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.