Prevalence, Characteristics, and Outcomes of Adults in Sub-Saharan Africa with World Health Organization Defined Severe Respiratory Distress without Shock

Abstract

Background Sepsis is the leading cause of global mortality, and it is frequently attributed to lower respiratory tract infections and subsequent acute respiratory distress syndrome (ARDS). Patients from sub-Saharan Africa (sSA) are underrepresented in existing studies of sepsis, and little is known about ARDS in sSA. Severe respiratory distress (SRD) is a surrogate for ARDS defined by the WHO as O2 saturation 30 breaths/minute and a systolic blood pressure >90 mmHg plus suspected infection in the absence of cardiac failure. In the context of the current COVID-19 pandemic, a better understanding of SRD in sSA is urgently needed. In this study, we aimed to determine the prevalence, clinical characteristics, and in-hospital mortality of adults with SRD in sSA. Methods We analyzed pooled individual-level data from 16 studies of hospitalized patients conducted in 6 countries throughout sSA from 2009 to 2019. We used multiple imputation with chained equations with 10 iterations to impute missing data. We performed multivariable logistic regression to estimate associations between patient vital signs, laboratory studies, SRD, and in-hospital mortality. We characterized factors associated with in-hospital mortality in the subset of patients with SRD. Results The pooled data included 7385 patients with a median age of 37 years, of whom 3584 (49%) were women, 2282 (31%) were living with HIV, 3190 (43%) had a known acute infection, and 946 (13%) had SRD. The mortality for the total population and for patients with SRD was 15% and 22%, respectively. Older age, lower temperature, increased heart rate, increased respiratory rate, decreased oxygen saturation, Glasgow Coma Scale score <15, HIV infection, and SRD were associated with increased in-hospital mortality. For every increase of 5 breaths/minute, there was a 72% increase in the odds of in-hospital mortality, and conversely for every 1% increase in O2 saturation there was a 5% reduction in the odds of in-hospital mortality. In a subset of patients with available laboratory values, decreased hemoglobin and increased lactate were independently associated with increased inhospital mortality. We found similar associations with in-hospital mortality in the subset of patients with SRD. Conclusions In the first comprehensive evaluation of the prevalence, characteristics, and outcomes of hospitalized patients from sSA with WHO-defined SRD, we found that the prevalence of SRD was high and independently associated with in-hospital mortality. These findings can serve as a benchmark for future studies of patients with SRD in sSA including those with COVID-19.