(LONDON) — COVID-19 patients in Africa who become critically ill are more likely to die than those in any other region of the world, according to a new study.

The report, published Thursday in the peer-reviewed medical journal The Lancet, was based on data from 64 hospitals across 10 African nations — Egypt, Ethiopia, Ghana, Kenya, Libya, Malawi, Mozambique, Niger, Nigeria and South Africa — between May and December 2020.

“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,” said Bruce Biccard, who co-led the research and is an anesthesiologist and professor at Groote Schuur Hospital in Cape Town, South Africa, the chief academic hospital of the University of Cape Town.

“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,” Biccard noted.

Africa, the world’s second-largest continent, has reported more than 4.7 million confirmed cases of COVID-19 and over 127,000 deaths from the disease so far, representing less than 3% of the world’s cases and just under 4% of the fatalities, according to data collected by Johns Hopkins University and the Africa Centers for Disease Control and Prevention.

Among 3,077 adult patients with severe cases of COVID-19 who were admitted to high acuity and critical care units, researchers found that 48.2% died within 30 days compared with a global average of 31.5%. The death rate was also higher than reported from studies done in Asia, Europe, North America and South America, researchers said.

The study was purely observational and was conducted by a large team called The African COVID-19 Critical Care Outcomes Study Investigators. The patients enrolled in the study had an average age of 56 with few underlying chronic conditions, unlike many other critically ill COVID-19 patients who are often older and have comorbidities.

The patients with pre-existing conditions had the highest risk of death from COVID-19, as has been the case in other studies. Researchers said chronic kidney disease or HIV/AIDS almost doubled the risk of death, while chronic liver disease more than tripled the risk of dying. But contrary to previous studies in other parts of the world, men in Africa were no more likely to die than women.

“The finding that men did not have worse outcomes than women is unexpected,” said Dean Gopalan, who co-led the study and is head of anesthesiology and critical care at the University of KwaZulu-Natal’s Nelson R. Mandela School of Medicine in Durban, 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,” Gopalan added.

Researchers said a scarcity of critical care resources and under-resourced facilities could have been factors in the deaths of these patients. Just one in two patients referred to critical care units were admitted due to a lack of beds. Only nine of the hospitals had extracorporeal membrane oxygenation (ECMO) machines, which artificially add oxygen into the bloodstream of severely ill patients when a ventilator alone is not enough. Dialysis, a procedure to treat kidney failure, which is sometimes needed in severe cases of COVID-19, was available in 39 of the hospitals, according to the study.

“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,” said the study’s co-author, Dr. Vanessa Msosa, a general surgeon at Kamuzu Central Hospital in Lilongwe, Malawi. “Patient outcomes will continue to be severely compromised until the shortfall in critical care resources is addressed.”

But researchers also found an apparent failure to utilize the resources and medical interventions that were available. ECMO machines were only offered to less than 1% of patients, while dialysis was offered to just 10%, according to the study. Researchers said at least six times more patients could have received proning, which is when patients are turned over onto their stomachs to improve breathing. Meanwhile, one in two patients died without receiving oxygen and one in three died without receiving inotropic drugs to increase the force of their heart contractions, and researchers said they have little data to explain why.

Researchers also noted there may have been a lack of specialized staff at the hospitals, even though critical care units reported relatively high rates of staffing.

A commentary on the study, written by specialists who were not involved and published in The Lancet, said there are only a small number of pulmonary and critical care training programs in Africa, and it’s common to have expensive equipment that is not functional due to poor maintenance or lack of skilled human resources. More than a third of the hospitals that participated in the study were in Egypt and South Africa, which generally have better resources than many other African nations, indicating COVID-19 death rates outside the cohort study could be even higher.

“The underuse of resources is an intriguing finding and contrary to popular belief that resources are scarce,” the authors of the commentary wrote. “It is important to think beyond the availability of resources and to also consider issues of functionality.

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