Unravelling why African ICUs have the world’s highest COVID-19 mortality rates

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Africa has the highest COVID-19 ICU mortality on any continent with more than half of admissions dying in hospital by the 30-day mark, found a University of Cape Town study conducted in 38 hospitals in six countries, writes MedicalBrief.

The countries were Egypt (9 hospitals), Ethiopia (7), Ghana (2), Libya (7), Nigeria (2) and South Africa (11). The study, which has still to be peer reviewed, suggested limited critical care resources contributed to the higher death rate on the continent: 55% compared to 31% in other regions.

Access to necessary critical care interventions in Africa were between seven- and 14-fold less than what was needed. Only 60% of the sites (21 out of 35 hospitals) could provide the critical care interventions of proning or dialysis and 83% could provide pulse oximetry.

The principal finding was that the 30-day mortality following critical care admission for suspected and confirmed COVID-19 infection in this African cohort was 54·7%, representing an excess mortality of between 18 and 29 deaths per 100 patients when compared to other regions.

“This high mortality does not appear to be driven by limited human resources nor patient comorbidities, with the exception of increasing age. Comorbidities, such as hypertension, diabetes, HIV and increasing BMI were not associated with mortality. Mortality was associated with the severity of organ dysfunction on presentation, and the need for maximal respiratory and cardiovascular support. The qSOFA (Quick Sequential Organ Failure Assessment) score of 3 appears to be a simple and effective tool for triaging COVID-19 patients at risk of mortality when referred for admission to critical care,” the study reports.

“The higher death rate in African ICUs was also associated with the severity of the illness and increasing age, but comorbidities such as hypertension and diabetes were not; nor was HIV in the sample from the studied hospitals.

“The patients were young with few comorbidities. The most common comorbidities were hypertension (52·7%), diabetes (39·6%) and HIV/AIDS (10·1%).Mortality was more common in patients who were older, had diabetes or HIV/AIDS.

“Current smokers and a history of malarial infection were associated with a lower mortality.

“The severity of disease at critical care presentation was associated with increased mortality; including cardiorespiratory arrest prior to admission, the need for increasing organ support, and an increasing qSOFA score. Critical care interventions including ventilatory and respiratory support, inotropes and dialysis were all associated with mortality.”

On average, African Union countries have reported a case fatality rate of 2.4%, compared to the global fatality rate of 3.6%. But according Africa Centres of Disease Control, 16 are reporting far higher mortality rates than the global figure: Sudan (7.8%), Sahrawi Arab Democratic Republic (7.1%), Chad (6.3%), Egypt (5.8%), Liberia (5.4%), Niger (5.3%), Mali (3.5%), Gambia (3.3%), Algeria (3.1%), Sierra Leone (3.1%), Malawi (3.1%), Tunisia (3.0%), Zimbabwe (2.9%), SA (2.7%), Democratic Republic of the Congo (2.7%), and Burkina Faso (2.6%).

TimesLIVE quotes first author, UCT anaesthesiologist Prof Bruce Biccard, saying: “There are limited critical care resources so access to critical care is likely to be limited to sicker patients, with potentially poorer outcomes due to the severity of illness on presentation.

“The limited resources (including) both access to critical care interventions, for example dialysis, and the limited healthcare personnel available to provide care, means the care that can be given is compromised.”

An African, Multi-Centre Evaluation of Patient Care and Clinical Outcomes for Patients with COVID-19 Infection Admitted to High-Care or Intensive Care Units

Authors: Biccard, Bruce and Miller, Malcolm Gregory and Michell, William L. and Thomson, David and Ademuyiwa, Adesoji O. and Aniteye, Ernest and Calligaro, Gregory L. and Dhufera, Hailu Tamiru and Elfiky, Mahmoud and Elhadi, Muhammed and Fawzy, Maher and Fredericks, David and Gebre, Meseret and Bayih, Abebe Genetu and Hardy, Anneli and Joubert, Ivan and Belachew, Fitsum Kifle and Kluyts, Hyla and Macleod, Kieran DM and Mekonnen, Zelalem and Mer, Mervyn and Omigbodun, Akinyinka O. and Owoo, Christian and Paruk, Fathima and Piercy, Jenna and Scribante, Juan and Seman, Yakob and Taylor, Elliott H. and van Straaten, Dawid and Gopalan, P. Dean and Group, ACCCOS Investigators.


Background: There is little data on critically ill COVID-19 patients in under-resourced environments, and none from Africa. The objectives of this study were to determine resources, patient comorbidities and critical care interventions associated with mortality in critically ill COVID-19 African patients.

Methods: African multicentre, prospective observational cohort study of adult patients referred to intensive care or high-care units with suspected or known COVID-19 infection. Patient follow up was until hospital discharge, censored at 30 days. The study recruited from March to September 2020.

Findings: 1243 patients from 38 hospitals in six countries participated. The hospitals had a median of 2 (interquartile range (IQR) 1-4) intensivists, with a nurse to patient ratio of 1:2 (IQR 1:3 to 1:1). Pulse oximetry was available to all patients in 29/35 (82·9%) sites, and 21/35 (60%) of sites could provide dialysis or proning. The 30-day mortality following critical care admission was 54·7% (95% confidence interval (CI) 51·9-57·6). Factors independently associated with mortality were an increasing age (odds ratio (OR) 1·04, 95% CI 1·02-1·05, p<0·001), a quick SOFA score of 3 (OR 3·61, 95% CI 1·41-9·24, p=0·01), increasing respiratory support defined as the need for continuous positive airway pressure (OR 5·86, 95% CI 1·47-23·35, p=0·01), invasive mechanical ventilation (OR 16·42, 95% CI 4·52-59·65, p<0·001), three organ systems requiring support at admission (OR 5·52, 95% CI 1·13-27·01, p=0·04), cardiorespiratory arrest within 24 hours prior to admission (OR 4·43, 95% CI 1·01-19·54, p=0·05) and vasopressor requirements (OR 2·73, 95% CI 1·71-4·36, p<0·001). Human immunodeficiency virus was not associated with mortality (OR 1·84, 95% CI 0·99-3·40, p=0·05). Interpretation: Mortality in critically ill COVID-19 African patients is higher than any other region, with an excess mortality of 18 and 29 deaths per 100 patients compared to other regions. Mortality is associated with limited critical care resources and severity of organ dysfunction at admission.

Trial Registration: This study was registered on ClinicalTrials.gov (NCT04367207).

Funding Statement: African Covid-19 Critical Care Outcomes Study (ACCCOS) was partially supported by a grant from the Critical Care Society of Southern Africa.

Declaration of Interests: We have no competing interests to declare.

Ethics Approval Statement: The primary ethics approval was from the Human Research Ethics Committee of the University of Cape Town (HREC 213/2020)


Full The Lancet preprint (open access PDF)


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