Type 1 Diabetes and COVID-19: Preliminary Findings From a Multicenter Surveillance Study in the U.S.

The Centers for Disease Control and Prevention states that individuals with diabetes are at higher risk for severe illness with coronavirus disease 2019 (COVID-19) and poorer health outcomes (1). Research suggests the underlying reason for an increased risk of COVID-19 complications in individuals with diabetes may be poor glycemic control or hyperglycemia (2). Information on clinical outcomes for patients with type 1 diabetes who have confirmed cases of COVID-19 is limited. To our knowledge, this is the first U.S.-based multicenter study that addresses these questions in a population with type 1 diabetes.

This study aimed to examine patient characteristics and adverse outcomes among patients with type 1 diabetes with confirmed COVID-19. As a secondary objective, we investigated patient attributes and clinical outcomes in people with COVID-19–like symptoms for whom testing was unavailable or results were pending.

The T1D Exchange Quality Improvement Collaborative (T1DX-QI) (3) is conducting this study in collaboration with an additional 49 endocrinology clinics (a total of 64 U.S. sites). The study was approved as exempt by a central review board (Western Institutional Review Board [WIRB]). Each clinic obtained approval locally as appropriate. In this study, clinics report deidentified data from their patients with type 1 diabetes who tested positive for COVID-19 as well as for patients with symptoms and a medical history consistent with COVID-19 illness.

In the registry, patients were classified as COVID-19 positive if they had tested positive for COVID-19 through a molecular test (RT-PCR) of samples collected from nasopharyngeal swabs, throat swabs, sputum, etc. (1).

Patients were classified as having COVID-19–like cases if they exhibited any of the most common COVID-19 symptom profiles as identified by the Centers for Disease Control and Prevention including fever, cough, shortness of breath, myalgia, runny nose, sore throat, headache, nausea or vomiting, abdominal pain, diarrhea, or any combination of these symptoms (4). Additionally, household exposures for COVID-19 were recorded for patients who presented with any of the above-listed symptoms.

Data were collected using a 33-item questionnaire via the Qualtrics survey tool (https://t1dexchange.org/COVID19). As of 5 May 2020, we described data available on 33 COVID-19–positive and 31 COVID-19–like patients with type 1 diabetes, reported from participating clinics within the U.S. (Table 1).

Table 1

Preliminary data: patient characteristics, symptoms, and outcomes in the T1D COVID-19 study

Patient attributes	All patients (N = 64)	COVID-19–positive case group (N = 33)	COVID-19–like case group (N = 31)
Mean age in years (SD)	20.9 (14.84)	24.8 (17.49)	16.8 (10.10)
Age categories
≤18 years	42 (65.6)	17 (51.52)	25 (80.6)
>19 years	22 (34.4)	16 (48.5)	6 (19.4)
Female sex	39 (60.9)	18 (54.5)	15 (48.3)
Race/ethnicity
Non-Hispanic white	31 (48.4)	12 (36.4)	19 (61.3)
Non-Hispanic black	12 (18.8)	10 (30.3)	2 (6.5)
Hispanic	16 (25)	7 (21.2)	9 (29.0)
Asian/other/unknown	5 (7.8)	4 (12.1)	1 (3.23)
Education level (patient, or parent if patient <18 years of age)
No high school	8 (12.5)	3 (9.1)	5 (16.1)
High school graduate	12 (18.8)	7 (21.2)	5 (16.1)
College graduate or above	7 (10.9)	6 (18.2)	1 (3.2)
Unknown	37 (57.8)	17 (51.5)	20 (64.5)
Insurance
Private	20 (31.3)	9 (27.3)	11 (35.5)
Public	36 (56.3)	23 (69.7)	13 (41.9)
HbA1c median, %	8.0	8.5	8.0
Duration of type 1 diabetes
New onset	6 (9.8)	5 (15.6)	1 (3.4)
<1 year	2 (3.1)	—	2 (6.9)
1–2 years	9 (14.8)	2 (6.3)	7 (24.1)
3–5 years	15 (24.6)	9 (28.1)	6 (20.7)
6–10 years	12 (19.7)	4 (12.5)	8 (27.6)
>10 years	17 (27.9)	12 (37.5)	5 (17.2)
CGM use (yes)	32 (52.5)	13 (40.6)	19 (65.5)
Insulin pump use (yes)	27 (44.3)	9 (28.1)	18 (62.1)
Care managed remotely (yes)	37 (60.7)	15 (46.9)	22 (75.9)
Video/telemedicine as primary mode of remote care	17 (46)	8 (53.3)	9 (40.9)
COVID-19 symptoms and medical care information
Most prevalent symptoms
High blood glucose	32 (50.8)	16 (48.5)	16 (51.6)
Elevated temperature	26 (41.3)	15 (45.5)	11 (36.7)
Dry cough	24 (38.1)	13 (39.4)	11 (36.7)
Nausea	19 (30.2)	9 (27.3)	10 (33.3)
Excess fatigue	18 (28.6)	11 (33.3)	7 (23.3)
Body/headaches	17 (27.0)	7 (21.2)	10 (33.3)
Shortness of breath	17 (27.0)	10 (30.3)	7 (23.3)
Vomiting	16 (25.4)	11 (33.3)	5 (16.7)
Loss of taste	7 (11.1)	3 (9.1)	4 (13.3)
Loss of smell	6 (9.5)	1 (3.0)	5 (16.7)
Low blood glucose	5 (7.9)	1 (3.0)	5 (16.7)
Loose stools	5 (7.9)	—	5 (16.7)
Most prevalent comorbidities
Obesity	25 (39.7)	13 (39.4)	12 (40)
Hypertension/CVD	9 (14.3)	4 (12.1)	5 (16.7)
Asthma	5 (7.9)	—	5 (16.7)
Hashimoto thyroiditis	7 (4.8)	4 (12.1)	3 (10.0)
Hyperlipidemia	3 (4.8)	1 (3.0)	2 (6.7)
Smoking/vaping history
Yes (current or previous)	6 (9.8)	2 (6.3)	4 (13.8)
No	41 (64.1)	20 (60.1)	21(67.7)
Unknown	15 (23.4)	11 (32.3)	4 (12.9)
Influenza vaccine this season
Yes	26 (42.6)	14 (43.8)	12 (41.4)
No	12 (18.8)	3 (8.8)	9 (29.0)
Unknown	26 (40.6)	16 (47.1)	10 (32.3)
Highest level of care
Intensive care unit	14 (22.2)	10 (30.3)	4 (13.3)
Inpatient or hospitalization	11 (17.5)	9 (27.2)	2 (6.7)
Emergency room	5 (7.9)	1 (3.0)	4 (13.3)
Clinic or urgent care	8 (12.7)	4 (12.1)	4 (13.3)
At home	22 (34.9)	9 (27.3)	13 (43.3)
Unknown	3 (4.8)	—	3 (10.0)
Adverse outcome
Death	2 (3.2)	1 (3.0)	1 (3.3)
DKA	19 (30.2)	15 (45.5)	4 (13.3)
Severe hypoglycemia	3 (4.8)	1 (3.0)	2 (6.7)
Other	6 (9.5)	5 (15.2)	1 (3.3)
None	33 (52.4)	13 (39.4)	20 (66.7)
Unknown	3 (4.8)	1 (3.0)	2 (6.7)

Data are n (%) unless otherwise indicated. Data submitted to the registry as of 5 May 2020. CGM, continuous glucose monitoring; CVD, cardiovascular disease.

In the COVID-19–positive group (N = 33), 54.5% of patients were female and 36.4% were non-Hispanic white. The mean age was 24.8 years (SD 17.49, range 7.0–79.0). Median HbA1c for all COVID-19–positive patients was 8.5%. The most prevalent presenting symptom reported was high blood glucose (48.5%), followed by elevated temperature (45.5%), dry cough (39.4%), excess fatigue (33.3%), vomiting (33.3%), shortness of breath (30.3%), nausea (27.3%), and body/headaches (21.2%). A smaller proportion (<15%) of patients experienced chills, chest pain, loose stools, abdominal pain, loss of taste, and loss of smell.

The most prevalent comorbidity among patients with a confirmed case of COVID-19 was obesity (39.4%), followed by hypertension or cardiovascular disease (12.1%). The most prevalent adverse outcome within COVID-19–positive patients was diabetic ketoacidosis (DKA) (45.5%).

In the group that presented with COVID-19–like symptoms (N = 31), 48.3% of patients were female and 61.3% were non-Hispanic white. The mean age was 16.8 years (SD 10.1). Median HbA1c was 8.0%. The most prevalent adverse outcome was DKA (13.3%). Most patients reported symptoms similar to those of patients who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), including high blood glucose (51.6%), elevated temperature (36.7%), dry cough (36.7%), nausea (33.3%), body/headaches (33.3%), excess fatigue (23.3%), and shortness of breath (23.3%).

This preliminary report describes the most common presenting symptoms and outcomes for 64 people with type 1 diabetes who have confirmed or suspected COVID-19. More than 50% of all cases reported hyperglycemia, and nearly one-third of patients experienced DKA.

Future publications will address risk factors, provide regional insights, and describe associations and outcomes in pediatric and adult patients as more data are collected and analyzed.