key: cord-0906359-q15f72zy authors: Thomaz Ugliara Barone, Mark; Villarroel, Douglas; Vieira de Luca, Patrícia; Bega Harnik, Simone; Lima, Bruna; José Pineda Wieselberg, Ronaldo; Giampaoli, Viviana title: COVID-19 Impact on People with Diabetes in the South and Central America date: 2020-07-03 journal: Diabetes Res Clin Pract DOI: 10.1016/j.diabres.2020.108301 sha: 352da07181fff0deef01b07b9e59cbc1ac50304b doc_id: 906359 cord_uid: q15f72zy Abstract Aims The present observational study aims to describe the political actions in place to fight COVID-19 in the South and Central America region (SACA) while protecting individuals with diabetes. Methods A survey with 12 questions was shared with all IDF-SACA member organizations, in 18 countries. A descriptive analysis was performed and a multivariate cluster analysis technique pam (partitioning around medoids) was applied. Results Two groups of countries were identified. The first group reported more difficulties (limitations in accessing basic or health needs) and fears (concerns regarding the impact of the pandemic), mostly countries with stricter measures to contain the spread of the virus, whereas most of the second group consisted of countries with less restrictive measures, and reported fewer difficulties. Only 37% responded that a policy was put into place to protect individuals with diabetes delivering their medicines and supplies at home (16%) or receiving at once medicine and supplies enough for 2-3 months (21%). All respondents reported as one of the main fears “be infected and do not receive adequate treatment” and/or “getting infected if going to the hospital or medical appointments”. Conclusions Most of the SACA countries lack timely implemented measures to protect individuals with diabetes, which may lead to present and future severe impact on the individuals, health system and economy. The COVID-19 pandemic has been testing the capacity to respond and adapt of populations, governments and health systems worldwide. A highly contagious disease that started in China, in December of 2019, in a few months spread unprecedentedly throughout the world and collapsed the health system of regions and countries considered well prepared [1] [2] [3] [4] [5] . Data show that the time to respond and measures adopted predict outcomes [4, [6] [7] [8] . In the South and Central America region (SACA), Brazil presented the first suspected and the first confirmed cases on January 27th and February 26th, respectively [9] . Notwithstanding, in a region where differences in time and measures to respond were astonishing [10] , Brazil did not take advantage of the early alerts and, as a consequence, quickly climbed to one of the highest global positions of cases, deaths and case fatality rates [11] [12] [13] . Neighbor countries responded much faster and in a stringent manner, with lockdowns starting in Peru on March 15th [10] , followed by many of the other SACA nations, and lasting much longer than initially planned [13, 14] . The first publications about the pandemic in China and Italy revealed that people with diabetes and other noncommunicable diseases are in risk for higher COVID-19 severity and mortality [4, [15] [16] [17] [18] , which was shown to be especially associated with hyperglycemia [15, 19] . SACA presents a prevalence of diabetes of 9.4%, which surpasses 31.6 million people [20] . The region is also known for its active vector-borne diseases, where malaria, dengue and yellow fever should be highlighted due to their current outbreaks in some of the countries and because they add uncertainty to recommendations and diagnosis where COVID-19 tests are insufficient [13, [21] [22] [23] . Despite all local and global alerts [17, 24] , it is unclear whether governments are taking specific measures to protect people with DM that, if infected, would quickly occupy the limited number of ICU beds available, in a region where health systems are already considered fragile [13, 21, 22] . The present study aimed to identify the main public political actions in place to fight COVID-19 in the SACA region while protecting individuals with diabetes, and also the main challenges and worries faced by this population during the pandemic period. A survey in Spanish, with 12 questions, was shared through e-mail and the WhatsApp group with representatives of all the 40 diabetes organizations, in 18 countries, that are members of the International Diabetes Federation (IDF), in the SACA region. It was composed of 4 questions for identification of the association, representative who was answering, country and type of the town (coastal, capital or inland). Four other questions were regarding policies including: presence of policies to fight COVID-19, social distancing orientations, specific policies to protect people with diabetes and potential changes in terms of subsidies to medicines, supplies and exams for people with diabetes. One question was about the presence of official data on infection and mortality of people with diabetes during the pandemic and the following two were about main challenges and fears of people with diabetes due to COVID-19 (respondents could select more than one fear and one challenge). The last was an open space for adding country information on how the pandemic was affecting individuals with diabetes. A database was built aggregating answers of respondents from the same regions (i.e. all answers from Argentina were from the capital and were aggregated in one final answer; from Ecuador there were two answers from the capital, one from the coast and one from inland, with different aspects in each of them, reason why Ecuador-capital, Ecuador-coast and Ecuador-inland were created). As a result, from the total number of 26 responding organizations, from 16 different countries, the processing led to 19 different final analyzed reports (table 1) . A multivariate cluster analysis technique pam (partitioning around medoids) was applied using the silhouette method to identify the group of countries. The multivariate cluster analysis determined the ideal number of groups, identifying similarities in relation to the reported challenges and fears, which resulted in 2 groups. In the group 1 were countries reporting greater number of difficulties and fears: Argentina, Chile, Costa Rica, Ecuador, Ecuador-inland, Ecuador-coast, Nicaragua, Puerto Rico, Dominican Republic and Venezuela. In group 2 were: Bolivia, Brazil, Brazil-inland, Cuba, Guatemala, Honduras, Paraguay, Peru and Uruguay. Nicaragua was the only country in which it was reported that there are no public policies to deal with the pandemic, nor even recommendations for social isolation. Brazil-inland, Cuba and Honduras were the only ones that did not report one or more of the challenges or fear related to shortage or lack of medicines and medical supplies, difficulties in access to medical services. The countries that already reported shortage or lack of medicines and medical supplies were: Argentina, Ecuador-inland, Ecuador-coast, Guatemala, Nicaragua, Uruguay, and Venezuela (most of them in the group 1 above). Current difficulties to access health services were reported by Argentina, Bolivia, Brazil, Chile, all three Ecuador, Nicaragua, Paraguay, Peru, Puerto Rico, Uruguay, and Venezuela. Concerns about the consequences for the economy were reported by most respondents, with the increase in product price of first necessity the most cited (figure1). Although the responses unveil the presence of COVID-19 policies in most of the countries (95%), only one of them (5%) without any policy, half reported partial lockdowns, where there is a recommendation to "stay-at-home", but no mobility restriction enforced by law (which is the case of the other half). Although Asian and European countries have experimented different tactics and specialists have alerted SACA countries on the potential consequences of not adopting certain restrictive measures [3, 12, 22] , most of these answers were aligned with previous reports [10, 13] , however we were also interested in understanding specific policies to protect people with diabetes. Unfortunately, only 37% responded that a policy was put into place to protect individuals with diabetes delivering their medicines and supplies at home (16%) or receiving at once medicine and supplies enough for 2 or 3 months (21%). This means that the other 63% is just being advised to stay at home (42%) or not even that (21%). For the reasons presented in the introduction, higher risk of poor outcome for people with diabetes when infected by SARS-CoV-2 [4, [15] [16] [17] [18] 25] , it would be wise for governments to implement early strategies on this matter aiming to, prevent the spread of the virus and protect its hospitals from unsustainable high demand. The absence or weakness of protective policies creates fear, reason why all respondents reported as one of the main fears "be infected and do not receive adequate treatment" and/or "getting infected if going to the hospital or appointment with a physician" (figure 2). Consequently, a survey in Brazil [24] revealed that 38.4% of the individuals with diabetes are postponing their medical appointments or laboratory exams and 5.8% stopped reclaiming their medicines and medical supplies for diabetes self-care. Therefore, the potential consequences of these fears on populations with diabetes can be catastrophic, increasing the already high incidence of chronic complications and favoring that they get in an even more risky metabolic situation if infected by SARS-CoV-2 [15, 19] . Thus, among the protective measures to be promptly implemented, we recommend telehealth, teleconsultation and other online strategies to overcome the challenges of healthcare professionals' limitation, while keeping individuals with diabetes protected and assisted [24, [26] [27] [28] . Successful measures used by different nations included monitoring, testing, isolating and treating, which would work especially within a well-organized and integrated health structure and data systems with availability of COVID-19 tests, and trained healthcare professionals. In SACA and other regions, these components have constraints [3, 13, 21] , a probable reason why only 26% of our group reported that official data on COVID-19 in people with diabetes is available in their country. The multivariate cluster analysis revealed that, in general, countries with more restrictive measures were the ones where more challenges and fears were reported, the exceptions in this analysis are Bolivia, Nicaragua and Venezuela. Bolivia, even reporting among the most restrictive measures, listed few challenges and fears (compatible with group 2, where countries that adopted less stringent measures were). In Nicaragua, no social distancing policy was reported, while Venezuela reported policies and measures of the same level as Honduras or Brazil, but both still listed many challenges and fears (equivalent to group 1). Therefore, the perceived challenges during the pandemic would also be associated with the trust in the country's health system and potential to respond. It is also clear that the unfortunate prediction of lack of medication and supplies -such as syringes, needles and glucose strips -and difficulties to access medical services -especially consultation with a physician and lab exams -were reported by most of the respondents, 68.4% and 57.9%, respectively [29] . These findings play against the recommendation of maintaining or even improving during the pandemic blood sugar levels and diabetes selfcare [25, 26, 28, 30] , since diabetes is a known risk factor for severity and mortality by SARS-CoV-2 infection [4, 15, 16, 25] , which is especially increased when associated with hyperglycemia [15, 19] . An aspect that must not be disregarded, highlighted by other authors [13, 21, 31] is the socioeconomic harm caused by the pandemic, already suffered by 12 out of the 16 respondent countries, 78.9% of the answers (figure 1: increase in costs, unemployment and lack of economic support from the government). Since not all SACA region count on full health coverage and in different countries where there is coverage by the public health system, part of the population still has additional private plans [24, 32] , this economic burden may severely impact diabetes management and control in short, mid and long term. The consequences of reduced access to healthcare and medicines because of impoverishment would be disastrous, with dramatic increase in the prevalence of chronic complications. While four countries did not report those same challenges, it is worth emphasizing that they reported other severe current experiences; two of them (Bolivia and Paraguay) experiencing challenges to access health services, Cuba experiencing lack of fresh fruits and vegetables, and Honduras experiencing lack of food in general. Among the limitations of the present study is the lack of response from members of all the 40 diabetes organizations that are IDF members. We received responses from 26 of them, representing 16 out of the 18 countries and regions that form the IDF SACA group. Noting that the survey was not conducted in a representative sample of the population with diabetes in this region, and therefore no generalization can be made for the people with diabetes, but for the organizations who represent them, and are likely to be aware of the adopted policies and measures. Therefore, as such, reported perceptions were built by the experiences of each respondent, and may not necessarily reflect the general opinion of the population that they represent. We would also highlight the fact that, since most diabetes organizations are based in the capitals, the interior and coastal areas of the region may be experiencing situations that were not captured. Another limitation, intrinsic to surveys, is the absence of all answers that the respondents would like to find, reason why we found the following comments "question 9 is not well formulated" or "not all questions reflect precisely the situation in our country". Although SACA region was not among the first to be infected by SARS-CoV-2 and, theoretically, would benefit from more time to prepare than nations in Asia or Europe for example, several of those nations experienced great and/or prolonged consequences. The previous preparedness for disasters, presence of a consistent universal health system and coverage, effective communication channels and means to invest in new priorities would differentiate countries in this unexpected battle. Notwithstanding, the diabetes organizations of "better prepared countries" not necessarily reported less perceived challenges or fears. Thus, in the present study we identified that, according to the respondent organizations, individuals with diabetes, known to be in higher risk for poor prognosis if infected by the new coronavirus, did not feel protected, and most are already suffering socio-economic restrains and/or limitations to access healthcare and/or supplies as effects of this pandemic. We understand that, as shown in countries where the SARS-CoV-2 spread started earlier, measures must be quickly and timely implemented to protect the population, with potential to reduce time in quarantine or lockdown. Moreover, specifically about individuals with diabetes, knowing about their higher risk, especially when presenting glycemic levels out of target, protective measures and strategies to facilitate optimum self-care must be adopted. In the present study, more than 68% of the respondents reported current shortage or lack of medicines and almost 58% difficulties in accessing health services. 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