While it has long been known that people with Type 2 diabetes are at an enhanced risk of severe illness and death from COVID-19, our understanding of the disease’s impact on people with Type 1 diabetes has taken longer to emerge. As a result, we can say with some confidence that people with T2D should and probably will be granted vaccine priority, but it’s unclear to what extent authorities will prioritize people with T1D.
What research we have seems to indicate that T1D represents a very serious risk to patients with COVID-19, at least on level with T2D. But in the United States, the Centers for Disease Control and Prevention (CDC) appears to classify Type 1 diabetes as a less serious underlying condition, one that only “might” represent an increased risk of severe illness from the coronavirus.
The author of a new study on T1D outcomes, however, has asserted that the classification “needs revision based on the current evidence.”
Vaccine Priority
The first approved COVID-19 vaccines have now been administered in the United States and the United Kingdom, among other countries, and world governments are now in a race to approve, acquire, and distribute the drugs. For many months, demand for the vaccines will far outstrip supply, and as a result authorities are now tackling the tricky question of who should receive vaccination priority.
On December 3, the CDC recommended that the first doses of COVID-19 vaccine should go to healthcare personnel and residents of long-term care facilities. What comes next? The government experts haven’t decided yet, or at least have not announced their decisions. The organization merely states that “as vaccine availability increases, vaccination recommendations will expand to include more groups.”
The CDC recommendations are not binding—states and other local authorities ultimately have discretion on how they administer the vaccines they have in their possession.
The Classification of Risk
As writer Miriam Tucker noted for Medscape, the CDC currently classifies Types 1 and 2 diabetes differently. According to the organization, adults with Type 2 diabetes “are at an increased risk,” whereas those with Type 1 “might be at an increased risk” (emphasis added). The difference implies that patients with Type 2—as well as a host of other comorbidities, such as heart disease, kidney disease and obesity—will likely be ahead in the pecking order of those with Type 1.
Other conditions that officially “might” pose an increased risk range from very serious disorders, such as cystic fibrosis, to exceedingly common conditions, including hypertension and overweight (BMI > 25), which affect tens of millions of American adults.
Should Type 1 diabetes get promoted to a more serious category of risk?
A New Study on T1D & COVID-19 Outcomes
The newest data on T1D outcomes comes from a study published in Diabetes Care this month. This work found that people with Type 1 diabetes were in fact at dramatically increased risk of hospitalization and severe illness from COVID-19: overall risks are “three- to four-fold higher” than the non-diabetic population, and were similar to the already widely publicized and understood risks suffered by people with Type 2 diabetes.
Dr. Justin Gregory, the lead author of the study, said that the CDC classification “needs revision based on the current evidence.” Speaking with Ms. Tucker, Dr. Gregory said “I think the data presented in our study… indicate the need to place type 1 diabetes at parity with type 2 diabetes.”
Dr. Gregory’s study analyzed the fortunes of patients admitted to 137 facilities of the Vanderbilt University Medical Center network during the spring and summer of 2020. Though the sample was not terribly large, the Vanderbilt team’s conclusions are extremely similar to those of the first major study of T1D COVID-19 outcomes, released in May by United Kingdom’s National Health Service. That earlier study found that the risk to people with Type 1 diabetes was roughly tripled. The agreement between the two studies must lend credence to the results.
Risk Factors
Further analysis of the Vanderbilt data showed that Type 1 outcomes were unsurprisingly made worse when accompanied by other indications of poor health, such as poor blood sugar control (high HbA1c) and high blood pressure. But more significant still were less modifiable factors such as race and socioeconomic status.
Remarkably, a patient’s use of diabetes technology may have been the best predictor of COVID-19 outcomes. For example, patients with T1D using a standard glucometer were more than eight times as likely to suffer severe illness from COVID-19 than patients using a continuous glucose monitor (CGM). This finding seems both sad and plausible—patients with a CGM are likely to represent the slice of the T1D community that is both unusually devoted to the management of their condition and, perhaps more importantly, that can afford the best possible medical care.
We can hope that the CDC—and similar international organizations—will take the results of these studies seriously, and consider adding Type 1 diabetes to the list of conditions that deserve vaccine priority.
In the meantime, the authors of the Vanderbilt study also underline how important infection avoidance remains in the diabetes community: “we call on our colleagues to emphasize the importance of social distancing measures and hand hygiene, with particular emphasis on patients with diabetes, including those in the most vulnerable communities whom our study affirms will face the most severe impact.”
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