Maahs, D, Alonso, G.T, Gallagher, M.P, Ebekozien, O

We commend Gregory and colleagues for their well-designed prospective study to quantify and contextualize the risk for coronavirus disease 2019 (COVID-19)–related hospitalization and illness severity in type 1 (and type 2) diabetes (1). High-quality data such as these are required to inform public health approaches, including defining the risk of severe acute respiratory syndrome coronavirus 2 infection and health outcomes in people with diabetes. Indeed, these data inform a JDRF campaign (https://www.jdrf.org/coronavirus) advocating for prioritization of people with type 1 diabetes for COVID-19 vaccinations.

However, as pointed out in a recent Diabetes Care Commentary (2), data from adults should not be extrapolated to the pediatric population, especially for COVID-19, as outcomes differ significantly by age (3). In the article by Gregory et al. (1), age was the strongest risk factor for illness severity; only 8 of 40 people with type 1 diabetes were <18 years of age. Additional analyses, clinical profiles, and outcomes on these 8 people <18 years old with type 1 diabetes and COVID-19 could help inform policy decisions and answer questions such as whether youth with type 1 diabetes have increased risk for severe illness and poor outcomes compared with their peers without diabetes. Moreover, the authors report no cases of COVID-19 in youth with type 2 diabetes <18 years of age, a group for whom few data have been reported.

Larger pediatric data sets, for example, the ongoing T1D Exchange COVID-19 multicenter surveillance study (4), will be required to inform public health decisions in youth with type 1 diabetes. As of December 2020, over 270 type 1 diabetes patients <18 years old with COVID-19 have been entered in the T1D Exchange COVID-19 registry by more than 35 participating pediatric centers in the U.S. (www.t1dexchange.org/COVID19). There has been no recorded death or mechanical ventilation in this cohort, similar to international reports (5).

Therefore, it is extremely important to base public health messages about COVID-19 in the pediatric diabetes population on data from this age group, not on extrapolation from data in adults with diabetes. Families need to understand how emerging data apply to their children and adolescents with type 1 diabetes. Communications that do not clarify the role of age may inappropriately raise concerns and lead to unintended consequences.

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