April 08, 2021 COVID-19, Vaccinations & Diabetes
Join Dr. Akshay Jain (MD, FRCPC, FACE, CCD, ECNU, DABIM, DABOM, endocrinologist), Dr. Susy Hota (MD, MSc, FRCPC, infectious diseases specialist and epidemiologist), and Diabetes Canada's Brooks Roche for a session about navigating COVID-19, vaccination, and life with diabetes.
00:00 Welcome everyone and uh thank you for your understanding of a couple of technical difficulties. My name is Brooks Roach I am a diabetes education specialist with Diabetes Canada. I'm very excited to welcome you to this webinar today. Today we're going to be talking about the relationship between COVID-19 and diabetes with a specific lens for vaccinations. As many of you know this is an ongoing priority for folks across Canada no matter what jurisdiction you may be living in. We're joined today by Dr. Susy Hota infectious diseases specialist, an epidemiologist at Toronto's University Health Network and associate professor at the University of Toronto, and Dr. Akshay Jain endocrinologist at Fraser River Endocrinology in Surrey, BC and the first Canadian physician to be triple board certified by the American boards in endocrinology internal medicine and obesity medicine
00:54 These two wonderful guests will be answering questions that many of you living with diabetes may have so I’d like to issue a warm welcome to both of you and thank you very much for being here
01:05 Now because of the change in format we will not be having a Q&A, however our experts have convened beforehand to share some questions that they've been receiving very frequently as healthcare professionals. So they're going to enlighten and inform us in this format and as always if you have any questions after the fact please do feel free to reach out to Diabetes Canada through email at email@example.com or one eight hundred banting and we'll be happy to answer any further questions and potentially answer them in future. So with that I’d like to uh turn the floor over to our guest Dr. Susy Hota to start with a little fireside chat between our guests
01:47 Thank you so much Brooks and I will get us started and I'm going to start off just because we've heard so much about things like age and certain health conditions being important risk factors dictating outcomes and those who actually get COVID-19 infection.
02:05 I'm going to start off Dr. Jain with a question to you, what about diabetes, what is a risk to those who are living with diabetes if they get COVID-19 infection?
02:16 Great thanks so much for the fantastic question, we do know that people living with diabetes have roughly the same chance as acquiring the infection as someone without diabetes. Acquiring the infection or getting exposed to the infection is very similar for those with or without diabetes. However, when someone living with diabetes gets infected with COVID-19 that's when things can be quite different compared to those without diabetes. What tends to happen is diabetes is a condition in which blood sugars could be quite variable they can go up and down, and that can cause inflammation in the body as well, and diabetes makes the individual more susceptible to having multi-organ damage.
03:06 Organs like the heart, the lungs, the kidneys, can all get affected with diabetes by that same yardstick COVID-19 is an acute infection that sets off a lot of inflammation in the body, and this inflammation will also increase the risk of damage to these organs. We've seen in studies that when people with diabetes get infected with COVID-19 the outcomes could potentially be worse. For those who have poorly controlled diabetes the risk of hospitalization is much more, about three to four times higher compared to those without diabetes. The severity of the infection can be worse, which in turn increases the risk of death from COVID-19 as well in those with diabetes versus those without diabetes. In many cases individuals with diabetes are about 30 percent more likely to require ICU admission or ventilation. Especially if the sugars are not well controlled
04:13 Thank you for that. Is there a difference in complication rates then? Between those who have type 1 versus type 2 diabetes?
04:20 Yeah so that's again a really good question, in some of the studies that have been done across you know different countries in the world we know both type 1 and type 2 diabetes have a higher risk of these infections and the complications of the infection. I'm sorry but comparing between type 1 and type 2 it has been seen that the risk of complications is slightly more in individuals with type 1 diabetes versus those with type 2 diabetes.
04:53 So I’m going to hand it over to you to ask the next questions.
04:56 Yeah, I think you know we are talking about the higher likelihood of complications with diabetes and which of course brings us to the question about vaccination. Do you think Dr. Hota that people with diabetes should take the vaccine? We know that you know a lot of these immune compromised patients, they're thoughts about whether or not they should get vaccine. Does type 1 diabetes come under that same umbrella of diseases?
05:30 So in terms of the first, question should people with diabetes get vaccinated. Absolutely for all the reasons that you really clearly outlined. You know the risk of complications if you have diabetes being greater, the risk of the more severe outcomes, ICU admissions, death even these are things that can be modified quite effectively by the vaccines that we have.
05:50 You know at the moment we've got four approved vaccines by Health Canada, at least approved within Canada, one of them the Johnson and Johnson's not yet available but soon will come available to Canadians. The others we've had months of experience rolling it out. Actually across the world and so not only do we have good clinical trials data but we have real life experience, and in those early clinical trials that led to the approval of the vaccines by Health Canada.
06:16 There were exclusions and this is very common with any clinical trial that's done to get a vaccine approved. They exclude people with higher risk conditions just for safety reasons, as you're studying, starting to get the early stages of information, and one of the exclusions was as you mentioned those who are immune compromised. But also those who had autoimmune diseases and when they talked about autoimmune diseases they were really referring up to, you know things like um lupus, and rheumatoid arthritis that severe, and that requires a lot of treatment. Type one diabetes does not uh really fall into that category and in fact you know the common prevailing thinking right now is that the benefits of getting immunized if you have even type one diabetes far outweighs any of the risks that could be associated with these vaccines. I won't even say that there are necessarily risks in those with autoimmune disorders or immune compromises just purely that we don't have a lot of information on how well the vaccines work in those groups, and that's why at the present time the advice is if you have one of these, talk to your health professional but overall I'd say absolutely if you have diabetes type 1 or type 2 you should get vaccinated.
07:25 So in your experience Dr. Hota in Ontario for instance are people with diabetes being prioritized for vaccination?
07:32 Yes, so they are being prioritized although there are several layers of prioritization in our scheme. So right now in Ontario we've entered into phase two of our vaccine rollout just recently and in phase two it includes a number of people with different health conditions that put them at risk for complications of COVID-19 and those are stratified according to the highest level of risk. Which includes people with, you know recent transplants for example, with certain cancers like blood cancers, really bad renal impairment, kidney impairment. Things like that and then there's the high risk groups people with really significant obesity and some other health conditions. Those you know are smaller numbers of people in Canada that would end up qualifying for those uh conditions and so we'll probably move through that relatively quickly I'm thinking. Then beyond that are the at-risk people and this includes a large number of people with different health conditions. Including diabetes so i do think in the next month or so we will be cycling through to get to all of those individuals. I hope that with more supply we can get there faster
08:38 Yeah and that's a really good point. Also just to mention to the audience in BC where I reside, individuals with diabetes say who are on insulin are being prioritized because we've seen in studies that people requiring more medications for diabetes, or those who are on insulin, they need to be prioritized because of the risk of complications.
09:00 Speaking about the vaccine Dr. Hota, you just mentioned about four different vaccines being available, three at least commonly available already in Canada. Which one is the is the best one for people with diabetes?
09:13 We don't really know if there is a vaccine that's better than the others for different types of subgroups. All I can say is that in the clinical trials for each of these vaccines they were very careful to try and include a reasonable number of people with different common sort of health conditions that we know put them at risk for covenanting
09:32 We can say that the vaccines work for those individuals and we can say that they're represented in the trials but we don't really know that one's better than the others. I would say get the first one you have available to you.
09:42 Yeah, I would encourage everyone listening in to make sure that you get the vaccine. The data is really strong there's no need to really to pick and choose.
09:51 One of the doctors that i work with gave the analogy that you know if god forbid if someone is drowning and someone throws out a lifesaver you don't pick the color of the lifesaver you just grab onto the lifesaver.
10:02 It's really important because of the risk of complications. One should consider getting the vaccine
10:08 How about after the vaccine Dr. Hota you know if someone gets the vaccine does it mean that they have absolutely no risk of getting the COVID-19 infection?
10:17 None of the vaccines are 100 ineffective. I don't think anyone's claiming that they are in terms of preventing symptomatic infection with COVID-19 and that's what they were studied against. That was the end point of the clinical trials that led to the authorization of these vaccines. Did you get symptoms? and then you tested positive for COVID-19. None of the trials were designed to answer the question could you still get COVID-19 but be asymptomatic have no symptoms and we know that happens in 30 percent of people who have COVID-19.
10:46 That question is being answered over time. We are getting some data to suggest that yes it does reduce the risk of asymptomatic infection as well, but it may not eliminate it completely.
10:56 First point to make even with the best of our vaccines that we have out there none of them are 100 some approach 95 in terms of the efficacy in clinical trials, but there's still that five percent that could get infected and be symptomatic. It may reduce the asymptomatic infections but there's also a possibility that that could happen
11:17 The third consideration is we do have some different variants of COVID-19. The virus that causes COVID-19 that are circulating worldwide and some of them are a bit concerning and two of them in particular, one that originated from South Africa originally and the other that originated from Brazil, are circulating quite widely even within Canada. They're starting to circulate and they may reduce your immune system's ability to respond to the vaccines effectively.
11:46 We don't know what the overall effect will be on how well the vaccines work. It's likely that they'll have some effect but I don't think it's likely that they will eliminate the effectiveness completely of these vaccines, but they might be reduced by this.
11:59 We have to learn that over time it is possible that people could still get infected but the important thing is how much will it affect their bodies and all of these vaccines right now are showing dramatic reductions to almost elimination, and the risk of hospitalization, severe illness and death and to me that's the bottom line that we need to focus on.
12:25 That's a really good point, I'm going to take over from this question and ask you a few. Really what I wanted to shift to is recognizing that people with diabetes can still get COVID-19 infection. As I just mentioned in spite of being vaccinated, or as they're waiting for their second dose of the vaccine.
12:45 I have a few questions about what to think about in terms of infections and risks, you know with diabetes and covenanting. If you have poorly controlled blood sugars at the time of COVID-19 hospitalization can this lead to a worse outcome?
13:01 Thanks for the great question, we know that when blood sugars are poorly controlled and when I speak about poorly controlled blood sugars there can be one of three options. One is people with very high blood sugars, the second could be people at risk for recurrent or multiple low sugars or hypoglycemia, and the third are people with a high degree of glycemic variability. Which basically is a lot of ups and downs in the blood sugar so the blood sugars that are swinging from high to low all the time. That's called glycemic variability all of these three individually as well as together constitute poorly controlled blood sugars. When sugars are not well controlled at that point of time our body's ability to fight off infection also gets impaired.
13:48 We do know that people with poorly controlled blood sugars, say for instance if they were to get a skin infection, a bruise you know those things take a long time to heal. In the same way if there is a systemic infection such as COVID-19 then it affects our body's ability to fight off that infection.
14:10 That's really important to note, really important that we control our sugars if we have diabetes. In studies that have been done so far they've seen that people with those ups and downs of blood sugars, or glycemic variability, or those who have had higher sugars at the time of admission to the hospital, or those individuals who in the last five years have had previous hospitalizations either from low sugars or high sugars, all these individuals are at a very high risk of having worse outcomes when they get COVID-19 infection.
14:46 It's not just a question about when you get the infection but what leads to that when it comes to your blood sugar, control it makes a lot of difference, now is probably the most important time if there ever was one to make sure that our blood sugars are well controlled. That our immune system is tuned to the best of our ability to fight off these infections.
15:11 Can your blood sugars actually get worse during an infection if you have diabetes?
15:17 Absolutely, when the COVID-19 infection occurs it leads to that significant amount of inflammation that I was speaking about and that inflammation in turn can trigger off a high blood sugar response. We've seen that during the time of the infection people's blood sugars can go up quite a bit. Which leads to poorer outcomes. Some of the medications that we're using to treat COVID-19 infection, such as steroids can often cause the blood sugars to spike up. Which in turn can affect the outcomes even more so.
15:55 Even when one gets infected with COVID-19 the chances are that the sugars could swing quite a bit or go quite high and you may require escalation of your medications at the time of the infection. Whether it's serious or not, even if you're at home and with the infection you may require some escalation of your treatment. Make sure you talk to your doctor to see if the medications need to be adjusted when you're infected.
16:25 You mentioned that some of the treatments for covid-19 can actually cause swinging of your blood sugars but can you get diabetes from getting COVID-19?
16:35 That's been a very closely studied question across the world especially during the course of the pandemic. In the last year we're trying to see if COVID-19 can trigger new diabetes, take a step back, when we look at type 1 diabetes we know that many times a viral infection can set off type 1 diabetes. We've seen that over the past hundreds of years where infection is what can set off type 1 diabetes, and certainly in some cases we've seen that people who previously did not have any history of diabetes, after the COVID-19 infection they developed type 1 diabetes at the same time the treatment options that I was talking about, the steroids, can often lead to very high sugars thereby precipitating diabetes
17:26 However, there is no conclusive evidence at this point of time that suggests that COVID-19 is associated with the causation of diabetes. The risks do go up but there is no conclusive evidence that says that COVID-19 can cause diabetes. But there's a lot of research that is being done even as we speak and we'll know a little bit more in detail as time moves on.
17:53 That brings me to my question for you Dr Hota, when we talk about the vaccines and that you’ve just differentiated all the different ones, one thing that comes to my mind is all the studies previously were showing that the time duration between the vaccines, between the two shots, was different versus what we are now seeing here in Canada where the interval could be as much as four months. How does this affect the outcomes? And what are the implications for people with diabetes?
18:34 It's such a good question, and you know I think to answer it you kind of have to think about a bunch of different dimensions. First of all, the dosing intervals that were decided for the different vaccines, Pfizer initially being 21 days, Moderna 28 days between doses, Astrazeneca anywhere from four to 12 weeks that was decided based on science but also remembering that there is huge pressures to get the clinical trials completed quickly.
19:01 They didn't want to choose larger or longer dosing intervals, or it would take a lot longer to get the results of this trial and here we have this burning platform to try and get vaccines ready and out. We do have to remember that there is a little bit of design behind that was not related necessarily to science but us trying to get results on clinical trials quickly. That said, what the clinical trials used the data that we have on how well these vaccines work and the safety etc. is all based on those intervals. Here we fast forward to real life rolling out vaccines at a time when we're experiencing large waves of transmission and many parts of the country really are in dire need of getting vaccine out to as many people as possible.
19:50 At least first doses and we have a limited supply of vaccines, so we have to make difficult decisions. The decision to extend the dosing intervals based on many different things, but also some of our prior knowledge of other vaccines that have multiple doses required. With some of them it can be years even between the doses, they all work slightly differently but we do have that short duration and it doesn't necessarily have any negative impact on the outcome. In fact sometimes extending the duration between those doses actually improves the outcome. We saw a little bit of that with Astrazeneca where they found that people seemed to do better if you had waited 12 weeks rather than gave the second dose four weeks so.
20:31 There are a lot of different factors to balance in on that decision making but I will say that when four months was chosen as what we're using it's not that was based on any clear scientific data in the real world or from trials involving these particular vaccines.
20:46 There's a big question mark as to what it would do and when that question includes two different questions. Actually one is given that we're rolling out vaccination in many parts of the country where there's lots and lots of COVID transmitting. It becomes very relevant what is the level of protection that somebody gets after a single dose of these vaccines because they might have to wait a long time for their next dose. If there's rampant transmission around them that's a very important question if you're living in Atlantic Canada.
21:16 There really isn't that much around you're probably a little less concerned about that because the chances that you'll encounter the virus and that dosing intervals lower. That's one question and what we know so far is that in people who are young and healthy and don't have other health conditions you likely have moderate to good protection after a single dose. At least two weeks after the single dose it's not nearly as good as what you would get after your second dose but it's still pretty good. However, we're starting to get some data that in some other subgroups like people who are older, especially over the age of 80, those who are very immune compromised like if you've had a transplant or if you have cancers especially blood cancers you may not have nearly as good a response after a single dose.
21:59 The second question, we get this delay in the dosing interval will it have an effect on the overall effectiveness of the two dose regimen because you've changed that dosing interval and this is where I said extrapolating from other vaccine schedules kind of makes you think it probably shouldn't affect most people, but we don't know it hasn't been studied.
22:22 We do know that there's some very early studies that suggest that in people with certain cancers, especially blood cancers, it might affect their overall effectiveness if you don't give a second dose quickly enough. But it's very preliminary, I think these are things that we have to be watching very closely.
22:39 We don't know anything in particular about diabetes and how that affects where you lie on that spectrum of protection with a single dose or with a delayed second dose. I would really like to see us as we get more vaccine supply shortening that duration between the doses back to something that has been better studied so we feel a bit more confident with it.
23:01 These are excellent points, in the environment that we're in today with all this media speculation the one thing that's become quite a buzzword lately is the side effects of the vaccines. You spoke about how effective they are at controlling, especially the severe infection or hospitalization, but what advice would you give to people about what the rates of those side effects are? And what are the side effects that we need to watch out for?
23:33 There's side effects and then what we consider adverse effects, and the side effects are very common and these are things like headache, feeling very tired, chills, muscle aches, even a little bit of stomach issues and diarrhea in some people or flu-like symptoms. You feel like you're coming down with a flu and that happens frequently, more frequently after the second dose. The first dose of the vaccines they usually start about the next day, after you have the vaccine and can last for several days after that. Two to three days after that and then people generally get better and you don't really experience any further side effects. You can get things like fever with that and that can make people confused about whether they're coming down with an illness or if it's related to the vaccine. That's a bit of a clinical judgment and the other thing that's very common is injection site reaction. If it's the spot that they gave you the vaccine you might get some redness, swelling, pain, tenderness that kind of thing, even a bit of a rash. Again that usually does not last for very long and those things are not very concerning at all. Very frequent the things that are less frequent, but are a little bit more, cause a little bit more concern about the vaccine people can sometimes get swelling of lymph nodes in the arm where they got the injection. Again that is not something to be concerned about, it’s your local immune system really showing itself, but it can sometimes trigger a bunch of investigations and things like that so that's something to be aware of. There have been some reports in the clinical trials of the subjects getting something called bell's palsy. Which is you get paralysis of part of the face. When that was explored further it was determined that actually it didn't happen any more frequently than it does in the general population. That actually is not a vaccine-related side effect but it is something to be aware of because we're rolling out vaccines in millions of people so we're likely to hear about some of these things getting reported.
25:31Then the important one that is a very, very, very rare adverse event that's gotten a lot of media attention is related to the Astrazeneca vaccine and this is a particular type of blood clot that's induced by an immune related reaction that also is related with a low platelet count, and this is thought to happen anywhere from one and a hundred thousand, to one in a million people who receive this Astrazeneca vaccine.
26:01Anywhere from four to twenty days after you get the vaccine, and it tends to be in younger people who are mostly women, although there were a few men who were involved as well and this is the reason why NASI the national advisory committee for immunizations in Canada decided while this is being investigated we are not going to advise you give this vaccine to those under the age of 55. It's a precaution and that might get revised over time for those over the age of 55. The benefit is outweighed by any risk of this very rare side effect.
26:33 We'll hear more about this, I think that people need to understand it's important for us to get this information really quickly and if you want full transparency as we do and to be well informed.
26:45 will hear things, signals as people are reporting and really being cautious and monitoring and we shouldn't react with panic when we hear these things. We just need to get the full story, we know what to do with that information
27:02 That's really helpful to know, to summarize what Dr Hota and I just spoke about, we discussed that people living with diabetes have a higher risk of worse outcomes or more severe COVID-19 infection. If they were to get infected especially, if their blood sugars are not well controlled.
27:23 People with diabetes it's very safe for them to take the vaccine. The type of vaccine doesn't matter, the adverse effect events are quite rare and it is strongly recommended that you consider getting the vaccine and just making sure that you continue to follow all the precautions. Including after you've gotten vaccinated, so all of those things are really important.
27:51 Any other points Dr. Hota that you wanted to mention?
27:54 I think you really covered all the important things, the vaccine is going to be a really important tool for us to get through this pandemic and to protect those who are most vulnerable to the harms of covid-19, and that includes people with diabetes and it includes a large number of people we should all be getting it.
28:11 I hope that this session has given you some more information, more confidence in what's out there and certainly we don't have all the answers at this point, we don't pretend to have all the answers, but there is a ton of information out there for those who are seeking it.
28:28 I think you know information is also a powerful tool as these decisions are being made.
28:33 All right so we are on the cusp of improvement here, hopefully we'll see that together we can overcome this tide and thanks so much for your time and attention. Take care everyone and stay safe.
28:49 Thank you everyone
28:52 Dr. Hota and Dr. Jain, thank you both so much. That's it, greatly appreciated to hear some insights from you both and just a quick question before we do take off, and that's recognizing a few things that you're both in a fascinating position. Where we have access to both of you, you know all this data and this global scale information that you're referencing, as well as interacting with individuals that are navigating this system.
29:16 A question that I hear that we in the diabetes community here very often is this problem or this challenge of information overwhelm, where folks struggle to advocate for themselves or figure out what's best practice for them in their own situation in their province and their territory, etc.
29:34 You've been mentioning Dr. Hota the fact that right now NASI has made specific recommendations around the Astrazeneca vaccine that may change. Today's April 7th, it may be if someone's watching this video in the future that may be different, so do you have any advice for individuals that are struggling with that information overwhelm? And are just looking for a sense of confidence in looking for information? Looking for a next step.
30:03 It's very difficult because everything about this pandemic is new and whenever you're dealing with something new you end up having to sort through what's an association and what's a true signal.
30:16 This has come up as a theme in many of the questions that we've answered today, you know diabetes can’t be caused by COVID-19, there is an association between these different things, what does that end up panning out is only time and further studying and monitoring is going to tell us.
30:33 For people trying to sift through all that in this era of us being so overtly transparent about every single tiny development in this story, it becomes really difficult.
30:44 There are probably things we can all do in terms of limiting the amount of doom scrolling and you know surveying what's coming up in every news article of the moment and really choosing some reliable sources of information and groups that you know are going to be taking an unbiased view and trying to look at the big picture.
31:08 To get that information, I will say in my view for the most part the media has been doing an excellent job at trying to cover some really complex issues. I've been very impressed with how some of it's been covered.
31:23 But it doesn't matter it's just a lot of information. I don't know Dr. Jain do you have any thoughts about what your best sources are and how you manage the overload?
31:34 I mean it's a state of flux. As you really eloquently pointed out, it's a dynamic situation that's constantly evolving. I personally feel that anytime someone hears about something that just happened I think we should avoid a knee-jerk reaction because we need you know more data to assimilate and form a logical conclusion. Which is how we've been doing or managing scientific evidence for a while now
32:05 I would suggest not reacting to every new thing that you hear. Wait until there is a formal assessment of that by the medical community, by a provincial ministry of health, and also know you can have that chat with your doctors.
32:25 We're all in this together, things are changing all the time and we are still uncovering more and more details about this.
32:34 Thank you so much to both of you for those answers. Speaking personally as someone who lives with diabetes it can be very difficult to sift through all this information. Those are really helpful strategies and I really hope that to our viewers of this webinar has been helpful for you
32:50 I'll reiterate if you have any questions or want further information or resources please do feel free to contact Diabetes Canada, Call 1-800-BANTING or email firstname.lastname@example.org. Visit our website if you'd like to look for COVID-19 specific resources, diabetes.ca/coronavirus.
33:12 Once again a wholehearted thank you to our special guests Dr. Susy Hota and Dr. Akshay Jain, and everyone watching and hopefully applying all that you've learned in this session. This concludes today's program
33:27 To everyone watching and to our guests take care and thank you