By Chioma Obinna

First data published in The Lancet has shown that Africa has a higher death rate among critically ill COVID-19 patients than any other world region.

The study based on 3,140 adults admitted to 64 hospitals in 10 countries between May and December 2020 revealed that the high mortality may be partly explained by shortage of critical care resources and underuse of those available.

According to the study, estimates suggest that the provision of dialysis was seven times less, and the provision of ECMO (to oxygenate the blood) is 14 times lower than required to adequately treat COVID-19 patients in the study.

The researchers also pointed out that the findings have important implications for managing severely ill patients in resource-limited settings where a shortage of functioning equipment and specialised staff must be taken into consideration.

“Death rates among adults in the 30 days after being admitted to critical care with suspected or confirmed COVID-19 infection appear considerably higher in Africa with an average of 48.2 per cent, and 1,483/3,077 patients than globally average of 31.5 percent from a meta-analysis of 34,859 patients

The researchers who are all based in Africa in a prospective observational study revealed that the deaths may be a lack of intensive care resources and underuse of those available.

For example, half of the patients died without being given oxygen, and while 68 percent of hospitals had access to renal dialysis, only 10 percent of 330/3,073 severely ill patients received it.

In his views, Professor Bruce Biccard from Groote Schuur Hospital and 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.

Biccard who co-led the research added that the study indicates that the ability to provide sufficient care was 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could be factors in the deaths of these patients, and may also partly explain why one in eight patients had therapy withdrawn or limited. 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.”

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Until now, little was known about how COVID-19 was affecting critically ill patients in Africa as there have been no reported clinical outcomes data from Africa or patient management data in low-resource settings.

The study focused on 64 hospitals in 10 countries of Egypt, Ethiopia, Ghana, Kenya, Libya, Malawi, Mozambique, Niger, Nigeria, and South Africa. 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 percent, 1,483/3,077) of the critically ill patients had died.

The analysis estimates that death rates in these African patients were 11 percent in best case scenario, to 23 percent in worst case scenario higher than the global average of 31.5 percent.

The study further recommended that the provision of dialysis needs to be increased approximately 7 fold and ECMO approximately 14 fold to provide adequate care for the critically ill COVID-19 patients in the study.

The majority of patients were men (61percent; 1,890/3,118 patients, average age 56 years) with few underlying chronic conditions.

It also found that 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 percent increased risk of death. However, contrary to previous studies, being male was not linked with increased mortality.
Co-lead Professor Dean Gopalan from the University of KwaZulu-Natal, South Africa said: “The finding that men did not have worse outcomes than women is unexpected. It might be that the African women in this study had a higher risk of death because of barriers to accessing care, or care and limitations or biases in care when critically ill.”

According to Gopalan: “The quick SOFA score could be a simple tool to use at critical admission in low-resourced settings to help clinicians identify patients with poor prognosis at an early stage and to avoid delays in starting necessary organ support.”

According to the researchers, 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.

In Nigeria, the leaders of the study, Professor Akinyinka Omigbodun of the University College Hospital, Ibadan, and Professor Adesoji Ademuyiwa of the Lagos University Teaching Hospital, reported that the challenges faced by critically ill Nigerian COVID-19 patients could be partly mitigated by not only ensuring the availability of the human and material resources needed for the care of these patients but by devoting the required attention to the distribution of these resources across all the centres offering critical care services across the country.

They said: “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. “

According to co-author Dr Vanessa Msosa from Kamuzu Central Hospital in Malawi: “This cross-continental collaboration has provided much-needed data about our unique COVID-19 patient care needs. Although our younger demographic means that most countries in Africa have avoided the large-scale mortality seen in many parts of the world, in-hospital mortality is suffering from being under-resourced, with only half of referrals admitted to critical care because of bed shortages. Patient outcomes will continue to be severely compromised until the shortfall in critical care resources is addressed.”

Vanguard News Nigeria