Australian travellers may have some other vaccinations depending on where they plan to travel to. Common travel vaccines are hepatitis A, typhoid, cholera, Japanese encephalitis and tuberculosis. Farmers are encouraged to be vaccinated against Q fever.

Children and adults may receive different types of vaccines and different doses depending on their age.

How do vaccines work?

Vaccines work because they contain weakened or inactive parts of a particular bacteria or virus (antigen) that trigger the body’s immune system to respond. Newer vaccines contain the blueprint for producing antigens, rather than the antigen itself. Regardless of whether the vaccine is made up of the antigen or the blueprint, this weakened version will not cause the disease in the person receiving the vaccine. However, it will prompt their immune system to respond much as it would on its first contact with the actual disease.

This means that some people will feel symptoms similar to those as if they had contracted the real disease. Commonly people report a headache, mild fever or temperature, general aches and pains and feeling a bit unwell. Most of us who have had a Tetanus injection will be familiar with the feeling of a ‘dead arm’ after having this injection. These side effects are common to lots of immunisations.

Severe side effects, or an anaphylactic reaction, are rare. When the side effects are more than just a mild reaction, but not severe, some people think they have developed the actual disease. We hear people claim they got the flu from the flu shot. This is not correct. What they experienced was their body’s immune system responding to the vaccination. This means that if they do come into contact with the real virus their body will recognise the it and know how to fight it off.

Diabetes and vaccinations

People living with diabetes may also experience other signs or after-effects of immunisations, in addition to those described above. Most commonly, you may notice a rise in your blood glucose levels (BGLs).

When people living with diabetes become sick, particularly when severe, this can lead to hyperglycaemia or high BGLs due to the body releasing hormones such as cortisol and adrenaline. This then causes an increase in glucose production by the liver, which leads to a reduction of glucose uptake by the body, causing increased insulin resistance.

This response by the body to illness is very similar to what happens when we have a vaccination. This means some people will notice their BGLs rise following vaccinations.

If this happens, do not be alarmed. It is a fairly common side-effect of vaccinations in people living with diabetes. Some people will not notice any effects, but others may see a significant rise in BGLs. In some people it may mean you need to temporarily increase some of your diabetes medications, such as insulin (for those people who take insulin) to manage your diabetes.

Other people may see only a small rise in BGLs, so may be able to accept a short-term rise in their BGLs. Usually, the effect on BGLs is only for a few days, so it will have minimal impact on your overall diabetes management.

Do some vaccines have a greater impact on BGLs than others?

There are a few vaccines that seem to have a greater impact on BGLs than others. In some years the flu vaccine appears to affect BGLs more than other years. Clinicians are noticing that the COVID-19 vaccines cause BGLs to rise in a significant number of people following their first dose. Clinicians are also receiving reports that indicate the BGL rise can last from a few days up to two weeks following the vaccination.

This should not be a deterrent to having your COVID-19 vaccination, as with some planning you will be able to manage any BGL rise. You do not need to be alarmed. If you notice a significant rise in your BGLs, follow your ‘Diabetes Sick Day Management Plan’ or contact your diabetes educator or doctor for advice.

Final words

The bottom line is the risk of some side-effects, either mild or moderate, outweigh the possibility of being very ill or dying from a disease. History shows us the huge benefits of immunisations in saving people’s lives. Polio has nearly disappeared, with a 99% reduction in cases worldwide since 1988. In 1980, the World Health Organization declared the world was finally free from smallpox, nearly 200 years after Edward Jenner discovered how to protect people. These results were only achieved because of vaccinations.

Malcolm Flood, Registered Nurse, Credentialled Diabetes Educator and Authorised Nurse Immuniser.