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Does COVID-19 Play a Role in Type I Diabetes in Children?

  • Authors: News Author: Miriam E. Tucker; CME Author: Charles P. Vega, MD
  • CME / ABIM MOC / CE Released: 3/11/2022
  • Valid for credit through: 3/11/2023
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Target Audience and Goal Statement

This activity is intended for all primary care physicians, family medicine practitioners, pediatricians, diabetologists and endocrinologists, internal medicine specialists, infectious disease clinicians, nurses, pharmacists, and other members of the healthcare team who care for children at risk for type 1 diabetes (T1D).

The goal of this activity is to assess trends in the epidemiology of T1D during the COVID-19 pandemic.

Upon completion of this activity, participants will:

  • Compare characteristics of children with newly diagnosed T1D during the COVID-19 pandemic vs before the pandemic
  • Assess trends in the epidemiology of new T1D among children and adolescents during the COVID-19 pandemic
  • Outline implications for the healthcare team


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News Author

  • Miriam E. Tucker

    Freelance writer, Medscape


    Disclosure: Miriam E. Tucker has disclosed no relevant financial relationships.

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine


    Disclosure: Charles P. Vega, MD, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: GlaxoSmithKline; Johnson & Johnson Pharmaceutical Research & Development, L.L.C.

Editor/CME Reviewer/Nurse Planner

  • Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP

    Associate Director, Accreditation and Compliance
    Medscape, LLC


    Disclosure: Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP, has disclosed no relevant financial relationships.

CME/CE Reviewer

  • Yaisanet Oyola, MD

    Associate Director, Accreditation and Compliance
    Medscape, LLC


    Disclosure: Yaisanet Oyola, MD, has no relevant financial relationships.

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Does COVID-19 Play a Role in Type I Diabetes in Children?

Authors: News Author: Miriam E. Tucker; CME Author: Charles P. Vega, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 3/11/2022

Valid for credit through: 3/11/2023


Note: The information on the coronavirus outbreak is continually evolving. The content within this activity serves as a historical reference to the information that was available at the time of this publication. We continue to add to the collection of activities on this subject as new information becomes available. It is the policy of Medscape Education to avoid the mention of brand names or specific manufacturers in accredited educational activities. However, manufacturer names related to COVID-19 vaccines may be provided in this activity to promote clarity. The use of manufacturer names should not be viewed as an endorsement by Medscape of any specific product or manufacturer.

Clinical Context

The incidence of type 1 diabetes (T1D) has been on the rise by about 3% to 4% annually over the past 3 decades, and there is growing evidence that the COVID-19 pandemic may be exacerbating this problem. A research letter by Gottesman and colleagues compared cases of T1D from March 2020 to March 2021 with rates from the 5 years before the pandemic. Their research was published online January 24 in JAMA Pediatrics.[1]

A total of 187 children with a mean age of 9.6 years were admitted for a new diagnosis of T1D at their US academic health center during the 2020-2021 period. This rate was 57% higher compared with the same period in 2019-2020. The incidence of T1D significantly increased in a comparison of data from 2020 to 2021, with a quarterly moving average from the 5 years before the COVID-19 pandemic. In comparing the pre-COVID periods with 2020-2021, there was no difference in the average age of children with new T1D, mean body mass index, or initial glycated hemoglobin (HbA1c) level; however, the proportion of children presenting with diabetic ketoacidosis was higher during 2020-2021.

A larger study from Germany by Kamrath and colleagues further explored trends in the epidemiology of T1D among children during the COVID-19 pandemic. The results of this research are described in Study Highlights.

Study Synopsis and Perspective

Two new studies from different parts of the world have identified an increase in the incidence of T1D in children since the COVID-19 pandemic began, but the reasons still are not clear.

The findings from the two studies, in Germany and the United States, align closely, endocrinologist Jane J. Kim, MD, professor of pediatrics and principal investigator of the US study, told Medscape Medical News: "I think that the general conclusion based on their data and our data is that there appears to be an increased rate of new type 1 diabetes diagnoses in children since the onset of the pandemic."

Kim noted that because her group's data pertain to just a single center, she is "heartened to see that the [German team's] general conclusions are the same as ours."

Moreover, she pointed out that other studies examining this question came from Europe early in the pandemic whereas "now both they [the German group] and we have had the opportunity to look at what's happening over a longer period of time."

The reason for the association, however, remains unclear. Some answers may be forthcoming from a database designed in mid-2020 specifically to examine the relationship between COVID-19 and new-onset diabetes. Called "CoviDiab," the registry aims "to establish the extent and characteristics of new-onset, COVID-19-related diabetes and to investigate its pathogenesis, management, and outcomes," according to the website.[2]

The first new study, a multicenter German diabetes registry study, was published online January 17 in Diabetes Care by Clemens Kamrath, MD, of Justus Liebig University, Giessen, Germany, and colleagues.[3]

The other, from Rady Children's Hospital of San Diego, was published online January 24 in JAMA Pediatrics by Bethany L. Gottesman, MD, and colleagues, all with the University of California, San Diego.[1]

Mechanisms Likely to Differ for Type 1 vs Type 2 Diabetes

Neither the German nor the US investigators were able to directly correlate current or prior SARS-CoV-2 infection in children with the subsequent development of T1D.

Earlier this month, a study from the US Centers for Disease Control and Prevention[4] did examine that issue, but it also included youths with type 2 diabetes (T2D) and did not separate out the 2 groups.

Kim said her institution has also seen an increase in T2D among youths since the COVID-19 pandemic began but did not include that in their current article.

"When we started looking at our data, diabetes and COVID-19 in adults had been relatively well established. To see an increase in type 2 [diabetes] was not so surprising to our group. But we had the sense we were seeing more patients with type 1, and when we looked at our hospital that was very much the case. I think that was a surprise to people," said Kim.

Although a direct effect of SARS-CoV-2 on pancreatic beta cells has been proposed, in both the German[3] and San Diego[1] datasets, the diagnosis of T1D was confirmed with autoantibodies that are typically present years before the onset of clinical symptoms.

The German group[3] suggested possible other explanations for the link, including the lack of immune system exposure to other common pediatric infections during pandemic-necessitated social distancing -- the so-called "hygiene hypothesis" -- as well as the possible role of psychological stress, which several studies have linked to T1D, but as of now, Kim said, "Nobody really knows." 

Is the Effect Direct or Indirect?

Using data from the multicenter German Diabetes Prospective Follow-up Registry, Kamrath and colleagues compared the incidence of T1D in children and adolescents from January 1, 2020 through June 30, 2021 with the incidence in 2011-2019.

During the pandemic period, a total of 5162 youth were newly diagnosed with T1D at 236 German centers. That incidence, 24.4 per 100,000 patient-years, was significantly higher than the 21.2 per 100,000 patient-years expected based on the prior decade, with an incidence rate ratio (IRR) of 1.15 (P < .001). The increase was similar in both male and female youths.

There was a difference by age, however, as the phenomenon appeared to be limited to the pre-adolescent age groups. The IRRs for children aged younger than 6 years and aged 6 to 11 years were 1.23 and 1.18 (both P < .001), respectively, compared with a nonsignificant IRR of 1.06 (P = .13) in youths aged 12 to 17 years.

Compared with the expected monthly incidence, the observed incidence was significantly higher in June 2020 (IRR = 1.43; P = .003), July 2020 (IRR = 1.48; P < 0.001), March 2021 (IRR = 1.29; P = .028), and June 2021 (IRR = 1.39; P = .01).

Among the 3851 patients for whom data on T1D-associated autoantibodies were available, the adjusted rates of autoantibody negativity did not differ from 2018 to 2019 during the entire pandemic period or during the year 2020 or the first half of 2021.

"Therefore, the increase in the incidence of type 1 diabetes in children appears to be due to immune-mediated type 1 diabetes. However, because autoimmunity and progressive beta-cell destruction typically begin long before the clinical diagnosis of type 1 diabetes, we were surprised to see the incidence of type 1 diabetes followed the peak incidence of COVID-19 and also the pandemic containment measures by only approximately 3 months," Kamrath and colleagues wrote.

Taken together, they said, the data suggest that "the impact on type 1 diabetes incidence is not due to infection with SARS-CoV-2, but rather a consequence of environmental changes resulting from the pandemic itself or pandemic containment measures."

Similar Findings at a US Children's Hospital

In the cross-sectional study in San Diego,[1] Gottesman and colleagues looked at the electronic medical records at Rady Children's Hospital for patients aged younger than 19 years with at least 1 positive T1D antibody titer.

During March 19, 2020 to March 18, 2021, a total of 187 children were admitted for new-onset T1D compared with just 119 the previous year: a 57% increase.

From July 2020 through February 2021, the number of new T1D diagnoses significantly exceeded the number expected according to a quarterly moving average of each of the preceding 5 years.

Only 4 of the 187 patients (2.1%) diagnosed during the pandemic period had COVID-19 at the time of presentation. Antibody testing to assess prior infection wasn't feasible, and now that children are receiving the vaccine -- and therefore most will have antibodies -- "we've lost our window of opportunity to look at that question," Kim noted.

As has been previously shown, there was an increase in the percentage of patients presenting with diabetic ketoacidosis during the pandemic compared with the prior 5 years (49.7% vs 40.7% requiring insulin infusion); however, there was no difference in mean age at presentation, body mass index, HbA1c, or percentage requiring admission to intensive care.

Because these data only go through March 2021, Kim noted, "We need to see what's happening with these different variants. We'll have a chance to look in a month or two to see the effects of Omicron on the rates of diabetes in the hospital."

Will CoviDiab Answer the Question?

Data from CoviDiab[2] will include diabetes type in adults and children, registry co-principal investigator Francesco Rubino, MD, of King's College London, United Kingdom, told Medscape Medical News: "We aimed at having as many as possible cases of new-onset diabetes for which we can have also a minimum set of clinical data including type of diabetes and [Hb]A1c. By looking at this information we can infer whether a role of COVID-19 in triggering diabetes is clinically plausible -- or not -- and what type of diabetes is most frequently associated with COVID-19 as this also speaks about mechanisms of action."

Rubino said that the CoviDiab team is approaching the data with the assumption that, at least in adults diagnosed with T2D, the explanation might be that the person already had undiagnosed diabetes or that the hyperglycemia may be stress-induced and temporary.

"We're looking at this question with a skeptical eye... Is it just an association or does the virus have a role in inducing diabetes from scratch, or can the virus advance pathophysiology in a way that it ends up in full-blown diabetes in predisposed individuals?"

Although no single study will prove that SARS-CoV-2 causes diabetes, "combining observations from various studies and approaches we may get a higher degree of certainty," Rubino said, noting that the CoviDiab team plans to publish data from the first 800 cases "soon."

Kim has reported no relevant financial relationships. Rubino has reported receiving grants from Ethicon, Inc. and Medtronic, personal fees from Ethicon, Inc.; GI Dynamics, Inc.; Keyron; Novo Nordisk; and Medtronic, Inc.

Study Highlights

  • Study data was drawn from the German Diabetes Prospective Follow-up Registry.[3] This database contains information on > 90% of children with T1D in Germany.
  • Researchers searched for children and adolescents between ages 6 months and < 18 years who were newly diagnosed with T1D. They compared data from the period of January 1, 2020 through June 30, 2021 with data from 2011 to 2019.
  • The main study outcome was the incidence of T1D in comparing the pre-COVID era with 2020-2021. Researchers also compared characteristics of children diagnosed with T1D during the 2 time periods.
  • There were 5162 incident cases of T1D in the registry during the COVID-19 pandemic: 55.8% of these cases occurred among male youths, and the median age of the cohort was 9.7 years. The median HbA1c level at the time of diagnosis was 11.4%.
  • Between 2011 and 2019, the incidence rate of T1D increased by 2.4% per year. This increase was most pronounced among adolescents between the ages of 12 and 17 years.
  • The observed vs expected incidence rates of T1D during 2020-2021 were 24.4 and 21.2 cases per 100,000 patient-years, respectively, yielding a significant IRR of 1.15 (95% CI: 1.1, 1.2).
  • The increase in T1D cases during the pandemic was most pronounced among children aged < 6 years.
  • The incidence of T1D particularly spiked during summer 2020 and spring 2021, each time approximately 3 months after a surge in COVID-19 cases across Germany.
  • Rates of autoantibody-positive T1D did not differ in 2020-2021 compared with data from 2018 and 2019.

Clinical Implications

  • A new study by Kamrath and colleagues found that the COVID-19 pandemic coincided with a higher incidence of T1D diagnosed among children at a US academic health center. In comparing the pre-COVID periods with 2020-2021, there was no difference in the average age of children with new T1D, mean body mass index, or initial HbA1c level; however, the proportion of children presenting with diabetic ketoacidosis was higher during 2020-2021.
  • Another new study by Gottesman and colleagues found that the IRR for new T1D increased in German children during the COVID-19 pandemic compared with previous years. High rates of incident T1D followed COVID-19 surges by approximately 3 months, and the largest increase in T1D was recorded among children aged < 6 years.
  • Implications for the healthcare team: COVID-19 has not yet been confirmed as a risk factor for T1D, but the current studies suggest more research is needed.


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