COVID-19 vaccine prioritisation for type 1 and type 2 diabetes
Authors: Alvin C Powers, David M Aronoff, Robert H Eckel
Journal: The Lancet Diabetes & Endocrinology (2021)

With the availability of SARS-CoV-2/COVID-19 vaccines, a crucial challenge is the prioritisation of groups of individuals to receive vaccines that will be in limited supply for some time.1Rubin EJ Baden LR Barocas JA Morrissey S Audio interview: SARS-CoV-2 vaccination and vulnerable populations.New Engl J Med. 2020; 383: e143Crossref PubMed Scopus (2) Google Scholar Several clinical reports have described greater morbidity and mortality from COVID-19 in people with diabetes, often accompanied by obesity. Most of this information is from individuals with type 2 diabetes, with less known about the risk in type 1 diabetes, a phenotypically distinct disorder. Experts have cautioned against extrapolating from studies of type 2 diabetes to individuals with type 1 diabetes.2DiMeglio LA Albanese-O'Neill A Muñoz CE Maahs DM COVID-19 and children with diabetes—updates, unknowns, and next steps: first, do no extrapolation.Diabetes Care. 2020; 43: 2631-2634Crossref PubMed Scopus (55) Google Scholar In the USA, the Centers for Disease Control and Prevention (CDC) currently categorise type 1 and type 2 diabetes differently in terms of risk for severe illness from COVID-19, with people with type 2 diabetes considered "at increased risk for severe illness" and those with type 1 diabetes categorised as "might be at increased risk".3Dooling K Marin M Wallace M et al.The Advisory Committee on Immunization Practices' updated interim recommendation for allocation of COVID-19 vaccine—United States, Dec 2020.MMWR Morb Mortal Wkly Rep. 2021; 69: 1657-1660Crossref PubMed Google Scholar Importantly, several recent studies4Barron E Bakhai C Kar P et al.Associations of type 1 and type 2 diabetes with COVID-19-related mortality in England: a whole-population study.Lancet Diabetes Endocrinol. 2020; 8: 813-822Summary Full Text Full Text PDF PubMed Scopus (642) Google Scholar, 5Gregory JM Slaughter JC Duffus SH et al.COVID-19 severity is tripled in the diabetes community: a prospective analysis of the pandemic's impact in type 1 and type 2 diabetes.Diabetes Care. 2020; (published online Dec 2.)https://doi.org/10.2337/dc20-2260Crossref Scopus (172) Google Scholar, 6McGurnaghan SJ Weir A Bishop J et al.Risks of and risk factors for COVID-19 disease in people with diabetes: a cohort study of the total population of Scotland.Lancet Diabetes Endocrinol. 2020; (published online Dec 23.)https://doi.org/10.1016/S2213-8587(20)30405-8Summary Full Text Full Text PDF PubMed Scopus (213) Google Scholar have shown that both people with type 2 diabetes and those with type 1 diabetes have an increased vulnerability to serious illness from SARS-CoV-2 compared with people without diabetes. In relative terms, patients with type 1 diabetes and those with type 2 diabetes had similar adjusted odds ratios (ORs) for hospitalisation (3·90 for type 1 diabetes vs 3·36 for type 2 diabetes),5Gregory JM Slaughter JC Duffus SH et al.COVID-19 severity is tripled in the diabetes community: a prospective analysis of the pandemic's impact in type 1 and type 2 diabetes.Diabetes Care. 2020; (published online Dec 2.)https://doi.org/10.2337/dc20-2260Crossref Scopus (172) Google Scholar severity of illness (3·35 vs 3·42),5Gregory JM Slaughter JC Duffus SH et al.COVID-19 severity is tripled in the diabetes community: a prospective analysis of the pandemic's impact in type 1 and type 2 diabetes.Diabetes Care. 2020; (published online Dec 2.)https://doi.org/10.2337/dc20-2260Crossref Scopus (172) Google Scholar and in-hospital mortality (3·51 vs 2·02).4Barron E Bakhai C Kar P et al.Associations of type 1 and type 2 diabetes with COVID-19-related mortality in England: a whole-population study.Lancet Diabetes Endocrinol. 2020; 8: 813-822Summary Full Text Full Text PDF PubMed Scopus (642) Google Scholar In a population-based study in Scotland, the risk of fatal or critical care unit-treated COVID-19 was increased for both diabetes types (OR 2·4 with type 1 diabetes vs 1·4 with type 2 diabetes).6McGurnaghan SJ Weir A Bishop J et al.Risks of and risk factors for COVID-19 disease in people with diabetes: a cohort study of the total population of Scotland.Lancet Diabetes Endocrinol. 2020; (published online Dec 23.)https://doi.org/10.1016/S2213-8587(20)30405-8Summary Full Text Full Text PDF PubMed Scopus (213) Google Scholar Because risk classification and recommendations by the CDC and other health policy makers influence decisions by states and health systems related to vaccine prioritisation, these findings should prompt an immediate revision by the CDC and others of risk assessment, placing individuals with either form of diabetes in the same high-risk category. Such a change in risk categorisation will place the more than 1·6 million people in the USA with type 1 diabetes in the same prioritisation category as those with type 2 diabetes and other high-risk conditions. We call on public health officials and governors throughout the USA, as well as relevant policy makers in other countries, to carefully consider this new information as recommendations for vaccine prioritisation are developed. RHE was the 2020 President of Medicine & Science of the American Diabetes Association. He declares personal fees from Novo Nordisk, Provention Bio, and Kaleido. The other authors declare no competing interests.