COVID-19 patients with diabetes and/or obesity are three times more likely to die than those who are HIV positive, whether the latter are on anti-retroviral drugs or not.
That’s the hands-on experience of the country’s advance guard of clinicians treating coronavirus patients at Groote Schuur Hospital where 180 Coronavirus-infected patients were under care by June 5th, with numbers expected to double over the next fortnight as the Western Cape’s two main tertiary hospitals (Tygerberg Hospital is the other), deal with a surge in the country’s worst-affected metropole and province. More than 1 500 clinicians and other healthcare workers from across the country listened intently during a June 11th webinar in which Groote Schuur’s medical team leader, Professor Graeme Meintjes, shared his freshly-acquired knowledge on all aspects of C-19 patient care, symptoms and co-morbidities.
Prof Meintjes, a health advisor to the Department of Science and Technology and the country’s research chair in poverty-related infections, is also Deputy Head of the Department of Medicine at UCT. The webinar was held last Thursday (June 11th), as part of a series hosted by Discovery Health in conjunction with Medical Brief, the Desmond Tutu HIV Foundation, the SA Medical Association, the SA Private Practitioners Forum and the Unity Forum for Family Practitioners. The session was facilitated by Professor Linda-Gail Bekker, the deputy director of the Desmond Tutu HIV Centre at the Institute of Infectious Diseases and Molecular Medicine at UCT, and introduced by Dr Maurice Goodman, Chief Medical Officer at Discovery Health.
Prof Meintjes said that as of 11th June, there were 36 000 people in the Western Cape diagnosed with C-19 and 900 deaths. This represents well over half of the country’s C-19 burden, with tourism, the life-blood of the province’s economy, believed responsible for multiple seeding of the virus there by overseas visitors. Groote Schuur Hospital serves four of the heavy-burden sub-districts of the Cape Metropole. There was arguably a sigh of relief in the audience as Prof Meintjes said HIV-positive patients represented just over a two-fold higher C-19 infection risk than those without any other co-morbidities – a relatively low contributor to serious C-19 debilitation.
“There’s no difference between patients with suppressed viral load and those not on ART. It may be socio economic factors. HIV is associated with increased Covid risk, but what we’re seeing is probably lower than the cited figure of 2,7 times greater risk. While the obesity data are not available, we can see it’s a big contributor, especially when there’s accompanying high blood pressure. About half our C-19 deaths can be attributed to diabetes, but only 12% to HIV,” he revealed.
He said the first C-19 patient was admitted to GSH wards on March 18th and there’d been a gradual increase though March and April, escalating dramatically over the past few weeks.
“The first few weeks gave us an opportunity to prepare; psychologically, communications-wise, agree on a plan for the redeployment of staff, and to rapidly scale up. We now have isolation rooms and six wards set aside for those under investigation, including the maternity and psyche wards,” Prof Meintjes said.
Deaths strongly age-related
About 25% of deaths in the Western Cape were people in their 50’s and another 25% those in their 60’s, with the percentages climbing with age.
Serious co-morbidities nearly always contributed to the far lesser mortalities in younger age groups. C-19 affected males more severely than females with the biggest risk factors being uncontrolled diabetes, obesity, cardio-vascular, hypertension and pulmonary disease. About 5% of all their admissions required ICU treatment.
Asked how common pulmonary emoboli were, Prof Meintjes said about 25% of patients at the severe end of the C-19 spectrum were shown to have them and/or deep vein thrombosis, with an increased mortality risk of 22 to 33%.
He recommended treating patients without intubation, where possible. His team’s early experience was that high-flow nasal oxygen, (HFNO), had a 31% survival rate with 55% of serious patients intubated. Of those on failed HFNO that required ventilation, there had been no survivors – all had either died or were still on ventilators.
Answering a question on duration of HFNO, Prof Meintjes said the timing varied according to individual patients.
“Some we’ve been able to consider weaning after three days and some stay on for two weeks. For those on HFNO for 10 days or longer, we worry about pneumonia and so we do radiology and start them on steroids,” he added.
Prof Meintjes strongly promoted ‘awake-proning,’ (the turning of patients onto their stomachs for two hours or longer, if they can tolerate it), where gravity allows blood to settle in the anterior part of the lungs, providing better oxygenation in two thirds of patients, according to studies. He said oxygen saturation when doing this increased by up to 20%, dramatically increasing a patient’s chances of survival. However, he warned against doing this for severely restless or disoriented patients as they could easily turn onto their backs.
Asked about the use of extracorporeal membrane oxygenation, (ECMO), he said this was in the domain of his critical care colleagues, however it would only be considered in very select patients, especially those with single organ failure (not multiple). ECMO provides temporary support for patients with cardiac or pulmonary failure.
Thanking Prof Meintjes on behalf of webinar participants, Prof Bekker said he cut his teeth on the HIV/AIDS epidemic, which probably helped him prepare for the COVID-19 pandemic. He and his courageous colleagues were at the coalface of the coronavirus pandemic daily, serving at both Khayelitsha and Groote Schuur hospitals, risking their wellbeing in service of others and paving the way for the rest of the country, still bracing itself for a surge of C-19 admissions.