Published March 24, 2020 in Life with T1D
Every day, we receive a flurry of questions from our type 1 diabetes (T1D) community about the coronavirus and what it means for those of us living with T1D. Throughout this pandemic, we will share the Top Ten Questions and responses from experts in the field.
We here at JDRF are not medical experts, but we do work with the nation’s top professionals in the field and are looking to them to help with your questions. Even so, these responses are not intended to be medical advice, for that—as always—you must consult your own personal physician.
1. Are those of us with T1D more susceptible to catching COVID-19?
This is the most frequently asked question and carries with it so much understandable concern.
We consulted with leading physicians and experts across the country and understand from them that the answer is: NO. People who have well-managed T1D are NOT more likely to contract COVID-19. But, those with consistently elevated blood-sugar levels are likely to be at greater risk.
Below is input from Dr. Anne Peters, director of the University of Southern California Clinical Diabetes Programs and practicing physician, as shared in an interview with JDRF’s colleagues at Beyond Type 1.
“T1D all by itself is unlikely to be a risk factor for catching [COVID-19].
“We do know that poorly controlled blood sugars create an increased risk for all infections, and so there is no reason to think that this [illness] would be any different. Older people, sick people need to be very, very careful not to get this. Younger people, healthy people in good condition—I don’t believe they are at higher risk.”
2. Why is the CDC and World Health Organization saying that having diabetes DOES put us at greater risk?
We spoke to several experts about this and received the same response: the categorization that those with diabetes are at higher risk is broad and without specificity. For those with T1D, it applies directly to those without well-managed T1D. On this topic, here is nationally renowned endocrinologist Dr. Mary Pat Gallagher, director of pediatric diabetes at the Pediatric Diabetes Center at Hassenfeld Hospital at New York University, Langone. She spoke with JDRF on March 24 via Facebook Live:
“I can understand the confusion. The CDC, and the World Health Organization, and the American Diabetes Association…all mention that there are certain conditions that put you at increased risk or higher risk for severe illness. And diabetes is on that list.
When you don’t separate out what type of diabetes a person has, and you don’t separate them by age, and you don’t separate them by other medical conditions that also occur, and you don’t separate by their glycemic control—you just take everyone in one pot—people with diabetes are hospitalized more often, with COVID-19 as well as other respiratory illnesses, and, they have a higher fatality rate.
However, if we do control for all of those things. For age, for other types of diagnoses that occur, it changes things dramatically.
What we know about COVID-19, is that it seems that [those with T1D] are equally [not more] susceptible.”
3. If someone with T1D gets COVID-19, are they at greater risk of developing serious complications?
In speaking with several experts and physicians, we have repeatedly been told that those with well-managed T1D, and those who continue to manage glucose levels through this or any illness, should be at no greater risk of developing serious complications from COVID-19.
Managing glucose levels during an illness can be challenging, but is critically important. Read more here on steps to take to manage your T1D and your recovery with any illness.
4. If managing glucose levels is key to not being high-risk, should I be worried if my A1c is around 7?
Experts agree that someone with T1D and consistently elevated blood-sugar levels is likely to be at greater risk of contracting the illness and having more serious complications from the disease. We spoke to the experts about the range that might put someone at greater risk.
“Don’t worry about being at 6 vs 7.3. You are not at any greater risk,” said Dr. Gallagher. “If you are in good control, you will have better outcomes. For people who have an A1c of 12, yes, they’re considered high risk, and I am worried about people who have A1cs that are that markedly elevated because I worry that their immune systems are not going to be able to fight this off as effectively as people who have better control.”
5. Aren’t people with T1D considered “immuno-compromised” or “immuno-suppressed” and thus naturally at greater risk?
Dr. Peters: “I don’t think type 1 diabetes makes you immuno-suppressed. Historically, that’s how people thought of it—because if your sugars are sky high, it probably makes you more susceptible to infection. But it’s not immuno-compromised like you’re on an anti-rejection drug or getting chemotherapy. It’s not the same thing. There’s a glucose effect on the immune system and higher glucose levels can make the immune system less robust, but I don’t see that as a state of immunosuppression in a well-controlled patient with type 1 diabetes.”
6. Are children with T1D more susceptible?
There is no evidence that children with T1D are more susceptible to COVID-19. In fact, information coming from China, Italy and other areas that have longer-term exposure than the United States indicate that children are managing the illness far better than adults with many showing little or no symptoms.
“Pleasingly, our colleagues in Italy and Middle East report that the children and adolescents with diabetes have not been adversely affected by infection,” according to Kim Donaghue, President of the International Society of Pediatric and Adolescent Diabetes.
“Children seem very unlikely to get symptoms,” said Dr. Anne Peters. “It’s not that children are unlikely to catch it. It is unlikely that children will show signs of infection. One of the problems is they can be secret vectors of this—they can be asymptomatic—and…spread through sneezing, coughing and spit.”
7. Is it OK if my child visits grandparents who have T1D?
While this is difficult to hear, experts are advising, when possible, to “social distance” children from older adults who are in the high-risk-for-contamination category. A grandparent with T1D has both age, T1D and potentially other illnesses that they are managing. Children, even if not ill or showing any symptoms, may be carrying the virus.
Dr. Gallagher said that someone may be infectious for an average of five days prior to symptoms. Children, she noted, may show no symptoms at all.
“That is what is behind a recommendation to try to allow your grandparent-generation—people over 70, unless you’re providing actual direct care to them—to [keep away from] your children, who are very likely to be the ones who are infected and not showing any symptoms.” The aim is to “protect the population that’s most at risk for requiring hospitalization and having a severe outcome.”
8. What do I do if I live with someone who has T1D and has other factors, such as age or a chronic health condition, that puts them at higher risk?
If you live with or care for someone who is at high risk, experts are urging you to limit your potential to being exposed to COVD-19, so then, you reduce the chance of passing on the illness. You can be ill without showing symptoms. The illness also can live for several days on surfaces—so you might carry it in. When you cannot restrict your own activities, experts urge extra precautions: refrain from hugs and kisses; wash hands immediately upon entering the home; if you use a tissue, throw it away immediately then rewash your hands and use paper towels instead of cloth towels; and wipe down surfaces you touch.
Dr. Peters: “The person with whom I live is 75 years old and he has diabetes. I can’t get him sick. And it’s not because of the diabetes, it’s because he’s 75 years old. So, I am just insanely careful. We’re lucky enough that we have our own bathrooms—bathrooms are a point of spread. If you share a bathroom, decontaminate. You don’t want to share towels; you want to keep everything separate.
I’m in a high-risk position because I’m seeing patients all day. So, now I actually go to work in a set of scrubs. When I come back, and before I do anything, I take off the scrubs, throw them in the washing machine, run upstairs and take a shower. So, I decontaminate myself. And as soon as you’ve done that, you can be in the same house just fine. Let’s not contaminate each other!”
9. What are the overall risks of getting and becoming ill with COVID-19?
To understand the level of contamination and risk, we looked at several sources for perspective.
Risk: According to the CDC, the risk of serious illness is low for the vast majority of the population.
• The immediate risk of being exposed to this virus is still low for most Americans, but as the outbreak expands, that risk will increase.
• Reported illnesses have ranged from very mild (including some with no reported symptoms) to severe, including illness resulting in death. While information so far suggests that most COVID-19 illness is mild, a report out of China suggests serious illness occurred there in 16% of cases.
• 80% of deaths have been in adults 65 years and older with severe chronic medical conditions, with the highest percentage of severe outcomes occurring in people 85 years and older.
Impact vs flu: While COVID-19 remains a new disease, John Hopkins Medicine reports that COVID-19’s impact is far less than that of the annual flu. Consider:
• COVID-19: 351,731 cases worldwide; 35,241 cases in the U.S. (as of Mar. 23, 2020*)
• Flu: Estimated 1 billion cases worldwide; 9.3-45 million cases in the U.S. per year.
• COVID-19: 15,374 deaths reported worldwide; 473 deaths in the U.S. (as of Mar. 23, 2020*)
• Flu: 291,000 to 646,000 deaths worldwide; 12,000 to 61,000 deaths in the U.S. per year.
*Data from the Coronavirus COVID-19 Global Cases map, developed by the Johns Hopkins Center for Systems Science and Engineering.
Mortality Rate: According to data from the CDC, World Health Organization and compiled by MPR News, this is how deadly COVID-19 is when compared to other diseases:
• Ebola (2013-16): 39.5% fatality rate
• 1918 Flu (1918-20): 10%
• SARS (2002-03): 9.64%
• COVID-19 (2019-?): 1.40%
• Seasonal Flu: .15%
• Swine Flu: (2009-10): 0.02%
10. If the risks seem manageable, why all the precautions and worry?
“This is not about protecting most of us—this is about not overwhelming our hospital system and protecting our vulnerable population,” said Dr. Gallagher. “So it’s really an act of solidarity. I don’t think you need to panic and run for the hills. About 90% of the people who get this will feel as if they have colds. I understand it seems counterintuitive—like then what are we doing? But it really is about not overwhelming the hospital system because it’s a brand-new virus and nobody is immune to it.”
Dr Peters said: “I think it’s normal to be worried and it’s normal to be upset because all of our lives have changed so much. But I think that the type 1 diabetes community is a wonderful group because it’s so interconnected, and I think that everybody just needs to connect with each other. Stick to the basics of type 1 diabetes, you all know how to live with it, you know how to deal with it. That’s not going to change….We’ll create a new normal, this will get hopefully better….I think it’s awful on some level, but it’s also quite survivable on another, so just don’t panic.”
By Lisa Popyk
We would like to thank the Pediatrician Mrs Lamprini Giannakides with special interest and education in diabetes, who provided us with this particular article.