Missing during COVID‐19 lockdown: Children with onset of type 1 diabetes

Abstract

The redistribution of healthcare resources for coronavirus 2019 (COVID-19) pandemic has resulted in unintentional neglect of essential non-COVID-19 care.1 In low- and lower-middle-income countries, the already overstretched healthcare systems have crumbled under the COVID-19 pressure.1 In India, the first COVID-19 case was detected on January 30, and a nationwide total lockdown was announced from March 25 until May 3, 2020, followed by a partial lockdown. The hard-line lockdown restrictions and fear of exposure to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in healthcare settings force patients with non-COVID-19 illnesses to stay home and suffer until their illness deteriorates substantially, and sometimes irreversibly.2 The impact of COVID-19 on the paediatric population has so far been mild, except in children with comorbidities.3, 4 However, children who develop new time-sensitive non-COVID-19 illnesses during the pandemic are at risk of worsening or death due to compromised access to hospital care. In particular, children with onset of type 1 diabetes may progress rapidly to diabetic ketoacidosis if treatment with insulin is delayed, and are therefore at risk of increased morbidity and mortality. Recent reports suggest that children with onset of diabetes during COVID-19 pandemic presented to the emergency department in severe ketoacidosis due to delayed access to hospital care and required admission to the intensive care unit.2, 5 At our tertiary care paediatric referral hospital located in north-west India, we receive patients mainly from four federal states and two union territories with a total population of 78 361 289. We admit all new diabetes cases with or without ketoacidosis as well as those who need structured diabetes education. During the period of nationwide lockdown, we perceived an unusual decrease in the admissions of children with type 1 diabetes despite our institute's policy of keeping essential non-COVID-19 services open. To confirm this, we compared data on type 1 diabetes admissions during the month of lockdown with the previous 12-month period. From April 2019 to March 2020, the total number of admissions was 228, averaging 19 (range 12-28) per month; however, there was a major reduction (79%, 4 vs 19) during April 2020 (Figure 1). Sixty-five per cent (147) of cases admitted the previous year were new, averaging 12 (range 7-19) admissions a month. In April 2020, a sharp decline was noted in the admission rate of new diabetes cases as compared to the mean admission rate of the previous 12 months (3 vs 12 per month; reduction 75%) as well as in April months of the previous 2 years (3 vs 12 per month, reduction 75%). All three admissions with onset of type 1 diabetes in April 2020 were with severe ketoacidosis (mean pH 6.94, range 6.9-7.02; mean serum bicarbonate 4.73, range 4.4-5.0 mmol/L) as compared to only 15% (average 2 out of 12 per month) during the previous 12 months; the average pH and serum bicarbonate of these patients were 7.07 (range 6.8-7.30) and 8.48 mmol/L (range, 3.7-14.9 mmol/L), respectively. The parents of all three children admitted with severe diabetic ketoacidosis during April 2020 disclosed that they did not seek timely medical attention due to COVID-19 fear and they were repeatedly turned away from hospitals near their homes until their children became visibly sick. Our data show a major reduction in hospitalisation of children with onset of type 1 diabetes during April 2020. The situation appears similar in other large hospitals in our region, the usual sources of our referred patients (verbal communication). Furthermore, the proportion of presentations in severe ketoacidosis increased, suggesting that delays in seeking care by parents, and delayed diagnosis or referral due to closure of neighbourhood healthcare facilities probably increased the severity of ketoacidosis.5 The exact reasons for the reduction in admissions are unclear at present. Although the lockdown continues, there are no restrictions on the transport of sick persons. The Indian Government has also issued an advisory for re-opening essential non-COVID-19 health care.6 The fear of becoming infected with SARS-CoV-2, and delayed access or provision of care, as experienced in the countries with high-COVID-19 burden, probably reduced the hospitalisations in our set-up also.2 Irrespective of the cause, the lower rate of admitted and therefore treated new diabetes cases is worrisome. Type 1 diabetes is an acute illness that if left untreated for a few weeks results in ketoacidosis which causes death if untreated. In low- and lower-middle-income countries, children with type 1 diabetes are considered vulnerable to acute complications due to poor healthcare infrastructure in general and the lack of attention by the government, policymakers and healthcare professionals (HCPs) in particular.7 Experts still worry about missed diagnoses and deaths before the diagnosis of diabetes in children, especially in rural areas.7 Currently, the healthcare systems in low-resource countries are very likely to fail to provide essential care to non-COVID-19 conditions similar to the Ebola virus outbreak of 2014-2016. Post-epidemic data analysis revealed that deaths due to non-Ebola conditions exceeded those due to Ebola virus infection because the national healthcare systems failed to provide essential care to non-Ebola patients.8 Similarly, the indirect effects of COVID-19 pandemic on child mortality are expected to be devastating due to widespread disruption to health systems in the low-resource countries.1 Early estimates represent a 9.8%-44.7% increase in child deaths per month due to reduced care-seeking for common childhood killer diseases in countries with poor healthcare systems.1 But whereas we may get to know the number of children who died due to non-COVID-19 illnesses during the pandemic time, it is impossible to know how many died of undiagnosed or late diagnosed type 1 diabetes. India's performance on completeness of cause-of-death data is among the lowest, about 10% as compared to the global average, 48%, and the European average, 97%.9 Even post-pandemic verbal autopsy analysis is unlikely to ascertain the cause of death, as the nonspecific initial symptoms of paediatric diabetes often do not receive attention by the parents, or even the HCPs.8 Furthermore, after the inevitable COVID-19-related economic recession, the possibility of the national government undertaking a mammoth exercise of verbal autopsy seems remote. Our preliminary observations at a single centre may change as the lockdown extends further. Nevertheless, this report hints at delays in access to hospital care, which needs systematic monitoring. In this regard, the general public and the HCPs need clear guidelines on the provision of care to children with non-COVID-19 conditions, specifically type 1 diabetes. The national governments and health agencies in low- and lower-middle-income countries should respond with aggressive media campaigns to make parents aware that the risk of delayed access to hospital care for new diabetes cases can be much higher than that posed by COVID-19. There is a need for the public to bring children to hospital when unwell especially because the chance of catching COVID-19 is less risky than many non-COVID-19 childhood illnesses, and hospitals are still open for treating all unwell children. None. DD analysed the data and drafted the manuscript. All authors provided the data, and revised and approved the manuscript. All relevant ethical guidelines have been followed for data collection and reporting. We obtained verbal consent from parents of children admitted during lockdown and approval from the Departmental Review Board for reporting data.

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