Infectious Disease

Challenges in providing critical care in resource-poor environments

October 19, 2021

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Fischer W. et al. Critical Care in Global Health from Ebola to COVID-19 and Beyond. Presented at: CHEST annual conference; October 17-20, 2021 (virtual meeting).

Disclosure:
Fischer, Godard and Kojan do not report any relevant financial information.

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At CHEST’s annual meeting, a global panel highlighted the inequalities in admission and access to critical care around the world and the challenges of providing critical care services in resource-poor settings.

According to a press release, many hospitals around the world are lacking proper ICU equipment, medication, and trained health workers, from doctors to nurses to respiratory therapists. The COVID-19 pandemic has highlighted these and other challenges in an environment with limited resources. In light of advances in Ebola treatment and the current pandemic, experts discussed practical solutions to the challenges of critical care in resource-poor environments, lessons learned and how the health system can adapt, the press release said.

Source: Adobe Stock.

Differences in intensive care worldwide

William Fischer, MD, Associate Professor of Medicine in the Department of Lung Diseases and Critical Care Medicine and Director of Emerging Pathogens at the University of North Carolina’s Institute of Global Health and Infectious Diseases, Chapel Hill, highlighted four key challenges from an outbreak response perspective: Inequality in access to health care; community-centered strategies of care and response; the need to prioritize research knowledge; and the need to evolve into integrated preparation cycles.

During the Ebola outbreak in West Africa, patient responses focused on identifying the infected person, isolating that person, and tracking anyone who had contact with the infected person to isolate them as well, Fischer said.

“Many of the outbreaks have been stopped early by preventing transmission, and while this is important to the community, it does not do much for the isolated person,” Fischer said during the session.

Of the 28,600 Ebola patients treated in West Africa between 2014 and 2016, most received limited supportive care and less than 1% received access to investigational drugs. Of 27 Ebola patients treated outside West Africa during the same period, all received oral and intravenous fluids, 81% received empirical antibiotics, and 41% received non-convalescent blood products. In addition, the 41% of critically ill patients received supplemental oxygen (70%), mechanical ventilation (26%), vasopressors (30%) and renal replacement therapy (19%). According to Fischer, 85% of these patients received at least one test therapy and 70% at least two test therapies.

Because of these differences in access to intensive care and investigational drugs, there were large differences in the treatment outcomes for the patients. Patients treated in West Africa had a 63% death rate, which was very different from the 18.5% death rate seen in patients treated outside West Africa, Fischer said.

According to Fischer, this access to supply inequality is not limited to the Ebola virus, but exists for every disease, including COVID-19, for which 50% of Americans received a full COVID-19 vaccination, compared with less than 5% of Africans .

“Médecins Sans Frontières (Doctors Without Borders) started out from the surgical patients, realizing that most of them actually died after surgery rather than during surgery, and they died of things we could have fixed. Most of them died from lack of or inadequate monitoring, and we could see sepsis at the level of septic shock or bleeding [gastrointestinal complication] Levels that are untreatable in our fields, ”said Aurélie Godard, MD, anesthetist, intensive care doctor and intensive care nurse at Médecins Sans Frontières, France. “So the mission in the intensive care unit began with this need to monitor the surgical patients of the intensive care team.”

Godard and colleagues from Médecins Sans Frontières / Doctors Without Borders work with intensive care patients, for example with COVID-19, but also with HIV, noncommunicable diseases and pediatric patients. In the humanitarian context, Godard cited the following restrictions in low and middle income countries:

  • logistical constraints: working in complex security situations, access to health care, architecture and challenges in drug and equipment supply; and
  • scientific limitations: different medical skills worldwide, intensive care medicine not recognized or taught as a subject, low employee loyalty in health care; various pathologies, publication bias; limited diagnostic tools.

Additionally, there is massive need for critical care, knowledge sharing and training, portable tools, and even basic therapeutics in many countries in low- and middle-income countries, Godard said. For example, nearly 90% of patients with hypoxia in Malawi are deprived of oxygen, Godard said.

“I think the essential concept of emergency care is now on the stage and promoting this access for every seriously ill patient anywhere in the world to at least the basic needs in order to build a more developed and more complex intensive care unit. Care is what this population really needs”, said Godard.

Steps forward

To even out some of the disparities, the panel highlighted the following:

  • Expanding access to care for patients and service providers;
  • Inclusion of community-oriented strategies with patient-centered implementation;
  • Prioritizing investment in research, bedside learning, and local investigators; and
  • Integration of patient care with highly effective pathogens into the existing health infrastructure.

Reintegration and the development of infrastructures to combat infection can help doctors to continue to guarantee a higher level of care, not only for patients with Ebola, but for patients with any disease during and after outbreaks, according to Fischer.

In addition to these recommendations, it is also important to standardize approaches for patients with Ebola and patients with COVID-19.

“We know Ebola patients from rich countries have many options given that they receive good monitoring, good medicine, good supportive care, and critical care,” said Richard Kojan, MD, critical care practitioner at Kinshasa Teaching Hospital at Kinshasa University and President of the Alliance for International Medical Action (ALIMA), Democratic Republic of the Congo. “In contrast, Ebola patients in our context have received minimal care during various outbreaks over the past 10 years, and the goal then was to protect health facilities and health workers from possible infection.” So this is one of the main reasons for the higher mortality in our region. “

To address the inequalities in supportive care during outbreaks around the world, researchers developed CUBE – a portable biosecure emergency care unit. The CUBE is a single room with temperature and pressure control with lock entrances and lock exits for materials and samples. CUBE was first implemented during the Lassa fever outbreak in Nigeria, then was implemented during the Ebola outbreak and is now being used for patients with COVID-19, Kojan said.

In the CUBE, patients can be visited by doctors for treatment, while they can also see family and relatives without a high risk of virus contamination. In addition, doctors in the CUBE do not have to wear full personal protective equipment, but can still carry out clinical monitoring 24 hours a day. This also makes it possible to introduce laboratory monitoring, biochemistry, hematology and mood recording for patients and at the same time to shorten the care window, explained Kojan.

The challenges and strategies discussed during the CHEST session require collaboration between physicians to provide equitable intensive care to every patient in disease outbreaks and pandemics, regardless of the country’s income.

“None of this happens to a person or a group,” said Fischer. “This requires a community of all of us who are committed to the idea that there should be a uniform standard of care and equal access to both care and therapy.”

“A Global Medical Community”

Panel co-chair, Orlando Garner, MD, emphasized “the stark contrast between the level of care that can be provided in the US and a lower-income country,” noted in the press release that “[i]In most cases, the practice guidelines come from high-income environments and cannot be adequately followed anywhere in the world. “

“If COVID has taught us anything, it is that we live in a global medical community and what is happening around the world can affect anyone,” Aditya Nadimpalli, MD, co-chair of the panel, said in the press release. “It is critical that the global focus be on rapid tests, novel and accessible treatments, and vaccinations to control the spread of viral diseases.”

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CHEST annual meeting

CHEST annual meeting

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