key: cord-0736515-rnedx2j8 authors: Wolf, Risa M.; Noor, Nudrat; Izquierdo, Roberto; Jett, Destiny; Rewers, Amanda; Majidi, Shideh; Sheanon, Nicole; Breidbart, Emily; Demeterco‐Berggren, Carla; Lee, Joyce M.; Kamboj, Manmohan K.; Ebekozien, Osagie title: Increase in newly diagnosed type 1 diabetes in youth during the COVID‐19 pandemic in the United States: A multi‐center analysis date: 2022-03-16 journal: Pediatr Diabetes DOI: 10.1111/pedi.13328 sha: f9c8d77dd1bec0850f1f0e2b9c9184d3f45756fb doc_id: 736515 cord_uid: rnedx2j8 BACKGROUND: An increase in newly diagnosed type 1 diabetes (T1D) has been posited during the COVID‐19 pandemic, but data are conflicting. We aimed to determine trends in newly diagnosed T1D and severity of presentation at diagnosis for pediatric and adolescent patients during COVID‐19 (2020) as compared to the previous year (2019) in a multi‐center analysis across the United States. METHODS: This retrospective study from seven centers in the T1D Exchange Quality Improvement Collaborative (T1DX‐QI) included data on new onset T1D diagnosis and proportion in DKA at diagnosis from January 1 to December 31, 2020, compared to the prior year. Chi‐square tests were used to compare differences in patient characteristics during the pandemic period compared to the prior year. RESULTS: Across seven sites, there were 1399 newly diagnosed T1D patients in 2020, compared to 1277 in 2019 (p = 0.007). A greater proportion of newly diagnosed patients presented in DKA in 2020 compared to 2019 (599/1399(42.8%) vs. 493/1277(38.6%), p = 0.02), with a higher proportion presenting with severe DKA (p = 0.01) as characterized by a pH <7.1 and/or bicarbonate of <5 mmol/L. Monthly data trends demonstrated a higher number of new T1D diagnoses over the spring and summer months (March to September) of 2020 compared to 2019 (p < 0.001). CONCLUSIONS: We found an increase in newly diagnosed T1D and a greater proportion presenting in DKA at diagnosis during the COVID‐19 pandemic compared to the prior year. Future longitudinal studies are needed to confirm these findings with population level data and determine the long‐term impact of COVID‐19 on diabetes trends. p = 0.02), with a higher proportion presenting with severe DKA (p = 0.01) as characterized by a pH <7.1 and/or bicarbonate of <5 mmol/L. Monthly data trends demonstrated a higher number of new T1D diagnoses over the spring and summer months (March to September) of 2020 compared to 2019 (p < 0.001). We found an increase in newly diagnosed T1D and a greater proportion presenting in DKA at diagnosis during the COVID-19 pandemic compared to the prior year. Future longitudinal studies are needed to confirm these findings with population level data and determine the long-term impact of COVID-19 on diabetes trends. 3, 4 Historically, viruses have been associated with acute-onset diabetes, including SARS coronavirus 1 pneumonia, but the relationship between the current COVID-19 pandemic and newly diagnosed type 1 diabetes (T1D) remains uncertain, particularly in the pediatric population. 3, 4 As lockdowns ensued around the world during the first wave of the COVID-19 pandemic, early reports suggested that individuals were avoiding hospitals and medical care, leading to increased severity of illness at presentation. 5, 6 Data from Germany, Italy, and the United States demonstrated an increase in diabetic ketoacidosis (DKA) incidence at the presentation of newly diagnosed T1D in children and adolescents, suggesting delays in seeking medical care. [7] [8] [9] Further, the T1D Exchange showed that in patients with existing T1D, the most common adverse outcome associated with concurrent COVID-19 infection was DKA, and this was more prevalent in non Hispanic (NH) and Hispanic individuals than N.H. Whites. [10] [11] [12] An increase in newly diagnosed T1D has been posited during the COVID-19 pandemic. However, published reports have shown conflicting findings, with some reports suggesting an increase in newly diagnosed T1D in children and adolescents, [13] [14] [15] and others showing no change in expected or actual numbers of newly diagnosed T1D. 16, 17 Our objective for this study was to describe trends in newly diagnosed T1D, as well as the severity of presentation at diagnosis during COVID-19 compared to the prior year using data from seven large U.S. clinical centers. This retrospective, multi-center study was conducted as part of the T1DX-QI project, a collaborative quality improvement platform engaging over 40 diabetes clinics in the United States evaluating the current state of diabetes care and sharing data and best practices to improve care delivery in type 1 diabetes. [18] [19] [20] guidelines were used to define DKA severity: mild DKA was categorized at presentation with pH <7.3 and/or bicarbonate <15 mmol/L, moderate DKA (pH <7.2, and/or bicarbonate <10 mmol/L), and severe DKA (pH <7.1, and/or bicarbonate <5 mmol/L). 21 Descriptive statistics were used to summarize data. Because centers reported categorical age data, the midpoint coding method was used to calculate mean and standard deviation. Chi-square tests were used to compare differences in patient characteristics during the pandemic period compared to the pre-pandemic comparison group. All analysis was performed using R version 2.4.1. Seven sites contributed longitudinal data for this cross-sectional analysis assessing trends in newly diagnosed T1D. There was a total of 17,749 and 17,597 T1D patients seen as outpatients at these centers in 2019 and 2020, respectively. As shown in Table 1 were independently analyzed and are provided in the Supplement. showed that 6 out of the 7 contributing sites had an increase in incidence during this period (3 of 6 had a statistically significant increase), while one site had a statistically significant decrease in incidence. (Figures S1-S7 ). Our analysis presents the largest multi-center study of longitudinal trends of newly diagnosed T1D in the United States during the COVID-19 pandemic. These sites represented U.S. hospitals in the Northeast, Midwest, and West. In 2020, there was a significant increase in newly diagnosed T1D patients compared to the prior year. There was also an increase in patients with newly diagnosed T1D presenting in DKA during COVID-19 compared to the same period for the previous year, possibly representing delayed care due to lockdowns and deferred primary care. [7] [8] [9] Initial reports suggested an increase in newly diagnosed T1D during There was a decrease in non-Hispanic white youth with newly diagnosed T1D in 2020 compared to 2019. This is similar to recent SEARCH data suggesting that the incidence of T1D is increasing in Hispanic youth more significantly than non-Hispanic white youth and that minority populations will likely represent a larger burden of diabetes in the future. 24 Seasonal variation in the diagnosis of type 1 diabetes has previously been described, with more children being diagnosed between the months of December and February. 29 While 2019 data followed these typical trends, there were fewer newly diagnosed T1D in our cohort in January through April of 2020, suggesting that the COVID-19 pandemic upended typical temporal trends in T1D diagnosis. It is possible that some of the newly diagnosed patients would have been diagnosed sooner and have avoided DKA if not for "stay-at-home" orders, limited access and hesitance to seek preventive care during the initial wave of the pandemic. Further, there were regional differences in COVID-19 waves and pandemic lockdowns, which likely accounts for the site-tosite variation in incidence of new onset T1D. 30 Osagie Ebekozien conceived of the study. All authors collected the data. Nudrat Noor analyzed the data. Risa M. Wolf wrote the manuscript. All authors reviewed, edited, and approved the final version of the manuscript. Osagie Ebekozien, Nudrat Noor had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. The peer review history for this article is available at https://publons. com/publon/10.1111/pedi.13328. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. COVID-19 in people with diabetes: understanding the reasons for worse outcomes Associations of type 1 and type 2 diabetes with COVID-19-related mortality in England: a wholepopulation study New-onset diabetes in Covid-19 Binding of SARS coronavirus to its receptor damages islets and causes acute diabetes Delayed access or provision of care in Italy resulting from fear of COVID-19 Pediatrician, watch out for corona-phobia Increased DKA at presentation among newly diagnosed type 1 diabetes patients with or without COVID-19: data from a multi-site surveillance registry Ketoacidosis in children and adolescents with newly diagnosed type 1 diabetes during the COVID-19 pandemic in Germany Has COVID-19 delayed the diagnosis and worsened the presentation of type 1 diabetes in children? Diabetes Care Diabetic ketoacidosis drives COVID-19 related hospitalizations in children with type 1 diabetes Inequities in diabetic ketoacidosis among patients with type 1 diabetes and COVID-19: data from 52 US clinical centers Type 1 diabetes and COVID-19: preliminary findings from a multicenter surveillance study in the U New-onset type 1 diabetes in children during COVID-19: multicenter regional findings in the U.K. Diabetes Care Increase in the diagnosis and severity of presentation of pediatric type 1 and type 2 diabetes during the COVID-19 pandemic Risk for new diagnosed diabetes >30days after SARS-CoV-2 infection among persons ages <18years -United States Frequency of autoantibodynegative type 1 diabetes in children, adolescents, and young adults during the first wave of the COVID-19 pandemic in Germany. Diabetes Care Did the COVID-19 lockdown affect the incidence of pediatric type 1 diabetes in Germany? Diabetes Care Establishment of the T1D exchange quality improvement collaborative (T1DX-QI) The T1D exchange clinic registry T1D exchange quality improvement collaborative: accelerating change through benchmarking and improvement science for people with type 1 diabetes ISPAD clinical practice consensus guidelines 2018: diabetic ketoacidosis and the hyperglycemic hyperosmolar state Diabetic ketoacidosis at diagnosis of type 1 diabetes in Colorado children Temporal trends in diabetic ketoacidosis at diagnosis of paediatric type 1 diabetes between 2006 and 2016: results from 13 countries in three continents Incidence trends of type 1 and type 2 diabetes among youths Increase in prevalence of diabetic ketoacidosis at diagnosis among youth with type 1 diabetes: the SEARCH for diabetes in youth study Diabetic ketoacidosis at diagnosis of type 1 diabetes and glycemic control over time: the SEA-RCH for diabetes in youth study Diabetes and COVID-19: risks, management, and learnings from other national disasters COVID-19 and racial/ethnic disparities Trends and cyclical variation in the incidence of childhood type 1 diabetes in 26 European centres in the 25 year period 1989-2013: a multicentre prospective registration study Incidence of COVID-19 and risk of diabetic ketoacidosis in new-onset type 1 diabetes. Pediatrics Enterovirus persistence as a mechanism in the pathogenesis of type 1 diabetes Viral trigger for type 1 diabetes: pros and cons Detection of a low-grade enteroviral infection in the islets of langerhans of living patients newly diagnosed with type 1 diabetes Enterovirus infection and type 1 diabetes mellitus: systematic review and meta-analysis of observational molecular studies Changes in influenza and other respiratory virus activity during the COVID-19 pandemic -United States National norovirus and rotavirus bulletin week 51: data to week 49 Additional supporting information may be found in the online version of the article at the publisher's website.