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Laura Woerner has diligently managed her type 1 diabetes since she was diagnosed at age 11. She’s remained vigilant about anything that might throw her blood sugar levels out of balance, and now, at 36, she has had two healthy pregnancies and avoided such severe complications of diabetes as limb neuropathy or eye disease.

Woerner knows what she needs to do to maintain her health. What she doesn’t know is why the nation’s leading public health authority places people like her farther down the priority list for receiving Covid-19 vaccination than people with type 2 diabetes.

As written now, the guidelines put her in with the rest of the U.S. population under age 65, despite research showing that people with type 1 diabetes are at just as high a risk of dying from Covid-19 as those with type 2, if not higher.

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“I don’t feel like I’m an apples-to-apples comparison with another healthy 36-year-old because another healthy 36-year-old, if they get a stomach virus, it doesn’t wind them up in the ER, but for me, it always has,” said Woerner, who’s an AP biology teacher in Montgomery Ala., teaching remotely. “There’s a very intricate balance. There’s thousands of decisions made in a day by somebody with type 1 diabetes that could either kill them or keep them healthy.”

Guidelines from the Centers for Disease Control and Preventions released in December rank a person with type 2 diabetes as someone who “is at increased risk” of more severe illness from Covid-19. That means people with that condition will follow health care workers and people living in long-term care settings, getting their vaccines in Phase 1c of the rollout. Data behind that ranking are considered “strongest and most consistent evidence.”

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People with type 1 diabetes are in Phase 2, deemed to be patients who “might be at an increased risk” for severe illness. Data behind that ranking are classified as “limited evidence.”

Type 2 diabetes is more common, affecting 90% to 95% of people with the condition. In type 2, people can’t make enough insulin to convert the glucose their bodies need for fuel, or they grow insensitive to the insulin they do make. In the 1.6 million people in the U.S. with type 1 diabetes, their insulin-producing pancreatic islet cells have been destroyed, meaning they can’t make insulin to process glucose into energy and the sugar accumulates in the blood.

The CDC’s interpretation of risk differs from the decision made by U.K. health officials to include both type 1 and type 2 diabetes in its list of conditions that pose higher risk after Covid-19 infection.

The CDC responded with a statement that reiterates the guidelines and current evidence used to write them. “This list is a living document that will be periodically updated by CDC, and it could rapidly change as the science evolves,” Kristen Nordlund of CDC’s public affairs office wrote Monday. States are free to create their own priority lists, and in Tennessee, for example, people with both types of diabetes are classified together as at higher risk than the general population.

More recent data do exist, the advocacy and research organization JDRF argued in a December letter to the CDC’s Advisory Committee on Immunization Practices, urging the inclusion of both type 1 and type 2 diabetes in the same Phase 1c category for underlying conditions that elevate risk of bad outcomes from Covid-19 infection.

A Lancet Diabetes & Endocrinology study published in August and cited by JDRF mined 61 million medical records from the National Health Service in England to conclude that the risk of dying from Covid-19 was almost three times higher for people with type 1 diabetes and almost twice as high for type 2 than for those without diabetes. In Scotland, another Lancet study said being admitted to a critical-care hospital unit or dying was more than twice as likely for type 1 diabetes patients and nearly 1.5 times more likely for type 2 diabetes patients than for people without diabetes.

In December a study conducted by Vanderbilt University and published in Diabetes Care said people with either type 1 or type 2 diabetes who fall ill with Covid-19 have a three to four times higher risk of severe illness and hospitalization compared to people without diabetes.

And reflecting the disproportionate burden of illness borne by people of color during the pandemic, a January study in the Journal of Clinical Endocrinology & Metabolism revealed racial disparities in the diabetes numbers. Black patients with type 1 diabetes and Covid-19 were almost four times more likely as white patients to develop a serious complication called diabetic ketoacidosis.

“There is new data that warrants the CDC updating the guidelines and putting both type 1 and type 2 diabetes in the category of at risk for severe illness,” Cynthia Rice, chief mission strategy officer at JDRF, told STAT. “Glucose control has been identified as a risk factor from early in the pandemic. People with high blood sugar are at high risk of severe illness with Covid-19.”

Why is glucose control so critical?

People with diabetes aren’t more likely to become infected with Covid-19, but infections of any kind — viral, bacterial, or fungal — hit people with diabetes harder. Their bodies do not process glucose as well during illness, their immune response is weaker, and their circulation is impaired. Over a lifetime, problems with too much or too little glucose inflict widespread damage in the kidney, heart, and liver, as well as around nerves. Stroke, heart attack, kidney failure, eye disease, and limb amputations can follow poor glucose control. Inflammation rises and the immune system does not perform well.

Obesity, which is more common in type 2 diabetes but can also occur in type 1, makes all these conditions worse. Obesity is one of the underlying conditions cited by the CDC as increasing risk for worse outcomes after Covid-19 infection.

Justin Gregory, a pediatric endocrinologist and one of the Vanderbilt study authors, suspects vascular endothelial cells will explain why diabetes patients are more vulnerable to Covid-19. Forming a critical barrier between the blood and the body’s tissues, the cells fine-tune the immune system and regulate factors that cause blood to clot. These cells don’t function as well in people with either type of diabetes, increasing their chances of an exaggerated inflammatory immune response, capillary leakage in the lungs, or blood clotting throughout the body.

“It appears both groups have higher risk for severe outcomes compared with people who do not have diabetes,” Gregory said about the Vanderbilt study, which explored risk but not the biology behind it. “The data so far suggest people with type 1 diabetes have similar to somewhat higher adjusted risks of adverse Covid-19 outcomes compared to people with type 2 diabetes.”

The growing body of evidence suggests the CDC’s assessment needs revision, he said. “As states transition into immunizing individuals with high-risk conditions, I think these recent data make it imperative for health policy makers to prioritize people with type 1 diabetes among other groups with high-risk conditions.”

While states make their own policies, physicians would like latitude to do the same.

Mary-Elizabeth Patti, an adult endocrinologist at Joslin Diabetes Center, has written letters for type 1 diabetes patients asking their employers to allow them to work remotely to limit potential exposure to Covid-19.

“These are tough calls to make on who should go first to get vaccine,” she said. “There should be opportunities for physicians who know their patients to say particular factors affect immunity.”

Meanwhile, Laura Woerner waits at home with her husband — who has type 2 diabetes — and their 1-year-old and 4-year-old children. She’s pursuing a second master’s degree, in biology (her first was in secondary education) and hoping to return to a classroom someday. The CDC guidelines are baffling to her.

“I understand that the evidence is overwhelming for type 2. There’s no denying that, but I’m not really sure why it’s being treated in two different categories because the outcome is the same or even worse,” she said. “Why exclude it?”

It’s not clear when a vaccine will be available to her.

“Maybe they’ll have it at CVS in a month or two and I’ll go in and they’ll say, ‘Do you have any comorbidities?’ and I’ll say, ‘Diabetes.’ I really hope the question isn’t posed, ‘Which kind?’”

 This story has been updated with a response from the CDC.

  • Yeah I just read this story and I agree that this is wrong with people who have diabetes I have it type 2 and my sugar is not in order I have a problem with higher sugars than most people it’s like I have to starve myself to death just to bring my sugar down and I went to a lot of places to see if I could get the vaccine and they turn me away and say that it is not my turn yet I’m like when will it be my turn when I get Covid and die from it and they don’t care they say you don’t fit the age group just wait until they do and i live in a apartment building and I hear people coughing a night and day long I just know that it’s a matter of time that I might get this virus because people don’t wear mask or anything

  • I have type 1 diabetes, very well controlled, not obese, but last January when my husband & I both developed a chest infection within days of each other, I ended up with DKA, as unable to control my blood sugars & he recovered & was ok within 2 weeks. I know how vulnerable diabetics are when faced with respiratory infections & can’t understand why we’re not higher up the priority list for the vaccine!

  • I should be livid after reading this article. I have been a type?1 diabetic for over 65 years since?1955 when I was?2 years old. I am over 65 years old. I have survived viral pneumo is and being put into 6 week long medically induced coma and ARDS 11 years ago. I do not have health insurance, social security or SSI, Medcaid or Medicare. I have no close family members. I have no idea?what the state of Oklahoma would consider me to be. Would being 1/8 Cherokee make?a difference. I have no proof because that great grandmother was never on a reservation and it was common law marriage probably in Colorado before Oklahoma became a state in 1907. I also have no transportation to take me to be tested or get a vaccine. I seem to fall through all the cracks. Fortunately I am too emotionally numb to be livid.

    • Wow! My heart goes out to you ❤️I too have type I and am in healthcare filling in gaps that insurance and providers seem to be missing. Your story breaks my heart!

  • my sister and my mother had been diagnosed with diabetes, my sister type 2 and my mother pre-diabetes. What can we do, about vaccinations?

  • Diabetics are most likely not included in the first rounds of vaccination because they were part of the cohort that was excluded from the phase 3 study, so they have no idea what adverse affects it will cause. It’s the same for any of us with immunocompromised systems, or autoimmune disease. People who had anaphalactic shock to meds or vaccines were also excluded from the study. That’s why they’re scrambling to minimize the media reports of the incidence of anaphylaxis related adverse events.

  • Where is the data to supportthese opinions? How many who’ve died with COVID also had Type 1 or Type 2 Diabetes? How many people had other complications like obesity, poor liver or heart conditions, asthmatic, canncer, etc? As a Type 1 diabetic for 41 of 45 years, this article feels like more fear based and obviously there is more risk due to defeciency than non diabetics but no actual facts have been presented. Saying it is 2 to 3 times more deadly is based on what data? The flu is risky too for diabetics.

  • Even if CDC acknowledges that type 1 Diabetes is at the same risk as type 2, this is still being talked about regarding adults. How about children with type 1 Diabetes which is fairly common among them ? My 8 years old child has been locked up at home since this pandemic started, doing virtual school and I quitted my job to be with him and avoid bringing it home to him and we’re not sure if he’ll ever get the vaccine or not since vaccine isn’t approved for children and meanwhile he’s at high risk !!!!

    • Agree-ALL individuals with type 1 diabetes should be in the first phase regardless of age. And then type 2 with other comorbidities conditions/age. Are there any vaccine studies by you enrolling kids like yours? Maybe that would be a way to get him vaccinated sooner!

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