Surgical burn care in sub-Saharan Africa: A systematic review

The Burden of Plastic Surgery in Rural Kenya: The Kapsowar Hospital Experience

Purpose

Both governmental and nongovernmental training programs are expanding efforts to train the next generation of plastic surgeons who will work in low- and middle-income countries (LMICs). Sufficient training is dependent on acquiring the appropriate skillset for these contexts. Few studies have characterized the spectrum of practice of plastic surgeons in LMICs and their relative disparity.

Methods

We performed a retrospective review on all patients who received plastic surgery at a single institution in rural western Kenya from 2021 to 2023. Data such as diagnoses, procedures, and home village/town of residence were collected. Patient home location was geomapped using an open-access distance matrix application programming interface to estimate travel time based on terrain and road quality, assuming patient access to a private vehicle and ideal traveling conditions. Descriptive statistics were performed.

Results

A total of 296 patients received surgery. Common procedures included treatment of cleft lip/palate (CLP), burn reconstruction, and reconstruction for benign tumors of the head and neck. The average distance to treatment was 159.2 minutes. Increased travel time was not associated with time to CLP repair (P > 0.05). Increased travel time was associated with delayed treatment for burns (P = 0.005), maxillofacial trauma (P = 0.032), and hand trauma (P = 0.016).

Conclusions

Training programs for plastic surgeons in LMICs should ensure competency in CLP, flaps, burn reconstruction, and head and neck reconstruction. Our novel use of an application programming interface indicates that international partnerships have been more successful in decreasing treatment delays for CLP patients, but not other reconstructive procedure patients. Expanded commitment from international partners to address these reconstructive burdens in LMICs is warranted.

The treatment effect of operative intervention for flame versus scald burns in resource-limited settings

INTRODUCTION

In resource-limited environments, it is critical to triage burn patients most likely to benefit from operative intervention. This study sought to identify patients with a more significant treatment effect after operative intervention following burn injury at a tertiary burn center in Lilongwe, Malawi.

METHODS

This is a retrospective analysis of burn patients presenting to Kamuzu Central Hospital from 2011 to November 2022. We compared patients based on whether they had scald or flame burns. Using logistic regression, we estimated the adjusted treatment effect of operative intervention on in-hospital mortality. Operative intervention was defined as burn excision and debridement with or without skin grafting.

RESULTS

We included 3266 patients. 2099 (64.7 %) patients had a scald burn, and 1144 (35.3 %) had a flame burn. 630 patients (19.3 %) underwent surgery. Crude mortality among all patients was 18.1 %, and for patients who underwent surgery, it was 9.7 %. When adjusted for total body surface area burned (TBSA) and age, the average treatment effect of surgery on mortality was - 0.07 (95 % CI - 0.11, - 0.033) for patients with scald burns and - 0.17 (95 % CI - 0.22, - 0.11) for patients with flame burns (Fig. 1). For patients with flame burns, the adjusted odds ratio of death associated with surgery was 0.26 (95 % CI 0.17, 0.39).

CONCLUSIONS

Operative intervention confers a survival advantage for patients with flame burns, and the average treatment effect was more significant compared to patients with scald burns. In general, in resource-limited environments flame burns should be prioritized for surgery over scald burns to improve patient outcomes.

Burn injuries and acute burn management in the rural areas in northern Bangladesh - A household survey

INTRODUCTION

Burn injuries pose a significant public health challenge, especially in low- and middle-income countries (LMICs). In Bangladesh, burn injuries are prevalent and often result in severe disability or death. However, knowledge regarding the causes of burn injuries, acute burn management, and barriers to seeking burn care in the riverine areas of northern Bangladesh is limited.

METHODS

We conducted a questionnaire-based study in eight subunits and five selected districts in northern Bangladesh to determine the prevalence, causes, and management of burn injuries in these areas. A total of 210 individuals from different households were interviewed, which represented a population of 1020 persons.

RESULTS

Among the respondents, 55% reported that at least one member of their household suffered from a burn injury in the past. The most common causes of burn injuries were open fire (41%) and hot fluids (30%). More than 40% of burns were not rinsed with water directly after sustaining the injury. Additionally, almost 30% of respondents did not seek medical care immediately after the injury, with financial constraints being the most commonly cited reason.

DISCUSSION

We found a low rate of adequate cooling and seeking medical care. The need for basic knowledge on prevention and treatment of burn injuries and improved access to affordable health care services in the region is high.

The Timing of Operative Intervention for Pediatric Burn Patients in Malawi

BACKGROUND

Defining the optimal timing of operative intervention for pediatric burn patients in a resource-limited environment is challenging. We sought to characterize the association between mortality and the timing of operative intervention at a burn center in Lilongwe, Malawi.

METHODS

This is a retrospective analysis of burn patients (<18 years old) presenting to Kamuzu Central Hospital from 2011 to 2022. We compared patients who underwent excision and/or burn grafting based on the timing of the operation. We used logistic regression modeling to estimate the adjusted odds ratio of death based on the timing of surgery.

RESULTS

We included 2502 patients with a median age of 3 years (IQR 1-5) and a male preponderance (56.8%). 411 patients (16.4%) had surgery with a median time to surgery of 18 days (IQR 8-34). The crude mortality rate among all patients was 17.0% and 9.1% among the operative cohort. The odds ratio of mortality for patients undergoing surgery within 3 days from presentation was 5.00 (95% CI 2.19, 11.44) after adjusting for age, sex, % total burn surface area (TBSA), and flame burn. The risk was highest for the youngest patients.

CONCLUSIONS

Children who underwent burn excision and/or grafting in the first 3 days of hospitalization had a much higher risk of death than patients undergoing surgical intervention later. Delaying operative intervention till >72 h for pediatric patients, especially those under 5 years old, may confer a survival advantage. More investment is needed in early resuscitation and monitoring for this patient population.

State of burns management in Africa: Challenges and solutions

INTRODUCTION

Understand the availability of human resources, infrastructure and medical equipment and perceived improvement helps to address interventions to improve burn care.

METHODS

Online survey covering human resources, infrastructure, and medical equipment of burn centers as well as perceived challenges and points for improvement. The survey was distributed in English and French via snowball method. Descriptive statistics and AI-based technique random forest analysis was applied to identify determinants for a reduction of the reported mortality rate.

RESULTS

271 questionnaires from 237 cities in 40 African countries were analyzed. 222 (81.9 %) from countries with a very low Human Development Index (HDI) (4th quartile). The majority (154, 56.8 %) of all responses were from tertiary health care facilities. In only 18.8 % (n = 51) therapy was free of charge for the patients. The majority (n = 131, 48.3 %) had between 1 and 3 specialist doctors (n = 131, 48.3 %), 1 to 3 general doctors (n = 138, 50.9 %) and more than 4 nurses (n = 175, 64.6 %). A separate burn ward was available in 94 (34.7 %) centers. Regular skin grafting was performed in 165 (39.1 %) centers. Random forest-based analysis revealed a significant association between HDI (feature importance: 0.38) and mortality. The most important reason for poor outcome was perceived late presentation (212 institutions, 78.2 %). The greatest perceived potential for improvement was introduction of intensive care units (229 institutions, 84.5 %), and prevention or education (227 institutions, 83.7 %).

INTERPRETATION

A variety of factors, including a low HDI, delayed hospital presentation e.g. due to prior care by non-physicians and lack of equipment seem to worsen the outcome. Introduction of an intensive care unit and communal education are perceived to be important steps in improving health care in burns.

Prevalence and Severity of Burn Scars in Rural Mozambique

Background

Burn injuries are common in low- and middle-income countries (LMICs) and their associated disability is tragic. This study is the first to explore burn scars in rural communities in Mozambique. This work also validated an innovate burn assessment tool, the Morphological African Scar Contractures Classification (MASCC), used to determine surgical need.

Methods

Using a stratified, population-weighted survey, the team interviewed randomly selected households from September 2012 to June 2013. Three rural districts (Chókwè, Nhamatanda, and Ribáuè) were selected to represent the southern, central and northern regions of the country. Injuries were recorded, documented with photographs, and approach to care was gathered. A panel of residents and surgeons reviewed the burn scar images using both the Vancouver Scar Scale and the MASCC, a validated visual scale that categorizes patients into four categories corresponding to levels of surgical intervention.

Results

Of the 6104 survey participants, 6% (n = 370) reported one or more burn injuries. Burn injuries were more common in females (57%) and most often occurred on the extremities. Individuals less than 25 years old had a significantly higher odds of reporting a burn scar compared to people older than 45 years. Based on the MASCC, 12% (n = 42) would benefit from surgery to treat contractures.

Conclusion

Untreated burn injuries are prevalent in rural Mozambique. Our study reveals a lack of access to surgical care in rural communities and demonstrates how the MASCC scale can be used to extend the reach of surgical assessment beyond the hospital through community health workers.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00268-022-06682-y.

Characteristics and predictors of mortality in-hospital mortality following burn injury in infants in a resource-limited setting

PURPOSE

Burn outcome data in infants is lacking from sub-Saharan Africa. We, therefore, sought to assess the characteristics and predictors of in-hospital burn mortality in a resource-limited setting.

METHODS

We performed a retrospective study of the prospectively collected Burn Injury Surveillance database from June 2011 to December 2019. We performed bivariate analysis and Poisson regression to assess risk factors for mortality in our infant burn population.

RESULTS

115 (7.3%) infants met inclusion criteria. The median age of 8 months (IQR: 6-10) and primarily male (n = 67, 58.8%). Most burns were from scald (n = 62, 53.9%). Infant burn mortality was 12.2%. Poisson multivariable regression to determine burn mortality risk in infants showed that increased %TBSA burns (RR 1.04, 95% CI 1.01-1.07) and flame burns (RR 3.08, 95%CI 1.16-8.16) had a higher risk of mortality. Having surgery reduced the relative risk of death for infants with burns.

CONCLUSION

We show that factors that increase infant burn mortality risk include percent total body surface area burn, flame burn mechanism, and lack of operative intervention. Increasing burn operative capability, particularly for infants and other children, is imperative.

Impact of COVID-19 on global burn care

Background

Worldwide, different strategies have been chosen to face the COVID-19-patient surge, often affecting access to health care for other patients. This observational study aimed to investigate whether the standard of burn care changed globally during the pandemic, and whether country´s income, geographical location, COVID-19-transmission pattern, and levels of specialization of the burn units affected reallocation of resources and access to burn care.

Methods

The Burn Care Survey is a questionnaire developed to collect information on the capacity to provide burn care by burn units around the world, before and during the pandemic. The survey was distributed between September and October 2020. McNemar`s test analyzed differences between services provided before and during the pandemic, χ2 or Fisher’s exact test differences between groups. Multivariable logistic regression analyzed the independent effect of different factors on keeping the burn units open during the pandemic.

Results

The survey was completed by 234 burn units in 43 countries. During the pandemic, presence of burn surgeons did not change (p = 0.06), while that of anesthetists and dedicated nursing staff was reduced (<0.01), and so did the capacity to manage patients in all age groups (p = 0.04). Use of telemedicine was implemented (p < 0.01), collaboration between burn centers was not. Burn units in LMICs and LICs were more likely to be closed, after adjustment for other factors.

Conclusions

During the pandemic, most burn units were open, although availability of standard resources diminished worldwide. The use of telemedicine increased, suggesting the implementation of new strategies to manage burns. Low income was independently associated with reduced access to burn care.

Access to burn care in low-and middle-income countries: An assessment of timeliness, surgical capacity, and affordability in a regional referral hospital in Tanzania

This study investigates patients' access to surgical care for burns in a low-and-middle-income setting by studying timeliness, surgical capacity, and affordability. A survey was conducted in a regional referral hospital in Manyara, Tanzania. In total, 67 patients were included. To obtain information on burn victims in need of surgical care, irrespective of time lapsed from the burn injury, both patients with burn wounds and patients with contractures were included. Information provided by patients and/or caregivers was supplemented with data from patient files and interviews with hospital administration and physicians. In the burn wound group, 50 percent reached a facility within 24 hours after the injury. Referrals from other health facilities to the regional referral hospital were made within three weeks for 74 percent in this group. Of contracture patients, seventy four percent, had sought healthcare after the acute burn injury. Of the same group, only 4 percent had been treated with skin grafts beforehand, and 70 percent never received surgical care or a referral. Combined, both groups indicated that lack of trust, surgical capacity, and referral timeliness were important factors negatively impacting patient access to surgical care. Accounting for hospital fees indicated patients routinely exceeded the catastrophic expenditure threshold. It was determined that healthcare for burn victims is without financial risk protection. We recommend strengthening burn care and reconstructive surgical programs in similar settings, using a more comprehensive health systems approach to identify and address both medical and socio-economic factors that determine patient mortality and disability.

Factors associated with outcomes after burn care: A retrospective study in Eastern Democratic Republic of Congo

OBJECTIVE

In low income countries, incidence of burns is high and severe burns are frequently managed at peripheral facilities. Outcome after burn care is poorly studied although it might help identify risk-group and improve treatment strategies. This study aimed to study factors associated with in-hospital outcomes in a burn cohort in the Democratic Republic of Congo.

METHODS

In this retrospective study we included burn patients admitted to the surgical department at the Hôpital Provincial Général de Référence de Bukavu between January 2013 and December 2018. Differences between groups were tested using χ2 test or Fisher's exact tests or Wilcoxon rank sum test, as appropriate. Multivariate logistic regression was used to analyze the effect of patients and of burn characteristics on in-hospital mortality, prolongated length of stay (=LOS≥25days) and occurrence of complications.

RESULTS

The study population consisted of 100 patients, mainly young male with rural origin, moderate sized but deep burns. Of them, 46 developed complications, 12 died. Median LOS was 25 days (IQR: 15-42). In-hospital death was independently associated with Total Burn Surface Area percentage "TBSA%" (OR=3.96; 95% CI=1.67-9.40) and Full thickness Burns "FTB" (10.68; 1.34-84.74); prolongated LOS with FTB (3.35; 1.07-10.49), and complication with rural origin (5.84; 1.51-22.53), TBSA% (3.96; 1.67-9.40), FTB (4.08; 1.19-14.00) and burns on multiple sites (4.38; 1.38-13.86).

CONCLUSION

In-hospital death was associated with TBSA% and FTB, prolongated LOS with FTB, and complication with burns characteristics and rural origin of the patients. Further studies are necessary to investigate the effect of provided burn care on outcomes.

Re-evaluation of the Effect of Age on In-hospital Burn Mortality in a Resource-Limited Setting

BACKGROUND

This global burden of burn injury is suffered disproportionately by people in low-income and middle-income countries, where 70% of all burns occur. Models based in high-income countries to prognosticate burn mortality treat age as a linearly increasing risk factor. It is unclear whether this relationship is similar in resource-limited settings.

METHODS

We analyzed patients from the Kamuzu Central Hospital Burn Registry in Lilongwe, Malawi, from 2011 to 2019. We examined the relationship between burn-associated mortality and age using adjusted survival analysis over 60 d, categorized into four groups: (1) younger children <5 y; (2) older children 5-17 y; (3) adults 18-40 y; and (4) older adults >40 y.

RESULTS

A total of 2499 patients were included. Most patients were <5 y old (n = 1444) with only 133 patients >40 y. Older adults had the highest crude mortality at 34.6% and older children with the lowest at 13%. Compared to younger children, the hazard ratio adjusted for sex, percent total body surface area, and operative intervention was 0.59 (95% confidence interval, 0.44, 0.79) for older children and 0.55 (95% confidence interval, 0.40, 0.76) for adults. Older adults were statistically similar to younger children.

CONCLUSIONS

We show in this cohort study of burn-injured patients in a resource-limited environment that the relationship between mortality and age is not linear and that the use of age-categorized mortality prediction models is more accurate in delineating mortality characteristics. Categorizing age based on local burn epidemiology will help describe burn mortality characteristics more accurately, leading to better-informed management strategies aimed at attenuating burn mortality for different populations.

Access to Operative Intervention Reduces Mortality in Adult Burn Patients in a Resource-Limited Setting in Sub-Saharan Africa

INTRODUCTION

Early excision and grafting remains the standard of care after burn injury. However, in a resource-limited setting, operative capacity often limits patient access to surgical intervention. This study sought to describe access to excision and grafting for adult burn patients in a sub-Saharan African burn unit and its relationship with burn-associated mortality.

METHODS

We analyzed patients recorded in the Kamuzu Central Hospital Burn Registry in Lilongwe, Malawi from 2011-2019. We examined patient characteristics, interventions, and outcomes for adults aged ≥16 years. Modified Poisson regression modeling was used to identify risk factors for mortality.

RESULTS

Five hundred and seventy-three patients were included. Median age was 30 years (IQR 23-40) with a male preponderance (63%). Median percent total body surface area burned (%TBSA) was 15% (IQR 8-26) and 68% of burns were caused by flame. 27% (n = 154) had burn excision with skin grafting, with a median time to operation of 18 days (IQR 9-38). When adjusted for age, %TBSA, and time to presentation, operative intervention conferred a survival benefit for patients with flame burns with a RR 0.16 (95% CI 0.06, 0.42).

CONCLUSIONS

In a resource-limiting setting, access to the operating room is inadequate, and burn patients are not prioritized. While many scald burn patients may be managed with wound care alone, patients with flame burn require surgical intervention to improve clinical outcomes. Burn injury in this region continues to confer a high risk of mortality, and more investment in operative capacity is imperative.