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Background
During the pandemic situation, patients with Diabetes Mellitus (DM) showed the highest risk of mortality rate. According to the data,Diabetes mellitus (DM) played the most significant role as a comorbidity during the pandemic situation. Existing studies show the fact that DM was the main determinant of the mortality rate. It is very much clear that the patient who was admitted to the hospital with DM showed the highest risk ofmortality, which had an independent association with clinical and biological predictors including the “micro and macro vascular complications of DM (Singh et al. 2020).” According to the data, the negative effect of the COVID-19 pandemicis observed in a patient who was suffering from DM because of the conversion of the enzyme-2 receptor-mediated entry of the virus SARS-CoV-2 which simplifies the entry of the virus into the host cell. As a result, it ultimately damages the insulin producing "pancreatic islet cells” which increases the risk factors for those patients. The first case of COVID-19 was observed in Libya, North Africa in March 2020. The predominant Comorbidities, whichwere observed in Libya, North Africa was the DM.
Figure 1: Covid-19 cases rates in Northern Africa
(Source: Statista.com, 2021)
People with DM who were admitted to the local hospitals after being affected by COVID-19 showed the highest rate of mortality among the other comorbidities. More than 490 patientswere admitted to the hospitals due to the presence of DM, which indicates the fact that more than 40.6% of the patients died after the infection (Frontiers in.org, 2022). Due to the presence of some illegal activity in North Africa, the healthcare system is not properly working in those areas that are the reason people with DM showed the highest morbidity in Libya in comparison with the other countries of North Africa. As per the report, diabetic patients showed the highest chance of serious complications during this pandemic situation due to the low amount of the immune system.In the year 2020, about35,486patients were admitted due to the presence of COVID-19, whowere already exposed to the `DM among them 5867 people died which showed the highest amount of mortality during the pandemic situation. That is near about 16% of the mortality rate, which is showing the effect of DM globally in comparison with Libya, and North Africa.
Rationale
The issue is related to the different kinds of risk factors associated with Diabetic patients who faced huge issues during the Covid-19 pandemic situation. Different factors influenced the infection with Covid-19 and those risk factors increased the mortality rate of diabetic patients during the pandemic, which is the core topic of this research article. After getting the infection, the virus damages the cells, which are associated with the glucose control activity within the patient. That is the reason the person who was dealing with diabetes showed the highest morbidity rate. In the development in the present scenario where the negative impact on the patient who is suffering from DM will help to understand, the effect of COVID-19 can be still observed. The effect of this pandemic on these people who have been suffering from DMcan be observed due to the presence of the virus within the host cell, which damages the insulin-producing cells, which produce insulin, which controls the blood glucose.
Significance
The significance of the study is to find out the risk factors, which are associated with diabetic patients who are suffering from diabetes. This is necessary to find out the proper treatment, which can reduce the high risk of morbidity for patients who are diabetic, and this will guide the patients to stay positive during the pandemic, which is beneficial for their mental health also.
Aim
What are the most significant risk factors of dying or being hospitalized because of covid-19 if you have diabetes?
Objectives
The first objective is based on the different factors, which are associated with COVID-19. That deals with the relationship between diabetes and COVID-19. This is one of the most important objectives. The second objective is completely based on the fact that risk factors of diabetic patients during the pandemic situation of COVID-19 are very much important to understand the role of the virus and its mechanism to use the host cell of a diabetic person to increase its effectiveness in human beings.
The effectiveness of COVID-19 among diabetic patients is another objective that helps in the development of the proper idea about the role of the viruses, which damage the insulin production cells as a result the control of the glucose within a person,is indirectly controlled by those viruses, which open a broad field of research. The last objective is wholly based on the different interventions, which help in the proper management of diabetic patients who have been suffering from COVID-19. These interventions are necessary for the health workers who are dealing with diabetic patients who are infected by COVID-19.
RESEARCH QUESTIONS
Conceptual framework
Concepts
Several factors may influence the COVID 19 infection. Lower immune systems have a direct relation with COVID 19 disease. Diabetes causes lower immune systems in the body hence, it can be said that it may influence the impact of COVID 19 infection. Following are some of the factors that may also increase the severity of the disease due to low immune system,
Age
People belonging to any age can be affected by this virus infection. However, most cases of this disease can be found among middle-aged people as well as old people. The risk is very high in the case of old people. The immune system of old people is very low; hence, resistance to the effect of the virus may be reduced. Hence, it can be said that there is a higher chance of COVID 19 disease in old-aged people. Besides, the rate of hospitalization or mortality due to this viral infection is higher in the case of old people.
Lung problems
Coronavirus attacks mainly the respiratory system of humans. Hence, it damages the respiratory system. However, if the person already has lung problems, he or she might be severely infected due to the infection. Hence, according to Al-Jayyousiet al. (2021), this situation can lead to hospitalization and mortality of the patient. Several lung problems that may increase the severity of the disease may include asthma, Cystic fibrosis, pulmonary hypertension, COPD, and so on.
Heart disease
Many health diseases can influence the development of COVID 19 symptoms, such as Cardiomyopathy, Heart failure, disease of the Coronary artery, and so on.
Condition of the nervous system and the brain
Some health conditions that may impact the nervous systems and the brain of humans can be the influencing factors of COVID 19 infection. Those factors are Stroke, Dementia, and many more.
Figure 2: Factors influencing COVID 19
(Source: Al-Jayyousi et al. 2021)
Obesity and Diabetes
These two diseases are responsible for the reduction of the immune system of the body; hence, the risk of COVID infarction is higher among the people who have these two diseases. When the immune system is weak, the body cannot fight against the virus infection, hence, the severe impact of the viral infection can be seen (Chaudharyet al. 2021).
“Sickle cell anaemia”:
These are the blood-related disorders that have influenced the impact of coronavirus upon the human body. This disease is inherited from the previous generations, due to this disease; the RBC becomes sickle or C-shaped. Hence, the RBCs cannot carry enough oxygen to the lungs. Hence, as the COVID 19 disease impacts the respiratory system, sickle cell anaemia can be the influencing factor for the severity of the COVID 19 infection.
Severe liver or kidney disease: COVID 19 is highly related to weaker immune systems. Liver and kidney diseases can weaken the immune system (Almaiahet al. 2020). As a result, the impact of COVID 19 becomes severe in the case of these diseases.
Down’s syndrome
This is a genetic disorder. Due to this syndrome, severe physical, as well as mental problemscan be seen in the affected person (Bull, 2020). Hence, there is a higher chance of severity of coronavirus infection among people who already have many physical and mental health problems.
Bidirectional relations can be found between diabetes and COVID 19 disease. Diabetes is associated with the increased risk of severity of the COVID 19 infection. However, on the other hand, the severity of diabetes can be seen in the case of COVID 19 infected patients. “Severe acute respiratory syndrome coronavirus 2” or SARS-CoV-2 is the virus that causes COVID 19.
When it attacks a human body, it binds to ACE2 or “angiotensin-converting enzyme 2”. This is related to several metabolic organs (Singh et al. 2020). This is related to beta cells of the pancreas, small intestine, and kidneys. Hence, there is a possibility that if the virus attacks a person, a malfunction of glucose metabolism can be seen that may cause disease. Hence, it can be said that it may also impact or affect the metabolism of glucose. Hence, the level of glucose in the body may increase rapidly. This may cause diabetes as a result. If the pancreas is affected by the viral infection, there might be a problem in the release of insulin. Insulin is one of the most important chemicals to convert glucose into energy (Erener, 2020). Hence, it can be said that if glucose is not converted to energy properly, the level of glucose can be increased. This situation is called diabetes. Hence, it can be said that if the rate of insulin is lower due to the malfunction of the pancreas, the glucose level will be high.
On the other hand, diabetes may have an impact on the immune system of the human body. Hence, it can be said that this may influence the severity of the impact of COVID 19 infection. This infection is one of the reasons that decrease the chance of self-recovery of the body against the infection (Peric and Stulnig, 2020). Hence, from the above discussion, it can be said that diabetes and COVID 19 infection have Bidirectional relation. In some cases, coronavirus infection causes diabetes and in other cases, diabetes may be the reason for the severity of the coronavirus.
As mentioned before, COVID 19 disease, which is caused by the infection of coronavirus, is a widespread disease throughout the world. Infection of this virus causes many diseases, especially problems related to the respiratory system of humans (Saqibet al. 2020). However, the health impact due to the infection of this virus may vary from person to person. Hence, several factors have an impact on the health of the person who is infected with COVID 19 infection.
Diabetes mellitus or DM has a relation to the health impact of coronavirus infection. Several studies stated that there is a higher risk of health or even death with a poor outcome of corona infection if the person is diagnosed with diabetes mellitus (Sanyaoluet al. 2020). However, several factors may have a role to increase the health risk of the diabetic person who is infected by the virus. It can be said that people having DM generally have a weak innate immune response. As a result of this low level of inflammation can also be seen in the body of the person. Hence, the person may face an abrupt metabolism. Hence, the level of leptin becomes higher and the level of adiponectin decreases. This interruption in the proper response of the immune system is also caused by unfavorable hormonal conditions (Abu-Farha et al. 2020). Due to low levels of the immune system, the infection of the virus may cause more health damage to the patient with diabetes mellitus. Hence, it is clear that patients with high levels of glucose in the blood are more affected by the virus and hence, the number of hospitalizations canbe increased due to this reason. Hence, an increase in mortality rate due to disturbed immune systems can be seen in the case of COVID 19 patients.
However, it can be said that besides, DM, several other diseases like cardiovascular disease, and high blood pressure can also have a relation to an increase in the rate of hospitalization and rate of mortality for the patients who have been diagnosed with COVID 19 disease.
Coronavirus mainly targets the respiratory system of the human body. Due to diabetes, injuries in vascular systems can be seen. Hence, it can be said that coronavirus can affect injured areas more than other areas (Sacks et al. 2020). However, this is another reason that may indicate that a higher level of glucose in the blood may cause more damage to the body.
How Bere, it can be said that there is a link between the mechanism of COVID 19 and DM. An overlapcan be seen in the pathway of immune function regulation. It can be said that age is one of the most important factors for T2DM and low immune system (Bhandariet al. 2020). Hence, it can be said that COVID 19 has also a relation to T2DM and the age of the person due to a lower immune system.
According to several studies, the mortality rate and the severity of COVID 19 are much higher among diabetic patients. Hence, it can be said that level of glucose and reduction of the impact on the immune system can play a major role in increasing the severity of the disease. According to Carr et al. (2021) in the UK, the mortality rate of patients with diabetes has increased due to COVID 19. Another study shows that during 2020, the mortality rate of diabetic patients in Libya, North Africa was at the highest, considering the previous records of the disease. Hence, it can be said that there is a relationship between diabetes and the severity of this infection. On the other hand, according to Carr et al. (2022) during the pandemic, the mortality and severity of the disease is not only high among diabetic patients but also a decreased rate of diagnosis of DM in the UK. According to this study, there is a reduction in the diagnosis of diabetes 2, by 0.07%. More diagnoses can be seen over the last 10 years. However, older people have a smaller reduction in the rate of a diabetes diagnosis. However, in December 2020, the reduction rate of diabetes diagnosis was 0.32%.
Another study done by Carr et al. (2021) shows that during the pandemic period, over-reducing in health checks can be seen by 76%–88%. According to her study, among 61?414?470 individuals who have been diagnosed with the COVID 19 infection in the UK, 0.4% were diagnosed with type 1 diabetes and 4.7% with type 2 diabetes, and .01% with other types of diabetes.
Hence, for the above discussion, it can be said that there is a positive relationship between the severity of the viral infection and all types of diabetes. According to the mentioned data, it can be said that the rate of type 2 diabetes is higher, related to other types of diabetes.
However, from the above discussion, it can be said that diabetes patients have a higher risk of covid 19 infection. Hence, it can be said that the people who have been diagnosed with any form of diabetes must be careful during this pandemic situation. Diabetes causes the reduction of the power of the immune system of the body, hence, it can be said that if a person is diabetic, he or she must have a greater chance of being infected by the coronavirus as the body cannot fight back to the virus attack due to the lack of immunological power. On the other hand, if a person is infected by the coronavirus, it may reduce the functionality of the metabolic system which causes a reduced rate of glucose conversion and ultimately causes diabetes.
Hence, from the above discussion, it can be said that diabetes and COVID 19 have a relationship. This relationship is Bidirectional. In other words, it can be said that both diabetes and covid influence each other. Diabetes is the main reason for damaging the immune system of the human body. However, COVID 19 infection is the most important to damage the immune system as well (Verma et al. 2021). Hence, it can be said that if a person has diabetes and his immune system becomes weaker, the person is easily affected by COVID 19. On the other hand, if the virus infects a person, the pancreas and other metabolic organs of the person may be damaged. Hence, it can be said that this will lower the risk of diabetes in the person. However, several interventions must be maintained by the person to prevent these problems during COVID 19. Those have been mentioned below,
People with diabetes must be very careful when there is a higher chance of this viral infection. However, the above-mentioned recommendation can be very helpful for them to avoid the disease (Koliakiet al. 2020). This is very important to have proper safety in this situation as the severity of COVID 19 in case of diabetes can be seen. Hence, controlling the level of glucose and maintaining the proper safety protocols provided by the government can be very helpful to avoid such situations.
Models
Various models are present behind the analysis of a particular disease and its effect on a particular population. In this research article, the effect of COVID-19 on diabetic patients is completely discussed in two models and tw3o theories are taken for the analysis of this scenario. Those two models and theories are as follows:
Epidemiological triad
The model of the epidemiological triad or triangle is one of the most traditional models for understanding infectious diseases (Panditand Akkara,2020). The concept of the Epidemiological triad is mainly dependent on three factors they are as follows:
1) Agent
2) Host
3) Environment
In this model, the agent is mainly identified as the external factor which plays an important role in the development of a powerful impact on the people who are associated with the infectious disease. In this research, article Sars-CoV-2 plays the role of the agent that increases the mortality rate among diabetic patients (Kumar et al. 2021). The mechanism of the agent behind the penetration is important which helps to understand the target tissue of the agent within the host body and its role in damaging the pancreas cells that produce Insulin.
Host refers to the human beings who can get the disease. Different risk factors are associated with the diseases, which is the reason some infectious diseases are more dangerous than others. In this research article, the host is identified as a Diabetic patient who showed the highest death rate and hospitalization rate during the pandemic situation (Méndez-Martínezet al. 2018). The penetration mechanism of the agent within the host cell is important for a better understanding of its impact on people who have diabetes.
The term environment refers to factors that affect the agent. The environment is associated with exposure to the agent. There are different types of environmental factors, which are associated with the agent that is present insociety, which can be physical factors like the climate, or maybe biological factors such as insects that act as the agent is mainly the key factor behind the spread of the infectious disease (Tsuiet al. 2020). In this research article, the biological factors are identified as the main environment behind the spreading of the Coronavirus all over the world. The role of the biological factors and their impact on diabetic patients by COVId-19 is the main topic for discussion (Cdc.gov, 2022).
Figure 6: epidemiological triad
(Source: cdc.gov)
Baseline model
The baseline model is mainly used in the development of the aims and predictions of an infectious disease. In this article, the evolution of the COVID-19 pandemicis completely discussed with the progression of time. This model is a representation of the regression-based predictive model (Bardaet al. 2020). The model is completely based on the “regression analysis of cumulative count” of the infected cases daily. The growth rate of the process is mainly discussed within this particular model but this article is based on the risk factors associated with diabetic patients during the COVID-19 pandemic situation.
The main formula behind the baseline model, which is used to analyse the growth rate, is represented by the:
Where the Iis mainly unidentified by the infected people at a particular time t. λ is the main growth rate behind the infection, in this particular research, it can be used the understand the effect of COVID-19 on diabetic patients (Aljouie, et al. 2021).
Overall, the baseline model represents the effect of the pandemic on diabetic patients, which is necessary for understanding the effectiveness of this virus on the increasing mortality rate of diabetic patients in society.
Miasma theory
An airborne infection is the main concern of this theory (Greenhalgh, 2021). This is the reason the effect of airborne diseases on people and the risk factors of these airborne diseases are the main topic of this particular theory. The transmission path of the virus is different from the other diseases. According to some scientists, it is animal-borne, especially from bats and according to some other scientists it is borne from the polluted air, whichfulfils this theory. Due to the lack of information about the transmission path of the virus, it is not cleared the origin of the virus. The transmission of COVID-19 is mainly done by direct contact between the person, as per the report, it is spread by the droplets which are oozed out from the mouth or the nose (Glatter and Finkelman, 2021). This is a possible proof behind the application of this theory for this research article. The spreading of the droplets is mainly done with the help of aerosol, which indicates the fact that the transmission path of the virus is somehow dependent on polluted air (Polianski, 2021). This is shown g the effectiveness of this theory behind the appropriate application of this theory in this research article. In the end, it can be concluded that, if the idea behind the spreading of the virus with the help of aerosols is true then there is no other theory that can replace this theory to understand the effect of the different risk factors for this disease.Its impact on the diabetic presents can be completely described which will be more fruitful for the readers as well as for the other researchers who will do their research work on this topic.
The germ theory of disease
The most important theory behind the pandemic of COVID-19 is the germ theory of disease which is now considered the most popular scientific theory behind the explanation of any disease. This theory mainly focuses on the reproduction of nether agents within the ghost cells and in which way they are affecting the host cells is the main discussion topic of this theory. According to this theory, the diseases, which are spread by pathogens, are known as infectious diseases. This theory is completely appropriate for this particular case study. The disease is mainly spread by the SArs-CoV-2, which indicates the fact that COVID-19 is an infectious disease that is mainly controlled by different factors which makes it more dangerous than other infectious diseases (Sapkota, 2020). This theory also helps to understand the mechanism of the activity of the covid-19 virus, which showed the fact in which way it attacks the cells of the pancreas and damage4s theInsulin-producingcells, which mainly control the dise3awse4 of the covid pandemic situation (Santos et al. 2021). The effect of this pandemic on diabetic patients and the role of the different risk factors behind the vulner5ability of the virus is the main topic for discussion and this is completely presented in front of the reader with the help of this germ theory of disease.
METHODOLOGICAL OUTLINE
The methodological outline is completely focused on the detailed analysis of the processes which are involved in the research article that indicates the total concept of the data collection to the data analysis (Sileyew, 2019). The roadmap of the whole research article is mainly created by the outline of the methodology. The methodological outline for this article is:
|
Research approach |
Inductive |
|
Research design |
Descriptive |
|
Research philosophy |
Interpretivism |
|
Data collection method |
Secondary |
|
Data analysis method |
Strategic analysis |
Table 1: Methodological Outline
The research approach which is taken for this article is the inductive method. The concept of this approach mainly begins with the help of collecting data that is appropriate to this particular article. The design of the research represents the descriptive type of the analysis which helps in the proper alignment of the literature review with the objective of this research article. The principle behind the research philosophy is completely based on the activity of the researchers on a particular topic that is associated with the social world. The analysis of the risk factors associated with diabetic patients and the effect of COVID-19 on them is observed by the researchers which indicate this particular research type (Lagaaet al. 2022). The data collection method which is used for this research is mainly the secondary type which indicates all the data is taken from the existing articles based on this particular topic. All the data which is collected is based on the effectiveness of COVID-19 on diabetic patients in Libya or North Africa (Dawet al. 2020). The mode of statistical analysis is used in this research article for the better use of the identification, analysis, and proper analysis of the situation.
Inclusion and Exclusion Criteria
|
Inclusion criteria |
Exclusion criteria |
|
This research article is completely based on the negative impact of COVID-19 on diabetic patients in Libya or North Africa. |
The secondary data source is completely based on the different topics except then the one which is not related to the impact of COVID-19 on diabetic patients is completely rejected for this research article (Iwendiet al. 2021). |
|
The article is completely based on the population of Libya and North Africa. |
Other articles and journals which are associated with the different issues in different countries are completely rejected for this particular research article. |
|
All the secondary data which are taken for this particular case study are present between the years 2018 to 2022. |
The articles that were published before the year 2018 have been completely rejected for this particular research article. |
|
The chosen articles were based on primary data that has been collected by survey. |
Articles based on secondary data collection or systematic reviews themselves have been avoided. |
|
Articles that have a proper dissertation structure |
Articles lacking a proper thesis structure have been avoided. |
|
Having authentic information based on influencing factor such as gender, heritage and others related factors which poses greater risk on diabetic patients |
No relevant information on influencing factor such as gender, heritage and others related factors which poses greater risk on diabetic patients |
|
The language of all the data should follow the English language properly. |
Other different articles WHICH are based on different languages are completely rejected for this research purpose only. |
Table 2: Inclusion and exclusion criteria
|
Factors |
Eligibility Criteria |
|
Participants or patients |
The population of Libya or North Africa is selected for the main topic of this particular research. |
|
Interventions |
Maintain the proper diet and also to try fit in by consuming vegetables and fruits |
|
Comparison |
The comparison between the risk factors associated with the two different diseases is done. Here the two diseases COVID-19 and Diabetes are completely mentioned in this particular research article (Brendan and Bakoush, 2021). The primary identified risk factors are Covoid-19 and diabetes. The secondary factors include age, genetic pattern, awareness and prevailing health complications. |
|
Outcomes |
The rate of dying and being hospitalized increases with the progression of time which indicates the fact that the role of Covid-19 and its effect on people is completely analyzed as the outcome of the research. |
Table 3: PICO framework
The searching strategy is done for making the article more authentic. The words which are mentioned in the table are frequently used in this whole research article which will help the reader to find the different articles from which the secondary data is collected. The authenticity of the article can be measured with the help of these keywords.
The research has been conducted on the basis of a systematic review of collected articles, and the method that has been followed for the analysis of the collected data is statistical analysis. In this type of analysis, the patterns and the trends of the collected data are uncovered for this purpose. SPSS has been used in this study. Statistical analysis is part of data analytics that has been utilized in this study to evaluate the data of the chosen articles (Clifton and Clifton, 2019). In this study, the search process was based on keywords that highlight the aim of the study. In this case, the keywords have been “risk factors”, “diabetes”, “Covid-19”, “death”, “hospitalization”, “primary data” etc. A systematic has been conducted here, and hence the chosen articles were based on primary data. These keywords were used to search the required articles. The search was emphasized with the help of boolean operators like AND, WITH, and OR to enhance the search process. An inclusion and exclusion criteria have been created based on which the articles have been selected. The articles that did not meet the criteria have been eliminated from the study with the help of the PRISMA framework.
The dependent variable for the study is hospitalization and death and diabetes, and the independent variable is Covid-19. The relation between the dependent and independent variables is linear since one has been showing a gradual increase with the uprise of the other, i.e. the risk of complications associated with Covid-19 is greater in diabetes-affected people, and this leads to hospitalization and even death in extreme cases.
The first step in the process included identification of the factors based on which the numbers would be pointed out based on which the statistical analysis has been conducted. The main two factors that had to be present in the articles were diabetes and Covid-19 since this study is based on this. The secondary factors include “age”, “genetic inheritance”, “prevailing health complications” and “awareness”. Based on these secondary factors, the articles that have met each point have been numbered. Hence, the numbers mentioned against each factor represent the number of articles that have mentioned that particular factor. The articles have been chosen on the basis of the identified factors. These numbers have then been utilized to perform statistical analysis and comparison between the groups. The t-test and the chi-square test has also been performed in these numbers along with an evaluation of the mean and standard deviation. The cross tabulation was performed on this data as well, and the proportions have been identified.
The whole research article is completely based on secondary data which is the reason the maintenance of the privacy of the collected data is necessary. Proper maintenance of the collected data and maintaining proper security of the collected sources are very much important to follow all the ethical considerations. Overall, the promotion of the “authentic, original, and true knowledge”with the help of the article is very much important under the laws of ethical consideration.
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