People with type 2 diabetes as young as 40 years of age face a disproportionately increased risk of dying from COVID-19 infection, indicates a UK analysis of three large-scale datasets that shines a light on the need to prioritize vaccinations in younger vulnerable patient groups.

The research was published February 8 in the journal Diabetologia.

The majority of European countries have prioritized COVID-19 vaccinations for people with type 2 diabetes, but typically only at age 50 and older. However, the data from the current study suggest that this age limit should be lowered.

“It’s important to remember the risk to middle-aged people with diabetes of dying from COVID-19 is very low in absolute terms compared with the elderly,” said lead researcher Andrew P. McGovern, MD, of Royal Devon & Exeter Hospital, Exeter, United Kingdom, in a press release from his institution.

However, he said that “strategies to define priority groups for vaccination must consider the disproportionate relative risk of COVID-19 mortality in middle-aged people with type 2 diabetes whose COVID-19 risk is already elevated by their age.”

McGovern told Medscape Medical News that the magnitude of the effect of type 2 diabetes on COVID-19 deaths “is really what’s surprising” about these new findings, and “not what you would expect.”

He said it is therefore crucial that people with diabetes are put “into the queue” for the vaccine “in the right place, and obviously in countries where the vaccine rollout will be slower, it is more important.”

Bridget Turner, director of policy campaigns and improvement at Diabetes UK, which funded the study, said the results give “important new insights into how much type 2 diabetes adds to the overall risk of dying from coronavirus at different ages, particularly the additional risk that the condition adds in middle-age.”

“The UK has made good progress on prioritizing those who are most vulnerable for vaccination, which includes all adults with diabetes,” she added in the press release, “but we need to continue to work at pace to identify and protect those individuals at higher risk.”

Relationship Between COVID Death and Diabetes Is Complex

The authors note that the relationship between COVID-19-related mortality and type 2 diabetes is not simply an “additive effect of diabetes and age-related risk” but appears to be a “more complex” association, with a “disproportionately higher excess relative mortality risk in younger people with diabetes.”

To investigate this, they examined data from two UK population-based studies that had previously reported age-specific hazard ratios for COVID-19 mortality associated with diabetes:

• OpenSAFELY, which included 17.2 million people, of whom 8.8% had diabetes, and had an overall 90-day mortality rate of 0.06%

• QCOVID, comprising 6 million individuals, of whom 7% had diabetes, and had an overall 97-day mortality rate of 0.07%.

The team also looked at data on type 2 diabetes patients with severe COVID-19 from the COVID-19 Hospitalisation in England Surveillance System (CHESS), which contained 19,256 patients admitted to critical care in England, of whom 18.3% had diabetes.

The 30-day in-hospital mortality rate in this study was 26.4%.

They translated the mortality hazard ratios associated with COVID-19 infection in people with diabetes into a “COVID-age,” which equates to the additional years of “death risk” added to an individual’s chronological age if diabetes is present.

Taking the QCOVID dataset as an example, the results showed that the “COVID-age” associated with diabetes for someone aged 40 years was 20.4 years; that would indicate that their “mortality risk [for COVID-19] is similar to that of a 60-year-old person without diabetes.”

The impact of diabetes on the COVID-19 death risk decreased with increasing age, such that a diabetes patient aged 50 years had a COVID-age of 16.4 years. This fell to 12.1 years in someone aged 60, and 8.1 years in someone 70 years of age, which means the latter has the same risk of death from COVID-19 as someone without diabetes who is 78.

Similar results were obtained when the team looked at data from the OpenSAFELY study.

But when they looked at the effect of diabetes on COVID-19 mortality risk in the CHESS dataset, it was less pronounced.

Just Looking at Diabetes Is Oversimplistic, but It’s an Easy Marker for Vaccination

The researchers acknowledge that “considering only age and diabetes status when assessing COVID-19-associated risks…is an oversimplification,” as factors such as body mass index (BMI), diabetes duration, and glycemic control are also known to play a role.

However, they say consideration of these factors is “not practical for population-level vaccine rollout.”

“The time-critical nature of population COVID-19 vaccination necessitates pragmatic group-level prioritization, which is the approach initiated by governments thus far,” the team concludes.

This study was supported by Diabetes UK. Study author John M. Dennis is supported by an Independent Fellowship funded by Research England’s Expanding Excellence in England (E3) fund and by the NIHR Exeter Clinical Research Facility. McGovern is supported by the NIHR Exeter Clinical Research Facility.

Diabetologia. Published online February 8, 2021. Full text

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