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Diabetes and Influenza-Attributable Illness: The Rationale for Targeted Influenza Vaccinations in Adults with Diabetes Open Access


Other title
clinical practice guidelines
primary care
quality improvement
Type of item
Degree grantor
University of Alberta
Author or creator
Lau, Darren C H
Supervisor and department
Johnson, Jeffrey A (Public Health Sciences)
Examining committee member and department
Kumar, Deepali (Medicine, University of Alberta)
Majumdar, Sumit R (Medicine, University of Alberta)
Kwong, Jeffrey C (Family and Community Medicine, University of Toronto)
Eurich, Dean T (Public Health Sciences, University of Alberta)
School Public Health Sciences

Date accepted
Graduation date
Doctor of Philosophy
Degree level
While guidelines for seasonal influenza vaccinations single out working age (< 65) adults with diabetes, vaccination rates in this group remain below national targets. Historically, there has been limited evidence to support these guidelines. This dissertation comprises four studies investigating the clinical need for, and benefits of, vaccination; and identifying effective means of improving vaccination rates in adults with diabetes, emphasizing those of working age. Our first two studies identified the effects of influenza on a large population-based cohort. In working age adults with diabetes, influenza contributed a substantial proportion of visits and hospitalizations for influenza-like illness (13%), pneumonia and influenza (PI) hospitalizations (26%), and all-cause hospitalizations (6%) during influenza season. The effect of influenza on all-cause hospitalizations was higher in adults with diabetes. However, such individuals did not experience increased deaths or hospitalizations attributable to influenza when followed after acute respiratory infections. These results suggest that adults with diabetes indeed experience a higher relative frequency, though not severity, of illness attributable to influenza. We then examined the effectiveness of influenza vaccine in working age adults with diabetes, compared to the elderly, for whom vaccination recommendations are well accepted. We observed comparable relative reductions in PI (43-55%) and all-cause (28-34%) hospitalizations, in all groups – both during and outside of influenza season. These results suggest that many observational studies, our own included, have over-estimated the benefits of vaccine. In practice, public health authorities remain committed to influenza vaccination despite uncertainty in the supporting evidence. We thus performed a systematic review summarizing the effectiveness of interventions for improving influenza and pneumococcal vaccination rates in community-dwelling adults. Interventions that assign vaccination responsibilities to non-physician personnel, or that activate patients through personal contact showed particular promise, although the small extent of benefits suggests a need for further innovation. We have contributed new evidence showing that efforts to mitigate the effects of influenza in diabetic adults may be warranted by increased risk, although the benefits of vaccination remain uncertain. Our work highlights a need for randomized trials of vaccine effectiveness, and for studies examining the local factors mitigating or potentiating efforts to improve vaccination rates.
Permission is hereby granted to the University of Alberta Libraries to reproduce single copies of this thesis and to lend or sell such copies for private, scholarly or scientific research purposes only. Where the thesis is converted to, or otherwise made available in digital form, the University of Alberta will advise potential users of the thesis of these terms. The author reserves all other publication and other rights in association with the copyright in the thesis and, except as herein before provided, neither the thesis nor any substantial portion thereof may be printed or otherwise reproduced in any material form whatsoever without the author's prior written permission.
Citation for previous publication
A version of Chapter 5 has previously been accepted for publication. (Lau D, Hu J, Majumdar SR, Storie DA, Rees SE, Johnson JA. Interventions to Improve Influenza and Pneumococcal Vaccination Rates Among Community-Dwelling Adults: A Systematic Review and Meta-Analysis (Accepted manuscript, March 2, 2012). Annals of Family Medicine.

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