A new ground-breaking study on COVID-19 by Africa-based professors has indicated that adult mortality from 30 days of the coronavirus, after being admitted to critical care with suspected or confirmed infection, appeared considerably high in Africa.
“A critical factor in these excess deaths may be a lack of intensive care resources and underuse of it, the researchers, noted in the study, published on Friday, in the British medical journal, The Lancet.
A copy of the study indicated that the study focused on 64 hospitals in 10 countries Egypt, Ethiopia, Ghana, Kenya, Libya, Malawi, Mozambique, Niger, Nigeria, and South Africa.
They said that half of patients died without being given oxygen, and while 68% of hospitals had access to renal dialysis, only 10%; 330/3,073 of severely ill patients received it.
Prof Akinyinka Omigbodun, University College Hospital, Ibadan, and Prof Adesoji Ademuyiwa, Lagos University Teaching Hospital, were the leads in the Nigerian study.
Others were Prof. Bruce Biccard from Groote Schuur Hospital and the University of Cape Town, South Africa, and Prof. Dean Gopalan from the University of KwaZulu-Natal, South Africa, both of whom were co-leaders of the study.
The researchers said that the challenges faced by critically ill Nigerian COVID-19 patients could be partly mitigated by ensuring the availability of the human and material resources needed for their care.
In addition, mitigation could have been achieved by devoting the required attention to the distribution of these resources across all the centres offering critical care services across the country.
“It can be demoralizing for health personnel to watch helplessly as patients succumb to shortages of the oxygen needed to keep them alive till the body can tackle the virus.
“Or lack of access to dialysis to deal with acute kidney injury that is completely reversible with prompt care” they said.
The study said that an average of 48.2%; or 1,483/3,077 patients globally, and an average of 31.5% were from meta-analysis of 34,859 patients, according to the prospective observational study of the 64 hospitals in 10 African countries.
Co-lead, Biccard of the University of Cape Town, South Africa, said: “Our study is the first to give a detailed and comprehensive picture of what is happening to people who are severely ill with COVID-19 in Africa, with data from multiple countries and hospitals.
”Sadly, it indicates that our ability to provide sufficient care is compromised by a shortage of critical care beds and limited resources within intensive care units.
“Poor access to potential life-saving interventions such as dialysis, proning (turning patients on their front to improve breathing) and blood oxygen monitoring, could be factors in the deaths of these patients, and may also partly explain why one in eight patients had therapy withdrawn or limited,” he said.
He added: “We hope these findings can help prioritise resources and guide the management of severely ill patients and ultimately save lives – in resource-limited settings around the world.
“Until now, little was known about how COVID-19 was affecting critically ill patients in Africa, as there have been no reported clinical outcome data from Africa, or patient management data in low-resource settings.
“To address this evidence gap, the African COVID-19 Critical Care Outcomes Study (ACCCOS) is aimed to identify which human and hospital resources, underlying conditions and critical care interventions might be associated with mortality or survival in adults (aged 18 or older) admitted to intensive care or high-care units in Africa,” he said.
Biccard said that between May and December, 2020, around half (3,752/6,779) of patients with suspected or confirmed COVID-19 infection referred to critical care were admitted.
“Of those, 3,140 patients participated in the study. All participants received standard care and were followed up for at least 30 days, unless they died or were discharged.
“Modelling was used to identify risk factors associated with death. After 30 days, almost half (48%, 1,483/3,077) of the critically ill patients had died.
“The analysis estimates that death rates in these African patients were 11%, in the best case scenario, to 23%, in the worst case scenario, higher than the global average of 31.5%.
“Of the survivors, 16% (261/1,594) remained in hospital, and 84% (1,333/1,594) were discharged. The outcome of 63 patients was, however, unknown.
“The study estimates that the provision of dialysis needs to increase approximately seven fold and ECMO approximately 14 fold to provide adequate care for the critically ill COVID-19 patients in this study.
“For example, even inexpensive basic equipment was in short supply, with only 86% (49/57) of units able to provide pulse oximetry, to monitor blood oxygen levels, to all patients in critical care.
“Similarly, 17% (10/57) of hospitals had access to ECMO, but despite evidence to support its use in COVID-19 patients with respiratory failure, it was offered to less than 1% of patients,” he said.
He noted that the majority of patients were men (61%; 1,890/3,118 patients, with average age 56 years) with few underlying chronic conditions.
“For participants with available data, the most common underlying conditions were high blood pressure (51%, 1,572/3,104), diabetes (38%, 1,175/3,090), HIV/AIDS (7.7%, 237/3,084), chronic kidney disease (7.7%, 241/3085), and coronary artery disease (7.7%, 237/3093).
“People with pre-existing conditions had the highest risk of poor outcomes. Having chronic kidney disease or HIV/AIDS almost doubled the risk of death, while chronic liver disease more than tripled the risk of dying.
“Diabetes was also associated with poor survival (75% increased risk of death,” he said.
Biccard, however, said that contrary to previous studies, being male was not linked with increased mortality.
“The finding that men did not have worse outcomes than women is unexpected, said co-lead Prof. Dean Gopalan from the University of KwaZulu-Natal, South Africa.
“It might be that the African women in this study had a higher risk of death because of barriers to accessing care and limitations or biases in care, when critically ill.
“Compared with survivors, patients who died were also more likely to have a higher degree of organ dysfunction using Sequential Organ Failure Assessment (SOFA) and required more respiratory and cardiovascular support on admission to intensive care—yet the resources to provide this care are limited.
According to Gopalan, the quick SOFA score could be a simple tool to use at critical admission in low-resourced settings to help clinicians identity patients with poor prognosis at an early stage and to avoid delays in starting necessary organ support.
“Although critical care units reported relatively high rates of staffing with 24-hour physician coverage seven days a week, and a nurse-to-patient ratio of 1:2, mortality was high, possibly because of a lack of specialised staff”, the researchers said.
