It’s that time of year again. A nip of cold is in the air, and coughs and sneezes ring out in public places across the land. Yep. Flu season is here. Our Ask D'Mine weekly advice column mailbag has been filling up with questions from those wondering about the mix of diabetes and the flu shot.

So our in-house expert Wil Dubois has assembled a flu and related vaccine Q&A to get us up to speed. Take it away, Wil...

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What is flu?

Flu is a highly contagious respiratory illness caused by a family of quickly-evolving influenza viruses. Flu is not to be messed with. It can do more than make you sick. It can kill you. During last year’s flu season, one of the worst on record, 80,000 Americans died while nearly a million more were hospitalized. And yes, getting a flu shot is pretty much vital to those living with diabetes, at least according to this article here at Healthline.

What makes flu challenging is that it’s caused by a virus, making it damn hard to treat. Diseases caused by bacteria we can treat easily as we have all manner of antibiotics, but our anti-viral tools are severely limited. Truly, the best way to fight the flu is to avoid getting it in the first place, and believe it or not, that’s a pretty easy thing to do.


When is flu season?

Timing may vary. But per the CDC (Centers for Disease Control and Prevention), flu viruses are most common in the US during the fall and winter months. Influenza activity often begins to increase in October and November, and most of the time it peaks between December and February -- though it can last as late as May. The CDC reports that this past year's flu season (Oct. 1, 2018 to May 4, 2019) was actually the longest-stretching one we've seen in a decade, starting strong early on before abating and then followed by another strain of flu kicking in later in the season.


What is a vaccine?

A vaccine is like an accelerated training program for your body’s immune system. Here’s the thing: The human immune system is actually pretty good at fighting off viruses, but it has to learn its enemy. How does it do that? In nature, it learns to fight pathogens by surviving various illnesses. Over the course of a sickness, the immune system learns about the disease. The next time that particular bug comes along, the immune system is ready, and can knock it out with a quick punch.

The problem with the flu, however, is that it evolves rapidly. So much so that this year’s flu is not last year’s flu. And last year’s flu wasn’t the flu from the year before that, and so on an so forth back through time. This is where a vax comes in. It introduces your body to a new pathogen in a way that keeps you from getting truly sick. There are two basic types of vaccines: Inactivated and Attenuated.

Bear with me.

Inactivated is a polite word for “killed.” Yep. An inactivated vax is made by growing a bunch of viruses and then nuking them. Even though dead, once injected into your body, your immune system can still use the virus corpses to study the virus, understand it, and get ready to fight it off. The beauty of this system is that a dead virus can’t make you sick. If you got an inactivated virus vax and got sick, the truth that is you got your shot too late. You were already sick before the shot, because dead viruses don’t cause illnesses. Period.

An attenuated virus, on the other hand, is a virus that’s still alive. Barely. Instead of being nuked, the vax is made by growing a bunch of viruses and then kicking the crap out of them. They’re still alive, but being very weak, they are easy pickings for the immune system. Attenuated viruses can cause mild illnesses, but they greatly beef up the immune system for the main event.

Flu vaxes come in both flavors.


Are there different vaxes for flu?

Yes, there are several.

  • The nuked virus, called IIV, for Inactivated Influenza Vaccine, is the traditional flu shot, usually given as a shot in the arm using a needle you shouldn’t look at before you get the injection, but two brands are also approved for jet injector use.
  • For the older crowd, there are high-dose shots, as well as a vax formulated with an adjuvant, an ingredient that boosts the immune system response to the vax.
  • There’s also a recombinant flu vax. But it has a short self-life, so you’re not as likely to see it.
  • A Nose-Snort Flu Vaccine exists too. It's an alternative called LAIV, which stands for Live Attenuated Influenza, approved for non-pregnant peeps 2-49 years of age, so long as they don’t have “certain underlying medical conditions.” Diabetes isn't specifically listed as one of those underlying conditions, although the list includes “people with weakened immune systems” -- which certainly does include PWDs (people with diabetes). It's also important to consider that the CDC considers all types of diabetes a medical condition that puts us at “high risk” of developing “serious” flu-related complications that may include pneumonia, bronchitis, sinus infections and ear infections. Oh, and death. Death is pretty serious. But short answer: Yes, this is an option for PWDs.
  • The 2018-19 flu season brought news that the FDA approved a new medication dubbed Xofluza, the first flu antiviral OK'd in almost 20 years! It's for those ages 12 and older who've only been showing flu-like symptoms for 48 hours, max. For this latest 2019-20 flu season, the FDA's just recently expanded the indication for use on this newest Xofluzo -- in those 12 years or older who are at high risk of developing flu-related complications, such as those of us who live with diabetes.


There are many more, but we won't get lost in all the varieties at the moment.

Traditionally, a flu vaccine is grown in hen’s eggs, although that’s changing. The viruses for some brands of flu vaxes are now grown in cultured mammal cells, the idea being that it’s faster (if there is a pandemic), there’s less mutation risk (apparently a problem with some strains grown in eggs), and it’s egg-free for those with egg allergies. Which mammal? In the case of Flucelvax, the first FDA-approved cell-based flu vax, it’s grown in cells from dog kidneys.

Hey, I couldn’t make that up if I tried!

Some early reports suggest that these newer, cell-grown vaxes are more effective against this year’s flu, although in other years the hen’s egg shots did better. Apparently, this has to do with the various strains, some of which have a greater tendency to mutate (which is what viruses do) more in one environment than the other. If the vax virus mutates too much in production, it won’t match the target flu out in the environment, providing reduced protection.


Which vax is best?

Officially, the CDC says there is “no preference expressed for any one vaccine over another.”


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Flu season has arrived and that can be a dangerous time for people with diabetes.

So, which type should we PWDs get?

Despite all of that, according to the CDC, PWDs should get injectable dead-virus flu shots, thanks to the “long-established safety record” for this kind of vax in people with diabetes. So what about the nasal snort? While not prohibited, the CDC lists a “precaution” against using it for us.

Hey, we should be used to needles by now anyway, right?


Is it true that there's an “official” recommendation that all PWDs need a flu shot?

Yeppers. The CDC recommends it, and they recommend a pneumonia shot, too. Additionally, both the big diabetes  organizations -- the American Diabetes Association (ADA) and the American Association of Clinical Endocrinologists (AACE) -- recommend annual flu shots in their practice guidelines for treating people with diabetes.

If you're asking why, it's because we PWDs get sick more easily than non-diabetics, and when we do get sick, we get a lot sicker. This is needed every year because -- as mentioned above -- there's a different strain of flu every year.

But it’s not just PWDs who should get vaccinated. The CDC strongly advises that everyone older than 6 months old get a flu shot. Flu is an equal opportunity killer, and even if you’re the healthiest person in the world, and can easily survive the flu, you could still pass the flu on to someone not so strong. So don’t be a Typhoid Mary. Everyone should get a flu vax. It’s good citizenship.


Will a flu shot raise my blood sugar?

It might. You know how your arm often aches after a flu shot? Well, two things are going on there. First, a bunch of liquid just got shoved into your muscle. Until it’s absorbed, it can be a hair achy and any kind of pain can cause your blood sugar to spike. If you don’t believe me, just drop a hammer on your toe and see what happens. Additionally, although the flu buggers are dead, the immune system is still reacting to them, which, after all, is the whole point of a vax.

But this initial burst of immune reaction causes inflammation from the antigen reaction, and… you guessed it… any sort of antigen reaction can trigger a blood sugar spike the same way illnesses do. For what it’s worth, that annoying ache tells you that the vax is working. So smile and correct the elevated blood sugar with fasting-acting products, if you have them. Avoid increasing any long- acting blood sugar control meds, as there’s no predicting how long the elevated blood sugar from the flu shot will last.


How well do flu vaxes work?

It varies from year to year. Last year’s match was not the greatest, but based on the flu strains currently circulating in the southern hemisphere, where the flu season is winding down, this year’s vax looks to be a better match.

Still, they aren’t bulletproof. Remember, a vaccine is just a training system for the immune system. It’s not like some kind of super weed killer you can spray all over the ground to keep things from growing. A vax helps your body get ready to fight, but the vax itself isn’t a virus killer. The immune system still has to do the work of recognizing, seeking out, and destroying the virus once it sets up camp in your body. It might do this before you feel it at all. Or you might get a little sick. Or even a lot sick; but in all cases you’ll be less sick, for less time, than if you had not gotten the vax.

So getting vaxed doesn’t turn you into a superhero, and as a PWD, your immune system ain’t great in the first place, so you should still take precautions.

You know, exercise common sense by putting into practice the disease prevention methods they taught you in kindergarten are still the best ways to keep flu from spreading: Cover coughs, wash your hands often, stay home if you’re sick, and avoid sick people like the plague, because, you know, they have the plague!


How do I tell whether I have the flu or a common cold?

Both the flu and the common cold result from viruses, but the flu is a deadly killer that packs a major punch. It’s like the difference between a tropical depression and a Category 5 hurricane. Official flu symptoms include fever, cough, sore throat, runny or stuffy nose, body aches, headache, chills and fatigue, sometimes sprinkled with vomiting and diarrhea. If I had to pick symptoms that differentiate flu from a cold, I’d say (beyond the general severity of the symptoms) that body aches are the key warning sign for most people.

Importantly, remember that whenever someone with already-diagnosed diabetes is ill -- whether it's the flu, an infection or common cold -- it can cause our health to be out of whack. Blood sugars may spike as a result. Diabetic ketoacidosis (DKA) is a possibility, and that's why checking for ketones is important. And also please remember, that for those without diabetes, flu-like symptoms frequently appear as a telltale sign of newly-onset diabetes and it can get deadly, very quickly. So make sure to know the warning signs of diabetes and be ready to handle this whether it's actually the flu or not.


What if I get the flu before I get my shot? Do I still need the shot this year?

Yes, because the shot protects against several “circulating” strains. Without the shot, you could come down with another strain and be sick twice this year. Also, shot or not, if you get sick, get to your doc pronto. People with diabetes are candidates for anti-viral drugs, which are most effective if started within 48 hours of the onset of symptoms. They won’t cure you over night, but they can shorten the length of a bout of flu and greatly reduce the risk of serious complications.


Big final question: When should I get the flu shot to make sure it lasts the full season?

You should get a flu vaccine before flu begins spreading in your community. Yes, that's officially from the CDC recommendations even though it seems pretty darn intuitive.

It takes about two weeks after vaccination for the flu shot to start working in the body. So it makes the most sense to get vaccinated early in fall, before flu season kicks into full swing. CDC recommends that people get a flu vaccine by the end of October. Remember, that in 2018-19, the flu began early before taking a rest, and then another strain kicked up the flu panic going into the the time is now! Getting vaccinated later, however, can still be beneficial and vaccination should continue to be offered throughout flu season, even into January or later.

Children who need two doses of vaccine to be protected should start the vaccination process sooner, because the two doses must be given at least four weeks apart.


Will Dubois lives with type 1 diabetes and is the author of five books on the illness, including "Taming The Tiger" and "Beyond Fingersticks." He spent many years helping treat patients at a rural medical center in New Mexico. An aviation enthusiast, Wil lives in Las Vegas, NM, with his wife and son, and one too many cats.

This is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge from the trenches. Bottom Line: You still need the guidance and care of a licensed medical professional.