Germany Saw Significant Increase in T1D, DKA Onset During COVID-19 Pandemic


Based on trends between 2011 and 2019, type 1 diabetes (T1D) and diabetic ketoacidosis (DKA) incidence in German children and adolescents increased significantly more than previous estimates.

During 2020 and 2021, there was a significant increase in type 1 diabetes (T1D) and diabetic ketoacidosis (DKA) incidence in Germany, compared with long-term trends prior to the COVID-19 pandemic.

There were also deviations from pre-pandemic seasonal incidence patterns, but no significant increase in autoantibody-negative diabetes during this time.

These findings were published in Diabetes Research and Clinical Practice. The study authors said the results emphasize the need for further monitoring and efforts for DKA prevention at T1D onset.

The authors used data from 30,840 children and adolescents aged between 6 months and 18 years with new-onset T1D enrolled in the German multicenter Diabetes Prospective Follow-up Registry. Of this group, 45% were female and the median age was 9.7 years.

Using long-term trends from between 2011 and 2019, they estimated adjusted incidence rate ratios (IRR) for T1D and DKA, as well as prevalence rate ratios (PRR) for autoantibody status with 95% confidence intervals (CI) for 2020 and 2021. These estimates were then compared with actual trends in T1D and DKA onset during the latter years.

Between 2011 and 2019, the number of annual cases of T1D and DKA combined ranged between 2291 and 2981 per year. In 2020, this number increased to 3418, and jumped further to 3706 in 2021. Of these cases, 33.4% and 34.2% had DKA at the time T1D diagnosis in 2020 and 2021, respectively. Meanwhile, these proportions ranged between 13.8% and 26.5% prior to the pandemic.

“The increase of new diabetes and DKA cases in 2020-2021 compared to 2011-2019 becomes evident from the monthly cumulative numbers by year of manifestation,” the authors said.

Looking at T1D specifically, incidence increased by an average of 2.2% (95% CI, 0.9-3.6) per year. Following this trend, the authors predicted a T1D incidence of 22% (95% CI, 21.1-22.9) in 2020, and 22.4% in 2021 (95% CI, 21.6-23.4). However, the observed incidence was significantly higher in both years, with 24.9% (95% CI, 23.9-25.8) in 2020 and 27% (95% CI, 26.0-28.0) in 2021.

The authors measured an IRR of 1.13 (95% CI, 1.08-1.19, P < .001) in 2020 and an IRR of 1.20 (95% CI, 1.15-1.26, P < .001) in 2021. When stratified by age group, younger age group was associated with higher IRR.

Additionally, during the COVID-19 pandemic, the observed proportions of autoantibody-negative cases were not significantly higher than estimated, and while seasonal patterns of autoantibody-positive cases differed significantly compared with pre-pandemic patterns, the seasonality of autoantibody-negative and autoantibody status unknown cases did not change.

The incidence and proportion of DKA and severe DKA (sDKA) in new-onset T1D increased significantly prior to the COVID-19 pandemic, and incidence was also higher than predicted during the pandemic.

In new-onset T1D, observed DKA incidence was 8.3 in 2020 (95% CI, 7.8-8.9) and 9.2 in 2021 (95% CI, 8.7-9.8). The measured IRR for 2020 was 1.34 (95% CI, 1.23-1.46, P < .001) and the IRR for 2021 was 1.37 (95% CI, 1.26-1.49, P <.001). The observed DKA proportion at the time of T1D diagnosis during both pandemic years was also higher than expected.

Further, the observed sDKA incidence was significantly higher during the pandemic than predicted, with an IRR of 1.35 (95% CI, 1.17-1.57, P < .001) for 2020, and 1.30 (95% CI, 1.13-1.50, P < .001) for 2021.

The authors noted that several hypotheses have been proposed to explain this observed increase in DKA during the COVID-19 pandemic, including delays in seeking medical care, which could be attributed to restrictions, fear of infection, or health sector overload. Other hypotheses suggest the shift of the health care system’s focus to combatting COVID-19 may also have affected the recognition or interpretation of T1D symptoms.

“The increase in DKA highlights the fragility of care for children with new-onset diabetes during the COVID-19 pandemic and emphasizes the need for the introduction of effective prevention strategies such as educational campaigns,” the authors said.


Baechle C, Eckert A, Kamrath C, et al. Incidence and presentation of new-onset type 1 diabetes in children and adolescents from Germany during the Covid-19 pandemic 2020 and 2021: current data from the DPV Registry. Diabetes Res. Clin. Pract. Published online February 7, 2023. doi:10.1016/j.diabres.2023.110559

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