Vaccination in adults with diabetes

Red Flags

Diabetic patient with severe sepsis from vaccine-preventable infection (pneumococcus, influenza, HBV) — high mortality; preventable disease^[1]
Live vaccines contraindicated in significant immunocompromise (high-dose steroids, biologics) — give inactivated alternatives where available^[1]
Pregnancy with diabetes — inactivated influenza, Tdap, COVID-19 safe; defer live vaccines (MMR, varicella) until postpartum^[1]
Diabetic foot ulcer or significant skin breach — tetanus booster if last >5 years; tetanus immunoglobulin if heavily contaminated wound and inadequate prior immunisation^[1]

First-line treatment

Interventions

Annual influenza vaccine (inactivated)^[1]
All adults with diabetes annually; reduces hospitalisation and cardiovascular events. Quadrivalent or high-dose for adults ≥65
Pneumococcal vaccination^[1]
PCV15 followed by PPSV23 ≥1 year later, OR PCV20 alone, for all adults with diabetes age ≥19. Booster PPSV23 at age ≥65
Hepatitis B vaccination^[1]
All adults with diabetes age 19–59 (and ≥60 with risk factors). Three-dose schedule (0, 1, 6 months) or accelerated 2-dose Heplisav-B (0, 1 month)
COVID-19 vaccination^[1]
Per current annual schedule; diabetes is high-risk indication; updated formulation per circulating variants
RSV vaccination^[1]
Single dose recommended for adults ≥60, especially with diabetes or other high-risk conditions; not annual
Herpes zoster (recombinant)^[1]
Two-dose series of recombinant zoster vaccine (Shingrix) for all adults age ≥50 with or without diabetes; immunocompromised ≥18
Tetanus-diphtheria (Td or Tdap)^[1]
Td booster every 10 years; Tdap once in adulthood (replacing one Td); Tdap in each pregnancy 27–36 weeks
HPV vaccination^[1]
All adults age 9–26; shared decision making 27–45. Three-dose schedule. Diabetes does not change recommendation

Safety-net

Diabetes increases the risk of complications from vaccine-preventable infections — vaccinations are not optional^[1]
Inactivated vaccines are safe regardless of glycaemic control; live vaccines may be contraindicated with high-dose steroids or biologics^[1]
Mild local soreness or low-grade fever after vaccination is normal and does not require treatment changes^[1]

Referral criteria

Severe immunocompromise (transplant, biologic therapy, high-dose steroids) needing live vaccine considerationInfectious diseases / immunology^[1]
Vaccine refusal or hesitancy with high-risk diabetic patientStructured counselling per RSSDI shared-decision-making framework^[1]
Vaccine-preventable infection with severe complicationsHospital admission for treatment^[1]

Clinical summary

Recommended vaccinations for adults with diabetes — pneumococcal, influenza, hepatitis B, COVID-19, RSV, herpes zoster, tetanus, HPV, and travel-specific.

References

1.RSSDI Vaccination Guidelines for Patients with Diabetes (2024); ADA Standards of Care 2026 (2024)