Covid-19 hit diabetics with a double whammy and revealed deadly gaps in South Africa’s health system
The pandemic has put the risks associated with diabetes, particularly uncontrolled diabetes, in the spotlight.
Over the past two years Covid-19 has brought the heightened risks faced by people with diabetes into sharp relief. While diabetics are not at increased risk of getting infected with Covid-19, once they do contract it, they face a higher risk of severe disease and death – particularly if they have uncontrolled diabetes.
Available data suggest that, if a diabetic’s blood sugar is not controlled, they are more likely to have poor outcomes on contracting Covid-19, according to Dr Alisha Wade, endocrinologist and clinician scientist at the Medical Research Council/Wits Rural Public Health and Health Transitions Research Unit in the School of Public Health at the University of the Witwatersrand in Johannesburg.
“Multiple studies have shown a ‘dose-response’ curve between the degree of hyperglycaemia and the severity of Covid,” says Dr Ankia Coetzee, senior lecturer and endocrinologist in the faculty of medicine and health sciences at Stellenbosch University. “Individuals with prediabetes are at risk of severe Covid, albeit less so than individuals with diabetes, arguing for better glucose control in all hyperglycaemic states.”
The matter of diabetics’ vulnerability to Covid-19 is multifactorial, says Professor Joel Dave, who launched the Diabetic Centre at Groote Schuur Hospital and is head of the department of endocrinology at the health facility. He emphasised that much of the current data on this issue remain observational, since Covid-19 is a relatively new disease.
One issue is that people with high blood sugar have a greater number of angiotensin-converting enzyme 2 (ACE2) receptors, which are the receptors the virus uses to enter the body’s cells, says Dave. This means there are more points of entry into the cells for the virus. This can result in diabetics having more severe infections with higher viral loads than people with normal glucose levels.
High blood sugar also impairs the functioning of the white blood cells and, by extension, the body’s immune system. This reduces the ability of diabetics to fight off any type of infection, including Covid-19, says Wade.
Diabetes is often associated with older age, excess weight and other comorbidities, such as high blood pressure and kidney disease, she says. These factors can increase the vulnerability of diabetics to severe Covid-19.
In South Africa, 75,835 Covid-19 patients admitted to hospital were recorded as having diabetes. Of these, 25,472 died. This equates to a case fatality ratio of 33.6% of admitted diabetics who died of Covid-19, according to Foster Mohale, spokesperson for the national Health Department. Diabetics were 40% more likely to die from Covid-19 in hospital than non-diabetics.
Mortality among diabetics was highest in the second Beta-dominated wave and third Delta-dominated wave, at 39.5% and 37.3%, respectively. The fourth Omicron-dominated wave had the lowest mortality in this group, at 18.4%.
Mohale referenced a sentinel surveillance study conducted at 16 public hospitals by the National Institute for Communicable Diseases, saying: “Among 2,954 patients who were screened for diabetes, 215 (7.3%) had newly diagnosed diabetes when admitted for Covid-19 (not previously diagnosed). Among 901 patients who had [an] HbA1C [test] done as a marker for level of diabetes control, 777 (86.2%) had poorly controlled diabetes.” A paper on the study has been accepted by the South African Medical Journal but is not yet published.
Prevention, detection, vaccination
A person can prevent diabetes from developing by addressing risk factors for the condition, such as obesity and a sedentary lifestyle. Those with diabetes need to prioritise their cardiovascular health and prevent vital organ damage. The holistic, evidence-based management of diabetes includes cardiovascular risk reduction and control of glucose, cholesterol, high blood pressure and weight, says Coetzee.
“I think, with something like Covid, what it demonstrates is, it’s not about waiting until something happens to control your diabetes, but making sure that, as a rule, your diabetes is well controlled,” says Wade. “And that’s something you need to do in conjunction with your doctor because you need to have your markers of blood sugar control checked on a regular basis.”
Those at risk of diabetes – including people over 40, obese individuals and those with a family history of the condition – should be tested for it to ensure detection and proper management, Coetzee says.
“Based on the findings of various studies, improved or better glucose control before and during hospital admission [for Covid-19] was associated with improved outcomes in people living with diabetes,” she says. “This implies that glucose control is a modifiable risk factor that we can utilise to try [to] improve the outcome of these individuals, should they contract Covid-19.”
It is very important for diabetics to get vaccinated against Covid-19, says Dave – it’s a “no-brainer”.
The number of people with uncontrolled diabetes in the country varies between the public and private health sectors, as well as between provinces, because of differing levels of access to healthcare, according to Dave.
Diabetes control in the public health sector of the Western Cape – a region largely seen as having one of the more functional systems in the country – is poor, he says.
“Type 2 diabetes is an insidious disease that can be asymptomatic for an extended period, despite damaging the vital organs. Therefore, many individuals at risk for diabetes do not get tested and don’t utilise the opportunity of early secondary prevention,” Coetzee says about the prevalence of uncontrolled diabetes in the country.
Access to screening for non-communicable diseases such as diabetes is limited, particularly in the public sector, she adds. This is in part because of competing conditions that are more clinically evident.
“There is a huge mismatch between supply and access to health services that manage diabetes well. Inadequate medical care, including the lack of empowerment of patients through diabetes self-management education, makes it impossible for patients to take ownership of their disease,” says Coetzee.
To optimise the use of human resources in the field of endocrinology, endocrinologists should educate the wider medical community about how to manage people with diabetes, says Wade. This would not only help general practitioners and physicians in knowing how to treat diabetes, but also in recognising the point at which they need to refer cases to those with more expertise.
A primary aim of the Diabetic Centre at Groote Schuur Hospital is to provide training in diabetic care to doctors and nurses, says Dave. They, in turn, can transfer this training to others.
“So, we’re hopefully going to be a fulcrum on which better control is going to be unleashed on the whole of the Western Cape,” he says. “We’ve already started doing that with education courses for nurses, education courses for doctors, and that’s to address this gap of knowledge in diabetes. And also, the shortfall in the numbers of healthcare practitioners that are available to treat diabetes.”
Coetzee recommended providing screening for non-communicable diseases at vaccination sites and using these spaces to educate people who are at risk of diabetes. Furthermore, access to screening and immediate intervention for diabetes should be available at community healthcare level.
“Covid highlighted the significant burden of diabetes. Ironically, it is one of the diseases that all complications can be prevented or significantly decreased with timely diagnosis, timely intervention and access and adherence to evidence-based management,” explains Coetzee.
“It is unlikely that we will achieve care equity… until we can improve primary and secondary prevention.” DM168
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