From Ebola to COVID-19: Challenges in providing critical care in low-resource settings

At the CHEST Annual Meeting, a worldwide panel highlighted disparities in receiving and accessing critical care around the world and challenges in providing critical care services in low-resource settings.

Many hospitals around the world lack proper ICU equipment, medications and trained health care workers, from physicians to nurses to respiratory therapists, according to a press release. The COVID-19 pandemic has highlighted such challenges, and others, in low-resource settings. Through the lens of advances in Ebola treatment and the current pandemic, experts discussed practical solutions to the challenges of critical care in low-resource settings, lessons learned and how the health care system can adapt, according to the release.

Critical care disparities around the world

William Fischer, MD, associate professor of medicine in the division of pulmonary diseases and critical care medicine and director of emerging pathogens at the Institute of Global Health and Infectious Diseases at the University of North Carolina, Chapel Hill, highlighted four key challenges from the perspective of an outbreak response: inequity in access to care; community-centric 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 response was centered on identifying the infected individual, isolating said individual and tracking anyone who made contact with the infected individual to isolate them as well, Fischer said.

“Many of the outbreaks early on have been stopped by prevention of transmission, and while that’s important for community settings, it doesn’t do much good for that individual who is isolated,” Fischer said during the session.

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

Because of these disparities in access to critical supportive care and investigational therapeutics, there were stark differences in patient outcomes. Patients treated in West Africa had a case fatality rate of 63%, which was vastly different than the 18.5% case fatality rate among those treated outside of West Africa, Fischer said.

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

“Médecins Sans Frontières (Doctors Without Borders) came from the surgical patients at the beginning, based on the findings that most of them were actually dying after the surgery not during, and they were dying from things that we could have fixed. They were dying mostly by lack of monitoring or inadequate monitoring, and we were able to pick up sepsis at a septic shock level, or the bleeding at the [gastrointestinal complication] level, which are not treatable on our fields,” said Aurélie Godard, MD, anesthesiologist, intensivist and intensive care adviser with Médecins Sans Frontières, France. “So that’s where the ICU mission started with, with this need of monitoring the ICU team surgical patients.”

Godard and colleagues with Médecins Sans Frontières/Doctors Without Borders work with critical care patients, such as those with COVID-19, but also those with HIV, noncommunicable diseases and pediatric patients. In the humanitarian settings, Godard cited the following constraints in low- and middle-income countries:

• logistic constraints: working in complex security situations, accessibility to health care, architecture and drug and equipment supply challenges; and
• scientific constraints: varying medical skills worldwide, intensive care not recognized or taught as a specialty, low health care worker retention; different pathologies, publication bias; limited diagnostic tools.

In addition, there are massive needs required in low- and middle-income countries in terms of critical care, knowledge transmission and training, transportable tools and even basic therapeutics in many countries, Godard said. For example, almost 90% of patients with hypoxia in Malawi do not receive oxygen, Godard said.

“The essential emergency critical care concept, I think, is on the stage now, and promoting this access for every critically ill patient everywhere in the world to, at least, basic needs in order to build up to a more developed and more complex ICU care is what this population really needs,” Godard said.

Steps forward

To mediate some of the disparities, the panel highlighted the following:

• expanding access to care for patients and providers;
• embracing community-centric strategies with patient-centric implementation;
• prioritizing investment in research, bedside learning and local investigators; and
• integrating patient care with high consequence pathogens into the existing health care infrastructure.

According to Fischer, reintegrating and building up infection control infrastructures can aid physicians in continuing to provide higher levels of care, not just for patients with Ebola, but for patients with every disease during and after outbreaks.

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

“We know that, from rich countries, Ebola patients have many possibilities in that they have good monitoring, they have good medicine, good supportive care and critical care was received for them,” said Richard Kojan, MD, ICU specialist at Kinshasa Teaching Hospital at Kinshasa University and president of the Alliance for International Medical Action (ALIMA), Democratic Republic of Congo. “In contrast, the Ebola patients in our context are being provided with minimal care services during different outbreaks in the last 10 years, and the objective, at the time, was to protect the health care facilities and the health care workers from the possible contamination. So, this is one of the major reasons for higher mortality in our region.”

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

In the CUBE, patients can be seen by physicians for treatment while also able to see family and loved ones without high risk for virus contamination. Also, in the CUBE, physicians are not required to wear full personal protective equipment but can still provide clinical monitoring 24 hours a day. With this, it is also possible to introduce lab monitoring, biochemistry, hematology and mood capturing for patients while reducing the window of care, Kojan explained.

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

“None of this happens with one person or one group,” Fischer said. “This requires a community of all of us dedicated to the idea that there should be a single standard of care and increased equitable access to both care and therapeutics as well.”

‘A global medical community’

Panel co-chair Orlando Garner, MD, highlighted “the stark contrast between the level of care that can be provided in the U.S. versus a lower-income country,” noting in the release that “[i]n most cases, the practice guidelines are derived from high-income settings and cannot be adequately followed around the world.”

“If COVID has taught us anything, it’s that we live in a global medical community and what happens across the world can affect everyone,” panel co-chair Aditya Nadimpalli, MD, said in the release. “It is vital that the global focus be centralized around rapid testing, novel and accessible treatments and on vaccinations to control the spread of viral disease.”