A paper published in The Lancet states that the death rate following COVID-19 critical care admission is higher in Africa than any other region in the world. Excess deaths are estimated at between 11 and 23 per 100 admissions, compared to the global average. As the largest study out of Africa about COVID-19 critical care – this is likely also the only study in this setting with a significant cohort of HIV-positive patients.
Death rates among adults in the 30 days after being admitted to critical care, with suspected or confirmed COVID-19 infection, appear considerably higher on the continent. This, from co-lead of the study, University of Cape Town’s (UCT) Faculty of Health Sciences’ (FHS) Professor Bruce Biccard. The prospective observational African COVID-19 Critical Care Outcomes Study (ACCCOS) was conducted in 64 hospitals across 10 African countries including Egypt, Ethiopia, Ghana, Kenya, Libya, Malawi, Mozambique, Niger, Nigeria, and South Africa.
A critical factor in these excess deaths may be a lack of intensive care resources as well as the underuse of those available, say the researchers, who are all based in Africa. For example, half of the patients who did not receive oxygen died, and while 68% of hospitals had access to renal dialysis, only 10% of severely ill patients received it.
Poor resources compromise patient care
Until now, little was known about how COVID-19 was affecting critically ill patients on the continent as there have been no reported clinical outcomes data from Africa, nor has there been patient management data in low-resource settings.
“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.”
To address the evidence gap, ACCCOS 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, who were admitted to intensive care or high-care units.
The study investigated the results of 3 140 adults who were admitted to those 64 hospitals. Around half of the patients with suspected or confirmed COVID-19 infection referred to critical care were admitted. 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 – 1 483 of the critically ill patients had died. The analysis estimates that there are between 11 and 23 excess deaths per 100 critical care admissions in Africa when compared to the global average critical care mortality of 31.5%.
The majority of patients, 61%, were men, averaging 56 years. They had few underlying chronic conditions. For participants with available data, the most common underlying conditions were high blood pressure at 51%, diabetes at 38%, and HIV/AIDS, chronic kidney disease, and coronary artery disease each at 7.7%.
Groote Schuur Hospital at the helm of the South African leg
The South African leg of ACCCOS was led by UCT Critical Care specialist Dr Malcolm Miller at Groote Schuur Hospital (GSH). Miller was behind the co-ordination and recruitment of patients, as well as the data collection, with GSH recruiting the largest number of patients in the cohort.
"The greatest challenge was to conduct research during a pandemic, which placed huge pressures on the clinical service. The support received was tremendous from both colleagues and trainees despite these pressures on service delivery," Miller said.
According to the paper: The African hospital units admitting patients had limited access to a number of key resources or techniques, including dialysis; proning, turning patients on their front to improve breathing; extracorporeal membrane oxygenation (ECMO), the oxygenation of blood by means similar to “bypass” which is used when increasing available oxygen and ventilatory support does not provide sufficient oxygenation to a patient’s blood; arterial blood gases testing, used to monitor and measure the effectiveness of strategies to increase blood oxygenation in patients with severe respiratory disease and COVID-19; and pulse oximetry, a simple monitor to measure blood oxygen saturation through the skin which is routine and should be available to all intensive care patients.
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.
Biccard, also at GSH, explained what this means and the impact of limited access to these interventions for patient health: "The therapeutic support necessary for critically ill patients cannot be provided. The inability to provide all therapies, means that patients may die unnecessarily. And if one cannot adequately monitor these patients, then it is like treating patients in the dark because the effectiveness of the therapy cannot be monitored." He added that, “these limited resources may also partly explain why one in eight patients had therapy withdrawn or limited.”
The resource-limited nature of settings, like shortage of functioning equipment and specialised staff, must be taken into consideration when evaluating a country’s healthcare response. Especially because there is a: “limited number of critical care beds; only one in two patients referred to intensive care are actually admitted [there]. This suggests that the resource of critical care beds is severely limited in Africa," said Biccard.
In agreement Miller stated that: "This pandemic has highlighted the need for more critical care related resources such as beds, equipment and most importantly, adequately trained personnel able to care of critically ill patients across the continent."
It is important to take in what’s happening on the continent within context to develop a better understanding of the complexities of the problem: “A number of monitors and intensive care machines in Africa are not serviced or functional. So merely counting the number of machines that are available physically, is a number which is far more than what is in reality available to provide care.
"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,” said Biccard.
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