The continuing COVID-19 pandemic remains a public health emergency worldwide, and those with underlying health conditions like diabetes remain at the top of the list for risks associated with this deadly virus.

So, should we PWDs (people with diabetes) be especially concerned? And what can we do to prepare?

While scientific data varies on whether PWDs are more at risk, what has become clear is that more severe outcomes are more likely for those with type 1 and type 2 diabetes.

As a result, precaution and mitigation strategies are the most important tools our D-Community can practice in dealing with this continuing public health emergency.

Here’s what we know, based on information from health authorities including the Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO), the Food and Drug Administration (FDA), and credentialed medical professionals within and beyond the diabetes space.

The CDC reports that coronaviruses are a large family of viruses common in animal species, and only rarely do they infect and spread among humans.

As it pertains to COVID-19, the disease that this particular coronavirus, SARS-CoV-2, causes, some researchers believe it arose in 2019 with an outbreak in Wuhan, China. The exact origins and nature of how it began remain unclear as of August 2021.

What is known is that it’s gone global, and is responsible for more than 200 million infections and more than 4.5 million deaths worldwide. It was one of the leading causes of death in 2020 and early 2021, and the emergence of new strains and variants has prolonged the pandemic.

Importantly, the incubation period is 2 to 14 days, per the CDC. This means people can be exposed and transmit the virus for days or weeks before developing any symptoms, if they do even develop symptoms.

All U.S. states have CDC approval for coronavirus tests that produce results in 1 to 4 days, and many Americans are getting vaccinated with one of the three vaccines approved for use in the United States.

As of mid-2021, three COVID-19 vaccines are available in the United States:

  • U.S. pharma giant Pfizer and its German partner, BioNTech, released their first vaccine in mid-December 2020 for those 16 and older. After the first shot, a second dose is required 21 days later. This vaccine was approved for use in children 12 and older starting in May 2021. The FDA granted full approval for the Pfizer/BioNTech vaccine on Aug. 23, 2021, meaning it’s no longer just available only under emergency use authorization (EUA) for those 16 and older, but fully approved for ongoing use for everyone ages 12 and up, with a third dose for available for those with certain immune-compromising conditions.
  • Biotech company Moderna in Boston, Massachusetts, released its vaccine in late December 2020, approved for use in adults 18 and older. This also requires two shots, with a 28-day break before the second dose.
  • Pharma giant Johnson & Johnson (J&J) released its vaccine after getting FDA approval in late February 2021. This one is different in that it only requires a single shot (versus two separate doses) and it also does not require storage at very cold temperatures, as the others need. See more details on the J&J vaccine here.

The latest CDC data released in late August 2021 shows the vaccines were 90 percent effective in June at preventing hospitalization in people 75 and older, but that number fell to around 80 percent the following month.

President Joe Biden gave the go ahead to a third “booster” shot starting Sept. 20, 2021, for those individuals who received their second dose of either the Pfizer/BioNTech or Moderna vaccine at least 8 months ago. However, this requires a green light by regulators at the CDC and FDA before it takes effect.

Earlier in 2021, the FDA pushed back on Pfizer’s statement that vaccinated individuals would need a third shot. But they eased up on that position soon after, and White House chief medical advisor Dr. Anthony Fauci later said fully-vaccinated individuals would likely need a booster shot to improve immunity.

See DiabetesMine’s story on type 1 diabetes and the COVID-19 vaccines for more detail.

The initial strain of the virus causing COVID-19 became less of a concern as more people started getting vaccinated throughout 2021, but then the series of variants began making headlines. The Delta variant has quickly become the predominant virus strain and it’s caused a new surge of cases in the United States. The CDC describes it as the most aggressive and transmissible version yet.

The Delta variant accounts for the majority of new COVID-19 hospitalizations in the United States in late summer 2021, and those who are unvaccinated have proven to be at highest risk of developing the infection.

Other new mutations of this ever-changing virus causing COVID-19 — including the Mu variant that the WHO added to its watch list in August 2021 — are being monitored closely by health experts across the world.

“In general, people with diabetes face greater risks of complications when dealing with viral infections like flu, and that is likely to be true with COVID-19,” the American Diabetes Association (ADA) said in a statement in early 2021.

The ADA encourages people with diabetes to follow the guidance of the CDC and to review their diabetes sick day protocols in case they do develop an infection.

The fact is that people with diabetes are at higher risk when it comes to things like influenza (flu), pneumonia, and now COVID-19.

This is because when glucose levels are fluctuating or elevated consistently, we have a lower immune response (less protection against disease), so we risk getting sicker quicker.

There may also be an underlying risk of exacerbated illness simply due to having diabetes even if glucose levels are in range.

One study published in December 2020 by Vanderbilt University Medical Center in Nashville, Tennessee, showed that PWDs with T1D and T2D who’ve tested positive for COVID-19 are 3 times more likely to have severe illness or require hospitalization compared to those without diabetes.

But other data have contradicted those findings, and the actual impact for those living with T1D has yet to be determined.

In particular, an October 2020 study that looked at the first 3 months of the pandemic in Belgium found that there’s no increased hospitalization due to COVID-19 for those with T1D.

Another clinical study at the Joslin Diabetes Center in Boston, Massachusetts, found that age and glycemic control didn’t differ significantly between adult T1Ds hospitalized for COVID-19 and those hospitalized for other reasons.

Those studies confirmed previous clinical research by the nonprofit T1D Exchange, showing that most PWDs who keep tabs on their diabetes management aren’t more likely to see worse outcomes or death from COVID-19.

At the European Association for the Study of Diabetes virtual meeting in September 2020, Dr. Catarina Limbert in Portugal pointed out that increased risk is largely limited to a smaller number of more vulnerable PWDs: those with A1C levels at 10 percent or higher, those older than 50 with long-term diabetes, and those with compromised immune systems.

However, this May 2021 research suggests that COVID-19 might be causing new cases of hyperglycemia (high blood sugar) that could lead to diabetes in some rare cases. Scientists think that this may be because COVID-19 can directly infect the beta cells in the pancreas, leading to beta cell damage. Research presented at the ADA’s 81st Scientific Sessions in June 2021 suggested that higher glucose levels may increase the expression of COVID-19 receptors in the body, leading to worse outcomes and severity from the infection.

“People with type 1 diabetes don’t need to live in fear and have undue anxiety, but they need to be really diligent in doing the things we all should be doing,” said Dr. Justin Gregory, a pediatric endocrinologist at Vanderbilt Children’s Hospital and the study’s lead investigator.

“I’m not asking people with type 1 diabetes to do anything that all of us shouldn’t already be doing. I just think they need to be the most diligent about doing it day in and day out,” he said.

The CDC’s recommendations for protecting against COVID-19 continue to evolve based on the latest scientific data. Here are the general guidelines:

  • Wear a face covering.
  • Maintain physical (social) distancing of at least 6 feet.
  • Wash hands often with soap and water for at least 20 seconds.
  • Make sure you’re up-to-date with vaccinations, like the flu and pneumonia shot.
  • Keep unwashed hands away from your eyes, nose, and mouth, because that can allow germs that cause respiratory infections to enter the body.

In May 2021, the CDC revised its guidance to state: “Fully vaccinated people can resume activities without wearing a mask or physically distancing, except where required by federal, state, local, tribal, or territorial laws, rules, and regulations, including local business and workplace guidance.”

The CDC’s guidance cites a number of studies showing that masks reduce the risk of transmitting the virus by more than 70 percent.

Still, some businesses may decide to lift facemask rules, while others may opt to require employees to wear them even if customers do not.

The CDC and other authorities also continue to state that if you think you might be sick, stay home from work or school.

That recommendation isn’t without criticism, however.

An article in The Atlantic explores how difficult it can be for working adults to stay home in the event of any illness in the United States.

For that reason, many businesses have issued prolonged work-from-home policies, and have canceled most business travel and in-person events.

Most medical professionals who treat diabetes are emphasizing basic hygiene and illness precautions, as well as doubling down on efforts to achieve good glucose control.

Dr. Jennifer Dyer, a pediatric endocrinologist with a private practice in Columbus, Ohio, tells DiabetesMine that she’s received a barrage of calls from patients concerned about COVID-19. Her advice?

“Bottom line: Make sure you get a flu shot. If you or your loved ones get sick with a flu-like or cold-like illness, first make sure it’s not the flu, which is treatable. If there is any progression to pneumonia, get support and treatment fast as this is what typically makes these viruses dangerous,” she says.

Well-known Philadelphia-area diabetes education and care specialist Gary Scheiner reminds us that PWDs can also be more prone to dehydration, especially when blood sugars rise, so it’s important to stay hydrated.

This may mean stocking up on bottled water, or even sugar-containing liquids like Gatorade, which can also provide electrolytes and energy in the event of emergency situations.

In an interview on the “Diabetes Connections” podcast, Scheiner explains that if a person with diabetes contracts an infection with the new coronavirus, “it’ll affect them just like it affects a person without diabetes, but in a PWD it’s gonna cause the glucose levels to rise as well… You’re going to see some intense inflammation of the respiratory tract.

“One of the unique things about it compared to some other viruses like the flu is it can cause some severe shortness of breath, which we don’t always see with other communicable common illnesses. So, that’s something to watch for,” he said.

Scheiner also shared some specific reminders for people with diabetes:

  • “I tell patients to be a bit obsessive about handwashing — be very compulsive about that.”
  • “Get a flu shot, because you can prevent any form of the flu, and that’s always beneficial.”
  • “Be very careful around people who have signs of respiratory illnesses who are coughing, sneezing, etc. Keep your distance, or just try to be very cautious about physical contact with them.”
  • “A humid environment is also beneficial. If your house is dry, especially in the wintertime, use a humidifier. The first place where germs can penetrate into the body is the nasal passages, and if they dry out due to dry air, you’re kind of opening the door and marshaling germs into your system.”

Regarding glucose control, Scheiner said, “We see the risk of these types of problems almost go up exponentially when the A1C starts getting up into the 9 or 10 range. And with an A1C in the 6 or 7s, the risk is slightly increased. I wouldn’t say it’s dramatically higher than in someone without diabetes, but there is some increased risk.

“The other issue is managing the glucose if you do get sick, which becomes more challenging, but even more important, because when glucose levels are elevated, you’re sort of aiding and abetting the infection that virus or bacteria has a lot of fuel to grow off of.

“So you’re feeding the enemy in a way if your blood sugar is poorly controlled. When you’re sick, running a lot of high blood sugars is going to extend your recovery time and cause your symptoms to become that much worse,” he explained.

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Image via DiabetesDietBlog.com

No doubt, emergency and disaster planning is a critical component to all of this.

“In general, I think this virus is bringing up the question of disaster preparedness, and is reminding many in the diabetes community about how poorly we are prepared for disaster scenarios,” says endocrinologist Dr. Jason Baker in New York, who also lives with type 1 diabetes himself.

“We are indeed reminded right now of how vulnerable we are living with diabetes, how reliant we are on the uninterrupted manufacture and distribution of our life-sustaining insulin and glucose monitoring supplies; we are indeed naked without them,” he says.

Baker encourages PWDs to have extra insulin on hand, preferably a month’s worth at least, along with extra glucose monitoring and diabetes supplies.

He recognizes the built-in barriers of access and affordability, too often dictated by insurance companies.

That’s why it’s important to research any local grassroots relief efforts in your area, and to talk with your doctor now about working through and around these barriers if and when needed.

In Colorado, diabetes education and care specialist Jane Dickinson says she’s had conversations with people trying to stockpile insulin and supplies.

“I think there’s a feeling that people on pumps need to not only have pump supplies on hand, but also MDI (multiple daily injection) supplies as a backup,” she says. She adds that this is a wise thing to do.

Thankfully, dozens of medtech and pharma companies are proactively tackling awareness and disease preparation as it relates to COVID-19 — notably Johnson & Johnson, Medtronic, and Roche.

Industry trade group AdvaMed notes that by the end of February, nearly three dozen member companies had already donated a collective total of $26.8 million worth of medical products to the China Red Cross (since COVID-19 originated in that country) as well as other health institutions and clinics globally.

The group has also formed a Coronavirus Task Force focusing on personnel, transportation, supply, etc., that’s meeting regularly to coordinate the industry response.

While there was a concern about this issue early on during the pandemic, it didn’t materialize into a large concern for most companies or PWDs.

Spokeswoman Stephanie Caccomo with the FDA’s Center for Devices and Radiological Health, which regulates and oversees diabetes devices, told DiabetesMine in November 2020 that they hadn’t received any reports of diabetes products being directly affected by the COVID-19 pandemic to date.

The Association of Diabetes Care and Education Specialists has compiled a comprehensive list of drugmakers’ responses about product and supply availability during COVID-19.

Among the 18 companies listed, no significant shortages are noted.

The 2020, midyear mail delays at the U.S. Postal Service and the shipping delays with big third-party companies like Amazon, FedEx, and UPS turned out to be more of an issue than supply shortages.

Since most home deliveries are now going smoothly, the advice for PWDs has simply been to ensure they have enough diabetes supplies and medications on hand to hold them over in case of temporary delays.

An opinion article published in the British Medical Journal in November 2020 highlights some interesting global patient perspectives on the implications of COVID-19 on those with T1D.

Importantly, it notes that aside from practical and logistical worries, there’s also an impact on mental health.

“In addition to individual country and region-specific challenges, there has also been an increased mental health burden because of the pandemic, especially for people living alone. People with T1D are struggling to balance the need to leave the house for work or necessary hospital visits with the desire to self-isolate and self-protect. Self-managing T1D already causes a high cognitive load and mental health burden, and the current pandemic is adding to that,” the authors state.

We’ve seen PWDs online taking various stances on this, from heightened concern to brushing it aside as nothing more than typical flu season preparedness.

In one Twitter thread, advocate and former ADA magazine editor Kelly Rawlings shared her diabetes-centric #COVID19 strategy and welcomed others to share theirs:

  1. Refill insulin & key supplies prescriptions ASAP
  2. Update my primary care doctor contact info
  3. Review basal/bolus rates; convert to multiple daily injection plan, JIC I can’t operate pump
  4. Wash hands

Back in the early days of COVID-19 in spring 2020, Dana Lewis and her husband, Scott Leibrand, the entrepreneurs behind the first homemade Artificial Pancreas technology, were sharing early on what they had been doing to stay safe.

In this Twitter thread, Lewis announced: “I’ve been personally watching the information about #COVID19 for over a month and a half, and expecting it to come to my doorstep. It’s now here, as predicted, so I wanted to share some of what I’m personally able to choose to do & why, with regards to individual protection.”

She then explains which diabetes tools she’s using, and how she’s keeping herself safe inside and outside their home.

The couple lives in the Seattle, Washington, area, and Scott had traveled to Silicon Valley in mid-February — an area that subsequently reported high numbers of COVID-19 cases.

As a result, aside from taking general health precautions, Scott put himself into “self-isolation” at home for a time.

Lewis and Leibrand are also behind the push by the #WeAreNotWaiting community of diabetes DIY technology enthusiasts to do more than just wearing masks, washing hands, and staying home.

They’re working to generate a do-it-yourself tool for self-reporting of health factors related to virus monitoring.

Collaborating with health professionals, infectious disease experts, and others, they’re creating what is known as CoEpi (Community Epidemiology into Action), a mobile tracking app.

It will allow anyone to easily and privately track who they’ve been in contact with, and anonymously share reports and updates on their own symptoms and likely contagiousness — whether that be a cold, flu, COVID-19, or any other contagious disease.

A beta version of CoEpi is available now for both iOS and Android, though Leibrand points out they’re still “jumping through hoops” trying to get it into the Apple App Store.

Anyone interested in testing the beta version can download it using the links at the bottom of CoEpi.org.

Leibrand also notes that some parts of the United States now have an official Exposure Notification app, or the ability to turn it on via their smartphone settings.

He highly recommends everyone enable that, if possible.

And for anyone who’s not locked down tight in a tiny bubble, the Novid app is also very useful for your own contact tracing: It has a feature showing how many degrees of separation you have from someone who’s tested positive for COVID-19.

“This pandemic is scary, but it’s exciting that there’s something we personally can all do to help protect ourselves, our loved ones, our social networks, and our communities,” Leibrand told DiabetesMine.