Nigeria, nine others have lower survival rate for critical COVID-19 patients

A study published yesterday, in The Lancet medical journal, offered reasons why Egypt, Ethiopia, Ghana, Kenya, Libya, Malawi, Mozambique, Niger, Nigeria and South Africa have higher death rate among critically ill COVID-19 patients than any other regions of the world.

According to the observational survey from 64 hospitals in 10 African countries, death rates among adults in the 30 days after being admitted to critical care with suspected or confirmed COVID-19 infections appeared considerably higher in Africa (average 48.2 per cent; 1,483/3,077 patients) than the global (average of 31.5 per cent; from a meta-analysis of 34,859 patients).

The researchers, who are all based on the continent, said a critical factor in these excess deaths might be a lack of intensive care resources and underuse of those available. For example, half of patients died without being given oxygen, while 68 per cent of hospitals had access to renal dialysis, as only 10 per cent of severely ill patients received it.

Estimates suggest that the provision of dialysis was seven times less, even as availability of oxygenate blood (ECMO) was 14 times lower than required to adequately treat COVID-19 patients.

Findings have important implications for managing critical patients in resource-limited settings where shortage of functioning equipment and specialised staff must be taken into consideration.

Leaders of the study in Nigeria, Prof. Akinyinka Omigbodun of the University College Hospital, Ibadan, and Prof. Adesoji Ademuyiwa of the Lagos University Teaching Hospital (LUTH), Idi-Araba, reported that the challenges faced by this group of persons could be partly mitigated by not only ensuring the availability of the human and material resources needed for their care, but also devoting the required attention to the distribution of these resources across all the centres offering critical care services across the country.

Prof. Bruce Biccard from Groote Schuur Hospital and the University of Cape Town, South Africa, who co-led the research, pointed out that the work was first to give a comprehensive picture of what is happening to these people.

Until now, little was known about how the pandemic was seriously affecting this set of persons in the face of inadequate resources.
To address the gap, the African COVID-19 Critical Care Outcomes Study (ACCCOS) is identifying the human and hospital resources, underlying conditions and critical care interventions behind mortality or survival in adults (aged 18 or older) admitted to intensive care or high-care units in Africa.

The study focused on 64 hospitals in the above named countries.

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 per cent, 1,483/3,077) of the critically ill patients had died. The analysis estimates that death rates in these African patients were 11 per cent (in best case scenario) to 23 per cent (in worst case scenario) higher than the global average of 31.5 per cent.

Of the survivors, 16 per cent (261/1,594) remained in hospital, and 84 per cent (1,333/1,594) had been discharged. The outcome of 63 patients is 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 per cent (49/57) of units able to provide pulse oximetry (to monitor blood oxygen levels) to all patients in critical care. Similarly, 17 per cent (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 one per cent of patients.

The majority of patients were men (61 per cent; 1,890/3,118 patients, average age 56 years) with few underlying chronic conditions. For participants with available data, the most common underlying conditions were high blood pressure (51 per cent, 1,572/3,104), diabetes (38 per cent, 1,175/3,090), Human Immuno-deficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS) 7.7 per cent, 237/3,084), chronic kidney disease (7.7 per cent, 241/3085), and coronary artery disease (7.7 per cent, 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 per cent 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 is unexpected”, says co-lead Professor 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, or 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 (Sequential Organ Failure Assessment [SOFA] score), 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.”

The researchers said 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.

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.”

The authors noted some limitations of their study, including that it was mainly conducted in university affiliated, government funded, and tertiary hospitals, and it is likely that outcomes could be worse in lower level hospitals with less resourced critical care units. In addition, the study cohort was younger than other COVID-19 critical care cohorts, and is likely to be an underestimate of excess mortality if adjusted for age. They add that although this is the largest set of data on critically ill patients from under-resourced settings, it represents only 10 African countries, and most hospitals were in the relatively well-resourced countries of South Africa and Egypt, which may affect the generalisability of the results.

Writing in a linked Comment, Dr. Bruce Kirenga and Dr. Pauline Byakika-Kibwika from Makerere University, Uganda (who were not involved in the study) say, “The underuse of resources is an intriguing finding and contrary to popular belief that resources are scarce… It is important to think beyond the availability of resources and to also consider issues of functionality. It is common in Africa to have expensive equipment that is non-functional due to poor maintenance or lack of skilled human resource. In 2017, the Tropical Health and Education Trust reported that 40 per cent of medical equipment in Africa was out of service, 80 per cent of medical equipment was donated, 70 per cent to 90 per cent of donated equipment were never operationalised, and only two African countries had professional biomedical engineers.” The study was partially funded by a grant from the Critical Care Society of Southern Africa. ACCCOS) investigators conducted it.