Lancet, The (Journal)

Severe Covid Is More Often Fatal in Africa Than in Other Regions

People in Africa who become critically ill from Covid-19 are more likely to die than patients in other parts of the world, according to a report published on Thursday in the medical journal The Lancet.

The report, based on data from 64 hospitals in 10 countries, is the first broad look at what happens to critically ill Covid patients in Africa, the authors say.

The increased risk of death applies only to those who become severely ill, not to everyone who catches the disease. Over all, the rates of illness and death from Covid in Africa appear lower than in the rest of the world. But if the virus begins to spread more rapidly in Africa, as it has in other regions, these findings suggest that the death toll could worsen.

Among 3,077 critically ill patients admitted to the African hospitals, 48.2 percent died within 30 days, compared with a global average of 31.5 percent, the Lancet study found.

The study was observational, meaning that the researchers followed the patients’ progress, but did not experiment with treatments. The work was done by a large team called The African Covid-19 Critical Care Outcomes Study Investigators.

For Africa as a whole, the death rate among severely ill Covid patients may be even higher than it was in the study, the researchers said, because much of their information came from relatively well-equipped hospitals, and 36 percent of those facilities were in South Africa and Egypt, which have better resources than many other African countries. In addition, the patients in the study, with an average age of 56, were younger than many other critically ill Covid patients, indicating that death rates outside the study could be higher.

The other eight countries in the study were Ethiopia, Ghana, Kenya, Libya, Malawi, Mozambique, Niger and Nigeria. Leaders of 16 other African nations had also agreed to participate, but ultimately did not.

Reasons for the higher death rates include a lack of resources such as surge capacity in intensive care units, equipment to measure patients’ oxygen levels, dialysis machines and so-called ECMO devices to pump oxygen into the bloodstream of patients whose lungs become so impaired that even a ventilator is not enough to keep them alive.

But there was also an apparent failure to use resources that were available, the authors of the study suggested. Proning — turning patients onto their stomachs to help them breathe — was underused, performed for only about a sixth of the patients who needed it.

Almost 16 percent of the hospitals had ECMO, but it was offered to less than 1 percent of patients. Similarly, although 68 percent of the sites had access to dialysis to treat kidney failure, which is common in severe Covid cases, only 10 percent of the critically ill patients received it. Half the patients who died were never given oxygen, but the authors of the study said they had little data to explain why.

A Lancet editorial by experts not involved in the study said, “It is common in Africa to have expensive equipment that is non-functional due to poor maintenance or lack of skilled human resources.” Some 40 percent of the medical equipment in Africa was out of service, according to a 2017 report by the Tropical Health and Education Trust, the editorial said.

Another factor is that few doctors in Africa have the training in pulmonary and critical care that is considered essential in treating Covid patients.

As in other studies, chronic conditions like diabetes, high blood pressure, and diseases affecting the heart, kidney or liver increased the risk of death from Covid. This study was the first to include a large proportion of patients with H.I.V., which nearly doubled the risk of death. The report states, “Our data suggests that H.I.V./AIDS is an important risk factor for Covid-19 mortality.” But the authors also said they did not have data on how the severity of the H.I.V. infection might affect the risk.

An unexpected finding of the study was that, unlike Covid patients in the rest of the world, men in Africa were no more likely than women to die. That result suggests that African women are at higher risk than women in other regions.

The authors suggested that women in Africa might face “barriers to accessing care and limitations or biases in care when critically ill.”

The editorial asked whether new variants could be causing the high death rate found in the study, but also said, “This is a question which, in a continent with severe shortage of sequencing, could take a long time to answer.”

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Pfizer Vaccine Is Highly Effective Against Variants, Studies Find

The second new study, which was published in The Lancet, was conducted by researchers at the Israel Ministry of Health and Pfizer. It is based on more than 230,000 coronavirus infections that occurred in Israel between Jan. 24 and April 3. During that period, B.1.1.7 accounted for nearly 95 percent of all coronavirus cases in the country, which has vaccinated more than half of its population.

The researchers found that the vaccine was more than 95 percent effective at protecting against coronavirus infection, hospitalization and death among fully vaccinated people 16 and older. It also worked well in older adults. Among those 85 or older, the vaccine was more than 94 percent effective at protecting against infection, hospitalization and death.

As the percentage of fully vaccinated people in each age group grew, the incidence of coronavirus infections in that cohort fell, the researchers found. The declines in infection rates matched the timing of increasing vaccine coverage in each age group better than the start of a nationwide lockdown. The results suggest that Israel’s rapid pace of vaccination has been responsible for the decline in infections in the country.

“I’m just really happy to see this data that in the real world these vaccines are having such an amazing impact on curtailing infection and disease,” said Akiko Iwasaki, an immunologist at Yale University.

Both studies also reported that two doses of the vaccine provided significantly more protection than one dose did. In the Israel study, for example, one dose of the vaccine was 77 percent effective against death, while two doses were 96.7 percent effective.

“It absolutely emphasizes the need for the second dose,” said Dr. Kathleen Neuzil, who directs the Center for Vaccine Development and Global Health at the University of Maryland School of Medicine.

Together, the studies suggest that even with the new variants, vaccination remains a plausible path out of the pandemic, experts said. “If we can get vaccines to the world and get coverage up,” Dr. Neuzil said, “I believe we can get on top of this and we can get on top of the emergence of new variants.”

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Slovakia Claims a Bait-and-Switch With the Russian Vaccines it Ordered

The European Union’s regulator, the European Medicines Agency, has so far declined to approve the Russian vaccine for use and only two members of the bloc, Hungary and Slovakia, have placed orders for Sputnik V. Serbia, which is not a member of the bloc, has also ordered Sputnik V and begun using it in a mass inoculation program that has been far more successful than the stumbling efforts of most European Union states.

Even Germany, a stickler for procedure, has expressed growing interest in Sputnik V. Health Minister Jens Spahn told the public broadcaster WDR on Thursday that he would like to start bilateral talks with Russia over a potential purchase of the vaccine, which would go through only if it is approved by the European Medicines Agency.

The previous day, Markus Söder, the governor of Bavaria, said his government had signed a preliminary agreement to buy 2.5 million doses of the vaccine, which are to be produced at a Russian-owned plant in the southern state. That deal, too, is contingent on E.M.A. approval.

Sputnik V is manufactured at seven locations in Russia, and also at plants in India and South Korea. A number of other countries have signed manufacturing contracts, including Brazil, Turkey and Serbia. Russia has consistently delivered fewer doses of the vaccine than initially promised, suggesting glitches in manufacturing. Producing vaccines at scale is a difficult process and ramping up production has presented problems for Western vaccines, too.

Noting that about 40 countries are using or scheduled to use the Russian vaccine, the Slovak regulatory agency asserted that “these vaccines are only associated by the name.” That raised questions about deviations from the formula reviewed in The Lancet.

“The comparability and consistency of different batches produced at different locations has not been demonstrated,” the Slovak regulator said. “In several cases, they appear to be vaccines with different properties (lyophilisate versus solution, single-dose ampoules versus multi-dose vials, different storage conditions, composition and method of manufacture).”

The Slovak statement could damage Russia’s efforts to establish Sputnik V as a reliable brand. It could also exacerbate lingering doubts left by the vaccine’s highly politicized rollout in Russia, where President Vladimir V. Putin announced that the drug was ready for use in August, before clinical trials had finished.

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Coronavirus Reinfections Are Rare, Danish Researchers Report

The vast majority of people who recover from Covid-19 remain shielded from the virus for at least six months, researchers reported on Wednesday in a large study from Denmark.

Prior infection with the coronavirus reduced the chances of a second bout by about 80 percent in people under 65, but only by about half in those older than 65. But those results, published in the journal Lancet, were tempered by many caveats.

The number of infected older people in the study was small. The researchers did not have any information beyond the test results, so it’s possible that only people who were mildly ill the first time became infected again and that the second infections were largely symptom-free.

Scientists have said that reinfections are likely to be asymptomatic or mild because the immune system will suppress the virus before it can do much damage. The researchers also did not assess the possibility of reinfection with newer variants of the virus.

fishing trawler in Seattle, Marine Corps recruits in South Carolina, health care workers in Britain and patients at clinics in the United States.

The new study’s design and size benefited from Denmark’s free and abundant testing for the coronavirus. Nearly 70 percent of the country’s population was tested for the virus in 2020.

The researchers looked at the results from 11,068 people who tested positive for the coronavirus during the first wave in Denmark between March and May 2020. During the second wave, from September to December, 72 of those people, or 0.65 percent, again tested positive, compared with 3.27 percent of people who became infected for the first time.

That translates to a 80 percent protection from the virus in those who had been infected before. The protection fell to 47 percent for those over 65. The team also analyzed test results from nearly 2.5 million people throughout the epidemic, some longer than seven months after the first infection, and found similar results.

“It was really nice to see that there was no difference in protection from reinfection over time,” said Marion Pepper, an immunologist at the University of Washington in Seattle.

She and other experts noted that while 80 percent might not seem superb, protection from symptomatic illness was likely to be higher. The analysis included anyone who was tested, regardless of symptoms.

“A lot of these will be asymptomatic infections, and a lot of these will likely be people who have a blip of virus,” noted Florian Krammer, an immunologist at the Icahn School of Medicine at Mount Sinai in New York. “Eighty percent risk reduction against asymptomatic infection is great.”

The findings indicate that people who have recovered from Covid-19 should get at least one dose of a coronavirus vaccine to boost the level of protection, Dr. Krammer added. Most people produce robust immune response to a natural infection, “but there’s a lot of variability,” he said. Following vaccination, “we don’t see variability — we see very high responses in basically everybody, with very few exceptions.”

Experts were less convinced by the results in people over 65, saying the findings would have been more robust if the analysis had included more people from that age group.

“I wish it had actually been broken down into specific decades over 65,” Dr. Pepper said. “It would be nice to know whether the majority of people who were getting reinfected were over 80.”

The immune system grows progressively weaker with age, and people over 80 typically mount weak responses to infection with a virus. The lower protection in older people seen in the study is consistent with those observations, said Akiko Iwasaki, an immunologist at Yale University.

“I think we kind of tend to forget how the vaccines have been pretty amazing in offering protection in this age group, because you can see that natural infection doesn’t confer the same kind of protection,” she said. “This really does emphasize the need to cover older people with the vaccine, even if they have had Covid first.”

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