South Africa has recorded the highest COVID-19 morbidity and mortality compared to other African regions. Several authors have linked the least amount of death in African countries with under-reporting due to poor health systems and patients’ health-seeking behaviors, making the use of clinical audits more relevant for establishing the root causes of health problems, and improving quality patient care outcomes. Clinical audits, such as mortality audits, have a significant role in improving quality health care services, but very little is documented about the outcomes of the audits. Therefore, the study sought to determine the health care system and patient-related factors associated with COVID-19 mortality by reviewing the COVID-19 inpatient mortality audit narration reports. This was a retrospective qualitative research approach of all hospitalized COVID-19 patients, resulting in death between the first and second COVID-19 pandemic waves. Thematic analysis employed inductive coding to identify themes from mortality audits from all 41 public hospitals in Limpopo Province, South Africa. Four themes with seventeen sub-themes emerged: sub-standard emergency medical care provided, referral system inefficiencies contributed to delays in access to health care services, the advanced age of patients with known and unknown comorbidities, and poor management of medical supplies and equipment, as a health system and patient-related factors that contributed to the high mortality of COVID-19 patients. There is a need to routinely conduct clinical audits to identify clinical challenges and make recommendations for health promotion, risk communication, and community engagement. We recommend reviewing and expanding the scope of practice for health-care providers during epidemics and pandemics that include aspects such as task-shifting.

Background Data on biochemical markers and their association with mortality rates observed in patients with severe COVID-19 disease admitted to Intensive Care Units (ICUs) in sub-Saharan Africa are scanty. We performed an evaluation of baseline routine biochemical parameters as prognostic biomarkers in COVID-19 patients admitted to ICU. Methods Demographic, clinical, and laboratory data were collected prospectively on patients with PCR-confirmed COVID-19 admitted to the adult ICU in a tertiary hospital in Cape Town, South Africa, between October 2020 and February 2021. Robust Poisson regression methods and receiver operating characteristic (ROC) curve were used to explore the association of biochemical parameters with severity and mortality. Results A total of 82 patients [(median age 53.8 years (IQR: 46.4-59.7)] were enrolled, of whom 27 (33%) were male. The median duration of ICU stay was 10 days (IQR: 5-14); 54/82 (66% CFR) patients died. Baseline lactate dehydrogenase (LDH) (aRR: 1.002, 95%CI: 1.0004-1.004; P = 0.016) and N-terminal pro B-type natriuretic peptide (NTProBNP) (aRR: 1.0004, 95%CI: 1.0001-1.0007; P = 0.014) were both independent risk factors of a poor prognosis with optimal cut-off values of 449.5 U/L (sensitivity: 1; specificity: 0.43) and 551 pg/mL (sensitivity: 0.49; specificity: 0.86), respectively. Conclusion LDH and NTProBNP appear to be promising predictors of COVID-19 poor prognosis in the ICU. Larger sample size studies are required to confirm the validity of this combination of biomarkers.

More COVID-19 inpatient deaths occurred during the second wave when compared to the first wave in South Africa in both the public and private sectors. This study describes the characteristics of 969 COVID-19 inpatient deaths in the public sector of Limpopo Province during the first and second waves using population-based retrospective design. The results indicate that about 84% of deaths were aged 50+ years; 53.6% were females; 43% occurred in Capricorn district; 56% occurred in PUI wards; 64% had hypertension followed by diabetes mellitus; 88% manifested with shortness of breaths/respiratory distress on admission. The study concludes that as the average age among the population aged 60+ was greater among females than males, the increased death among females compared to males might be influenced by the older age of female inpatients during the first and second waves in Limpopo Province. Some COVID-19 inpatient deaths are possibly preventable if older women may be taken into consideration when planning prevention and management interventions in future pandemics.

Background Studies from Asia, Europe and the USA indicate that widely available haematological parameters could be used to determine the clinical severity of Coronavirus disease 2019 (COVID-19) and predict management outcome. There is limited data from Africa on their usefulness in patients admitted to Intensive Care Units (ICUs). We performed an evaluation of baseline haematological parameters as prognostic biomarkers in ICU COVID-19 patients. Methods Demographic, clinical and laboratory data were collected prospectively on patients with confirmed COVID-19, admitted to the adult ICU in a tertiary hospital in Cape Town, South Africa, between March 2020 and February 2021. Robust Poisson regression methods and receiver operating characteristic (ROC) curves were used to explore the association of haematological parameters with COVID-19 severity and mortality. Results A total of 490 patients (median age 54.1 years) were included, of whom 237 (48%) were female. The median duration of ICU stay was 6 days and 309/490 (63%) patients died. Raised neutrophil count and neutrophil/lymphocyte ratio (NLR) were associated with worse outcome. Independent risk factors associated with mortality were age (ARR 1.01, 95%CI 1.0–1.02; p = 0.002); female sex (ARR 1.23, 95%CI 1.05–1.42; p = 0.008) and D-dimer levels (ARR 1.01, 95%CI 1.002–1.03; p = 0.016). Conclusions Our study showed that raised neutrophil count, NLR and D-dimer at the time of ICU admission were associated with higher mortality. Contrary to what has previously been reported, our study revealed females admitted to the ICU had a higher risk of mortality.

COVID-19 is a priority health research agenda item in South Africa. The World Health Organization declared the COVID-19 outbreak as a Public Health Emergency of International Concern, which requires all countries to respond and share data with others. Responses included the implementation of measures to reduce the spread of COVID-19 and protect health systems from being overwhelmed by seriously ill patients. Each country was mandated to assess its own risk and rapidly implement the necessary measures to reduce COVID-19 transmission and minimize its impact. Countries were further encouraged to share their experiences of responding to the COVID-19 pandemic. Media reports in South Africa suggest that the Limpopo Department of Health implemented a successful COVID-19 response. This study aims to analyze, document and publish those successes to make them accessible to other researchers and public health practitioners. The study will also allow for the participation of public health students to meet the requirements of their postgraduate degrees. This convergent parallel mixed method study will collect secondary data of responses to COVID-19 by the Limpopo Department of Health from the records the department keeps. Quantitative and qualitative data detailing activities and statistics describing facilitators and barriers to implementation of COVID-19 response from March 2020 will be extracted from records.