Study Suggests Africa has the Highest Death Rate Among Critically ill COVID-19 Patients
A recent study based on 3 140 adults admitted to 64 hospitals in 10 countries between May and December 2020 suggests that Africa has a higher death rate among critically ill COVID-19 patients than any other region. This may be partly due to the shortage of critical care resources and underuse of those that are available. Professor Dean Gopalan, Head of UKZN’s Department of Anaesthesiology and Critical Care and former UKZN anaesthesiologist, Professor Bruce Biccard were the lead authors of the study that was recently published in the prestigious scientific journal The Lancet.
The study is ground-breaking as it is the first to offer evidence on how COVID-19 is affecting critically ill patients in Africa. The African COVID-19 Critical Care Outcomes Study (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) admitted to intensive care or high-care units on the continent. The study was conducted in Egypt, Ethiopia, Ghana, Kenya, Libya, Malawi, Mozambique, Niger, Nigeria and South Africa.
The researchers found that after 30 days, almost half (48%) of the critically ill patients had died. The study estimates that provision of dialysis needs to increase approximately seven-fold and Extracorporeal Membrane Oxygenation (ECMO) approximately 14-fold to provide adequate care for the critically ill COVID-19 patients in this study.
Furthermore, inexpensive basic equipment was in short supply, with only 86% of units able to provide pulse oximetry (to monitor blood oxygen levels) to all patients in critical care. Similarly, 17% 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.
Biccard from Groote Schuur Hospital and the University of Cape Town, who co-led the research 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.’
He explained, ‘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.’
The majority of patients were men (61%; with an average age of 56) with few underlying chronic conditions. According to Gopalan, ‘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). However, contrary to previous studies, being male was not linked with increased mortality.
‘The finding that men did not have worse outcomes than women was unexpected’, said Gopalan. ‘It might be that the African women in this study had a higher risk of death because of barriers to accessing care, or limitations or biases in receiving care when critically ill.’
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 affected by a shortage of resources, 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.’
The study was partially funded by a grant from the Critical Care Society of Southern Africa and was conducted by the African COVID-19 Critical Care Outcomes Study (ACCCOS) investigators.
Words: MaryAnn Francis