key: cord-309799-fhkbcp7z authors: Hwang, Yerin; Khasag, Altaisaikhan; Jia, Weiping; Jenkins, Alicia; Huang, Chien-Ning; Yabe, Daisuke; Kim, Doo-Man; Kadowaki, Takashi; Lee, Moon-Kyu title: Diabetes and COVID-19: IDF perspective in the Western Pacific Region date: 2020-06-25 journal: Diabetes Res Clin Pract DOI: 10.1016/j.diabres.2020.108278 sha: doc_id: 309799 cord_uid: fhkbcp7z Abstract The World Health Organization (WHO) declared a pandemic, the highest risk level in the infectious disease alert phase, on 11 March 2020. In the Western Pacific Region (WPR), 192,016 confirmed cases with 7,125 deaths had been reported as of 8 June 2020. In people with diabetes COVID-19 can be more difficult to treat due to the wide fluctuations in blood glucose levels or presence of comorbidities such as diabetes complications, including cardiovascular disease and renal damage, which are recognized risks for adverse outcomes. National diabetes associations and governments have established guidelines for subjects with diabetes in relation to COVID-19, and are trying to supply emergency and their regularly required medical products for them. The WPR is so large and composed of such diverse countries and COVID-19 situations, no one conclusion or program applies. Instead we could see a diverse COVID-19 pandemic profile in the WPR, and several creative diagnostic and therapeutic measures undertaken. This includes drive-through screening facilities, high-speed RT-PCR technologies, convalescent patients’ plasma therapy, which potentially had some positive contributions in combatting COVID-19 in the WPR as well as globally. Although the numbers of confirmed cases are currently decreasing in the region, the COVID-19 pandemic is not over, and many experts are recommending to prepare measures for potential second or third waves of COVID-19. In January 2020, a novel coronavirus (2019-nCoV, COVID-19) from a cluster of pneumonia cases of unknown etiology was discovered in Wuhan, China 1 In people with diabetes COVID-19 can be more difficult to treat due to wide fluctuations in blood glucose levels or presence of comorbidities such as acute and chronic diabetes complications, including CVD and renal disease, which even in the general population with COVID-19 are recognized risk factors for poor outcomes, including death 2,3,4,5 . To mitigate COVID-19 infection and poor outcomes many national diabetes associations and governments have established COVID-19 guidelines for subjects with diabetes, and are trying to supply the emergency and routinely required medical products for them. The following is a summary of the current situation of each country in the Western Pacific Region related to COVID-19. Western Pacific Region (WPR) 1) Australia -In Australia, as at June 9 2020, there have been 7,265 positive cases and 102 5 deaths. The first COVID-19 positive case in Australia was confirmed on January 25 th 2020 in a person returning from Wuhan China. This was followed by a lag phase with a doubling of positive cases approximately every 7-10 days. However, by March 21 st 2020, when COVID-19 positive cases in Australia exceeded 1,000 with 7 deaths, Australia was clearly on the exponential part of the curve 6 . With introduced measures the number of new cases has substantially reduced since mid-April. Since early May, 2020 daily testing nationally has ranged between 23,015 and 36,867 tests. Details regarding diabetes status are not yet available. Health personnel availability and support 8 -Reconfiguring wards-expanding or establishing new ICUs, with separate facilities for those with and without COVID-19: At no stage has there been a lack of ventilator facilities. -Setting up separate inpatient COVID-19 screening "hot" wards that were separate from "cold" wards -Setting up special "fever" clinics, initially attached to a hospital but separate from other services, particularly emergency departments -Novel screening pathways with initially more than less restrictive criteria for screening: an on-line self-registration and self-screening tool, drive-through screening and rapid throughput screening, to allow hospital workers with mild symptoms to be screened and get back to work in 24 hours -Securing adequate personal protective equipment (PPE), including from pre-existing national medical resources stockpiles and providing training on specialized techniques for urgent/safe gowning up -Suspension of non-urgent surgery and procedures in both public and private hospitals with graded reintroduction -Arrangements between State governments and private hospitals for the latter to take COVID and non-COVID patients, if and when required -Upskilling and education of appropriate staff in best practice in procedures such as intubation to minimize risk to health professionals -Call-up of, and short-term registration of, recently retired healthcare professionals and senior medical students -Limitation or suspension of face-face non-urgent medical ambulatory or outpatient services (including outpatient adult and pediatric endocrinology/diabetes services), with a provision of telehealth services that would prevent emergency department presentations/admissions. Newly diagnosed Type 1 diabetes patients were often still seen. -Contact tracing those exposed to a person diagnosed with COVID-19, and planning, and subsequently implementing the COVIDSafe contact tracing app -Fast-tracking of approval and implementation of COVID-19 related research studies, with additional specific funding being made available by our national research funding agencies -Implementing telephone/telehealth consultations for most endocrinology/diabetes services (including pediatric endocrinology) -The provision of inpatient diabetes education and medical review by telephone where possible for patients admitted with COVID-19 to reduce exposure to essential diabetes staff 6, 8 2) Chinese Mainland -China's goal in its medical response to Covid-19 has been to improve the patient admission and cure rates and reduce the infection and fatality rates. A conditionspecific and category-based approach was applied to medical treatment of patients. Pooling premium resources to treat severe cases. By directing resources to Wuhan, China expanded the capacity of designated hospitals to deal with severe cases and increased the number of beds. Two hospitals with 1,000-plus beds each -Huoshenshan and Leishenshanwere built as specialist hospitals for treating infectious diseases, and a number of designated and general hospitals were expanded or remodeled. The number of beds for severe cases quickly increased from around 1,000 to more than 9,100. Early intervention for patients with mild symptoms. China has been quick to have patients with mild symptoms admitted to designated medical facilities for early medical intervention, and has done its best to prevent mild cases from worsening. The national clinical treatment network has been expanded to include more than 10,000 hospitals dedicated to the treatment of Covid-19 patients. A national network of medical treatment coordination has also been formed to provide technical support through online consultation. In Wuhan, faced with surging infections and considering that 80 percent of cases were mild, the city government mobilized resources to repurpose stadiums and exhibition centers into 16 temporary treatment centers. With some 14,000 beds, these centers were able to admit all confirmed mild cases for treatment. The 16 treatment centers received a total of more than 12,000 patients; 8,000 and more were cured and discharged; and more than 3,500 were transferred to hospitals. Temporary treatment centers, or Fangcang shelter hospitals, are a major innovative solution that provided enough beds to admit all confirmed cases, thus turning the tide in the battle against Covid-19. Based on scientific knowledge and accumulated evidence, research results and the diagnostic and therapeutic regimens that proved effective were incorporated in the national diagnosis and treatment plans. These include seven versions of the diagnosis and treatment protocol, three editions of the protocol for severe and critical cases, two editions of the manual for mild case management, two editions of convalescent plasma therapy treatment protocol, and one rehabilitation treatment program for patients discharged from hospitals 7 . 3) Japan -Since early April 2020 with the sharp increase in the number of COVID-19 cases, the health care systems in Japan has barely evaded collapse by ramping up the number of hospital beds dedicated to those with the disease (more than 12,000 beds nationwide) as well as by reallocating medical resources. That has accompanied postponing significant numbers of elective procedures and outpatient clinic visits. As of May 26th, 2020, there are 13,384 total dedicated beds for COVID-19 in facilities, and 1,942 mechanical ventilators. Korea have been making tremendous efforts to prevent the spread of the virus. As many as 74 hospitals have been designated as hospitals dedicated to COVID-19 and over 7,500 beds in total have been made operative in preparation for a surge in cases. As the number of confirmed cases decrease, there was a stage-by-stage bed reduction to ultimately operate 1,500-2,300 beds, viewed as the lower limit for emergencies. Aside from public hospitals, private medical centers are serving as main centers of treating patients with COVID-19. In addition, 3,729 medical staff were additionally allocated to support the hospitals, screening and treatment facilities. Specifically, the Korean government newly recruited and stationed 750 public health doctors and 96 army doctors, while continuing to recruit nurses. Most of them were dispatched to Daegu and Gyeongsangbuk-do, which is the major epidemic region in Korea. Work was done to strengthen the monitoring and online reporting of cases identified at fever clinics of medical facilities. All such cases had to be reported online to higher authorities within 2 hours; their test results sent back to the reporting clinics within 12 hours; and on-site epidemiological investigation completed within 24 hours -so that confirmed cases and asymptomatic carriers would be identified and reported without delay. As of May 31, a total of more than 740,000 close contacts had been traced and handled as appropriate. Providing free treatment for patients. Government funds for Covid-19 control were made available in advance to ensure that patients could receive timely treatment and local authorities could proceed smoothly with measures for medical treatment and epidemic control. 2) Chinese Mainland -All Covid-19 patients, including those with diabetes, received subsidies from state finance for any medical bills not covered by basic medical insurance, serious disease insurance, or the medical assistance fund. These also cover the diabetic medication, including insulin support for patients. Besides, urban and rural residents, 3) Hong Kong -Initially some patients with diabetes mellitus, they may have difficulty in sourcing alcohol swab, posing a challenge especially for those requiring insulin injections, in the initial period of COVID-19 outbreak. However, the supply of disinfectant products was stabilized in a reasonable time frame. 4) Japan -Although reduced, visits to clinics, hospitals, and pharmacies by those with diabetes had not been restricted in Japan. Likewise, distribution logistics in general has been constrained but maintained especially for medical supplies. Although some hospitals and clinics reported a shortage of alcohol swabs used for insulin injections and/or finger-pricking for blood glucose testing, no major incidence of shortage has been reported for medical supplies for those with diabetes including insulin. This is partly aided by temporary lifting of restrictions on telemedicine, which had been only limitedly covered by Japan's national care insurance. Now, willing medical providers are able to send prescriptions and medical supplies to their patients by consulting over communication tools such as phone and video conference. Continuity of medical care is relatively maintained by those means, but not ideally. For example, some diabetes specialists show concerns on patients' limited access to diabetes self-care education and support, which potentially deteriorates their glycemic control. We have some problems of insulin supply because borders are closed. The supply of insulin in Taiwan is sufficient to cope with both emergency demand and usual care. Perspectives in managing the pandemic in the country 1) Australia -It is recognized that that people with diabetes are at greater risk of serious outcomes during pandemics such as COVID-19 than people without diabetes. It is anticipated that effective management of blood glucose in people with diabetes and COVID-19 may lead to better outcomes and lower mortality rates. Whether the resources that have been developed and measures that have been implemented have had a positive effect on the health of people with diabetes is not yet known. Feedback from people with diabetes and health professionals has been positive and supportive of the proactive approach to this unprecedented pandemic. Australian healthcare professionals and researchers are also proactive in proposing and participating in national and international COVID-19 related research 6, 8 . China has made vigorous efforts to resume work and reopen schools. Since diabetic individuals might be susceptible to COVID-19 infection, the following principles for COVID-19 patients with comorbid diabetes were put forward by the Chinese Diabetes Society (CDS). For inpatients, blood glucose target should be individualized to minimize the risk for hypoglycemia after a careful evaluation. For out-patients, self-management of blood glucose and following doctors' advice are suggested 7 . 3) Hong Kong -Outdoor activities have been restricted for all, which may have a negative impact on exercise. Yet, people have cut down on dining as well, which may mean a healthier diet. Although the widespread lockdown seen in many other countries has not been implemented in Japan, a nationwide state of emergency was declared by the Japanese government in the middle of April 2020. This resulted in significant reduction of social and commercial activities in many sectors and it appeared that Japan may have passed the current apex of infection rate as of early May. It is, however, difficult to predict whether this pandemic will end soon in Japan and we are still undecided when and how to ease social and economic restrictions. The current transmission classification in the Philippines is identified as 22 clusters of cases with evidence of community transmission in highly urbanized areas (National Capital Region (NCR), Cebu and Davao). In spite of continued enhanced community quarantine in most affected regions in the country, several barangays (districts) are reporting a large increase in cases, resulting in local authorities to issue total lockdowns in these areas. Over 7,000 COVID-19 tests per day are being conducted by 23 accredited laboratories throughout the country using PCR tests. No rapid antibody test kit has as yet been validated by the WHO or DOH, so is not in use. and Korean government are especially cautious when caring for patients who are vulnerable to this viral disease. Subjects with diabetes are one of the top prioritized groups over any other chronic disease. The KDA have announced recommendations for people with in this COVID-19 outbreak. We will continue to do our best to prevent the spread COVID-19 in Korea and minimize deaths and complications related with COVID-19. Taiwan -There have been no indigenous cases of COVID-19 since April 22, 2020, and the Central Epidemic Command Center (CECC) in Taiwan will continue active surveillance and border control programs to prevent future outbreaks. Meanwhile, the academic facilities in Taiwan continue their work on improving laboratory diagnostic capacities, development of rapid testing, vaccination and antiviral agents. Although the risk of community transmission of COVID-19 in Taiwan is very low, the pandemic has changed Taiwanese ways of living and medical-seeking behaviors. How to track and educate patients with diabetes in Taiwan, as well as providing necessary medical support and diet consultations has become challenging. We will develop individualized online education programs, and promote efficient data sharing 23 between healthcare providers and patients via a National Health Insurance (NHI) MediCloud system. The WPR is so large and composed of such diverse countries and COVID-19 situations, no one conclusion can be developed. We see such diverse COVID-19 pandemic profiles in the WPR, and several creative diagnostic and therapeutic measures have been implemented, such as drive-through screening facilities, high-speed RT-PCR testing technologies, convalescent patients' plasma therapy (which seems to show some benefit in the WPR and globally). Although the numbers of confirmed cases are decreasing in the region, the war against the COVID-19 pandemic is not over, and many experts are recommending to prepare measures for potential second or third waves of the COVID-19 pandemic and for pandemics of other infectious agents in the future. A spirit of co-operation and knowledge sharing between countries and organizations is key to reduce the negative consequences of such infectious agents. World Health Organization, WHO Western Pacific Regional Action Plan for Response to Large-Scale Community Outbreaks of COVID-19 COVID-19 pandemic, coronaviruses, and diabetes mellitus Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study Clinical characteristics of 140 patients infected with SARS-CoV-2 in Wuhan, China Prevalence of comorbidities and its effects in patients infected with SARS-CoV-2: a systematic review and meta-analysis The Australian response to the COVID-19 pandemic and diabetes -lessons learned Fighting Covid-19 China in Action" released by The State Council Information Office 26 ofthe People's Republic of China COVID-19, Type 1 Diabetes Clinical Practice, Research, and Remote Medical Care: A View From the Land Down-Under Management suggestions for patients with diabetes and novel coronavirus pneumonia The authors declare no conflict of interest. The authors received no funding from an external source.