What vaccinations should be updated for a 54-year-old female patient with diabetes who has not received any vaccinations in the past 10 years?

Vaccination Update for 54-Year-Old Female with Diabetes

This patient requires immediate catch-up vaccination with Tdap (or Td), pneumococcal vaccines (PCV13 followed by PPSV23), annual influenza vaccine, hepatitis B series, and consideration for recombinant zoster vaccine, given her 10-year vaccination gap and diabetes status. 1

Priority Vaccinations for This Patient

Tetanus-Diphtheria-Pertussis (Tdap/Td)

• Administer 1 dose of Tdap immediately if she has not received it previously, regardless of when her last tetanus-containing vaccine was given 1
• If her last tetanus vaccination was >10 years ago (which it is), Tdap should replace the Td booster 1, 2
• After Tdap, continue with Td boosters every 10 years 1
• The minor trauma mentioned makes this particularly urgent for wound prophylaxis considerations 2

Pneumococcal Vaccination (Critical for Diabetes)

• Administer PCV13 first, followed by PPSV23 at least 8 weeks later for patients aged 19-64 with diabetes 1
• People with diabetes are at significantly increased risk for bacteremic pneumococcal infection with mortality rates as high as 50% 1
• At age 65 or older, she will need an additional dose of PPSV23 (at least 5 years after the previous PPSV23) 1

Influenza Vaccination

• Administer annual influenza vaccine immediately and every year thereafter 1
• Influenza vaccination in people with diabetes significantly reduces influenza and diabetes-related hospital admissions 1
• Use inactivated influenza vaccine (IIV) or recombinant influenza vaccine (RIV); live attenuated vaccine is contraindicated in diabetes 1

Hepatitis B Vaccination

• Administer a 2- or 3-dose hepatitis B series (depending on vaccine formulation) 1
• This is specifically recommended for unvaccinated adults with diabetes ages 18-59 years 1
• People with diabetes have higher rates of hepatitis B due to potential contact with infected blood through glucose monitoring devices 1

Zoster (Shingles) Vaccination

• Consider administering recombinant zoster vaccine (RZV) as a 2-dose series 2-6 months apart 1, 3
• RZV is recommended for adults aged 50 years and older, making this patient eligible 1, 3
• RZV is preferred over the older live zoster vaccine due to higher efficacy 3

Additional Considerations

Hepatitis A

• Administer 2-dose series if she has chronic liver disease, travels to endemic areas, or has other risk factors 1, 3

MMR and Varicella

• If born in 1957 or later and lacks documentation of vaccination or immunity, consider MMR (1-2 doses) and varicella (2-dose series) 1
• If born before 1957, generally considered immune unless she is a healthcare worker 1

Common Pitfalls to Avoid

• Do not delay Tdap waiting for the 10-year interval from her last tetanus vaccine; Tdap can be given regardless of interval 1, 2
• Do not administer PPSV23 before PCV13 in this age group with diabetes; the sequence matters for optimal immune response 1
• Do not forget annual influenza vaccination going forward, as this is the single most important recurring vaccine for diabetic patients 1
• Do not overlook hepatitis B in diabetic patients under age 60, as this is a specific CDC recommendation for this population 1

Implementation Strategy

1. Today's visit: Administer Tdap, PCV13, and current season's influenza vaccine (these can be given simultaneously at different injection sites) 1
2. 8 weeks later: Administer PPSV23 and initiate hepatitis B series (dose 1) 1
3. 1-2 months after hepatitis B dose 1: Administer hepatitis B dose 2 1
4. 6 months after hepatitis B dose 1: Complete hepatitis B series with dose 3 1
5. Anytime after age 50: Initiate RZV series (dose 1), with dose 2 given 2-6 months later 1, 3
6. Annually: Influenza vaccine every fall 1

Documentation is critical: Record all vaccines administered in a registry and provide the patient with a written record to prevent future gaps 4, 5