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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.

  • Count your lucky stars. In some countries prisoners are getting vaccinated even before health care workers.

  • Everyone ought to respect that there are several other pre-existing conditions that have a grim bearing on Covid outcomes: heart diseases, lung diseases, kidney diseases etc etc. It is therefore presumptuous to single out just one condition (T1D) for jumping the vaccination line. Stay home, stay safe, await your turn – you are just one category of among the many others where the afflicted are predisposed to a bad Covid outcome.

    • I get the concern and desire to get vaccinated, but what does not seem to being said is that a possible reason for the difference between strategies in the US and the UK likely has to do with the litigious nature of our country. The NHS (UK’s health system) has made several different decisions such as using a mixture of vaccines because they ran out of one or the other and floating the idea that you could just get one dose of the two dose medication in order to vaccinate everyone.

      The fact of the matter is that the CDC doesn’t know what the vaccine will do to diabetics because studies are still ongoing. The finished studies have been done on healthy people. I was cautioned against getting the vaccine by the hospital I work in, but my own doctor thought it was riskier for me to get Covid than to get the vaccine. I now have two lesions on my hand and one on my toe that no one knows what they are and I am supposed to go have them biopsied. Be patient, we don’t know if it might be harmful to you to get the vaccine.

  • I also am a Type one diabetic of 57+ years I don’t understand that about tape to getting it for us I am 63 years old and I am afraid of dying where can I get the shot I live in Rhode Island. Cathy

  • This is terrible. My 18 year old niece has type 1 diabetes. She is terrified to go anywhere. She has been holed up in her parent’s home since this started. She has almost died twice from other illnesses. I can’t Believe this is not a priority!

  • The ACIP prioritization queue is simply the latest demonstration of decision-making by our most important health agencies. Having the prioritization so far removed from quantitative risk data, and then attempting to pass blame down to states for not revising the prioritization to better match evidence is particularly rich.

  • Horrible & sad how the CDC first said Type one then all information suddenly changed to type 2. This is a big mistake as we see reading above. Type 1 can be or is at greater risk than Type 2 for DEATH! Our immune systems are compromised & healing takes much longer.
    I urge You to write your Governor- call representatives! States have choices!! In Texas, 1B is a person with health risks! Good luck to you & our to our Country on fixing the many issues on roll outs of the vaccine!

  • Thanks for this insightful article. As the mother of someone with T1D, I appreciate the efforts you took to draw a distinction between two conditions that share a common name, to the detriment of each. I do wish, however, that in your paragraph describing the differences between T1D and T2D that you had mentioned that T1D is an inherited autoimmune disease. T2D, by contrast, is sometimes inherited but more often, caused by lifestyle choices. Also, T1D is incurable and irreversible, whereas T2D can be reversed in many cases and is treatable by certain medications. Not to worry–I don’t expect a response, as I have made these points to you concerning earlier articles with no response forthcoming. Thank you again for posting this story.

  • Hello,
    The same issue is with this case in Pennsylvania.
    A 72 y/o with COPD stage 2 & her chances to get over the Covid are Zero but because she is under 75 she doesn’t get it till the end of March & there is no one to talk too!!!

  • So I am a post left lobe lung transplant patient that also has developed steroid induced type 2 diabetes ; it was done at Columbia Presbyterian hospital where both my parents went to school ; I feel blessed to be able to write this note at all now in my tenth year post ; main reason not me but my father and all family members have Phd’s in science from Columbia, Harvard, Yale and 3 generations at Cambridge university so I understand how to limit my exposure quite well

  • I am a type I diabetic. I feel as if suddenly chronic conditions are being put at the bottom of the list for a vaccine! I am at high risk but no one in NY at health dept or local CVS can tell me where and when I can get the vaccine. I am extremely frustrated.
    Certainly I am higher priority than a young Bodega worker and they are being put higher on the list than me!

    • It is despicable that type 1 diabetics are being put at the bottom of the list.
      Juvenile diabetics are critically at risk.
      Are there any telephone numbers or contact numbers of people who can be directly notified of this unbelievable situation?

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