The burden of diabetes mellitus in Saudi Arabia regarding its prevalence and incidence rate has increased dramatically in the last four decades . Previous studies have shown the role of vaccinations in decreasing hospitalization related to influenza and pneumococcal disease in diabetic patients. Unfortunately, few studies have been performed in Saudi Arabia regarding the vaccination of diabetic patients. The purpose of this study was to measure the prevalence of HBV, influenza, and pneumococcal vaccinations and to assess the factors that hinder the uptake of these vaccines. Lack of proper documentation of the ICD 9/10 code established in diagnosing diabetes and the accuracy of date of diagnosis were the major hindrances for this study. This study shows that only 15.2% of diabetic patients had received the influenza vaccine in the last 12 months, while 14.2% of diabetic patients received the pneumococcal vaccine. In addition, only 12.9% of patients were vaccinated against HBV. The hospitalization rates in type 1 and 2 diabetic patients decreased significantly in individuals who received the influenza vaccine 22.8% versus 77.8% in unvaccinated individuals. Patients vaccinated against HBV showed decreased hospital admissions (P = 0.011). Additionally, this study showed that diabetic patients were recommended by their primary care physicians to receive the influenza vaccine (25.8%), pneumococcal vaccine (15.5%), and HBV vaccine (10.8%). Furthermore, most diabetic patients were not aware of PCV, HBV, and influenza vaccine recommendations by their primary health care provider. The percentage of vaccinated patients with PCV, HBV, and influenza vaccine who did not receive recommendations was higher than those who were recommended by their physicians, which was statistically significant (P > 0.001) (P = 0.014) (P = 0,003), respectively. While HBV and influenza vaccination uptake were significantly associated with not receiving recommendations by primary health care providers, the number of vaccinated patients was extremely low. National cross-sectional surveys to investigate barriers, motivations, and expectations of diabetic patients with regard to vaccination would further this research aim (Table 1).
Recent A1C levels, sex, marital status, treatment type, and macrovascular complications did not significantly influence the uptake of all recommended vaccinations. Marital status also did not influence the uptake of all recommended vaccinations, as 61.4% were married, and no significant relation was found. A study performed in Saudi Arabia showed that the prevalence of influenza vaccine uptake in type 2 diabetic patients was 61% . Another study performed in Arar, Saudi Arabia, showed an influenza vaccine uptake of 42.3% in type 2 diabetic patients . Moreover, another study in Saudi Arabia demonstrated adherence rates of 46% in type 2 diabetic patients to influenza vaccine and 46.2% to pneumococcal vaccine . In contrast, only 35.8% of all adult diabetic patients in the United States reported not taking the influenza vaccine . A total of 74.3% of diabetic patients reported that their primary care physicians did not recommend the influenza vaccine to them. The perception of diabetic patients toward vaccination demonstrated that 12.8% were against taking the annual influenza shot. In Spain, 24% did not believe in influenza vaccine effectiveness . In a study conducted in Saudi Arabia, half of type 2 diabetic patients did not know if PPV23 and influenza vaccine were important for them . The extremely low influenza vaccine coverage can be explained by the fact that most patients in Saudi Arabia did not receive recommendations from their physicians and the perception that some diabetic patients are against taking annual influenza vaccination . Diabetic patients in Saudi Arabia portrayed a noticeable decrease in HBV vaccine coverage, as only 12.9% reported receiving it, while 28.6% in the United States reported taking the HBV vaccine . (Table 2)
Age and body mass index were significant factors for HBV vaccination, and in a study done in the US, age was also a factor for HBV vaccine uptake, as patients as elderly patients are more likely to be vaccinated, yet the prevalence in Saudi Arabia is considerably lower . Additionally, only 10.8% of diabetic patients received recommendations for HBV vaccination, contributing to its low prevalence. Pneumococcal vaccination in the US in the ages between 19–64 years was estimated to be approximately 23%, which is higher than PPV23 in Saudi Arabia . Moreover, the US vaccination rate for the pneumococcal vaccine in participants aged over 65 was nearly triple that in those between the ages of 19–64 (63.6%) (23.0%). The diagnosis type of diabetes played an important role in the uptake of the pneumococcal vaccine, as it was more prevalent in type 1 diabetic patients. The overall coverage for the recommended vaccination for diabetic patients in Saudi Arabia was lower than that in the US. A major factor for vaccine uptake is the knowledge of the healthcare provider and the accessibility of vaccination for the patients . In a longitudinal study that was performed in Brazil, there was an increasing number of hospitalizations by 1.83% between 2008 and 2019, and 95% of all admissions were more severe cases . In the US, 30% of diabetic patients have multiple hospitalizations, which increases the financial burden . Vaccination in diabetic patients has been associated with a decrease in hospitalization [33–35]. A case–control influenza vaccination demonstrated a 79% reduction in hospital admission . The hospitalization rate for diabetic patients in Saudi Arabia was significantly decreased in influenza-vaccinated patients. The high hospital admission in unvaccinated patients could be explained as 82% of all patients having an HbA1c of more than 7. Additionally, 33.8% of influenza-vaccinated patients developed nephropathy, in contrast to 66.2% of unvaccinated patients (P < 0.001), but a correlation between not receiving the influenza vaccine and developing nephropathy was not established, as patients were not followed up. Additionally, in Saudi Arabia, a study of 5917 patients showed that 21% of all admissions were for blood glucose control . Further studies to assess the knowledge and attitudes of primary care physicians regarding vaccination for diabetic patients are essential (Table 3) (Fig. 1)