January 11, 2021
José R. Romero, MD, FAAP
Chair, Advisory Committee on Immunization Practices (ACIP)
Little Rock, AR
Amanda Cohn, MD
Executive Secretary, ACIP
Atlanta, GA
CC: Kathleen Dooling, MD, MPH and Sara Oliver, MD, MSPH, ACIP COVID-19 Vaccination Work Group
Re: Recent evidence on type 1 diabetes and COVID-19 risk and the need to revise public guidance
Dear Dr. Romero and Dr. Cohn,
Our organizations represent insulin-dependent people with diabetes across America. We write to express our concern with current CDC guidance related to the risk that COVID-19 poses to people living with type 1 diabetes, which states that this patient population “might be at an increased risk for severe illness from the virus that causes COVID-19.”[1] By comparison, CDC guidance states, “having type 2 diabetes increases your risk of severe illness from COVID-19.”
We believe this disparity in the CDC’s guidance is influencing states, including Iowa, Illinois and Virginia[2], to prioritize the vaccination of people living with type 2 diabetes before people living with type 1 diabetes. We encourage you to review the Table attached cited below that contrasts publicly stated vaccine prioritization, by diabetes type, in over 20 states[3].
We believe this is a mistaken approach and that people living with all types of diabetes, including type 1, should be prioritized at the same level in the vaccine rollout.
New clinical evidence regarding the elevated risk COVID-19 poses to people with type 1 diabetes has recently been published that the CDC should take into account to update its guidance to states. We reviewed the most recent evidence used in determining the risk of various underlying medical conditions[4] and wish to highlight studies released after the most recent update.
A prospective American study by Gregory et al. at Vanderbilt University Medical Center in Nashville has found:
“Compared with not having diabetes, people with type 1 diabetes had adjusted odds ratios of 3.90 (95% CI 1.75–8.69) for hospitalization and 3.35 (95% CI 1.53–7.33) for greater illness severity, which was similar to risk in type 2 diabetes.”
A whole-population study of 61.4 million individuals in England by Barron et al. found:
“Adjusted for age, sex, deprivation, ethnicity, and geographical region, compared with people without diabetes, the odds ratios (ORs) for in-hospital COVID-19-related death were 3·51 (95% CI 3·16-3·90) in people with type 1 diabetes and 2·03 (1·97-2·09) in people with type 2 diabetes. These effects were attenuated to ORs of 2·86 (2·58-3·18) for type 1 diabetes and 1·80 (1·75-1·86) for type 2 diabetes when also adjusted for previous hospital admissions with coronary heart disease, cerebrovascular disease, or heart failure.”
A large scale observational study by Holman et al. from the NHS in England found the following:
“...Compared with people with an HbA1c of 48–53 mmol/mol (6·5–7·0%), people with an HbA1c of 86 mmol/mol (10·0%) or higher had increased COVID-19-related mortality (hazard ratio [HR] 2·23 [95% CI 1·50–3·30, p<0·0001] in type 1 diabetes and 1·61 [1·47–1·77, p<0·0001] in type 2 diabetes).”
A cohort study by McGurnaghan et al. which included the entire population of Scotland, has also found the following with respect to risk of COVID-19 and risk factors of disease and suggested type 1 may have even higher risk than type 2:
“...the overall odds ratio (OR) for diabetes, adjusted for age and sex, was 1·395 (95% CI 1·304–1·494; p<0·0001, compared with the risk in those without diabetes. The OR was 2·396 (1·815–3·163; p<0·0001) in type 1 diabetes and 1·369 (1·276–1·468; p<0·0001) in type 2 diabetes... Overall risks of fatal or critical care unit-treated COVID-19 were substantially elevated in those with type 1 and type 2 diabetes compared with the background population.”
Furthermore, it appears there are differences in risk across racial lines. A study that has analyzed 52 Centers in the United States treating patients with type 1 diabetes and COVID-19, released this month by Ebekozien et al, found:
“We included 180 patients with T1D and laboratory-confirmed COVID-19 in the analysis. Forty-four percent (n=79) were NH [non-hispanic] White, 31% (n=55) NH Black, 26% (n=46) Hispanic. NH Blacks and Hispanics had higher median HbA1c than Whites ((%-points) [IQR]:11.7[4.7], p<0.001, and 9.7[3.1] vs. 8.3[2.4], p=0.01). We found that more NH Black and Hispanic presented with DKA compared to Whites (55% and 33% vs. 13%, p<0.001 and p=0.008, respectively). After adjusting for potential confounders, NH Black patients continued to have greater odds of presenting with DKA compared with NH Whites (OR [95%CI]: 3.7 [1.4,10.6]).”
Full citations of these studies are attached in Appendix A. We have reached out to members of the study team and all are willing to discuss their findings with the CDC.
In summary, we ask that you review the evidence outlined in the Appendix to this letter and update the public guidance to reflect that people living with type 1 diabetes face at least much risk as people living with type 2 diabetes with respect to COVID-19 mortality and severe disease, and that people with all types of diabetes should be prioritized equally in the COVID-19 vaccine rollout. We further ask you to communicate this message to state and local authorities involved with COVID-19 vaccine rollout.
Yours Sincerely,
Organizations:
Cystic Fibrosis Foundation of Greater New York
Mutual Aid Diabetes
T1International
California #insulin4all
Connecticut #insulin4all
Illinois #insulin4all
Kentucky #insulin4all
Massachusetts #insulin4all
Maine #insulin4all
New York #insulin4all
North Carolina #insulin4all
Ohio #insulin4all
Utah #insulin4all
Washington #insulin4all
Individuals:
Daniel J. Moore, MD, PhD
Assistant Professor of Pediatrics
Ian M. Burr Division of Pediatric Endocrinology and Diabetes
Vanderbilt University Medical Center
Justin M. Gregory, MD
Assistant Professor of Pediatrics
Ian M. Burr Division of Pediatric Endocrinology and Diabetes
Vanderbilt University Medical Center
Professor Partha Kar, MBBS, MD, FRCP
Consultant Endocrinologist
Portsmouth Hospitals NHS Trust
National Specialty Advisor, Diabetes, NHS England
GIRFT Co-lead, Diabetes, NHS Improvement
Holly Witteman, PhD
Associate Professor and Canada Research Chair, Faculty of Medicine, Université Laval
Scientist, VITAM Research Centre for Sustainable Health and CHU de Québec-Université Laval
Quebec City, Canada
Laura Nally, MD
Instructor of Pediatrics
Division of Pediatric Endocrinology
Yale University School of Medicine
Outreach Lead for Connecticut #insulin4all Chapter
Appendix A:
[1] Emphasis added. Source: People with Certain Medical Conditions
https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fneed-extra-precautions%2Fgroups-at-higher-risk.html#diabetes
[3] Hannah Crabtree, U.S. COVID-19 Vaccine Prioritization Tracker for People with Diabetes, last updated Jan. 11, 2021. Source:
https://docs.google.com/spreadsheets/u/1/d/e/2PACX-1vQlKdSMoE5GkCAyJ5q2FLq29_8c6n6fIkqqeyo2gEi6IIaKRqtESB4BwXnU8eIWKMXW8ITQJRk0I7Sz/pubhtml
[4] Evidence used to update the list of underlying medical conditions that increase a person’s risk of severe illness from COVID-19
https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/evidence-table.html