Why COVID-19 is killing U.S. diabetes patients at alarming rates
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[July 24, 2020]
By Chad Terhune, Deborah J. Nelson and Robin Respaut
(Reuters) - Devon Brumfield could hear her
father gasping for breath on the phone.
Darrell Cager Sr., 64, had diabetes. So his youngest daughter urged him
to seek care. The next day, he collapsed and died in his New Orleans
home.
The daughter soon learned the cause: acute respiratory distress from
COVID-19. His death certificate noted diabetes as an underlying
condition. Brumfield, who lives in Texas and also has type 2 diabetes,
is “terrified” she could be next.
“I'm thinking, Lord, this could happen to me,” she said of her father's
death in late March.
She has good reason to fear. As U.S. outbreaks surge, a new government
study shows that nearly 40% of people who have died with COVID-19 had
diabetes.
Among deaths of those under 65, half had the chronic condition. The U.S.
Centers for Disease Control and Prevention analyzed more than 10,000
deaths in 15 states and New York City from February to May.
Jonathan Wortham, a CDC epidemiologist who led the study, called the
findings “extremely striking,” with serious implications for those with
diabetes and their loved ones.
A separate Reuters survey of states found a similarly high rate of
diabetes among people dying from COVID-19 in 12 states and the District
of Columbia.
Ten states, including California, Arizona and Michigan, said they
weren’t yet reporting diabetes and other underlying conditions, and the
rest did not respond - rendering an incomplete picture for policymakers
and clinicians struggling to protect those most at-risk.
America’s mortality rates from diabetes have been climbing since 2009
and exceed most other industrialized nations. Blacks and Latinos suffer
from diabetes at higher rates than whites and have disproportionately
suffered from COVID-19.
“Diabetes was already a slow-moving pandemic. Now COVID-19 has crashed
through like a fast-moving wave,” said Elbert Huang, a professor of
medicine and director of the University of Chicago’s Center for Chronic
Disease Research and Policy.
Keeping diabetes under control - among the best defenses against
COVID-19 - has become difficult as the pandemic disrupts medical care,
exercise and healthy eating routines.
The high price of insulin has also forced some people to keep working -
risking virus exposure - to afford the essential medicine. And as the
country grapples with an economic crisis, millions of Americans have
lost their jobs and their employer-sponsored health insurance.
Much of this could have been anticipated and addressed with a more
comprehensive, national response, said A. Enrique Caballero, a Harvard
Medical School endocrinologist and diabetes researcher.
Top health officials should have done more to emphasize the threat to
people with diabetes and assuage their fears of hospital visits, he
said, while also focusing more on helping patients manage their
condition at home.
Policymakers had ample warning that COVID-19 posed a high risk for
diabetes patients. In 2003, during the coronavirus outbreak known as
SARS, or Severe Acute Respiratory Syndrome, more than 20% of people who
died had diabetes.
In 2009, during the H1N1 flu pandemic, patients with diabetes faced
triple the risk of hospitalization.
Most recently in 2012, when the coronavirus Middle East Respiratory
Syndrome, or MERS, emerged, one study found 60% of patients who entered
intensive care or died had diabetes.
The COVID-19 pandemic, however, has unearthed previously unknown
complications because it has lasted longer and infected many more people
than earlier coronavirus epidemics, said Charles S. Dela Cruz, a Yale
University physician-scientist and Director of the Center of Pulmonary
Infection Research and Treatment.
Doctors warn that the coronavirus pandemic may indirectly lead to a
spike in diabetes-related complications - more emergency-room visits,
amputations, vision loss, kidney disease and dialysis.
“My fear is we will see a tsunami of problems once this is over,” said
Andrew Boulton, president of the International Diabetes Federation and a
medical professor at the University of Manchester in England.
‘ONE BIG PUZZLE’
Researchers have scrambled for months to unravel the connections between
diabetes and the coronavirus, uncovering an array of vulnerabilities.
The virus targets the heart, lung and kidneys, organs already weakened
in many diabetes patients. COVID-19 also kills more people who are
elderly, obese or have high blood pressure, many of whom also have
diabetes, studies show.
On the microscopic level, high glucose and lipid counts in diabetes
patients can trigger a “cytokine storm,” when the immune system
overreacts, attacking the body. Damaged endothelial cells, which provide
a protective lining in blood vessels, can lead to inflammation as white
blood cells rush to attack the virus and may cause lethal clots to form,
emerging research suggests.
“It’s all one big puzzle,” said Yale’s Dela Cruz. “It’s all
interrelated.”
Many of their vulnerabilities can be traced to high blood sugar, which
can weaken the immune system or damage vital organs. COVID-19 appears
not only to thrive in a high-sugar environment but to exacerbate it.
Recent evidence suggests the virus may trigger new cases of diabetes.
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Devon Brumfield holds a photo of her father Darrell Cager Sr., who
died on March 31 from complications of the coronavirus disease
(COVID-19), in this undated handout image. Devon Brumfield/Handout
via REUTERS
David Thrasher, a pulmonologist in Montgomery, Alabama, said up to
half of COVID-19 patients in his local hospital ICU have diabetes.
“They are often my most challenging patients,” he said, and the
immune system response may be a big reason why.
‘DIABETES BELT’
The pandemic has ripped through several southern states with some of
the nation’s highest diabetes rates. A Reuters examination of state
data found that nearly 40% of COVID-19 deaths were people with
diabetes in Alabama, Louisiana, Mississippi, North Carolina, South
Carolina and West Virginia. Much of this area lies within what the
CDC calls the “diabetes belt.”
Alabama has the highest percentage of adults with diabetes at 13.2%,
or more than 550,000 people, CDC data show. Diabetes patients
accounted for 38% of the state’s COVID-related deaths through June,
officials said. Karen Landers, Alabama’s assistant state health
officer, said she is particularly heartbroken at the deaths of
diabetes patients in their 30s and 40s.
Medical professionals in these states say they struggle to keep
patients’ diabetes under control when regular in-person appointments
are canceled or limited because of the pandemic.
Sarah Hunter Frazer, a nurse practitioner at the Medical Outreach
Ministries clinic for low-income residents in Montgomery, Alabama,
said diabetes is common among her COVID-19 patients. With clinic
visits on hold, she stays in touch by phone or video chat. If a
problem persists, she insists on an outdoors, face-to-face meeting.
“We meet them under a shade tree behind the clinic,” Frazer said.
In similar fashion, doctors at the University of North Carolina
stepped up their use of telemedicine to reach at-risk rural
patients. Despite those efforts, John Buse, a physician and director
of the university’s diabetes center, said he’s certain some foot
ulcers and dangerously high blood sugars are being missed because
people avoid health facilities for fear of the virus.
‘UNDER CONTROL’
Many diabetes patients with severe or deadly cases of COVID-19 were
in good health before contracting the virus.
Clark Osojnicki, 56, of Stillwater, Minnesota, had heard early
warnings about the risks of the coronavirus for people with
diabetes, said his wife, Kris Osojnicki. But the couple didn’t think
the admonitions applied to him because his glucose levels were in a
healthy range.
“He was incredibly active,” she said.
On a Sunday in mid-March, Osojnicki jogged alongside his border
collie, Sonic, on an agility course for dogs inside a suburban
Minneapolis gym. Three days later, Osojnicki developed a fever, then
body aches, a cough and shortness of breath. He was soon in the
hospital, on a ventilator. Clark, a financial systems analyst, died
April 6 from a blood clot in the lungs.
Osojnicki is among 255 recorded deaths in Minnesota of people with
COVID-19 and diabetes mentioned on their death certificate as of
mid-July, according to state data. The records describe people who
died as young as 34.
WORKING FOR INSULIN
For years, the skyrocketing cost of insulin has fueled much of the
national outrage over drug prices. Early in the pandemic, the
American Diabetes Association asked states to eliminate
out-of-pocket costs for insulin and other glucose-lowering
medications through state-regulated insurance plans.
But no state has fully followed that advice, the ADA said. Vermont
suspended deductibles for preventive medications, like insulin,
starting in July. Other states ordered insurers to make prescription
refills more available but didn’t address cost.
Robert Washington, 68, knew his diabetes put him at risk from
COVID-19. When his employer, Gila River’s Lone Butte Casino in
Chandler, Arizona, reopened in May, he decided to keep working as a
security guard so he could afford insulin.
Washington’s supervisors had assured him he could patrol alone in a
golf cart, said his daughter, Lina. But once back at work, he was
stationed at the entrance, where long lines of gamblers waited, most
without masks, Robert told his daughter.
“He was terrified at what he saw,” Lina said.
He tested positive for the virus in late May and was admitted to the
hospital days later. He died from complications of COVID-19 on June
11, his daughter said.
A week after Washington’s death, the casino again closed as COVID-19
cases exploded in the state. The casino did not respond to a request
for comment.
“It’s hard to accept he is gone. I have to stop myself from wanting
to call him,” said Lina, a sports anchor and reporter at a
Sacramento, California, TV station. “A lot of these deaths were in
some way preventable.”
(Reporting by Chad Terhune, Deborah J. Nelson and Robin Respaut;
Editing by Brian Thevenot)
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