What have we learned from COVID-19 in persons with type 1 diabetes?
While diabetes is established as a risk factor for severe SARS-CoV2 infection several important specific aspects need to be considered for people with type 1 diabetes. In contrast to older persons with diabetes, children, adolescents and young adults with type 1 diabetes are not at risk for unfavourable outcomes.
However in a special session on COVID-19 at this year's Annual Meeting of the European Association for the Study of Diabetes (EASD), Prof. Catarina Limbert of the University Center of Central Lisbon and Hospital Dona Estefania, Lisbon, Portugal, will a new review of viruses that are known to contribute to the new onset of type 1 diabetes and new evidence that SARS-CoV2 infection needs to be added to this list.
"Until now, larger multicentre studies did not find a rise in the number of new cases during the pandemic months compared to the same period in years before," she explains. "Nevertheless, the COVID-19 crisis has increased the severity at onset of type 1 diabetes with a doubling of people being admitted with diabetic ketoacidosis during the lockdown."
A population study of 23,804 COVID-19 related deaths in England during 1 March 2020—1 May 2020 revealed that the odds of dying in hospital with COVID-19 was higher in people with type 1 diabetes (3·5 times) compared to type 2 diabetes (2 times). However, the average age at death was 78 years in type 2 diabetes and 72 in type 1 diabetes. It appears, that in type 1 diabetes, only older people aged over 50 years), with longer duration of the disease (80% with more than 15 years of disease) and worse glucose control (glycated haemoglobin / HbA1c >10%) are at higher risk of severe clinical outcomes of COVID-19.
Moreover, according to an early report by the US Centers for Disease Control and Prevention (CDC) from the United States with data from 149 082 COVID-19 cases, only 1.7% were among children <18 years. Diabetes was not among the co-morbidities, indicating that with or without diabetes, young people are coping better with COVID-19 infection. Differences in the anatomy, epidemiology and gene expressions are some of the reasons for the low prevalence of COVID-19 infection in children.
In contrast to challenges related to disease severity and outcomes in type 1 diabetes, the pandemic also offered opportunities for improving diabetes care management.
"The COVID-19 crisis was the booster shot to put telemedicine into practice," explains Prof Limbert. "During the lockdown period, health care delivery had to adapt and make a sudden transition to remote care. In paediatric diabetes, digital revolution in type 1 diabetes management already started many decades ago with pumps and now extended to integration of sensors, automated insulin delivery or dosage advisors."
"The need to upload the data for a meaningful telemedicine consultation has motivated families to become more involved with digital diabetes data," she adds. "The use of remote health care promoted autonomy of both young people and their parents in interpreting the data and making decisions. Thus, challenges of COVID-19 turned out to be an opportunity for empowerment of people with type1 diabetes."
Reports of better glycaemic control through diabetes technology among people with type 1 diabetes during the lockdown period are encouraging health care providers establishing a virtual diabetes clinic to complement standard diabetes outpatient care. However, Prof Limbert adds: "But to accomplish a revolution in modern diabetes care management, a new concept of multidisciplinary team that includes an IT specialist, must be considered. This would ensure technical support, technological literacy and data base support that are cornerstones of a diabetes centre."
She concludes: "Importantly, the COVID-19 crises brought to mind how urgent it is to mitigate great disparities in access to health care and diabetes technology in Europe, to achieve more equal standards of type 1 diabetes care."