Influenza vaccination in discharge protocol for patients with comorbid conditions: an expert review
DOI:
https://doi.org/10.18203/2349-3933.ijam20261094Keywords:
Influenza, Vaccination, Comorbidities, Cardiovascular disease, COPD, Asthma, Diabetes mellitus, Chronic kidney disease, Hospital-based vaccinationAbstract
Influenza remains a significant global health challenge, contributing to substantial morbidity and mortality, particularly among individuals with chronic comorbidities such as cardiovascular disease, chronic obstructive pulmonary disease (COPD), asthma, diabetes mellitus, and chronic kidney disease (CKD). Despite strong recommendations, influenza vaccine uptake in India continues to be low. The aim of this consensus was to assess the role of influenza vaccination as part of hospital discharge protocols for patients with comorbidities in clinical settings. A focused expert advisory meeting was conducted with nine leading pulmonologists from India to evaluate the role of influenza vaccination as part of hospital discharge protocols in patients with comorbidities. The discussion was supported by a comprehensive literature review. Current national and international guidelines were also analyzed to provide contextual insights. Annual influenza vaccination significantly reduces complications, hospitalizations, and all-cause mortality among high-risk populations. Evidence demonstrates reductions in cardiovascular events, respiratory morbidity, and exacerbations in COPD and asthma. In patients with diabetes and CKD, vaccination is associated with decreased hospitalization rates, fewer ICU admissions, and slower progression of renal decline. However, barriers such as limited awareness, absence of standardized hospital protocols, and logistical constraints impede vaccine uptake. Incorporating influenza vaccination into discharge protocols and enhancing patient education can substantially improve coverage in these vulnerable groups. Hospital-based vaccination programs represent a feasible and effective strategy to mitigate influenza-related morbidity and mortality in India. Expert consensus strongly supports the inclusion of influenza vaccination in discharge protocols for patients with comorbidities.
References
Marchi S, Fallani E, Salvatore M, Montomoli E, Trombetta CM. The burden of influenza and the role of influenza vaccination in adults aged 50-64 years: A summary of available evidence. Hum Vaccin Immunother. 2023;19(2):2257048.
Nayak J, Hoy G, Gordon A. Influenza in Children. Cold Spring Harb Perspect Med. 2021;11(1):a038430.
Javanian M, Barry M, Ghebrehewet S, Koppolu V, Vasigala V, Ebrahimpour S. A brief review of influenza virus infection. J Med Virol. 2021;93(8):4638-46.
World Health Organization. Influenza (seasonal). Available at: https://www.who.int/news-room/fact-sheets/detail/influenza-(seasonal). Accessed on 12 February 2026.
Vander Sluijs KF, van der Poll T, Lutter R, Juffermans NP, Schultz MJ. Bench-to-bedside review: bacterial pneumonia with influenza - pathogenesis and clinical implications. Crit Care. 2010;14:219.
Rowe HM, Meliopoulos VA, Iverson A, Bomme P, Schultz-Cherry S, Rosch JW. Direct interactions with influenza promote bacterial adherence during respiratory infections. Nat Microbiol. 2019;4:1328-36.
Lowen AC, Steel J. Roles of humidity and temperature in shaping influenza seasonality. J Virol. 2014;88:7692-5.
Chadha MS, Potdar VA, Saha S, Koul PA, Broor S, Dar L, et al. Dynamics of influenza seasonality at sub-regional levels in India and implications for vaccination timing. PLoS One. 2015;10:e0124122.
Vemula SV, Zhao J, Liu J, Wang X, Biswas S, Hewlett I. Current approaches for diagnosis of influenza virus infections in humans. Viruses. 2016;8:96.
Hayden F. Developing new antiviral agents for influenza treatment: what does the future hold? Clin Infect Dis. 2009;48:S3-13.
Koul PA, Ali S, Mir H, Ahmad SJ, Bhat SA, Bhat MA. Influenza vaccination in north Indian patients with heart failure. Indian Heart J. 2017;69(1):28-31.
Andrew MK, Pott H, Staadegaard L, Paget J, Chaves SS, Ortiz JR, et al. Age differences in comorbidities, presenting symptoms, and outcomes of influenza illness requiring hospitalization: A worldwide perspective from the Global Influenza Hospital Surveillance Network. Open Forum Infect Dis. 2023;10(6):ofad244.
Mao J, Li Y, Lv D. Impact of influenza on chronic obstructive pulmonary disease: pathophysiology, exacerbations, and preventive approaches. Ther Adv Respir Dis. 2025;19:1753466625136330.
Froes F, Timóteo A, Almeida B, Raposo JF, Oliveira J, Carrageta M, Duque S, Morais A. Influenza vaccination in older adults and patients with chronic disorders: A position paper from the Portuguese Society of Pulmonology, the Portuguese Society of Cardiology, the Portuguese Society of Diabetology, the Portuguese Society of Infectious Diseases and Clinical Microbiology, the Portuguese Society of Geriatrics and Gerontology, and the Study Group of Geriatrics of the Portuguese Society of Internal Medicine. Pulmonology. 2024;30(5):422-36.
Wallick C, To TM, Korom S, Masters H 3rd, Hanania NA, Moawad D. Impact of influenza infection on the short- and long-term health of patients with chronic obstructive pulmonary disease. J Med Econ. 2022;25(1):930-9.
Xiong X, Wei Y, Lam HCY, Wong CKH, Lau SYF, Zhao S, et al. Association between cold weather, influenza infection, and asthma exacerbation in adults in Hong Kong. Sci Total Environ. 2023;857(Pt 1):159362.
Lewing BD, Wallick C, To TM, Masters H, Daya P, Tam S. Short and long-term impact of influenza infection on individuals with type 2 diabetes: Effect on healthcare utilization and diabetes complications. Diabetes Management. 2021;11(2):171-9.
Bowman BT, Rosner MH. Lixivaptan - an evidence-based review of its clinical potential in the treatment of hyponatremia. Core Evid. 2013;8:47-56.
Watanabe, T. Renal complications of seasonal and pandemic influenza A virus infections. Eur J Pediatr. 2013;172:15-22.
Van Kerkhove MD, Cooper MJ, Cost AA, Sanchez JL, Riley S. Risk factors for severe outcomes among members of the United States military hospitalized with pneumonia and influenza, 2000–2012. Vaccine. 2015;33(49):6970-6.
Corral M, Castro RC, To TM, Arndorfer S, Wang S, Stephens J. Burden of influenza in patients with cardiovascular disease who receive antiviral treatment for influenza. J Med Econ. 2022;25(1):1061-7.
Skaarup KG, Modin D, Nielsen L, Jensen JUS, Biering-Sørensen T. Influenza and cardiovascular disease pathophysiology: strings attached. Eur Heart J Suppl. 2023;25(Suppl A):A5-11.
Mallia P, Johnston SL. Influenza infection and COPD. Int J Chron Obstruct Pulmon Dis. 2007;2(1):55-64.
Mao J, Li Y, Lv D. Impact of influenza on chronic obstructive pulmonary disease: pathophysiology, exacerbations, and preventive approaches. Ther Adv Respir Dis. 2025;19:17534666251363307.
Ruiz Azcona L, Roman-Rodriguez M, Llort Bove M, van Boven JF, SantibáñezMargüello M. Prevalence of Seasonal Influenza Vaccination in Chronic Obstructive Pulmonary Disease (COPD) Patients in the Balearic Islands (Spain) and Its Effect on COPD Exacerbations: A Population-Based Retrospective Cohort Study. Int J Environ Res Public Health. 2020;17(11):4027.
Chen X, Zhang P, Ma Y. Prevalence of acute infection in adults with asthma exacerbation: A systematic review and meta-analysis. Ann Thorac Med. 2023;18(3):132-51.
Vasileiou E, Sheikh A, Butler CC, Robertson C, Kavanagh K, Englishby T, et al. Seasonal Influenza Vaccine Effectiveness in People With Asthma: A National Test-Negative Design Case-Control Study. Clin Infect Dis. 2020;71(7):e94-e104.
Allard R, Leclerc P, Tremblay C, Tannenbaum TN. Diabetes and the severity of pandemic influenza A (H1N1) infection. Diabetes Care. 2010;33(7):1491-3.
Hulme KD, Gallo LA, Short KR. Influenza Virus and Glycemic Variability in Diabetes: A Killer Combination? Front Microbiol. 2017;8:861.
Lewing B, Wallick C, To T, Masters H, Daya P, Tam S. Short and long-term impact of influenza infection on individuals with type 2 diabetes: Effect on healthcare utilization and diabetes complications. Diabetes Management. 2021;11:171.
Hao WR, Yang TL, Lai YH, Lin KJ, Fang YA, Chen MY, et al. The Association between Influenza Vaccine and Risk of Chronic Kidney Disease/Dialysis in Patients with Hypertension. Vaccines (Basel). 2023;11(6):1098.
Sung LC, Chen CC, Liu SH, Chiu CC, Yang TY, Lin CH, et al. Effect of influenza vaccination on the reduction of the incidence of chronic kidney disease and dialysis in patients with type 2 diabetes mellitus. J Clin Med. 2022;11(15):4520.
Skaarup KG, Modin D, Nielsen L, Jensen JUS, Biering-Sørensen T. Influenza and cardiovascular disease pathophysiology: strings attached. Eur Heart J Suppl. 2023;25(Suppl A):A5-11.
Wedzicha JA, Seemungal TA. COPD exacerbations: defining their cause and prevention. Lancet. 2007;370(9589):786-96.
Veerapandian R, Snyder JD, Samarasinghe AE. Influenza in Asthmatics: For Better or for Worse? Front Immunol. 2018;9:1843.
Dicembrini I, Silverii GA, Clerico A, Fornengo R, Gabutti G, Sordi V, et al. Influenza: Diabetes as a risk factor for severe related-outcomes and the effectiveness of vaccination in diabetic population. A meta-analysis of observational studies. Nutr Metab Cardiovasc Dis. 2023;33(6):1099-110.
Kute VB, Shah PR, Goplani KR, Vanikar AV, Trivedi HL. Successful treatment of critically ill chronic kidney disease patient with multi-organ dysfunction associated with H1N1 infection. Indian J Nephrol. 2011;21(1):59-61.
Cheng Y, Cao X, Cao Z, Xu C, Sun L, Gao Y, et al. Effects of influenza vaccination on the risk of cardiovascular and respiratory diseases and all-cause mortality. Ageing Res Rev. 2020;62:101124.
Mulpuru S, Li L, Ye L, Hatchette T, Andrew MK, Ambrose A, et al. Serious Outcomes Surveillance (SOS) Network of the Canadian Immunization Research Network (CIRN). Effectiveness of influenza vaccination on hospitalizations and risk factors for severe outcomes in hospitalized patients with COPD. Chest. 2019;155(1):69-78.
Owusu D, Rolfes MA, Arriola CS, Daily Kirley P, Alden NB, Meek J, et al. Rates of severe influenza-associated outcomes among older adults living with diabetes - Influenza Hospitalization Surveillance Network (FluSurv-NET), 2012–2017. Open Forum Infect Dis. 2022;9(5):ofac131.
Martínez-Baz I, Navascués A, Portillo ME, Casado I, Fresán U, Ezpeleta C, et al. Effect of influenza vaccination in preventing laboratory-confirmed influenza hospitalization in patients with diabetes mellitus. Clin Infect Dis. 2021;73:107-14.
Agarwal S, Kesavadev J, Saboo B. RSSDI update on vaccination in people with diabetes. Int J Diabetes Developing Countries. 2024;45:5-12.
Dhar R, Ghoshal AG, Guleria R, Sharma S, Kulkarni T, Swarnakar R, et al. Clinical practice guidelines 2019: Indian consensus-based recommendations on influenza vaccination in adults. Lung India. 2020;37(Suppl):S4-18.
Sharma N, Verma M, Goel K, Kulkarni MM, Bhardwaj A, Sharma S, Singh T, et al. IAPSM's Position Paper on Influenza Vaccines for Adult Immunization in India. Indian J Community Med. 2024;49(Suppl 2):S146-52.
Roy A, Yadav S. Influenza vaccine in cardiovascular disease: Current evidence and practice in India. Indian Heart J. 2024;76(6):365-9.
CDC. Inactivated Influenza Vaccine VIS. 2025. Available at: https://www.cdc.gov/vaccines/hcp/ current-vis/influenza-inactivated.html. Accessed on 12 February 2026.
Khan T, Das RS, Jana M, Bhattacharya SD, Halder S, Ray S, et al. Factors influencing vaccine acceptance in pregnancy during the COVID-19 pandemic: A multicenter study from West Bengal, India. Hum Vaccin Immunother. 2024;20(1):2383030.
Vora A, Shaikh A. Awareness, Attitude, and Current Practices Toward Influenza Vaccination Among Physicians in India: A Multicenter, Cross-Sectional Study. Front Public Health. 2021;9:642636.
Welch VL, Metcalf T, Macey R, Markus K, Sears AJ, Enstone A, et al. Understanding the Barriers and Attitudes toward Influenza Vaccine Uptake in the Adult General Population: A Rapid Review. Vaccines (Basel). 2023;11(1):180.
Mohammed H, McMillan M, Andraweera PH, Elliott SR, Marshall HS. A rapid global review of strategies to improve influenza vaccination uptake in Australia. Hum VaccinImmunother. 2021;17(12):5487-99.
Anderson CS, Hua C, Wang Z, Wang C, Jiang C, Liu R, et al. Influenza vaccination to improve outcomes for patients with acute heart failure (PANDA II): a multiregional, seasonal, hospital-based, cluster-randomised, controlled trial in China. Lancet. 2025;406(10507):1020-31.
Orenstein EW, ElSayed-Ali O, Kandaswamy S, Masterson E, Blanco R, Shah P, et al. Evaluation of a Clinical Decision Support Strategy to Increase Seasonal Influenza Vaccination Among Hospitalized Children Before Inpatient Discharge. JAMA Netw Open. 2021;4(7):e2117809.
Committee on Infectious Diseases. Recommendations for Prevention and Control of Influenza in Children, 2025-2026: Policy Statement. Pediatrics. 2025;156(6):e2025073620.