Rethinking burns for low & middle-income countries: Differing patterns of burn epidemiology, care seeking behavior, and outcomes across four countries

Interventions for postburn pruritus

BACKGROUND

Postburn pruritus (itch) is a common and distressing symptom experienced on healing or healed burn or donor site wounds. Topical, systemic, and physical treatments are available to control postburn pruritus; however, it remains unclear how effective these are.

OBJECTIVES

To assess the effects of interventions for treating postburn pruritus in any care setting.

SEARCH METHODS

In September 2022, we searched the Cochrane Wounds Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE (including In-Process & Other Non-Indexed Citations), Ovid Embase, and EBSCO CINAHL Plus. We also searched clinical trials registries and scanned references of relevant publications to identify eligible trials. There were no restrictions with respect to language, publication date, or study setting.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that enrolled people with postburn pruritus to compare an intervention for postburn pruritus with any other intervention, placebo or sham intervention, or no intervention.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included 25 RCTs assessing 21 interventions with 1166 randomised participants. These 21 interventions can be grouped into six categories: neuromodulatory agents (such as doxepin, gabapentin, pregabalin, ondansetron), topical therapies (such as CQ-01 hydrogel, silicone gel, enalapril ointment, Provase moisturiser, beeswax and herbal oil cream), physical modalities (such as massage therapy, therapeutic touch, extracorporeal shock wave therapy, enhanced education about silicone gel sheeting), laser scar revision (pulsed dye laser, pulsed high-intensity laser, fractional CO2 laser), electrical stimulation (transcutaneous electrical nerve stimulation, transcranial direct current stimulation), and other therapies (cetirizine/cimetidine combination, lemon balm tea). Most RCTs were conducted at academic hospitals and were at a high risk of performance, attrition, and detection bias. While 24 out of 25 included studies reported change in burn-related pruritus, secondary outcomes such as cost-effectiveness, pain, patient perception, wound healing, and participant health-related quality of life were not reported or were reported incompletely. Neuromodulatory agents versus antihistamines or placebo There is low-certainty evidence that doxepin cream may reduce burn-related pruritus compared with oral antihistamine (mean difference (MD) -2.60 on a 0 to 10 visual analogue scale (VAS), 95% confidence interval (CI) -3.79 to -1.42; 2 studies, 49 participants). A change of 2 points represents a minimal clinically important difference (MCID). Due to very low-certainty evidence, it is uncertain whether doxepin cream impacts the incidence of somnolence as an adverse event compared to oral antihistamine (risk ratio (RR) 0.64, 95% CI 0.32 to 1.25; 1 study, 24 participants). No data were reported on pain in the included study. There is low-certainty evidence that gabapentin may reduce burn-related pruritus compared with cetirizine (MD -2.40 VAS, 95% CI -4.14 to -0.66; 1 study, 40 participants). A change of 2 points represents a MCID. There is low-certainty evidence that gabapentin reduces the incidence of somnolence compared to cetirizine (RR 0.02, 95% CI 0.00 to 0.38; 1 study, 40 participants). No data were reported on pain in the included study. There is low-certainty evidence that pregabalin may result in a reduction in burn-related pruritus intensity compared with cetirizine with pheniramine maleate (MD -0.80 VAS, 95% CI -1.24 to -0.36; 1 study, 40 participants). A change of 2 points represents a MCID. There is low-certainty evidence that pregabalin reduces the incidence of somnolence compared to cetirizine (RR 0.04, 95% CI 0.00 to 0.69; 1 study, 40 participants). No data were reported on pain in the included study. There is moderate-certainty evidence that ondansetron probably results in a reduction in burn-related pruritus intensity compared with diphenhydramine (MD -0.76 on a 0 to 10 numeric analogue scale (NAS), 95% CI -1.50 to -0.02; 1 study, 38 participants). A change of 2 points represents a MCID. No data were reported on pain and adverse events in the included study. Topical therapies versus relevant comparators There is moderate-certainty evidence that enalapril ointment probably decreases mean burn-related pruritus compared with placebo control (MD -0.70 on a 0 to 4 scoring table for itching, 95% CI -1.04 to -0.36; 1 study, 60 participants). No data were reported on pain and adverse events in the included study. Physical modalities versus relevant comparators Compared with standard care, there is low-certainty evidence that massage may reduce burn-related pruritus (standardised mean difference (SMD) -0.86, 95% CI -1.45 to -0.27; 2 studies, 166 participants) and pain (SMD -1.32, 95% CI -1.66 to -0.98). These SMDs equate to a 4.60-point reduction in pruritus and a 3.74-point reduction in pain on a 10-point VAS. A change of 2 VAS points in itch represents a MCID. No data were reported on adverse events in the included studies. There is low-certainty evidence that extracorporeal shock wave therapy (ESWT) may reduce burn-related pruritus compared with sham stimulation (SMD -1.20, 95% CI -1.65 to -0.75; 2 studies, 91 participants). This equates to a 5.93-point reduction in pruritus on a 22-point 12-item Pruritus Severity Scale. There is low-certainty evidence that ESWT may reduce pain compared with sham stimulation (MD 2.96 on a 0 to 25 pressure pain threshold (PPT), 95% CI 1.76 to 4.16; 1 study, 45 participants). No data were reported on adverse events in the included studies. Laser scar revision versus untreated or placebo controls There is moderate-certainty evidence that pulsed high-intensity laser probably results in a reduction in burn-related pruritus intensity compared with placebo laser (MD -0.51 on a 0 to 1 Itch Severity Scale (ISS), 95% CI -0.64 to -0.38; 1 study, 49 participants). There is moderate-certainty evidence that pulsed high-intensity laser probably reduces pain compared with placebo laser (MD -3.23 VAS, 95% CI -5.41 to -1.05; 1 study, 49 participants). No data were reported on adverse events in the included studies.

AUTHORS' CONCLUSIONS

There is moderate to low-certainty evidence on the effects of 21 interventions. Most studies were small and at a high risk of bias related to blinding and incomplete outcome data. Where there is moderate-certainty evidence, practitioners should consider the applicability of the evidence for their patients.

Consumer focus group testing with stakeholders to generate an enteral resuscitation training flipbook for primary health center and first-level hospital providers in Nepal

INTRODUCTION

Enteral resuscitation (EResus) is operationally advantageous to intravenous resuscitation for burn-injured patients in some low-resource settings. However, there is minimal guidance and no training materials for EResus tailored to non-burn care providers. We aimed to develop and consumer-test a training flipbook with doctors and nurses in Nepal to aid broader dissemination of this life-saving technique.

MATERIALS AND METHODS

We used individual cognitive interviews with Nepali (n = 12) and international (n = 4) burn care experts to define key elements of EResus and specific concepts for its operationalization at primary health centers and first-level hospitals in Nepal. Content, prototype illustrations, and wireframe layouts were developed and revised with the burn care experts. Subsequently, eight consumer testing focus groups with Nepali stakeholders (5-10 people each) were facilitated. Prompts were generated using the Questionnaire Appraisal System (QAS) framework. The flipbook was iteratively revised and tested based on consumer feedback organized according to the domains of clarity, assumptions, knowledge/memory, and sensitivity/bias.

RESULTS AND DISCUSSION

The flipbook elements were iterated until consumers made no additional requests for changes. Examples of consumer inputs included: clarity-minimize medical jargon, add shrunken organs and wilted plants to represent burn shock; assumptions-use locally representative figures, depict oral rehydration salts sachet instead of a graduated bottle; knowledge/memory-clarify complex topics, use Rule-of-9 s and depict approximately 20% total body surface area to indicate the threshold for resuscitation; sensitivity/bias-reduce anatomic illustration details (e.g. urinary catheter placement, body contours).

CONCLUSION

Stakeholder engagement, consumer testing, and iterative revision can generate knowledge translation products that reflect contextually appropriate education materials for inexperienced burn providers. The EResus Training Flipbook can be used in Nepal and adapted to other contexts to facilitate the implementation of EResus globally.

Burns among adults in a major Malawian burn unit: epidemiology and factors associated with prolonged hospital stay

Aim

This study sought to describe the epidemiology of burns and factors associated with prolonged hospital stay among adult patients admitted in the Queen Elizabeth Central Hospital burns unit.

Methods

All files of patients aged at least 17 years and admitted in the Queen Elizabeth Central Hospital burns unit between 1 June 2007 and 31 May 2017 with acute burns, were reviewed. Data on socio-demographic characteristics, injuries sustained, comorbidities, length of hospital stay, and clinical outcomes were extracted from the files. Summary statistics, independent sample T-test, and odds ratios were computed to determine the distribution and associations of the variables collected.

Results

A total of 515 patient files, all from rural or informal urban settlements, were reviewed. The median age at the time of presentation was 32 years (IQR: 25-45), and 52% (n=279) were male. Most of the burns occurred at home (81.0%; n=379), were of flame etiology (75.7%; n=385), and were reported to have been accidental (94.7%, n=445). The mean monthly rate of new burn injury patients was highest in the cool-dry season, and epileptic seizures were a common precedent of burn injury (30.7%; n=158). Most (62.7%) of the patients with recorded burn sites sustained multiple burns injuries, and more than half of the patients had upper and lower limb burns (64.6% & 59.5% respectively). Thirty patients sustained additional non-burn injuries, and 26.4% (n=132) of all patients with recorded outcomes died in the hospital.

Conclusion

The data on burn injuries among adults presenting at the QECH burns unit suggests the existence of socio-economic inequalities associated with burn incidence. There is also a need for improvement in the quality and uptake of epilepsy care in primary care facilities.

Reliability, Validity, and Predictive Validity of Cutaneous Functional Units Predicted to Scar Following Palmar Burn Injury in Young Children

Identification of children at risk of palmar burn scar is important for early initiation of scar management. This study determined the interrater reliability of face-to-face and photographic assessments of 29 palmar cutaneous functional units (CFUs) predicted to scar following palmar burn. The validity of photographic compared to face-to-face assessment, and the predictive validity of both assessment types to identify scarring at 3 to 6 months following burn, was also established. Thirty-nine children (40 hands) post burn injury were assessed face-to-face in the clinical setting, following healing of their palmar burn, by three burn therapists. Photographs of the children's hands at initial assessment were assessed by the same therapists a minimum of 6 months later. To determine which CFUs scarred, children were reassessed face-to-face in the clinical setting 3 to 6 months following their burn. For analysis, 29 CFUs were merged into eight separate groups to determine the number of CFUs predicted to scar per CFU group for face-to-face and photographic assessments. The range of agreement for individual CFUs within CFU groups was also calculated for both assessment types. Excellent interrater reliability was established for face-to-face assessment in all eight CFU groups (ICC2,1 0.83-0.96). Photographic assessment demonstrated good to excellent interrater reliability in six CFU groups (ICC2,1 0.69-0.90) and validity in seven CFU groups (ICC2,1 0.66-0.87). Good to excellent predictive validity was established for both assessment types in seven CFU groups (face-to-face ICC2,1 0.60-0.95, photographic ICC2,1 0.69-0.89). Experienced therapists can reliably assess CFUs face-to-face or via photographs and predict future scar development.

Picture Cards Versus Physical Examination: A Proof-of-Concept Study to Improve the SOSAS Survey Tool

INTRODUCTION

The Surgeons OverSeas Assessment of Surgical Needs (SOSAS) survey tool is used to determine the unmet surgical needs in the community and has been validated in several countries. A major weakness is the absence of an objective assessment to verify patient-reported surgically treatable conditions. The goal of this study was to determine whether a picture portfolio, a tool previously shown to improve parental recognition of their child's congenital deformity, could improve the accuracy of the SOSAS tool by how it compares with physical examination. This study focused on children as many surgical conditions in them require prompt treatment but are often not promptly diagnosed.

METHODS

We conducted a descriptive cross-sectional community-based study to determine the prevalence of congenital and acquired surgical conditions among children and adults in a mixed rural-urban area of Lagos, Southwest Nigeria. The picture portfolio was administered only to children and the surgical conditions to be assessed were predetermined using an e-Delphi process among pediatric surgeons. The modified The Surgeons OverSeas Assessment of Surgical Needs-Nigeria Survey Tool (SOSAS-NST) was administered to household members to collect other relevant data. Data were analyzed using the REDCap analytic tool.

RESULTS

Eight hundred and fifty-six households were surveyed. There were 1984 adults (49.5%) and 2027 children (50.5%). Thirty-six children met the predetermined criteria for the picture portfolio-hydrocephalus (n = 1); lymphatic malformation (n = 1); umbilical hernia (n = 14); Hydrocele (n = 5); inguinal hernia (n = 10) and undescended testes (n = 5). The picture portfolio predicted all correctly except a case of undescended testis that was mistaken for a hernia. The sensitivity of the picture portfolio was therefore 35/36 or 97.2%.

CONCLUSIONS

The SOSAS-NST has improved on the original SOSAS tool and within the limits of the small numbers, the picture portfolio has a high accuracy in predicting diagnosis in children in lieu of physical examination.

Why is priority setting important for global burn care research?

The use of robust evidence is a key component of providing high quality care to patients. Synthesised evidence to support clinical decision-making is lacking for many aspects of clinical burn care. Identifying the most important areas of care that lack high quality evidence and requires research is necessary, as funding for primary research is limited. Priority setting research studies are a joint endeavour between patients, carers and clinicians to identify and rank topics for research in a healthcare area in order to reduce research waste. Such an exercise has yet to be undertaken in burns. The aim of this paper is to outline the importance of research prioritisation in burn care, to discuss how it facilitates the maximum benefit from limited research funding and to explain the methodologies used.

Burn Admissions Across Low- and Middle-income Countries: A Repeated Cross-sectional Survey

Burn injuries have decreased markedly in high-income countries while the incidence of burns remains high in Low- and Middle-Income Countries (LMICs) where more than 90% of burns are thought to occur. However, the cause of burns in LMIC is poorly documented. The aim was to document the causes of severe burns and the changes over time. A cross-sectional survey was completed for 2014 and 2019 in eight burn centers across Africa, Asia, and Latin America: Cairo, Nairobi, Ibadan, Johannesburg, Dhaka, Kathmandu, Sao Paulo, and Guadalajara. The information summarised included demographics of burn patients, location, cause, and outcomes of burns. In total, 15,344 patients were admitted across all centers, 37% of burns were women and 36% of burns were children. Burns occurred mostly in household settings (43-79%). In Dhaka and Kathmandu, occupational burns were also common (32 and 43%, respectively). Hot liquid and flame burns were most common while electric burns were also common in Dhaka and Sao Paulo. The type of flame burns varies by center and year, in Dhaka, 77% resulted from solid fuel in 2014 while 74% of burns resulted from Liquefied Petroleum Gas in 2019. In Nairobi, a large proportion (32%) of burns were intentional self-harm or assault. The average length of stay in hospitals decreased from 2014 to 2019. The percentage of deaths ranged from 5% to 24%. Our data provide important information on the causes of severe burns which can provide guidance in how to approach the development of burn injury prevention programs in LMIC.

Preferences for Oral Rehydration Drinks among Healthy Individuals in Ghana: A Single-Blind, Cross-Sectional Survey to Inform Implementation of an Enterally Based Resuscitation Protocol for Burn Injury

BACKGROUND

Enterally based resuscitation for major burn injuries has been suggested as a simple, operationally superior, and effective resuscitation strategy for use in austere contexts. However, key information to support its implementation is lacking, including palatability and acceptability of widely available rehydration drinks.

METHODS

We performed a single-blinded, cross-sectional survey of 60 healthy children (5-14 years), adults (15-54 years) and older adults (≥55 years) to determine palatability and overall acceptability of five oral rehydration solutions (ORS) and a positive control drink (Sprite Zero®) in Ghana. Quantitative data were described and differences between our control drink and the others across age groups were visually examined with Likert plots. Qualitative responses were analyzed using a content analysis framework.

RESULTS

Twenty participants in each age group completed the study. Participants were as young as 5 years and as old as 84 years. Nearly two thirds of the sample identified as male (n = 38, 63% of all participants). The positive control was reported to taste 'good or 'very good' by the majority of participants (89%) followed by lemon-flavored ORS (78%) and orange-flavored ORS (78%). Conversely, homemade and low-osmolarity ORS were reported to taste 'good' or 'very good' by only 20% and 15% of participants, respectively. There were no major taste differences across the age groups. However, children more frequently reported positively (i.e., tastes 'good' or 'very good') about flavored and sweet drinks than did adults and older adults. When faced with the hypothetical situation of being critically injured and needing resuscitation, participants tended to be more agreeable to consuming all the drinks, even low-osmolarity and homemade ORS.

CONCLUSIONS

These findings can be used to support the development of protocols that may be more acceptable among patients undergoing enterally based resuscitation, thus improving the effectiveness of the treatment. Specifically, enterally based resuscitation should likely include citrus-flavored ORS when available, given superior palatability and the fact that different flavor additives for patients of different ages do not seem necessary.

Global trends in pediatric burn injuries and care capacity from the World Health Organization Global Burn Registry

BACKGROUND

Burn injuries are a major cause of death and disability globally. The World Health Organization (WHO) launched the Global Burn Registry (GBR) to improve understanding of burn injuries worldwide, identify prevention targets, and benchmark acute care. We aimed to describe the epidemiology, risk factors, and outcomes of children with burns to demonstrate the GBR's utility and inform needs for pediatric burn prevention and treatment.

METHODS

We performed descriptive analyses of children age ≤ 18 years in the WHO GBR. We also described facility-level capacity. Data were extracted in September of 2021.

RESULTS

There were 8,640 pediatric and adult entries from 20 countries. Of these, 3,649 (42%) were children (0-18 years old) from predominantly middle-income countries. The mean age was 5.3 years and 60% were boys. Children aged 1-5 years comprised 62% (n = 2,279) of the cohort and mainly presented with scald burns (80%), followed by flame burns (14%). Children >5 years (n = 1,219) more frequently sustained flame burns (52%) followed by scald burns (29%). More than half of pediatric patients (52%) sustained a major burn (≥15% total body surface area) and 48% received surgery for wound closure during the index hospitalization. Older children had more severe injuries and required more surgery. Despite the frequency of severe injuries, critical care capacity was reported as "limited" for 23% of pediatric patients.

CONCLUSIONS

Children represent a large proportion of people with burn injuries globally and often sustain major injuries that require critical and surgical intervention. However, critical care capacity is limited at contributing centers and should be a priority for healthcare system development to avert preventable death and disability. This analysis demonstrates that the GBR has the potential to highlight key epidemiological characteristics and hospital capacity for pediatric burn patients. To improve global burn care, addressing barriers to GBR participation in low- and low-middle-income countries would allow for greater representation from a diversity of countries, regions, and burn care facilities.

Gender-based disparities in burn injuries, care and outcomes: A World Health Organization (WHO) Global Burn Registry cohort study

BACKGROUND

We aimed to describe the gender-based disparities in burn injury patterns, care received, and mortality across national income levels.

METHODS

In the WHO Global Burn Registry (GBR), we compared patient demographics, injury characteristics, care and outcomes by sex using Chi-square statistics. Logistic regression was used to identify the associations of patient sex with surgical treatment and in-hospital mortality.

RESULTS

Among 6431 burn patients (38 % female; 62 % male), females less frequently received surgical treatment during index hospitalization (49 % vs 56 %, p < 0.001), and more frequently died in-hospital (26 % vs 16 %, p < 0.001) than males. Odds of in in-hospital death was 2.16 (95 % CI: 1.73-2.71) times higher among females compared to males in middle-income countries.

CONCLUSIONS

Across national income levels, there appears to be important gender-based disparities among burn injury epidemiology, treatment received and outcomes that require redress. Multinational registries can be utilized to track and to evaluate initiatives to reduce gender disparities at national, regional and global levels.

What is Known About Burns in East Africa? A Scoping Review

BACKGROUND

Burns are a global public health concern, with the majority of the disease burden affecting low- and middle-income countries. Yet, as suggested by previous publications, there is a widespread belief that literature about burns in low- and middle-income countries is lacking. Therefore, we aimed to assess with a scoping review, the extent of the literature output on burns in East Africa, and to investigate patient demographics, injury characteristics, treatment and outcomes, as reported from the existing publications.

METHODS

Studies discussing burns in East Africa were identified by searching PubMed / Medline (National Library of Medicine), EMBASE (Elsevier), Global Health Database (EBSCO), and Global Index Medicus on December 12, 2019. Controlled vocabulary terms (i.e., MeSH, EMTREE, Global Health thesaurus terms) were included when available and appropriate. No year restrictions were applied.

RESULTS

A total of 1,044 records were retrieved from the database searches, from which 40 articles from 6 countries published between 1993 and 2019 were included in the final review. No studies were found from five East African countries with the lowest GDP. Most papers focused on pediatric trauma patients or tertiary hospital settings. The total number of burn patients recorded was 44,369, of which the mean proportion of males was 56%. The most common cause of injury was scalds (61%), followed by open flame (17%). Mortality rate ranged from 0-67%. The mean length of stay in hospital was between 9-60 d.

CONCLUSIONS

Burn data is limited in the East African region, with socio-economically weak countries being particularly underrepresented. This scoping review has identified the largest set of literature on burns in East Africa to date, indicating the importance of reviewing data at a regional or local level, as "global" studies tend to be dominated by high-income country data. Data collection in specific registries is needed to better characterize the exact burden of burn injuries in East Africa.

The development of burn scar contractures and impact on joint function, disability and quality of life in low- and middle-income countries: A prospective cohort study with one-year follow-up

OBJECTIVE

The aim of this study was to assess the development of burn scar contractures and their impact on joint function, disability and quality of life in a low-income country.

METHODS

Patients with severe burns were eligible. Passive range of motion (ROM) was assessed using lateral goniometry. To assess the development of contractures, the measured ROM was compared to the normal ROM. To determine joint function, the normal ROM was compared to the functional ROM. In addition, disability and quality of life (QoL) were assessed. Assessments were from admission up to 12 months after injury.

RESULTS

Thirty-six patients were enrolled, with a total of 124 affected joints. The follow-up rate was 83%. Limited ROM compared to normal ROM values was observed in 26/104 joints (25%) at 12 months. Limited functional ROM was observed in 55/115 joints (48%) at discharge and decreased to 22/98 joints (22%) at 12 months. Patients who had a contracture at 12 months reported more disability and lower QoL, compared to patients without a contracture (median disability 0.28 versus 0.17 (p = 0.01); QoL median 0.60 versus 0.76 (p = 0.001)). Significant predictors of developing joint contractures were patient delay and the percentage of TBSA deep burns.

CONCLUSION

The prevalence of burn scar contractures was high in a low-income country. The joints with burn scar contracture were frequently limited in function. Patients who developed a contracture reported significantly more disability and lower QoL. To limit the development of burn scar contractures, timely access to safe burn care should be improved in low-income countries.

Surgical Unmet Need in a Low-Income Area of a Metropolitan City in India: A Cross-Sectional Study

INTRODUCTION

We investigated the burden of surgical conditions, level of unmet needs and reasons for non-utilization of surgical services in a slum of Ahmedabad, India.

METHODS

A community-based cross-sectional study was carried out from August to December 2019. Inclusion criteria was age > 14 years; any type of injury/condition that requires surgery; subject has had surgery in last 1 year, and death information of family members. Data were stored and coded in Microsoft excel and exported to IBM SPSS statistics version 25 software for data analysis. Frequencies and proportions (categorical variable) are used to summarize utilization of surgical services and understanding surgical need. The Surgeons Overseas Assessment of Surgical was used to identify surgical met and unmet needs translated into local language. Open Data Kit software was used to install questionnaire in the "Tablet" to collect information and stress-free workflow in field.

RESULTS

Out of 10,330 population in 2066 households, 7914 were more than 14 years of age. 3.46% (n = 274) people needed surgery; 116 did not avail surgery and were categorized in "unmet need." Fifty percent of individuals with surgical needs had abdominal- or extremities-related problems followed by eyes surgery need (14%); back, chest and breast surgical need was 13.5%. Seventeen percent of participants with surgical needs had wounds related to injury or accident while 63% had wounds that were not related to injury. Almost all participants had gone to a physician to seek healthcare, however 42% did not avail surgical care needed for a variety of reasons. Forty-six percent of participants needing surgical care underwent major surgical procedure, while 11% had minor procedures. Financial reasons (34.5%) and lack of trust (35.3%) were major reasons for not availing surgical care.

CONCLUSIONS AND RELEVANCE

Ahmedabad is a relatively high income metropolitan city, has universally free health care and multiple healthcare facilities. Despite this, we have shown that there is significant unmet need for surgical procedures in the low-income population. A unique finding was that most patients sought a consultation but approximately 50% did not avail of the free surgical procedures under the universally free health care system in this city. We propose creation of community healthcare workers focused on surgical conditions.

Barriers to Surgical Care Among Children in Somaliland: An Application of the Three Delays Framework

BACKGROUND

There are complex barriers that increase delays to surgical care in low- and middle-income countries, particularly among the vulnerable population of children. Understanding these barriers to surgical care can result in targeted and strategic intervention efforts to improve care for children. The three-delay model is a widely used framework in global health for evaluating barriers associated with seeking (D1), reaching (D2), and receiving health care (D3). The goal of our study is to evaluate reasons for delays in the surgical care for children in Somaliland using the three-delay framework.

METHODS

Data were collected in a cross-sectional study in Somaliland from 1503 children through a household survey. Among children with a surgical need, we quantified the number of children seeking, reaching, and receiving care along the surgical care continuum, according to the three-delay framework. We evaluated predictors of the three delays through a multivariate logistic regression model, including the child's age, gender, village type, household income level, region, and household size.

RESULTS

Of the 196 children identified with a surgical condition, 50 (27.3%) children had a delay in seeking care (D1), 28 (20.6%) children had a delay in reaching care (D2), and 84 (71.2%) children had a delay in receiving care (D3), including 10 children who also experienced D1 and D2. The main reasons cited for D1 included seeking a traditional healthcare provider, while lack of money and availability of care were main reasons cited for D2. Significant predictors for delays included household size for D1 and D3 and condition type and region for D2.

CONCLUSION

Children in Somaliland experience several barriers to surgical care along the entire continuum of care, allowing for policy guidance tailored to specific local challenges and resources. Since delays in surgical care for children can substantially impact the effectiveness of surgical interventions, viewing delays in surgical care under the lens of the three-delay framework can inform strategic interventions along the pediatric surgical care continuum, thereby reducing delays and improving the quality of surgical care for children.

Interpreting the Lancet surgical indicators in Somaliland: a cross-sectional study

BACKGROUND

The unmet burden of surgical care is high in low-income and middle-income countries. The Lancet Commission on Global Surgery (LCoGS) proposed six indicators to guide the development of national plans for improving and monitoring access to essential surgical care. This study aimed to characterise the Somaliland surgical health system according to the LCoGS indicators and provide recommendations for next-step interventions.

METHODS

In this cross-sectional nationwide study, the WHO's Surgical Assessment Tool-Hospital Walkthrough and geographical mapping were used for data collection at 15 surgically capable hospitals. LCoGS indicators for preparedness was defined as access to timely surgery and specialist surgical workforce density (surgeons, anaesthesiologists and obstetricians/SAO), delivery was defined as surgical volume, and impact was defined as protection against impoverishment and catastrophic expenditure. Indicators were compared with the LCoGS goals and were stratified by region.

RESULTS

The healthcare system in Somaliland does not meet any of the six LCoGS targets for preparedness, delivery or impact. We estimate that only 19% of the population has timely access to essential surgery, less than the LCoGS goal of 80% coverage. The number of specialist SAO providers is 0.8 per 100 000, compared with an LCoGS goal of 20 SAO per 100 000. Surgical volume is 368 procedures per 100 000 people, while the LCoGS goal is 5000 procedures per 100 000. Protection against impoverishing expenditures was only 18% and against catastrophic expenditures 1%, both far below the LCoGS goal of 100% protection.

CONCLUSION

We found several gaps in the surgical system in Somaliland using the LCoGS indicators and target goals. These metrics provide a broad view of current status and gaps in surgical care, and can be used as benchmarks of progress towards universal health coverage for the provision of safe, affordable, and timely surgical, obstetric and anaesthesia care in Somaliland.

Waiting Too Long: The Contribution of Delayed Surgical Access to Pediatric Disease Burden in Somaliland

BACKGROUND

Delayed access to surgical care for congenital conditions in low- and middle-income countries is associated with increased risk of death and life-long disabilities, although the actual burden of delayed access to care is unknown. Our goal was to quantify the burden of disease related to delays to surgical care for children with congenital surgical conditions in Somaliland.

METHODS

We collected data from medical records on all children (n = 280) receiving surgery for a proxy set of congenital conditions over a 12-month time period across all 15 surgically equipped hospitals in Somaliland. We defined delay to surgical care for each condition as the difference between the ideal and the actual ages at the time of surgery. Disability-adjusted life years (DALYs) attributable to these delays were calculated and compared by the type of condition, travel distance to care, and demographic characteristics.

RESULTS

We found long delays in surgical care for these 280 children with congenital conditions, translating to a total of 2970 attributable delayed DALYs, or 8.4 avertable delayed DALYs per child, with the greatest burden among children with neurosurgical and anorectal conditions. Over half of the families seeking surgical care had to travel over 2 h to a surgically equipped hospital in the capital city of Hargeisa.

CONCLUSIONS

Children with congenital conditions in Somaliland experience substantial delays to surgical care and travel long distances to obtain care. Estimating the burden of delayed surgical care with avertable delayed DALYs offers a powerful tool for estimating the costs and benefits of interventions to improve the quality of surgical care.

Incidence of childhood burn injuries and modifiable household risk factors in rural Ghana: A cluster-randomized, population-based, household survey

BACKGROUND

We aimed to determine the incidence of childhood burn injuries in rural Ghana and describe modifiable household risk factors to inform prevention initiatives.

METHODS

We performed a cluster-randomized, population-based survey of caregivers of children in a rural district in Ghana, representing 2713 households and 14,032 children. Caregivers were interviewed regarding childhood burn injuries within the past 6 months and household risk factors.

RESULTS

357 households were sampled. Most used an open fire with biomass fuel for cooking (85.8%). Households rarely cooked in a separate kitchen (10%). Stove height was commonly within reach of children under five years (<1 m; 96.0%). The weighted annualized incidence of CBI was 63 per 1000 child-years (6.4% of children per year); reported mean age was 4.4 years (SD 4.0). The most common etiology was flame burn. Older age (OR 0.89, 95% CI 0.8-1.0) and households with an older sibling ≥12 years (OR 0.58, 95% CI 0.3-1.3) seemed to be associated with lower odds of CBI.

CONCLUSIONS

Childhood burn injury is common in rural Ghana. Opportunities exist to reduce the risk of childhood burn injury childhood burns in rural settings by supporting the transition to safer cooking arrangements, child barrier apparatuses in homes without older children, and/or development of formal childcare programs.

Epidemiological analysis of patients with burns in third-line hospitals in Turkey

Burns are a major health problem worldwide. Burn injury resulting from making contact with hot objects, direct or indirect contact with flame, and exposure to chemical agents or electric current is usually preventable. In this study, epidemiological data of the patients who had been hospitalised in the burn unit was assessed. The records of 1453 patients who were admitted to the burn unit of Diyarbakir Gazi Yaşargil Training and Research Hospital between July 2008 and April 2018 were retrospectively examined. Out of 1453 cases, 81.7% (1187) were children and 18.3% (266) were adults, 58.3% of the cases were male (847) and 41.7% (606) were females. Patients had a mean age of 11 ± 5 years (1-81 years). The most common cause of burns was contact with hot liquids (82.86%) while other causes were flame burns (12.04%), electrical contact burn (3.02%) contact with chemical substances (2.06%). Most of the cases were found to have burned 10% to 20% of the body surface. Localization was most frequently seen in the lower extremity and less frequently in the upper limb, trunk, head and neck, and perineal regions. The majority of burn injuries are preventable. Therefore, epidemiological studies in the field of burns will provide vital preventive information to develop strategies to reduce injury frequency and spend on health. Because burns are a social problem, prevention efforts require social co-operation. Promotional meetings in schools are important to increase family-school cooperation to inform children of school age, to give lectures and first aid measures to rural areas.

An Analysis of Factors Associated with Burn Injury Outcomes in Low- and Middle-Income Countries

BACKGROUND

Burn injuries are a major cause of morbidity and mortality within low- and middle-income countries (LMICs). The World Health Organization developed the Global Burn Registry to centralize data collection for the guidance of burn prevention programs. This study analyzed the epidemiologic and hospital-specific factors associated with burn injury outcomes in LMICs and high-income countries (HICs).

METHODS

A retrospective review was performed using the Global Burn Registry over 3 y. Patients were stratified by income region. Bivariate analyses and stepwise regressions were performed to evaluate patient and hospital demographics and variables associated with injury patterns and outcomes. Outcomes of interest included mortality and length of stay.

RESULTS

Over the study period, data were collected on 1995 patients from 10 LMICs (20 hospitals) and four HICs (four hospitals). Significantly higher mortality was seen in LMICs compared with HICs (17% versus 9%; P < 0.001). There was no significant difference between income regions for injury patterns (P = 0.062) or total body surface area of the burn injury (P = 0.077). Of the LMIC hospitals in this data set, 11% did not have reliable access to an operating theater.

CONCLUSIONS

HICs had a lower overall mortality even with higher rates of concurrent injuries, as well as longer length of stay. LMIC hospitals had fewer resources available, which could explain increased mortality, given similar total body surface area. This study highlights how investing in health care infrastructure could lead to improved outcomes for patients in low-resource settings.

Quantifying Inequitable Access to Rapid Burn and Reconstructive Care through Geospatial Mapping

Time-critical pathologies, such as the care of burn-injured patients, rely on accurate travel time data to plan high-quality service provision. Geospatial modeling, using data from the Malaria Atlas Project, together with census data, permits quantification of the huge global discrepancies in temporal access to burn care between high-income and low-resource settings. In this study, focusing on the United Kingdom and Ghana, we found that a 3-fold population difference exists with, respectively, 95.6% and 29.9% of the population that could access specialist burn care within 1-hour travel time. Solutions to such inequalities include upscaling of infrastructure and specialist personnel, but this is aspirational rather than feasible in most low- to middle-income countries. Mixed models of decentralization of care that leverage eHealth strategies, such as telemedicine, may enhance quality of local burns and reconstructive surgical care through skills transfer, capacity building, and expediting of urgent transfers, while empowering local healthcare communities. By extending specialist burn care coverage through eHealth to 8 district hospitals in rural Ghana, we demonstrate the potential to increase specialist population coverage within 1-hour travel time from 29.9% to 45.3%—equivalent to an additional 5.1 million people.

A Structured Review to Assess the Current Status of Cost-Based Burns Research in Nepal

The management of burns is costly and complex. The problem is compounded in low and middle income countries (LMICs) where the incidence of burn injuries is high but infrastructure and funding for management and prevention is limited. Cost of illness studies allows for quantification of the costs associated with public health problems. Without cost quantification, focus and allocation of funding is challenging. The authors explored the availability of cost-focused burns research data in a target LMIC. The focus of their research was Nepal. A structured literature review including published papers, Ministry of Health (MOH) and World Health Organization (WHO) statistics was conducted to identify cost of illness studies or evidence relating to burn-related resource and costs. Gaps in the evidence base were highlighted. Research methodologies from other LMICs were reviewed. We found 32 papers related to burn injury in Nepal, one key MOH document and one relevant WHO data source. Most research focused on the epidemiology and etiology of burns in Nepal. Of the papers, only 14 reported any type of burn-related resource use and only 1 paper directly reported (limited) cost data. No studies attempted an overall quantification of the cost of burns. MOH statistics provided no additional insight into costs. Our study found an almost complete lack of cost-focused burns research in Nepal. Primary research is needed to quantify the cost of burns in Nepal. Initial focus could usefully be on the cost of care in tertiary hospitals. A full cost of burns for Nepal remains some way off.

Comparison of Deep Transfer Learning Techniques in Human Skin Burns Discrimination

While visual assessment is the standard technique for burn evaluation, computer-aided diagnosis is increasingly sought due to high number of incidences globally. Patients are increasingly facing challenges which are not limited to shortage of experienced clinicians, lack of accessibility to healthcare facilities and high diagnostic cost. Certain number of studies were proposed in discriminating burn and healthy skin using machine learning leaving a huge and important gap unaddressed; whether burns and related skin injuries can be effectively discriminated using machine learning techniques. Therefore, we specifically use transfer learning by leveraging pre-trained deep learning models due to deficient dataset in this paper, to discriminate two classes of skin injuries—burnt skin and injured skin. Experiments were extensively conducted using three state-of-the-art pre-trained deep learning models that includes ResNet50, ResNet101 and ResNet152 for image patterns extraction via two transfer learning strategies—fine-tuning approach where dense and classification layers were modified and trained with features extracted by base layers and in the second approach support vector machine (SVM) was used to replace top-layers of the pre-trained models, trained using off-the-shelf features from the base layers. Our proposed approach records near perfect classification accuracy in categorizing burnt skin ad injured skin of approximately 99.9%.

Burn injury

Burn injuries are under-appreciated injuries that are associated with substantial morbidity and mortality. Burn injuries, particularly severe burns, are accompanied by an immune and inflammatory response, metabolic changes and distributive shock that can be challenging to manage and can lead to multiple organ failure. Of great importance is that the injury affects not only the physical health, but also the mental health and quality of life of the patient. Accordingly, patients with burn injury cannot be considered recovered when the wounds have healed; instead, burn injury leads to long-term profound alterations that must be addressed to optimize quality of life. Burn care providers are, therefore, faced with a plethora of challenges including acute and critical care management, long-term care and rehabilitation. The aim of this Primer is not only to give an overview and update about burn care, but also to raise awareness of the ongoing challenges and stigmata associated with burn injuries.

The contribution of pediatric surgery to poverty trajectories in Somaliland

BACKGROUND

The provision of health care in low-income and middle-income countries (LMICs) is recognized as a significant contributor to economic growth and also impacts individual families at a microeconomic level. The primary goal of our study was to examine the relationship between surgical conditions in children and the poverty trajectories of either falling into or coming out of poverty of families across Somaliland.

METHODS

This work used the Surgeons OverSeas Assessment of Surgical Need (SOSAS) tool, a validated household, cross-sectional survey designed to determine the burden of surgical conditions within a community. We collected information on household demographic characteristics, including financial information, and surgical condition history on children younger than 16 years of age. To assess poverty trajectories over time, we measured household assets using the Stages of Progress framework.

RESULTS

We found there were substantial fluxes in poverty across Somaliland over the study period. We confirmed our study hypothesis and found that the presence of a surgical condition in a child itself, regardless of whether surgical care was provided, either reduced the chances of moving out of poverty or increased the chances of moving towards poverty.

CONCLUSION

Our study shows that the presence of a surgical condition in a child is a strong singular predictor of poverty descent rather than upward mobility, suggesting that this stressor can limit the capacity of a family to improve its economic status. Our findings further support many existing macroeconomic and microeconomic analyses that surgical care in LMICs offers financial risk protection against impoverishment.

A systematic review of oil tanker truck disasters: Identifying prevention targets

INTRODUCTION

Oil tanker truck disasters have been reported worldwide; however, the circumstances, causes, and health effects of these disasters have not been described. To address this gap, we performed a systematic review using PRISMA criteria to better understand this public health problem and identify prevention targets.

METHODS

The academic and lay literatures were systematically searched for terms related to oil tanker truck disasters. Reports about civilian oil tanker truck disasters that occurred from 1997-2017 were included. Details about the disasters were summarized, including circumstances, identifiable causes, and health effects.

RESULTS

The search yielded 4713 Nexis Uni articles, 199 Google results, and one PubMed article; 951 records met inclusion criteria, describing 224 oil tanker truck explosions or fires. At least 2909 people died as a result of these disasters, and 3038 additional people were hospitalized. Almost all deaths (94%) occurred in low- and low-middle-income countries (LMIC). This may largely be due to scooping - the practice of collecting spilled oil from disabled tanker trucks for use or resale. Using the Haddon matrix, potential targets for future disaster prevention were identified.

CONCLUSIONS

These data highlight the circumstances, causes, and health burden related to oil tanker truck disasters. Most began as collisions or rollovers, but nearly half of the fatalities involved scooping. The findings suggest opportunities to promote road safety, improve scene safety and security protocols used by drivers and first responders, and promote public understanding of the dangers of scooping to prevent mass casualty disasters from disabled tanker trucks, particularly in LMIC.