Our data show a significant reduction in hospitalization of children with new-onset T1D 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 DKA increased significantly, suggesting that delays in seeking care by parents, and delayed diagnosis or referral due to closure of neighborhood healthcare facilities probably increased the severity of DKA (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 healthcare (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 hospitalizations in our set-up also (7). Irrespective of the cause, the lower rate of admitted and therefore treated children with new-onset T1D is worrisome for, one that these children may be suffering or dying at home, and second, there might be a surge of presentations with complications related to delayed or missed diagnoses of T1D after the COVID-19 pandemic begins to recede.
In LMIC, children with T1D are considered vulnerable to acute complications due to poor healthcare infrastructure in general and the lack of attention by the government, policy makers, and healthcare professionals (HCPs) in particular (8). Experts still worry about missed diagnoses and deaths before the diagnosis of pediatric T1D, especially in rural areas (8). Currently, the overwhelmed healthcare systems in LMIC are very likely to fail to provide essential care to non-COVID-19 conditions similar to the Ebola virus outbreak of 2014-16. 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 (9). After the COVID-19 pandemic, we may face a similar revelation about pandemic-time mortality due to non-COVID-19 conditions in children. 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 T1D. India’s performance on completeness of cause-of-death data is among the lowest of about 10% as compared to the global average of 48% and the European average of 97% (10). Even post-pandemic verbal autopsy analysis is unlikely to ascertain the cause of death, as the nonspecific initial symptoms of pediatric T1D 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 T1D. The national governments and health agencies in LMIC should respond with aggressive media campaigns to make parents aware that the risk of delayed access to hospital care for new-onset T1D can be much higher than that posed by COVID-19.