Increases in Pediatric T1D Incidence Seen During COVID-19

Two recently published studies documented an increase in type 1 diabetes (T1D) rates among children throughout the COVID-19 pandemic.

In one analysis carried out in California,¹ researchers found that the incidence of new-onset T1D among children presenting to Rady Children’s Hospital San Diego increased throughout the COVID-19 pandemic compared with rates recorded in the preceding 5 years. Findings were published in JAMA Pediatrics.

Even before COVID-19, T1D incidence has been growing globally each year, while some previously released data have indicated T1D presentation was more severe throughout the pandemic.

In the current analysis, the researchers assessed deidentified data of patients presenting to the center who were younger than age 19 and had at least 1 positive T1D antibody titer. The COVID-19 year was defined as the time between March 19, 2020, and March 18, 2021; 5 years of prior data, collected between March 19, 2015, and March 18, 2020, were included as a reference window.

As the only children’s hospital in the greater San Diego area, Rady Children’s Hospital routinely admits children with new-onset T1D who require initiation of insulin treatment, the authors said.

During the COVID-19 year, 187 children were admitted for new-onset T1D (mean [SD] age, 9.6 [4.2] years) compared with just 119 children admitted the previous year, marking an increase of 57%, the researchers found.

Data also showed that between July 2020 and February 2021, “the number of new diagnoses of T1D exceeded the number of patients anticipated within the 95% CI based on a quarterly moving average of the preceding 5 years (July 2020: 15 diagnoses; 10 forecasted diagnoses; 95% CI, 6.79-13.89; February 2021: 21 diagnoses; 10 forecasted diagnoses; 95% CI, 6.88-13.54).”

Analyses revealed:

• 4 of 187 patients (2.1%) had COVID-19 infection at the time of presentation
• There was an increase in the percentage of patients who presented with diabetic ketoacidosis (DKA), but no difference in mean age at presentation (9.6 [4.2] years vs 9.7 [4.2] years), body mass index z score, glycated hemoglobin (A_1C), or percentage of children requiring pediatric intensive care unit admission, between the COVID-19 year and any of the prior 5 years
• A significant increase in the frequency of DKA at the time of T1D diagnosis, with 93 of 187 patients (49.7%) requiring an insulin infusion during the COVID-19 pandemic, showing an increase from 261 of 641 patients (40.7%) in the 5 years before the pandemic

Investigators were unable to perform COVID-19 antibody testing at the time of diagnosis to determine potential previous COVID-19 infections, marking a limitation to the study.

An additional analysis² that assessed pediatric T1D rates in Germany throughout the pandemic revealed similar findings.

Using data from the multicenter German Diabetes Prospective Follow-up Registry, researchers found a significant increase in the incidence of T1D in children during the COVID-19 pandemic, “with a delay in the peak incidence of T1D by approximately 3 months after the peak COVID-19 incidence and also after pandemic containment measures.”

Writing in Diabetes Care, the authors conceded they do not yet know the underlying cause of the increase in T1D rates. Although common respiratory infections in early childhood may be a risk factor for T1D, they noted incident consequences of the pandemic are more likely to be the cause of increased rates as opposed to direct effects of a COVID-19 infection.

All children receiving a new T1D diagnosis between January 1, 2020, and June 30, 2021, in Germany and aged 6 months to 18 years were included in the study. These individuals were compared with 22,987 controls who received their diagnosis between 2011 and 2019.

Incidence rates were measured per 100,000 patient-years, while “expected incidences for 2020/21 were estimated based on the data from 2011 to 2019 and compared with observed incidences in 2020/21 by estimating incidence rate ratios (IRRs) with 95% CIs,” the authors explained

Analyses of the 5162 patients with a new diagnosis showed:

• The observed incidence in 2020/21 was significantly higher than the expected incidence (24.4; 95% CI, 23.6-25.2; vs 21.2; 95% CI, 20.5-21.9; IRR, 1.15; 95% CI, 1.10-1.20; P<.001)
• IRRs were significantly elevated in June 2020 (IRR, 1.43; 95% CI, 1.07-1.90; P = .003), July 2020 (IRR, 1.48; 95% CI, 1.12-1.96; P <.001), March 2021 (IRR ,1.29; 95% CI, 1.01-1.65; P = .028), and June 2021 (IRR, 1.39; 95% CI, 1.04-1.85; P = .010)

Similar to the previous investigation, information regarding the history of COVID-19 infections in children with new-onset T1D was not available.

The researchers hypothesized changes in lifestyle may have played an important role in the rise of T1D observed in the current analysis.

“COVID-19 pandemic control efforts abruptly [changed] social contacts, the behavior of families with children, and child health care practices, which may have resulted in a dramatic decrease in biodiversity in children, particularly in young children,” they wrote. “This change in total environmental exposure, the exposome, could be the link to the increased incidence of T1D in young children seen in our study.”

Increased stress, poorer mental health, and a high prevalence of anxiety and depression symptoms resulting from social isolation and school closure could have also affected T1D rates, as both psychological stress and stressors have been implicated in T1D pathogenesis.

Future long-term studies are warranted to better elucidate the association between T1D incidence in children, COVID-19 infection, and pandemic mitigation efforts, the authors concluded.

References

1. Gottesman BL, Yu J, Tanaka C, Longhurst CA, Kim JJ. Incidence of new-onset type 1 diabetes among US children during the COVID-19 global pandemic. JAMA Pediatr. Published online January 24, 2022. doi:10.1001/jamapediatrics.2021.5801
2. Kamrath C, Rosenbauer J, Eckert AJ, et al. Incidence of type 1 diabetes in children and adolescents during the COVID-19 pandemic in Germany: results from the DPV registry. Diabetes Care. Published online January 17, 2022. doi:10.2337/dc21-0969