Whenever a nip of cold is in the air, and coughs and sneezes ring out in public places, you know it’s flu season again. If you live with diabetes, you’re probably being prodded to go get a flu shot and related vaccines.

But over the years, our mailbag has filled up with questions about how those shots may mix with diabetes care.

Here’s a Q&A covering all you need to know:

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 the 2017-2018 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 the flu season from 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.

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 is that 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 vaccines 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 note 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.
  • 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 the 2019-20 flu season, the FDA expanded the indication for use of Xofluzo to 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.

Where do the vaccines come from?

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, we couldn’t make this up if we tried!)

Some early reports suggest that the newer, cell-grown vaxes 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 vax virus mutates too much in production, it won’t match the target flu out in the environment, providing reduced protection.

Which vaccine is best?

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

Which type should people with diabetes get?

Despite all of the info above, 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 people with diabetes.

Is there an “official” medical recommendation that all people with diabetes need a flu shot?

Yes. The CDC recommends it, and they also recommend 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 non-diabetics, 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 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. Additionally, although the flu buggers are dead, the immune system is still reacting to them, which in fact is the whole point of a vax.

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 vax is working. So smile and correct your elevated blood sugar with fasting-acting products, if you have them. 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.

How well do flu vaccines work?

It varies from year to year. The 2017-2018 match was rather poor, but the following year appeared to perform better.

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 is somewhat compromised the first place, so you should still take precautions.

It’s 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.

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. 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. This can be done using an at-home urine testing kit widely available at drug stores without a prescription.

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 in one year.

Also, shot or not, if you get sick, get to your doctor 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 overnight, but they can shorten the length of a bout of flu and greatly reduce the risk of serious complications.

When should I get the flu shot to make sure it lasts the full season?

The CDC recommends getting the flu vaccine before flu begins spreading in your community. This is because 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. Specifically, the CDC recommends that people get a flu vaccine by the end of October.

Some years, the flu may begin early and then ebb for a while before another strain kicks in, going into the spring, so don’t wait too long into the season.

Getting vaccinated later, however, can still be beneficial and 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, because the two doses must be given at least four weeks apart.

Where can I get a flu shot?

Almost all primary care physicians offer the shot in their offices these days. You can also get the shot on-site at many pharmacies across the country including Costco, CVS, Walgreens, and Rite Aid for around $30-$60.

The pneumonia vaccine is also recommended for PWDs, although you will have to go through your doctor to get a prescription. If you are under age 65, you will most likely need your doctor to submit a “Prior Authorization” urging your health plan to cover the pneumonia on the basis of your diabetes.

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.