Social vulnerability contributes considerably to the probability of hospitalisation among individuals with COVID-19 and diabetes with associated comorbidities. This is the conclusion of a recent cross-sectional study, published in Diabetes Care, from Sandra G Sosa-Rubí (Center for Health Systems Research, National Institute of Public Health, Cuernavaca, Morelos, Mexico) and colleagues. They notify readers that their findings can inform mitigation strategies for populations at the highest risk of severe COVID-19, and call for a reallocation of health care resources to vulnerable groups during this and future pandemics.
“Diabetes is an important risk factor for severe COVID-19, but little is known about the marginal effect of additional risk factors for severe COVID-19 among individuals with diabetes,” Sosa-Rubí et al say. They therefore tested the hypothesis that sociodemographic factors, access to health care, and presentation to care characteristics among individuals with diabetes in Mexico confer an additional risk of hospitalisation with COVID-19.
To assess this, they conducted a cross-sectional study using public data from the General Directorate of Epidemiology of the Mexican Ministry of Health. They included individuals with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SAR-CoV-2, the virus that causes COVID-19) between 1 March and 31 July 2020. The primary outcome was the predicted probability of hospitalisation, inclusive of 8.5% of patients who required intensive care unit admission.
Among 373,963 adults with COVID-19, 16.1% (95% confidence interval [CI], 16–16.3) self-reported with diabetes. The predicted probability of hospitalisation was 38.4% (37.6–39.2) for patients with diabetes only, and 42.9% (42.2–43.7) for patients with diabetes and one or more comorbidities (obesity, hypertension, cardiovascular disease, and chronic kidney disease). High municipality-level of social deprivation and low state-level health care resources were associated with a 9.5% (6.3–12.7) and 17.5% (14.5–20.4) increased probability of hospitalisation among patients with diabetes, respectively. In age-, sex-, and comorbidity-adjusted models, living in a context of high social vulnerability and low health care resources was associated with the highest predicted probability of hospitalisation. Speaking an indigenous language was also associated with an incremental probability of severe COVID-19 among individuals with diabetes and one or more comorbidities.
Highlighting the severity of this issue, Sosa-Rubí and colleagues explain: “Before the COVID-19 outbreak, type 2 diabetes, which is highly prevalent among individuals of low socioeconomic status in Mexico, represented one of the most significant challenges to Mexican health care, a fragmented health system, in a major process of transition, with well-documented disparities in health care delivery. The convergence of the COVID-19 and diabetes epidemics has widened these pre-existing health disparities in Mexico, thus raising the urgent need to better understand factors associated with poor outcomes among individuals with diabetes and COVID-19.”
They add: “These findings confirm what has been previously documented on the role of diabetes and associated comorbidities on severe COVID-19, and add to the existing literature on social disparities uncovered by this epidemic by highlighting social vulnerability characteristics that amplify the risk of severe COVID-19 in this high-risk population.”
Indeed, Sosa-Rubí and colleagues call for government action to provide social support to those identified as most at-risk of COVID-19. They write: “The COVID-19 epidemic has revealed pre-existing health disparities in Mexico and other contexts. Despite efforts aimed at increasing health care access for socioeconomically vulnerable groups, the unprecedented stress that this pandemic has brought to the fragmented Mexican health system has highlighted important shortcomings in previous attempts at reducing health inequalities in Mexico.
“It is noteworthy that shortly before the COVID-19 outbreak, the new government administration abolished or dismantled important social and health programmes. While strategies to reduce metabolic disease in the country and improve regular access to comprehensive and high-quality health care should be prioritised, reallocation of health care resources to vulnerable groups during epidemics such as COVID-19 is also of paramount importance. Resources should be used to finance focused interventions aimed at reducing the risk of infection in vulnerable populations, such as financial and social support to help them stay at home during the acute phase of an epidemic, and to improve timely access to health care in case of infection. While the Mexican government has implemented some measures to improve access to all public health care providers, pre-existing disparities in access to care remain an important barrier to mitigating the risk of severe COVID-19 among individuals with diabetes and associated comorbidities who live in contexts of high social vulnerability, most notably patients with diabetes in indigenous communities.”