|Year : 2014 | Volume
| Issue : 2 | Page : 61-67
Pediatric burn care in sub-Saharan Africa
Rene Albertyn, Alp Numanoglu, Heinz Rode
Department of Paediatric Surgery, Red Cross Children's War Memorial Hospital and University of Cape Town, Cape Town, South Africa
|Date of Web Publication||10-Apr-2015|
Dr. Rene Albertyn
Department of Paediatric Surgery, Red Cross Children's War Memorial Hospital and University of Cape Town, Cape Town
Source of Support: None, Conflict of Interest: None
Burn injuries in Africa are considered to be a major health care problem. Sub-Saharan Africa has the highest number of pediatric burn admissions in the world. Burn care is complicated by numerous factors such as financial constraints, lack of resources, health care personnel and modern well equipped easily accessible health care facilities. Despite these numerous obstacles, burn care professionals on the continent of Africa have delivered a sterling service. A review of 70 articles published by authors on the African continent revealed information on topics ranging from the management of the HIV + patient, burn prevention strategies and new trends in African burn care.
Keywords: Burn care, paediatric, sub-Saharan Africa
|How to cite this article:|
Albertyn R, Numanoglu A, Rode H. Pediatric burn care in sub-Saharan Africa. Afr J Trauma 2014;3:61-7
| Introduction|| |
Burn injuries, described as a major global public health problem are amongst the most devastating and traumatic injuries, and are a major contributor to morbidity and mortality in sub-Saharan Africa.  Global estimates revealed that the highest number of pediatric burn admissions per capita is found on the African continent.  These injuries were rated as the second most common cause of accidental death in African children younger than 5 years of age. , The World Health Organization (WHO) established that between 18 000 and 30 000 children aged 5 years or younger die annually of fire-related injuries in sub-Saharan Africa. ,
Burn care is complicated and at best challenging, even in modern well-equipped burn facilities. Factors related to burn injuries, e.g. ignorance regarding fire prevention, increased slumming, persistent reliance on traditional customs and believes  and problems associated with burn care provision, e.g. lack of supplies, lack of burn education, financial constraints and trained health care professionals are regularly documented.  Difficulties in burn management, e.g. lack in government involvement, insufficient numbers of burn care centers, the impact of low literacy rates on prevention programs are well described by African burn care providers. , The limited availability of resources and allopathic medical care in many African regions contributed to the growing recognition for the role of traditional medicine in burn care. More than 25 African plants species (e.g. Carica papaya, Banana leaves, honey)  have been described as useful in relation to burn management and wound healing although it is also associated with deleterious effects. 
Most of the reviewed epidemiological studies are hospital based, excluding information on burn injuries occurring in rural areas. During the WHO's 2008 global burden of disease investigations, 42 out of 45 African countries did not report country-specific data on pediatric burn injuries.  There is overwhelming evidence that burn injuries are preventable, especially in the pediatric group, which will require effective and sustainable community-wide prevention programs.
The purpose of this paper is to review available data on the status of burn care on the African continent.
| Methodology|| |
A web-based literature search identified one hundred publications in the English literature on various aspects of African burn care by authors from 15 sub-Saharan countries (Nigeria, Malawi, Gambia, Angola, South Africa, Ghana, Kenya, Liberia, Cote D 'Iviore, Mozambique, Zambia, Ethiopia, Zimbabwe, Rwanda and Tanzania) published over the past 45 years (from 1969 to 2014). The majority of papers were published by authors in Nigeria (n = 22) and South Africa (n = 36). Dominant themes in the reviewed literature included: Epidemiology, acute care, associated problems including first aid options, traditional medicine, facilities as well as prevention and training. This article reported on seventy of the one hundred reviewed publications to avoid duplication of information.
Epidemiological characteristics of burn injuries
Epidemiological studies featured prominently in the reviewed literature, although the existing data are largely incomplete.  The bulk of the reviewed literature were based on studies done in large teaching hospitals and burn centers situated in major African cities, the Nigerian Ahmadu Bello University Teaching Hospital,  the Neves Bendinha Hospital in Angola  and South African Red Cross War Memorial Children's Hospital,  while only a few studies reported on burn epidemiology in the more rural areas in South Africa and sub-Saharan Africa. , Despite the importance of epidemiological reviews, studies based only on hospital records cannot provide an in-depth insight into the problem as these studies are carried out on a small sample of the larger population at risk.  Most of the studies accounted for more severe cases, including those with easy access to treatment facilities. There must be a large hidden percentage of untreated or minor burns and those that have perished in the accident that are not accounted for. Community-based reviews, therefore, are essential for the development of appropriate prevention programs. 
The majority African studies reported on general epidemiological information including, the incidence, mortality rate, causative factors age groups involved and area burned ,,,,,, while a smaller number of publications contained information of a more thematic nature; kerosene burns,  therapeutic burns,  HIV infections in burns , recreational fires,  neonatal burns,  burns during pregnancy , and inhalation burns. ,
Reports from different regions in sub-Saharan Africa support WHO findings relating to the health care burden posed by burn injuries (e.g., Abijan, Cote D'Iviore, n = 314 adults and children,  Ahmadu Bello University Hospital in Zaria Nigeria (1971-1980): n = 429 children,  University of Calabar Teaching Hospital (1984-1985) n = 141 adults and children,  Neves Bendinha Hospital, Angola (1991-1994): n = 2569,  Red Cross Children's Hospital (1996-2009, n = 9348). It is not known if the difference in patient numbers reflects on the access to burn care, patterns or population served.
Adults' versus pediatric burns
Studies reporting on childhood burns have concluded that children aged 5 years of younger are more vulnerable to sustain burn injuries. Epidemiological studies involving both adults and children from various countries in Africa: Nigeria , Ethiopia  South Africa  Zimbabwe,  confirmed the higher incidence of burn injuries in the 5 years or younger age group. More than 12 650 children were treated for burn injuries at the Red Cross Children's Hospital in Cape Town during the period 1996-2009. Of these, 80% were younger than 5 years.  Burn statistics obtained from the Edenvale Hospital in KwaZulu Natal, South Africa revealed that out the 450 burn admissions, 203 were children younger than 12 years of age.  In Ghana, children aged 18-23 months were at a greater risk of burns (7.4/1000 children), while epidemiological data from a teaching hospital in Abidjan suggested that 75% of all pediatric admissions were younger than 5 years of age.  In addition, Nigerian studies suggested that an estimated 80% of burned children treated in Northern Nigeria were in this age group. 
In general terms, four injury patterns can be identified amongst children: Infant scalding mostly males suffering burns at home with the upper body parts over presented; toddler scalding, predominantly females affecting mostly the lower body parts and driven by their natural curiosity and unsteady physical stature; preschool and school age children with an over presentation of flame related burns, they are mobile, socially independent and have gender-specific high-risk activities; and a forth miscellaneous group exposed to environmental hazards in an expanding social network. 
Most burn injuries occur in and around the house. Hot liquids are the most prominent cause of injury in young children followed by flame burns and chemical burns. Nigerian studies have indicated that chemical burns although scarce, occur mostly because of the storage of caustic soda in the living rooms.  Information obtained from parents in the Ashanti Region in Ghana has revealed that scald injuries occurred in 62% of the 955 burned children included in the study. Scald injuries in this study included hot water, hot food or oil.  In contrast, a study done in the Benin Teaching Hospital, Benin City Nigeria revealed that flame burns from kerosene explosions occurred in 52% of the 62 children included in the study.  Researchers at the Ngwelezana Hospital burn unit in rural KwaZulu-Natal (n = 423 pediatric patients) found that hot water burns accounted for 69.5% of burn injuries while fire burns were reported for 19.6% of patients 16.
The situation analysis amongst adults is different. As an example a major burns unit in South Africa admitted a total of 1908 patients during a 6-year period, 44.4% of the patients sustained burns between 10% and 40% total body surface area (TBSA). Common causes were hot water scald (20%), flame burn (39%) and chemical/accelerant burns (21%), accidental burn (32%), intentional injuries (5.7%) and intentional self-harm (3.5%), injuries due to shack fires and fuel stoves (21%) with kerosene stoves accounting for 71% of injuries. Most fatal injuries occurred in the 20-40 year age group, mostly accidental (41%) with 5% and 8% due to assault and self-harm respectively.  A total different scenario therefore to pediatric burns.
Significant mortality was reported. According to the WHO, thermal injuries are responsible for the death of 6.1/100 000 people in Africa each year.  South Africa has an annual pediatric burn mortality rate of 2.8/100 000 children,  especially under the age of 5 years. In South Africa, burns are the third most common external cause of death in children younger than 18 years of age.  Country specific information concurred with the WHO estimates. Seventeen Nigerian studies reported mortality rates ranging from 4.3%  to 44%,  Liberia reported a 14.2% mortality rate in one publication  and Angola an overall mortality rate of 9.1% for the 7320 patients treated between 1991 and 1994. Hyder reported case-fatality mortality of 6-10% and between 18,000 and 30,000 burn deaths annually amongst African children. 
Theme related epidemiological studies
While the majority of the reviewed literature on burn epidemiology followed a more general trend of incidence, cause, mortality, specific themes were noted in other epidemiological reviews.
Burn injury survival during pregnancy
Very few studies reported on the outcome of burns in pregnant African women, possible because routine pregnancy tests are not performed on burned woman of reproductive age. Studies from South Africa, Zaria and Nigeria, recommend the following: Pregnancy does not influence maternal outcome after thermal injury and maternal survival is usually accompanied by fetal survival in the absence of significant maternal complications. Maternal survival is less likely if the burn exceeds 50% TBSA. Thermal injury increases the risk of spontaneous abortion and premature labor. Early obstetrical intervention is only indicated in the gravely ill-patient, especially if the burn exceeds 50% TBSA. The mode of delivery should be determined by obstetrical considerations. 
A retrospective review of 4451 children admitted with thermal injuries over a period of 10-year was conducted to determine the incidence, clinical presentation and pathology of inhalation burns at the Red Cross Children's Hospital in Cape Town South Africa. While stridor and acute progressive respiratory distress were the main symptoms, major airway burns were always seen in conjunction with either upper airway or parenchyma injury.  Findings suggested that inhalation burns are often not diagnosed or could present late, usually with significant consequences. Any burn above the clavicle in a child must be regarded to have an inhalation component until proven otherwise. There was scant reference to inhalation injuries in the articles under review.
Mass casualty due to fuel related disasters
Fire related burns are responsible for an annual global mortality rate of 265,000 people. In 2009, a fuel tanker carrying 30,000 L of fuel overturned and caught fire in Kenya, killing 90 people. In four petrol related disasters in Ghana, 212 people aged 3-53 years were injured. More than half of those admitted to hospital died of their injuries. The authors of this study concluded that most burn centers in Africa would be unable to cope with mass casualty as few have disaster plans in place. 
Intentional childhood burn injuries
Fewer studies in the developing world have studied the incidence of intentional childhood burn injuries. A community-based survey of children aged 0-5 years (n = 650) in the Ashanti region of Ghana revealed that 35 children sustained intentional (mostly flame) burns. Traditional healers were responsible for 6% of the inflicted burn injuries. The authors stressed the importance of early detection and public education, especially on the treatment for convulsions. 
Therapeutic burns are often administered as part of the traditional treatment of epilepsy. This ill-considered and unsubstantiated treatment to cure epilepsy is born out of ignorance and superstition (i.e., witchcraft and supernatural beliefs).  During treatment, the patient's feet are either covered in hot ashes or boiling water or held over an open flame.  Seizures in many African countries are related to ancestor wrath and the braking of cultural taboos.  This ignorance can contribute to the noncompliance with anti-convulsant drugs as epilepsy suffers may be unwilling to take drugs in fear of angering their ancestors.  The consequences of this treatment can be devastating - often resulting in full thickness burns to the feet, deformities or death. 
HIV and the burned patient
The HIV/AIDS epidemic/pandemic continues to grow in sub-Saharan Africa, and available studies on the impact of HIV on burns have produced conflicting results. A study conducted in 2001 demonstrated that the outcome of HIV-positive patients without stigmata of AIDS showed no difference when compared to HIV-negative patients with the recommendations that they should be managed similarly.  A study from Malawi involving 40 patients reported a two fold increase in mortality in HIV positive patients and a study from Zimbabwe could not find any increase in mortality or length of hospitalization among the HIV positive group.  However, a previous communication from the same unit demonstrated impaired graft survival in a group of 15 HIV patients.  Out of the 342 patients admitted to the burn unit of the Queen Elizabeth Central Hospital in Blantyre, Malawi (2000-2001), 12% (n = 40) patients were HIV+. An estimated 4% of these patients were children younger than 5 years of age. The mortality rate was high. Wound sepsis was responsible for almost half of these deaths. 
Current status of burn care in sub-Saharan Africa
Burn care provision is largely dependent on the availability of resources, trained staff and accessibility of health care facilities. Despite enormous challenges, expert burn care is provided under challenging circumstances. It is not uncommon for families to perform wound care without nursing supervision.  Born out of the need, traditional burn care is often provided by traditional healers in partnership with the more classical allopathic health systems. One compromising area in African burn care provision is the almost total lack of rehabilitation and reconstructive surgical support for burn survivors. 
In addition to the financial constraints and the lack of infrastructure, war and political instability also places a heavy burden on burn care delivery. The prewar burn care facilities of the Neves Bendinha Hospital in Luanda Angola consists of an intensive care unit (six adult beds, two pediatric beds), a high care facility (five adult beds, two pediatric beds) and a 42 bed unit (30 adult beds, 12 pediatric beds). The provision of burn care in this unit is compromised by a severe shortage of food, a chronic shortage of basic drugs and drinking water as a result of the destruction that followed the long extended period of civil unrest. A total of 100 USD is allocated to meet the annual nutritional needs of more than 300 patients and staff members.  Haq reported on circumstances at the Coast Province Hospital in Mombasa Kenya where in addition to a shortage of drugs, financial constraints only provided for a daily expenditure of 5 USD/patient on inpatient care compared to the 1000 USD/day equivalent in the United States. 
Specialized burn care is limited to only a few sub-Saharan countries (e.g. South Africa, Nigeria, Zimbabwe and Malawi), despite the fact that sub-Saharan Africa has the highest incidence of hospitalized pediatric burn patients in the world (estimated incidence of 0.0108).  The majority of patients are treated within existing health care facilities (e.g. rural healthcare centers, district hospitals or tertiary referral hospitals) with only few dedicated burn units available in mostly tertiary hospitals. ,,
Burn care at the more rural facilities is restricted to the provision of wound care for minor injuries, tetanus prophylaxis and anti-biotics.  Anti-biotics are often prescribed on an empirical basis only as very few can afford the laboratory costs associated with wound cultures.  Ideally more severe burn injuries should be admitted to tertiary burn centers, however, transport related problems  often necessitate the admission of severely burned patients to rural health care centers where they are cared for by trained community health care workers supervised by visiting general practitioners.
Burn care in district or community hospitals, apart from the basic care can also provide IV fluid therapy, topical agents and anti-biotics.  Burned patients are cared for in general or trauma wards where burn care is compromised by a lack of isolation and the risk of infection,  shortage of drugs,  delayed skin grafting due to a shortage of anesthetists,  lack of resuscitation equipment,  operating time and blood products.  The high incidence of HIV in sub-Saharan Africa and religious constraints negatively affected the use of blood products.  At the Royal Victoria Hospital in Banjul, Gambia, pediatric burn patients are managed in a burn unit with inadequate ventilation, water supplies and lightning. Policies relating to infection control are inadequate or not existing as bed occupancy could be as high as three children per bed.  Financial constraints often contribute to inadequate in-hospital nutrition. Nutrition at the St. Frances Hospital in Lusaka Zambia consisted of one bowl of cassava root provided each morning. Family members were largely responsible for caring for the patients, often sleeping in the same room as the patient. 
Specialized burn care is provided at tertiary hospitals by general and plastic surgeons. In addition, these hospitals can also offer intensive care  as well as surgical care, intravenous therapy, topical agents, analgesics, specialized nursing care and laboratory testing  in dedicated burn units. 
Traditional medicine plays an important role in burn care provision in sub-Saharan Africa. The lack of infrastructure, inaccessible roads, long distances to nearest health care center, high cost associated with medical care, ignorance and superstition all contributed to the dominant use of traditional burn care methods. A survey conducted amongst 2000 households in Ghana revealed that 56% of the respondents have never used a health care facility, while a Nigerian study reported on a 40% (n = 260) respondent use of modern health care facilities. 
A survey conducted in Ethiopia on the use of traditional medicine revealed a preference for the use of nontested first aid remedies such as egg yolk, butter, mud, salt, and cow dung ,[ 40] while traditional remedies popular in Kenya include the use of plants and plant juices as well as a preference for banana leaves to be used as wound dressing.  Plant material often used by traditional healers included the use of Grapefruit, Coriander and Biter Orange.  In Gambia financial constraints led to the successful introduction of the Carcia Papaya as a topical wound dressing.  In West Africa, more than 25 plant species have been identified in specifically the treatment of burn injuries.  The preference for traditional burn care often contributed to a delay in seeking Allopathic health care which could have a huge impact on the burn outcome. Burn care survivors in Ghana making use of traditional medicine admitted to only seeking modern health care once their wounds became infected, often waiting as long as 60 days postburn to seek help from a hospital or clinic. 
Methods of treatment
The lack of standardized burn care protocols has a huge impact on African burn care. Some African countries (e.g. Malawi,  Zimbabwe  ) use standard protocols inclusive of the assessment of wound severity, administration of analgesia, airway management, intravenous fluids administration, surgery and nutritional support.  Other countries have to make do with the expertise and experience of their health care providers. Resuscitation practices follow standard regimes with regard to burn size and resuscitation, fluids, monitoring practices and the use of enteral resuscitation and early feeding. 
Wounds are often treated via the "open method" due to financial constraints and inadequate staffing.  This method is used to treat burns involving the face, axilla, groin, perineum or neck. It is particularly suitable in the tropical African climate. 
Skin grafts are often delayed due to a lack of equipment, trained staff, and the donor skin, blood products and nutritional status of the patient. It is often postponed for several weeks due to the high incidence of malnutrition in particularly young children.  Underlying health problems (e.g. HIV/AIDS, tuberculosis, malaria) are also contributing to the late grafting of patients. ,,
Unfortunately, preventative measures are re-active, often fragmented and not subject to evaluation and sustainability to vulnerable communities. The prevention of burn related injuries in Africa would be very difficult, because inequities in health care, so prevalent on the continent, put people who are already socially disadvantage (poor, female, and members of racial, ethnic or religious group) at further disadvantage with respect of their health. High-income countries have made substantial progress in this regard through creating an "enabling environment" for their citizens, improved health care facilities, advanced education, enforceable changes though legislation and safe product designs. Can this be achieved on a global scale on this continent?
Even with limited resources burn care can be substantially improved with basic measures; cooling the wound, fluid resuscitation, basic topical therapy, triage and early referral. The challenge of adequate burn care in Africa depends on the successful prevention of thermal injuries, for social standards to improve, on health care education programs, legislation and public awareness programs, the provision of safe and available energy resources and a restructuring of basic health services. This is a massive task, but we believe that the burn fraternity working on the African continent is capable of changing the face of burn care on this continent.
Nigerian prevention strategies include fire safety awareness, education on correct first aid treatment and early presentation to hospital to reduce morbidity and mortality. Literature from Malawi identified educational programs on the correct storage of flammable substances, and improved health care training programs  while authors in Mozambique recognized the value of identifying risk factors before instituting burn prevention programs prior to the development of health educational programs.  Burn prevention programs from Zimbabwe and Malawi included active public educational programs and early prevention education. ,,
New developments in African burn care
The reviewed literature revealed publications on relatively new trends in African burn care: Telemedicine evaluation of acute burns has been shown to be accurate and cost effective and is particularly suitable for Africa with its limited care facilities and vast distances to treat the majority of burns. 
Kiser et al. described the use of photographic burn wound assessment in the evaluation of burn size and wound characteristics and Giaquinto-Cilliers reviewed the role of telemedicine to provide access to specialist burn care in remote areas in rural South Africa. If developed and implemented, it may become an integral part of future care. 
Cost associated with burn injuries
Health care for burns is one of the most expensive aspects of current health care systems with multiple factors influencing costs, including size of the burn, therapeutic factors, labor and length of stay. Unfortunately there is limited information on costing in Africa with one review indicating that period of hospitalization is the main cost driver during the direct and acute phase of treatment. Working already in a fiscal restricted environment, every effort must be used to optimize burn care without sacrificing quality of care.
| Conclusion|| |
Despite the fact that the burn fraternity is working under very difficult circumstances, we believe that there are men and women who have dedicated their professional life to improve burn care. It is incumbent upon the current and future generation to build on this solid foundation. Working and living in Africa calls for a particular dedication to serve the children with a commitment.
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