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Many diabetes doctors and care specialists are saying they’ve been getting more frequent questions from patients about flu shots this year due to the continuing COVID-19 pandemic.

Their answer: Getting the flu vaccine is more important than ever for people with diabetes (PWDs), because contracting the flu could weaken the immune system, leading to fluctuating and higher glucose levels — which puts us at elevated risk for COVID-19 and its effects on the body.

Surprisingly, stats show that the general public isn’t thinking about the flu as much as they ought to be.

A September 2020 survey from C.S. Mott Children’s Hospital at the University of Michigan found that only 1 in 3 parents agree it’s more important to get a flu shot this year, and nearly 1 in 3 won’t be vaccinating their kids for the season.

With that, some health experts describe the potential for a“twindemic” of both COVID-19 and flu in the United States this winter.

But for PWDs, getting a flu shot is as critical as it’s ever been, says Davida Kruger, a nurse practitioner and diabetes care and education specialist (DCES) at Henry Ford Health System in Detroit, Michigan.

“We do not want folks with diabetes to have to deal with anything more on top of everything else,” she said.

The Centers for Disease Control and Prevention (CDC) flags this in a yellow notification box at the top of its flu and diabetes page, calling out how critical it is for those with diabetes, asthma, and other chronic conditions to get a flu vaccine.

In New York, DCES Margaret Pellizzari agrees. She says that at Northwell Health pediatric endocrinology clinics, they’ve stepped up awareness on the need for flu vaccinations this year.

They cite the American Diabetes Association guidance specifically, which encourages PWDs and their families to get a flu shot as well as a pneumonia vaccine each year.

“We state the rationale for this practice and hope (patients) are able to make a reasonable decision to stay as protected as possible,” she told DiabetesMine. “We discuss the fact that while the vaccine may not be 100 percent protective, it may minimize the severity if a PWD catches the flu despite vaccination.”

We’ve compiled the following Q&A covering all you need to know about diabetes and the flu shot.

The flu is a highly contagious respiratory illness caused by a family of quickly evolving influenza viruses.

The flu isn’t to be messed with. It can do more than make you sick. It can be life threatening.

During the 2017-18 flu season, one of the worst on record, 80,000 Americans died while nearly 1 million more were hospitalized.

And yes, getting a flu shot is pretty much vital to those living with diabetes, according to a myriad of experts.

What makes flu challenging is that a virus causes it, making it darn hard to treat.

Diseases caused by bacteria can be treated more easily with antibiotics, but our antiviral 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.

Timing may vary. But per the CDC, flu viruses are most common in the United States 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.

According to CNN, the 2018-19 flu season was actually the longest-stretching one we’ve seen in a decade, starting strong early on before abating and then peaking again with another strain of flu kicking in later in the season.

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. In nature, it learns to fight pathogens by surviving various illnesses.

Over the course of a sickness, the immune system learns about the disease, so 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.

A vaccine 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.

Inactivated is a polite word for “killed.” Yep. An inactivated vaccine 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 is that a dead virus can’t make you sick. If you got an inactivated virus vaccine and got sick, the truth is that you got your shot too late. You were already sick before the shot, because dead viruses don’t cause illness.

An attenuated virus, on the other hand, is a virus that’s still alive. Barely. Instead of being nuked, the vaccine is made by growing a bunch of viruses and then passing them through a series of cell cultures or animal embryos (typically chick embryos) to weaken them.

They’re still alive, but being very weak, they’re 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 vaccines come in both flavors.

There are many varieties of flu vaccines, but some of the most common types are:

  • The nuked virus, called IIV for inactivated influenza vaccine, is the traditional flu shot. It’s usually given in the arm using a needle, but two brands are also approved for jet injector use.
  • For older adults, there are high-dose shots as well as a formulated variety with an adjuvant, an ingredient that boosts the immune system response to the vaccine.
  • There’s also a recombinant flu vaccine. But it has a short shelf-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 nonpregnant people ages 2 to 49 years, as 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.” (Note that the CDC considers all types of diabetes a medical condition that puts us at “high risk” of developing “serious” flu-related complications, which may include pneumonia, bronchitis, sinus infections, and ear infections.)
  • A new medication dubbed Xofluza came out in 2018-19 and is the first flu antiviral approved by the Food and Drug Administration (FDA) in almost 20 years! It’s approved for those who’ve been showing flu-like symptoms for 48 hours max. For the 2019-20 flu season, the FDA expanded the indication for use of Xofluza to those 12 years or older who are at high risk for developing flu-related complications, such as those of us with diabetes.

Traditionally, a flu vaccine is grown in hen’s eggs, although that’s changing. The viruses for some brands are now grown in cultured mammal cells.

The idea is that it’s faster (if there’s 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 vaccine, it’s grown in cells from dog kidneys (no kidding!).

Some early reports suggest that the newer, cell-grown vaccines are more effective against newer flu strains, although in previous years, the hen’s egg shots did better.

Apparently this has to do with how the various strains have different tendencies to mutate (which is what viruses do) more in one environment than another.

If the vaccine virus mutates too much in production, it won’t match the target flu that’s out in the environment, providing reduced protection.

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

According to the CDC, PWDs should get injectable dead-virus flu shots, thanks to the “long-established safety record” for this kind of vaccine in people with diabetes.

What about the nasal snort version?

While not prohibited, the CDC lists a “precaution” against using it for people with diabetes and other chronic conditions “because the safety and effectiveness of this vaccine in people with those conditions has not been established.”

Yes. The CDC recommends it as well as a pneumonia shot.

Additionally, the two big national 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 all people with diabetes.

This is because we PWDs get sick more easily than folks without diabetes, and when we do get sick, we get a lot sicker. A shot is recommended every year because, as mentioned, there’s a different strain of flu circulating annually.

But it’s not just PWDs who should get vaccinated. The CDC strongly advises that everyone older than 6 months 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 lucky.

So don’t be a Typhoid Mary. Everyone should get a flu vaccine. It’s good citizenship.

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 injected 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.

Additionally, although the flu bugs are dead, your immune system is still reacting to them, which in fact is the whole point of a vaccine.

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 in your arm tells you that the vaccine is working.

So smile and correct your elevated blood sugar with fast-acting insulin or other meds. Avoid increasing any long-acting blood sugar control medications, as there’s no predicting how long the elevated blood sugar from the flu shot will last.

Be aware that flu shots can also cause short-lived mild body aches, headache, and mild temperature elevation.

It varies from year to year. The 2017-18 match was rather poor, but the following year appeared to perform better.

Still, they aren’t bulletproof. Remember, a vaccine is just a training agent 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 vaccine helps your body get ready to fight, but the vaccine 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 vaccine.

It’s also strongly recommended to follow the common-sense rules for keeping the flu from spreading: Cover coughs, wash your hands often, stay home if you’re sick, and avoid spending time in the presence of sick people.

Both the flu and the common cold result from viruses, but the flu 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, and chills and fatigue, sometimes sprinkled with vomiting and diarrhea.

The body aches tend to be a key warning sign for most people that they have the flu rather than a cold.

Remember that any cold or illness striking someone with diabetes can cause our blood sugars to spike. The result can be dangerous diabetic ketoacidosis (DKA), so testing for ketones is important.

You can do this with an at-home urine testing kit widely available at drugstores without a prescription.

Also, please remember that for those without diabetes, flu-like symptoms frequently appear as a telltale sign of newly onset type 1 diabetes, which can become life threatening 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.

The CDC recommends getting the flu vaccine before the flu begins spreading in your community. This is because it takes about 2 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 — although during the COVID-19 crisis, there’s encouragement to get your flu shot as early as possible, even in spring or summer.

Getting vaccinated later, however, can still be beneficial. Vaccination typically continues 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 as the two doses must be given at least 4 weeks apart.

“People should know the importance of getting a flu shot not only every year but this year to reduce the risks of getting two viruses that can induce hyperglycemia and DKA,” said DCES Julia Blanchette at the Cleveland Clinic in Ohio.

“I think PWD often overlook the risks of the flu when you live with diabetes. We are scheduling patients for flu shots at their endo or DCES visits when possible and recommending to receive them now while the flu and COVID risks are lower, rather than later when COVID and flu cases may increase,” she said.

The CDC has noted in a new report that the United States might see lower flu rates this season due to the many precautions we’re all being encouraged to take as a result of the global health pandemic. But no one really knows how things will go this year at this point.

“We advise getting flu vaccine now,” said Dr. Stephen Ponder, a well-known pediatric endocrinologist in Texas.

He says if someone has routinely gotten annual flu vaccines in past years, it may be a plus for flu prevention in general because there’s a wider portfolio of anti-flu antibodies in that person’s body that might not be covered in a current year’s new vaccine.

“That also may act to prime the immune system to better fend off COVID-19,” he said. “This is what our [infectious disease] specialist shared with me a few weeks ago.”

Yes, because the shot protects against several “circulating” strains. Without the shot, you could come down with another strain and be sick twice in 1 year.

Also, shot or not, if you get sick, get to your doctor pronto. People with diabetes are candidates for antiviral drugs, which are most effective if started within 48 hours of the onset of symptoms.

They won’t cure you overnight, but they can shorten the length of a bout of flu and greatly reduce the risk of serious complications.

Almost all primary care physicians offer the shot in their offices these days. You can also get the shot onsite at many pharmacies across the country, including Costco, CVS, Walgreens, and Rite Aid, for around $30 to $60 without insurance.

The pneumonia vaccine is also recommended for PWDs, although you’ll have to go through your doctor to get a prescription.

If you’re under age 65, you’ll most likely need your doctor to submit a “Prior Authorization” urging your health plan to cover the pneumonia vaccine on the basis of your diabetes.