Researchers ID factors contributing to mortality of African patients severely-ill with Covid-19
- Faculty Communications
A multi-country study examines the resources, comorbidities, and critical care interventions associated with Covid-19 deaths in critically ill Africans.
The Covid-19 pandemic has challenged countries worldwide and has highlighted the flaws of many healthcare systems that are suddenly overburdened, particularly as countries are faced with peaking transmission rates.
Africa currently has the highest death rate of adults who become critically ill after contracting Covid-19.
Data from a multicentre cohort African Covid-19 Critical Care Outcomes Study (ACCCOS) published in The Lancet on 21 May 2021 indicate how a lack of intensive care facilities and critical resources has contributed to a continental Covid-19 mortality rate of 48%, almost 20% higher than the global average.
Led by researchers from the University of the Witwatersrand and collaborating institutions, ACCCOS aims to bridge the evidence gap, identifying which human and hospital resources, underlying conditions and critical care interventions might be associated with mortality or survival in over-18s admitted to Africa’s intensive care units.
About the study
Titled Patient care and clinical outcomes for patients with Covid-19 infection admitted to African high-care or intensive care units (ACCCOS): a multicentre, prospective, observational cohort study, the research is the first of its kind to be carried out on the African continent, consolidating data of critically ill patients with suspected or confirmed Covid-19 infection.
University of Witwatersrand researchers Professor Mervyn Mer and Associate Professor Juan Scribante served as co-investigators in the study.
Based on information obtained from 3140 adults who were admitted to 64 hospitals across 10 countries in Africa in the period between May and December 2020, it suggests that high mortality may be partly explained by a shortage of critical care resources and underuse of those resources available.
The study found that Covid-19 related deaths amongst participating patients who were admitted into critical care units during this period averaged at 48.2% compared to the 31.5% global average. Out of these participating patients, half died as a result of not being given oxygen and only 10% receiving renal dialysis despite a 68% accessibility by the participating hospitals.
Resources and skills shortfall
The data suggests the inadequacy linked to intensive care resources as well as human resources accounts for the critical shortfall of survival rate among the study population. This finding highlights the co-dependency between suitably skilled and/or specialised staff and available critical care resources such as advanced specialized machinery.
Although some participating hospitals were equipped with the necessary resources to treat patients, the research found that the underuse of basic resources that resulted in deaths in some cases was due to a lack of skills to operate such equipment.
Notwithstanding these challenges of low-resource settings, basic knowledge interventions such as monitoring blood oxygen levels, providing dialysis and proning (turning patients on their front to improve breathing) could have potentially saved lives.
The scale of in-hospital deaths in African despite a good nurse to patient ratio emphasises the dire need for specialised staff.
“Health care system improvement, especially intensive care, is complex, takes time and needs a holistic, systemic approach rather than a quick fix. However, a short-term intervention that might contribute to better outcomes for critically ill Covid-19 patients is the more effective use of available resources by sharing lessons learnt from both low- and high-income countries” says Scribante.
Covid-19 and Comorbidities
The majority (61%) of the study population were men who presented few underlying chronic conditions. Available participant data found that 51% of patients were hypertensive, 38% diabetic, 7.7% had HIV/AIDS, 7.7% chronic kidney disease and 7.7% had coronary artery disease.
These pre-existing conditions exposed affected patients (both men and women) to much higher risks of poor outcomes as they doubled and in some cases even tripled patients’ risk of fatality.
Organ dysfunction associated with Covid-19 related deaths
It was also uncovered that patients who die have a high likelihood to have had a higher degree of organ dysfunction which required respiratory and cardiovascular support in intensive care. Although there are limited resources to facilitate the high demand, the use of Sequential Organ Failure Assessment [SOFA] can be used to guide physicians to determine the urgency of patients’ admission for critical care at earlier stages. This would allow patients to be on organ support to avoid further deterioration.
Professor Mer is the Head of Critical Care at the University of the Witwatersrand and Clinical Head of the Adult Multidisciplinary Intensive Care Unit at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH). He was recently awarded the Absa Professional Excellence in Time of Covid Award for his role in equipping the hospital to battle the virus before it hit. Professor Scribante is the research manager in the Department of Anaesthesiology in the School of Clinical Medicine.