Pediatr Surg Int (2014) 30:699–706 DOI 10.1007/s00383-014-3519-5
REVIEW ARTICLE
Burn care in South Africa: a micro cosmos of Africa H. Rode • S. G. Cox • A. Numanoglu A. M. Berg
•
Accepted: 16 May 2014 / Published online: 7 June 2014 Springer-Verlag Berlin Heidelberg 2014
Abstract Burn injuries in Africa are common with between 300,000 and 17.5 million children under 5 years sustaining burn injuries annually, resulting in a high estimated fatality rate. These burns are largely environmentally conditioned and therefore preventable. The Western Cape Province in South Africa can be regarded as a prototype of paediatric burns seen on the continent, with large numbers, high morbidity and mortality rates and an area inclusive of all factors contributing to this extraordinary burden of injury. Most of the mechanisms to prevent burns are not easily modified due to the restraint of low socioeconomic homes, overcrowding, unsafe appliances, multiple and complex daily demands on families and multiple psycho-social stressors. Children \4 years are at highest risk of burns with an average annual rate of 6.0/10,000 child-years. Burn care in South Africa is predominantly emergency driven and variable in terms of organization, clinical management, facilities and staffing. Various treatment strategies were introduced. The management of HIV positive children poses a problem, as well as the conflict of achieving equity of burn care for all children. Without alleviating poverty, developing minimum standards for housing, burn education, safe appliances and legislation, we will not be able to reduce the ‘‘curse of poor people’’ and will continue to treat the consequences.
H. Rode (&) S. G. Cox A. Numanoglu Department of Paediatric Surgery, Red Cross War Memorial Children’s Hospital, University of Cape Town, Cape Town, South Africa e-mail: [email protected] A. M. Berg Department of Child and Adolescent Mental Health, Red Cross War Memorial Children’s Hospital, University of Cape Town, Cape Town, South Africa
Keywords Paediatric burns Environmental factors Rehabilitation South Africa
Introduction Sub-Saharan countries carry an extraordinary burden of burn injuries amongst their children. It is estimated that between 300,000 and 17.5 million children under 5 years sustain burn injuries annually and that fire-related burns are the second largest external cause of death in the region (8.7 per 100,000) [1, 2]. There is overwhelming evidence that these injuries are largely environmentally conditioned and therefore preventable [3, 4]. Many negative epidemiological risk factors have been identified and are driven by a lack of an ‘‘enabling environment.’’ 50 % of the population live below the international poverty line. Urban migration resulting in densely populated informal settlement areas with their inherent dangers of inadequate electrification, the use of kerosene stoves or open flame for heating, lighting and cooking; poverty, maternal illiteracy, single parent households, family psychosocial stressors and failure of prevention and educational programs all contribute to the burden and result in more severe and deeper burns than seen in the more affluent and well-planned urban areas [5]. The paediatric fatality rate for burn victims in Africa is reported as four times higher than in high income countries. These fatalities occur mostly in children under 14 years of age [6]. In low income households Kerosene constitutes 56 % of the energy source. In South Africa, 21 million households use kerosene on a daily basis resulting in 45,000 paraffinrelated fires and 3,000 reported burn deaths annually [personal communication: Paraffin Association of South
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Africa] This is often the result of defective appliances, contaminated fuel, unregulated supply chains and violation of standard safety principles [7]. In addition, local customs and beliefs regarding the emergency care of burns together with a lack of knowledge of first aid procedures contribute to more severe injury outcomes. In South Africa, burn injuries are the commonest external cause of death under the age of 4 years and the third most common cause of injury fatalities under the age of 18. The Western Cape Province in South Africa can be regarded as a prototype of the magnitude of paediatric burns seen on the African continent, with large numbers, high morbidity and mortality rates and an area inclusive of all factors contributing to this extraordinary burden of injury. The region has a population of 3.7 million with 25 % being children under 14 years of age. Twenty-two percent of the population live in informal settlements and 36 % of households live below the poverty line (350 US Dollars household income per month). Rapid urbanisation and lack of formal employment has directly contributed to the lack of ‘‘an enabling environment’’ for safe and proper living conditions [8].
Epidemiology A recent South African epidemiological study in the Western Cape Province has divided thermal injuries into four typical classes [9]: Class 1: infant burn injuries due to scalding at home, mostly amongst males and affecting the upper body parts; Class 2: typifies 2–3 year old children with burns caused by their curiosity and mobility in the home environment and mostly injured during summer and autumn seasons; Class 3: reflects the physical increasing mobility and social independence of preschool and older children and their high risk activities with an over representation of flame related burns; Class 4: includes a miscellaneous group exposed to environmental hazards in an expanding social network. The above study showed that the average annual rate of childhood burn injuries is 6.0/10,000 child-years (c-y).The estimated prevalence of thermal injuries is particularly high for toddlers (15.8/10,000 c-y) and for infants (14.6/10,000 c-y). The incidence of injury for boys is 7/10,000 c-y and for girls is 5.1/10,000 c-y whilst for children of African origin of all ages it is 11.4/10,000 c-y. The incidence therefore decreases by approximately half with increasing age groups. Burns are also more common during the cold rainy winter months [9].
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A local review of 647 paediatric burns showed that 80 % were burnt with hot liquids, 12 % sustained fire burns, 5 % electrical burns, and 3 % hot coals including walking into recreational fires [10, 11]. Accidently, pulling on kettle cords (40.5 %) was a major cause of burns, usually with a typical anatomical distribution and requiring surgery in 60 % of cases [12]. Of great concern is the number of burns amongst infants \4 months of age with a 10 % mortality and severe disability in the survivors [13]. Overall children \4 years of age are at highest risk to sustain burns. A 15-year analysis of the trauma registry from Child Safe South Africa’s Western Cape database analysing 9,438 children’s burns, showed that 39 % of the injuries were minor, 56 % were moderate and 5 % were severe, with 49 % of those seen in a level one trauma unit admitted for in hospital care [14]. Amongst adults in our geographical region, the epidemiological picture is different to that of children: assaults are responsible for 37 % of the burns; accidents (flame and scalds) for 20 %, informal settlement house fires 20%, epilepsy 8 %, electrical burns 6 %, self-immolation 5 %, and industrial and chemical burns 2 % [15]. Figures 1 and 2 show the number of admissions to the burn unit and the number of ambulatory children seen over an 11-year period at the Red Cross War Memorial Children’s Hospital Burn Unit. These tables show a generalised increase in numbers of both in and out patients, most likely reflecting a rise in burn injuries due to rapid migration from rural to urban areas resulting in the formation of disorganised informal settlements and the hazards associated with them.
Provision of burn care Burn care in South Africa is variable in terms of organization, clinical management, and facilities and staffing. Care is predominantly emergency driven. Patients lack universal access to dedicated burn facilities and fiscal restraints are severe. The developed world uses 5–6 % of the GDP on health care equating to approximately $2,000 US per patient annually, in comparison to South Africa allocating approximately $370 US per patient [7]. In Southern Africa, burn care funding has to compete with the epidemics prevalent in the region, notably; HIV/Aids, tuberculosis, violence and injuries, malnutrition and non-communicable diseases, with other aspects of health care such as maternal and child health also taking a large sum of the budget.
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Fig. 1 Number of admissions to the Red Cross War Memorial Children’s Hospital Burn Unit from 2002 to 2013
Fig. 2 Number of out patient clinic visits to the Red Cross War Memorial Children’s Hospital Burn Service from 2002 to 2013
In the Province of the Western Cape, a burn management infrastructure has been established, which on recent review functions satisfactory with a few important exceptions including inadequate infrastructure at a primary health care level, availability of modern consumables and fiscal restraints. In addition, all care givers express the view that they need ongoing education in the management of burn wounds and wounds in general. [Report: Evaluation of burn services in the Western Cape. Rode, 2012] An additional study in 2012 in the Western Cape region showed that many adult and paediatric patients meeting the
recognised list of admission criteria were not referred to a dedicated burn unit [16]. Adequate burn care provision therefore depends on both improving available resources in the area to treat the greater majority of children with minor burns in the existing health care facilities and provision of modern consumables and improved education of care givers, who feel they are unable to treat burn wound adequately. There are rural and urban health care centres, district hospitals and 2 tertiary referral hospitals with dedicated burns units—one for children up to age 13 years, and one
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for adults. Non-complex and minor injuries are treated initially at municipality run and provincial primary health care centres with care restricted to diagnosis and the provision of basic wound care for minor burns, tetanus prophylaxis, antibiotics and analgesia. For the next level of severity, patients would receive treatment at emergency departments, residing in provincial health care facilities. Larger or complex burns are stabilised and then referred to regional hospitals with adequate infrastructure to deal with most non-critical burns while critical burns and burns of a special nature are referred to or directly admitted to one of two regional burns units residing in the two teaching tertiary university hospitals.
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resuscitation and treatment of inhalation injuries, wound management and prevention and treatment of infection, early enteral feeding, early excision and wound closure, pain control and functional rehabilitation. Apart from these standard therapeutic endeavours, the unit has added the following management protocols. Many were developed out of necessity and the different circumstances under which we function. •
Pre-hospital management of burns There has been concern about the management of burned children before transfer to our unit. For this reason a survey was performed in 2012 to assess where the problems lie. Problems identified which adversely influenced care included appropriateness of referral: minor burns, late referrals, complications during transportation, errors in burn size estimation (30 %) delayed resuscitation, and initial burn wound care, wrong indications for intubation (40 %) and errors in observations. [A review of pre-hospital management of paediatric burns, unpublished data Rode et al. 2014]. Analysing the results of the survey, it became apparent that parents and caregivers and even local clinics had little understanding of the appropriate first aid and acute emergency management of burns in children, despite a concerted program of burn prevention by Child Safe in the communities. All patients resided in a low socioeconomic environment, often with less than standard home facilities, such as running water, own transport and a lack of knowledge of first aid. The survey has identified five crucial areas that if implemented could make a substantive difference in the pre-hospital management of children with burns. These include accident prevention education, immediate and effective cooling of the wound, early covering of the wound, pain management and appropriate transfer. To improve burn management, strategies to educate parents and care givers at the community clinic level are currently being rolled out at a provincial level. Treatment strategies In the Red Cross War Memorial Children’s Hospital Burn Unit management of paediatric burn injuries is based on standard guidelines and protocols; early and effective
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Our patients are often poorly nourished pre burn. Since 1992 and subsequently substantiated by Khorasani and Mansouri [17] enteral resuscitation, a method pioneered by paediatricians for children with gastroenteritis, has become standard in the unit as a complementary method of resuscitation and early enteral feeding [18]. This combination uses inexpensive fluids including crystalloids and polymeric feeds for minor to moderate size burns. (10–40 % TBSA) [19]. There are many benefits and only a few contraindications, including profound hypovolaemia, pre-existing gastro-intestinal disease, abdominal distension and diarrhoea. This concept has not been universally accepted despite its obvious physiological advantages. It is reassuring that burn resuscitation methods in some areas on the Southern African continent are on par with world standard [20, 21]. So many of our children come from very poor social circumstances with less than ideal hygienic standards. This resulted in a higher than reported sepsis rate, and thus necessitated procedural changes within the unit. As soon as possible after admission and stabilization, the children are washed with soap and water and dead tissue and blisters are debrided. This is followed by the topical application of an unbuffered 0.006 % sodium– hypo-chlorite solution [22]. This change in practise has decreased the SIRS and Sepsis criteria from 31 to 13 % if done within 8 h of sustaining the burn [23]. Diluted un-buffered sodium-hypochlorite applied to the burn wound and donor sites for 20 min pre-surgery is also used to reduce surface bacterial load. Fiscal and operative time restraints are a problem. We perform between 38 and 76 operations monthly which constitutes 11 % of all operations done in the main theatre complex of our hospital. A rational approach has therefore been adopted towards the management of paediatric burns. Partial thickness wounds are treated with short and long-acting topical antiseptic agents while burns of an indeterminate depth (especially hot water burns) are observed and dressed for 10–14 days before the final decision to operate or not is made. Deep burns are excised and grafted as soon as the patient is stable. This approach has decreased surgery; especially for hot water burns, by two-thirds
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•
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There are numerous challenges facing the burnt patient during the intraoperative period [24]. Anaesthetic techniques and maintenance of anaesthesia, the use of pharmacological agents and their altered pharmacodynamics, temperature and hemodynamic stability, the position of the patient during surgery, maintenance of an adequate and secured airway, monitoring vital signs, vascular access and rapid blood loss are some. Of the theatre complex (eight theatres), the burn theatre has the highest intraoperative anaesthetic complication rate, many of these relate to the maintenance of the airway, temperature control and blood loss. We have developed and published on a secure technique to stabilise an endotracheal tube during surgery. This is most useful when the patient undergoes frequent positional changes in theatre and in times when securing the tube poses a challenge such as for surgery to the face [25]. Blood loss during surgery may be substantial especially if the excision is delayed or the wound is infected. Preexsicional subeschar injection (clysis) of local anaesthetic (bupivacaine) and adrenaline to both the area for excision and the selected donor site/s is very effective in reducing blood loss by a factor of 50 % less blood loss [26]. The use of this technique that has now become routine, has reduced our transfusion rate by half and thus the associated costs. Inhalation injuries contributed significantly to morbidity and mortality amongst the children with major burns admitted to the ICU for initial stabilization. Risk factors indentified for developing pneumonia in our unit amongst 106 children were, fire burns, TBSA [30 %, young age and length of ICU stay. We have introduced remedial factors to reduce this high incidence including reducing the duration of ventilation, post-pyloric feeding, chlorhexidine mouth washed, head elevation and various staff factors such as hand washing and barrier nursing [27].
Ambulatory burn care With a large number of admissions and only 22 functional beds we have adopted a policy of ambulatory care for minor to moderate size burns changing inpatient care to outpatient treatment. The selection criteria are specific: partial thickness burns of\10 %TBSA, full thickness burns \5 % TBSA, fully resuscitated, stable condition, no evidence of infection and no co-morbidity. Patients are routinely followed up and if required re-admitted for day case surgery. Only patients with home circumstances permitting early discharge and those classified as ASA levels 1 or 2 are treated in such a manor. This policy has reduced the
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average stay in hospital to 4.3 days (range 3–6.7 days). As previously stated, many patients return to very poor home circumstances but despite this, we have not observed any additional adverse effects since this policy was adopted. HIV/AIDS and burns The impact of HIV infection on the pathophysiology of burns, complications, surgery and outcome is still to be determined. Sub-Saharan Africa is the epicentre of the epidemic with South Africa at the pinnacle with 2.9 % of children younger than 14 years infected. Routine HIV testing has not been a policy within the unit until recently. HIV testing was only done if the mother was on Highly Active Antiretroviral Therapy (HAART), or the child was exposed to or had clinical evidence of HIV or tuberculosis. Previously it was thought that only a few children with burns and concomitant HIV/AIDS are admitted annually and then usually with minor to moderate size burns. Anecdotally, over the last 4 years, staff in the unit has become aware of 23 children whose mothers were HIV positive. Of these, 8 were exposed to the virus in utero but were HIV negative, 12 were HIV positive and on HAART and 3 were HIV positive and not on treatment. Their average TBSA was 12 % (1–36 %) and 40 % needed surgery. Analysing these children there were no delayed wound healing or increased surgical complications, confirming the results amongst adults from the same geographical region [15, 28]. The burn wounds received standard care and anti-retroviral treatment was started if they were not already receiving HAART. Now that we have started to routinely test for HIV as a standard of care, it is noted that the HIV positive rate is indeed much higher than originally anticipated. It is our opinion that surgery should not be withheld or altered in the face of HIV infection. In cases with florid AIDS, children will be treated on merit, malnutrition and intercurrent infections treated, the child stabilised and the wounds treated as required. HAART has resulted, amongst surgical patients, in reduced morbidity and mortality by increasing the CD4 cell count and reducing the plasma viral load thus improving the nutritional states and immune function [29, 30].
Cost of burn care Health care for burns is one of the most expensive components of the allocated health care budget to the hospital. The financial cost is $1.14 million or 2.6 % of the annual total hospital budget. To reduce costs and without sacrificing the quality of care, the service has moved to the
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704 Table 1 Survival of burns exceeding 30 %TBSA at Red Cross War Memorial Children’s Hospital Burn Unit from 2000 to 2009
Pediatr Surg Int (2014) 30:699–706
Subject category
Proportion (%)
Mean age (years)
Flame burn
Scald
Mean burn size (%)
Mortality rate
All
117 (100 %)
4.3
64
53
48.5
27 (23 %)
Male
64
4.7
36
28
47
16 (25 %)
Female
53
3.6
32
21
49
11 (20.7 %)
30 B 45 %
73
3.2
30
40
37
7 (9.6 %)
45 \ 60 %
26
5.1
18
9
53
8 (30.7 %)
60 \ 75 %
9
5.1
8
3
71
7 (77.8 %)
[75 %
9
8.9
8
1
83
5 (55.6 %)
0\1
23
0.7
10
14
49
4 (17.4 %)
1B2 2B4
20 24
1.3 2.9
5 10
12 13
56 42
7 (35 %) 3 (12.5 %)
4B8
30
5.4
20
10
51
6 (20 %)
8 B 12
20
10.3
19
4
52
7 (35 %)
% TBSA
Age
utilisation of long-acting antiseptics and an ambulatory approach for minor to moderate size burns [31]. Currently 70 % of children are treated on this basis.
The dilemma of treating major burns The South African Medical Research Council has estimated that approximately 3.2 % of the South African population suffer from thermal injuries annually. The vast majority are from poor communities and only 6 % of patients are classified as private—those having sufficient income to pay for the burn management. The challenges facing South African burn surgeons are how to balance the current and future management of individual major burns in the face of the need of the greater majority. The question therefore is how do justify the enormous expenses required to treat an individual major burn against creating facilities that will make a substantative difference for minor to moderate size burns. The use of very expensive and highly specialised techniques for individual patients is ethically questionable when more accessible and cost-effective methods to serve the greater population of burn victims are needed [32].
African Region of 6.1/100,000 person years. Amongst children the highest mortality rates occur in the 0–2 and 3–6 year age groups and especially amongst young African children who have a 50 % higher mortality rate than other ethnic groups. Environmental circumstances contribute directly to this high mortality rate [35]. Our survival figures for burns exceeding 30 %TBSA are depicted in Table 1. The main causes for deaths in our unit were palliative care in 48 %, sepsis in 28 %, hypovolaemia in 10 %, inhalational injury in 7 % and aspiration in 3 %. Over many years of burn care experience with children, our unit has identified a subset of patients who, in our clinical situation, should only be offered quality end-of-life care due to the devastating outcome of their injuries. These patients include those with the probability of survival \10 %, the location and severity of the burn (destructive full-thickness facial and hand burns) that would result in severe disability, those with irreversible hypoxic brain damage and those with multi-organ dysfunction. These crucial decisions are made through open communication with support for the family including bereavement counselling, shared decisions and an end stage care plan [36].
Prevention Survival Accurate survival figures are not available for South Africa, but it is estimated that adult burns exceeding 40–50 % TBSA are unlikely to survive [33, 34]. The overall (adult and child) Cape Town burn mortality rate is 7.9/100,000 person years, which is higher than the world average of 5/100,00 person years, and even that of the
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There is not much evidence that house safety education without the provision of safety equipment reduces thermal injuries amongst children. In the developed world substantative improvements in burn prevention have decreased the incidence of burns substantially. This was brought about mostly by passive means such as smoke detectors, lowering geyser temperature, fire guards, flame retarding clothing for children, product design, legislation and the
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benefits of advances in burn care. Most of the mechanisms to prevent burns amongst our population are not easily modified due to the restraint of low socio-economic homes, overcrowding, unsafe appliances, multiple and complex daily demands on families and multiple psycho-social stressors contributing to material and social hardship [37]. Safety is also often considered by families as of secondary importance after other concerns of shelter, food stability, schooling, work security and clothing needs. These are insurmountable problems in a rapidly changing society [38–40].
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achieving universal primary education, promotion of gender equality and empowering of women and reducing child mortality rates. With the circumstances of rapid urbanization and poverty the only way to reduce the incidence of burns is to create an ‘‘enabling environment’’. As recognised by the Millennium Development Goals, interventions must be directed towards those factors that will make a substantial difference. Without alleviating poverty, developing minimum standards for entry-level housing, maternal education, safe appliances, products and legislation, we will not be able to reduce the ‘‘curse of poor people’’ and will continue to treat the consequences.
The future of the burnt child Burn injuries, especially amongst growing children, result in significant physical and psychosocial complications [41, 42]. Children are disfigured, visibly different and with negative self-perceptions and social consequences. How children emotionally cope with their burn injury is as important as the healing of a physical scar. Pre-morbid factors such as behaviour and other mental health problems as well as developmental delay have been found to predict functional outcomes in children at 6 months post-burn. Parent factors in the form of anxiety, depression extent of social support also contributed significantly to the variance in outcome of this group of children [42]. Given the fact that the majority of burn victims come from resource challenged environments it can be postulated that many of the above contributing factors exist in the children and their parents. The current rehabilitation program such as it is does not include a coherent psycho-social intervention which would deal with some of these problems. To address this caveat, we have started a psychotherapeutic intervention programme of reflective parenting. It is thus not surprising that in an environment with limited resources for an integrated rehabilitation program, low compliance and a 90 % drop-out rate after 1 year is noted. With a general acceptance of the inevitable and a sense of resignation, programs for rehabilitation are difficult to initiate and to maintain. This is one of the ‘‘Achilles Heel’s’’ of current burn care in the country. What has happened to the more than 1,000 children treated annually? They have mostly become incognito in our society. Many have accepted their disabilities and only seek remedial help if the disabilities are severe or restricting daily activities of living.
Conclusion At a United Nations Declaration Conference held in September of 2005 [43], key Millennium Development Goals were set. These goals include eradicating extreme poverty,
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REVIEW ARTICLE
Burn care in South Africa: a micro cosmos of Africa H. Rode • S. G. Cox • A. Numanoglu A. M. Berg
•
Accepted: 16 May 2014 / Published online: 7 June 2014 Springer-Verlag Berlin Heidelberg 2014
Abstract Burn injuries in Africa are common with between 300,000 and 17.5 million children under 5 years sustaining burn injuries annually, resulting in a high estimated fatality rate. These burns are largely environmentally conditioned and therefore preventable. The Western Cape Province in South Africa can be regarded as a prototype of paediatric burns seen on the continent, with large numbers, high morbidity and mortality rates and an area inclusive of all factors contributing to this extraordinary burden of injury. Most of the mechanisms to prevent burns are not easily modified due to the restraint of low socioeconomic homes, overcrowding, unsafe appliances, multiple and complex daily demands on families and multiple psycho-social stressors. Children \4 years are at highest risk of burns with an average annual rate of 6.0/10,000 child-years. Burn care in South Africa is predominantly emergency driven and variable in terms of organization, clinical management, facilities and staffing. Various treatment strategies were introduced. The management of HIV positive children poses a problem, as well as the conflict of achieving equity of burn care for all children. Without alleviating poverty, developing minimum standards for housing, burn education, safe appliances and legislation, we will not be able to reduce the ‘‘curse of poor people’’ and will continue to treat the consequences.
H. Rode (&) S. G. Cox A. Numanoglu Department of Paediatric Surgery, Red Cross War Memorial Children’s Hospital, University of Cape Town, Cape Town, South Africa e-mail: [email protected] A. M. Berg Department of Child and Adolescent Mental Health, Red Cross War Memorial Children’s Hospital, University of Cape Town, Cape Town, South Africa
Keywords Paediatric burns Environmental factors Rehabilitation South Africa
Introduction Sub-Saharan countries carry an extraordinary burden of burn injuries amongst their children. It is estimated that between 300,000 and 17.5 million children under 5 years sustain burn injuries annually and that fire-related burns are the second largest external cause of death in the region (8.7 per 100,000) [1, 2]. There is overwhelming evidence that these injuries are largely environmentally conditioned and therefore preventable [3, 4]. Many negative epidemiological risk factors have been identified and are driven by a lack of an ‘‘enabling environment.’’ 50 % of the population live below the international poverty line. Urban migration resulting in densely populated informal settlement areas with their inherent dangers of inadequate electrification, the use of kerosene stoves or open flame for heating, lighting and cooking; poverty, maternal illiteracy, single parent households, family psychosocial stressors and failure of prevention and educational programs all contribute to the burden and result in more severe and deeper burns than seen in the more affluent and well-planned urban areas [5]. The paediatric fatality rate for burn victims in Africa is reported as four times higher than in high income countries. These fatalities occur mostly in children under 14 years of age [6]. In low income households Kerosene constitutes 56 % of the energy source. In South Africa, 21 million households use kerosene on a daily basis resulting in 45,000 paraffinrelated fires and 3,000 reported burn deaths annually [personal communication: Paraffin Association of South
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Africa] This is often the result of defective appliances, contaminated fuel, unregulated supply chains and violation of standard safety principles [7]. In addition, local customs and beliefs regarding the emergency care of burns together with a lack of knowledge of first aid procedures contribute to more severe injury outcomes. In South Africa, burn injuries are the commonest external cause of death under the age of 4 years and the third most common cause of injury fatalities under the age of 18. The Western Cape Province in South Africa can be regarded as a prototype of the magnitude of paediatric burns seen on the African continent, with large numbers, high morbidity and mortality rates and an area inclusive of all factors contributing to this extraordinary burden of injury. The region has a population of 3.7 million with 25 % being children under 14 years of age. Twenty-two percent of the population live in informal settlements and 36 % of households live below the poverty line (350 US Dollars household income per month). Rapid urbanisation and lack of formal employment has directly contributed to the lack of ‘‘an enabling environment’’ for safe and proper living conditions [8].
Epidemiology A recent South African epidemiological study in the Western Cape Province has divided thermal injuries into four typical classes [9]: Class 1: infant burn injuries due to scalding at home, mostly amongst males and affecting the upper body parts; Class 2: typifies 2–3 year old children with burns caused by their curiosity and mobility in the home environment and mostly injured during summer and autumn seasons; Class 3: reflects the physical increasing mobility and social independence of preschool and older children and their high risk activities with an over representation of flame related burns; Class 4: includes a miscellaneous group exposed to environmental hazards in an expanding social network. The above study showed that the average annual rate of childhood burn injuries is 6.0/10,000 child-years (c-y).The estimated prevalence of thermal injuries is particularly high for toddlers (15.8/10,000 c-y) and for infants (14.6/10,000 c-y). The incidence of injury for boys is 7/10,000 c-y and for girls is 5.1/10,000 c-y whilst for children of African origin of all ages it is 11.4/10,000 c-y. The incidence therefore decreases by approximately half with increasing age groups. Burns are also more common during the cold rainy winter months [9].
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A local review of 647 paediatric burns showed that 80 % were burnt with hot liquids, 12 % sustained fire burns, 5 % electrical burns, and 3 % hot coals including walking into recreational fires [10, 11]. Accidently, pulling on kettle cords (40.5 %) was a major cause of burns, usually with a typical anatomical distribution and requiring surgery in 60 % of cases [12]. Of great concern is the number of burns amongst infants \4 months of age with a 10 % mortality and severe disability in the survivors [13]. Overall children \4 years of age are at highest risk to sustain burns. A 15-year analysis of the trauma registry from Child Safe South Africa’s Western Cape database analysing 9,438 children’s burns, showed that 39 % of the injuries were minor, 56 % were moderate and 5 % were severe, with 49 % of those seen in a level one trauma unit admitted for in hospital care [14]. Amongst adults in our geographical region, the epidemiological picture is different to that of children: assaults are responsible for 37 % of the burns; accidents (flame and scalds) for 20 %, informal settlement house fires 20%, epilepsy 8 %, electrical burns 6 %, self-immolation 5 %, and industrial and chemical burns 2 % [15]. Figures 1 and 2 show the number of admissions to the burn unit and the number of ambulatory children seen over an 11-year period at the Red Cross War Memorial Children’s Hospital Burn Unit. These tables show a generalised increase in numbers of both in and out patients, most likely reflecting a rise in burn injuries due to rapid migration from rural to urban areas resulting in the formation of disorganised informal settlements and the hazards associated with them.
Provision of burn care Burn care in South Africa is variable in terms of organization, clinical management, and facilities and staffing. Care is predominantly emergency driven. Patients lack universal access to dedicated burn facilities and fiscal restraints are severe. The developed world uses 5–6 % of the GDP on health care equating to approximately $2,000 US per patient annually, in comparison to South Africa allocating approximately $370 US per patient [7]. In Southern Africa, burn care funding has to compete with the epidemics prevalent in the region, notably; HIV/Aids, tuberculosis, violence and injuries, malnutrition and non-communicable diseases, with other aspects of health care such as maternal and child health also taking a large sum of the budget.
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Fig. 1 Number of admissions to the Red Cross War Memorial Children’s Hospital Burn Unit from 2002 to 2013
Fig. 2 Number of out patient clinic visits to the Red Cross War Memorial Children’s Hospital Burn Service from 2002 to 2013
In the Province of the Western Cape, a burn management infrastructure has been established, which on recent review functions satisfactory with a few important exceptions including inadequate infrastructure at a primary health care level, availability of modern consumables and fiscal restraints. In addition, all care givers express the view that they need ongoing education in the management of burn wounds and wounds in general. [Report: Evaluation of burn services in the Western Cape. Rode, 2012] An additional study in 2012 in the Western Cape region showed that many adult and paediatric patients meeting the
recognised list of admission criteria were not referred to a dedicated burn unit [16]. Adequate burn care provision therefore depends on both improving available resources in the area to treat the greater majority of children with minor burns in the existing health care facilities and provision of modern consumables and improved education of care givers, who feel they are unable to treat burn wound adequately. There are rural and urban health care centres, district hospitals and 2 tertiary referral hospitals with dedicated burns units—one for children up to age 13 years, and one
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for adults. Non-complex and minor injuries are treated initially at municipality run and provincial primary health care centres with care restricted to diagnosis and the provision of basic wound care for minor burns, tetanus prophylaxis, antibiotics and analgesia. For the next level of severity, patients would receive treatment at emergency departments, residing in provincial health care facilities. Larger or complex burns are stabilised and then referred to regional hospitals with adequate infrastructure to deal with most non-critical burns while critical burns and burns of a special nature are referred to or directly admitted to one of two regional burns units residing in the two teaching tertiary university hospitals.
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resuscitation and treatment of inhalation injuries, wound management and prevention and treatment of infection, early enteral feeding, early excision and wound closure, pain control and functional rehabilitation. Apart from these standard therapeutic endeavours, the unit has added the following management protocols. Many were developed out of necessity and the different circumstances under which we function. •
Pre-hospital management of burns There has been concern about the management of burned children before transfer to our unit. For this reason a survey was performed in 2012 to assess where the problems lie. Problems identified which adversely influenced care included appropriateness of referral: minor burns, late referrals, complications during transportation, errors in burn size estimation (30 %) delayed resuscitation, and initial burn wound care, wrong indications for intubation (40 %) and errors in observations. [A review of pre-hospital management of paediatric burns, unpublished data Rode et al. 2014]. Analysing the results of the survey, it became apparent that parents and caregivers and even local clinics had little understanding of the appropriate first aid and acute emergency management of burns in children, despite a concerted program of burn prevention by Child Safe in the communities. All patients resided in a low socioeconomic environment, often with less than standard home facilities, such as running water, own transport and a lack of knowledge of first aid. The survey has identified five crucial areas that if implemented could make a substantive difference in the pre-hospital management of children with burns. These include accident prevention education, immediate and effective cooling of the wound, early covering of the wound, pain management and appropriate transfer. To improve burn management, strategies to educate parents and care givers at the community clinic level are currently being rolled out at a provincial level. Treatment strategies In the Red Cross War Memorial Children’s Hospital Burn Unit management of paediatric burn injuries is based on standard guidelines and protocols; early and effective
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•
•
Our patients are often poorly nourished pre burn. Since 1992 and subsequently substantiated by Khorasani and Mansouri [17] enteral resuscitation, a method pioneered by paediatricians for children with gastroenteritis, has become standard in the unit as a complementary method of resuscitation and early enteral feeding [18]. This combination uses inexpensive fluids including crystalloids and polymeric feeds for minor to moderate size burns. (10–40 % TBSA) [19]. There are many benefits and only a few contraindications, including profound hypovolaemia, pre-existing gastro-intestinal disease, abdominal distension and diarrhoea. This concept has not been universally accepted despite its obvious physiological advantages. It is reassuring that burn resuscitation methods in some areas on the Southern African continent are on par with world standard [20, 21]. So many of our children come from very poor social circumstances with less than ideal hygienic standards. This resulted in a higher than reported sepsis rate, and thus necessitated procedural changes within the unit. As soon as possible after admission and stabilization, the children are washed with soap and water and dead tissue and blisters are debrided. This is followed by the topical application of an unbuffered 0.006 % sodium– hypo-chlorite solution [22]. This change in practise has decreased the SIRS and Sepsis criteria from 31 to 13 % if done within 8 h of sustaining the burn [23]. Diluted un-buffered sodium-hypochlorite applied to the burn wound and donor sites for 20 min pre-surgery is also used to reduce surface bacterial load. Fiscal and operative time restraints are a problem. We perform between 38 and 76 operations monthly which constitutes 11 % of all operations done in the main theatre complex of our hospital. A rational approach has therefore been adopted towards the management of paediatric burns. Partial thickness wounds are treated with short and long-acting topical antiseptic agents while burns of an indeterminate depth (especially hot water burns) are observed and dressed for 10–14 days before the final decision to operate or not is made. Deep burns are excised and grafted as soon as the patient is stable. This approach has decreased surgery; especially for hot water burns, by two-thirds
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•
•
•
There are numerous challenges facing the burnt patient during the intraoperative period [24]. Anaesthetic techniques and maintenance of anaesthesia, the use of pharmacological agents and their altered pharmacodynamics, temperature and hemodynamic stability, the position of the patient during surgery, maintenance of an adequate and secured airway, monitoring vital signs, vascular access and rapid blood loss are some. Of the theatre complex (eight theatres), the burn theatre has the highest intraoperative anaesthetic complication rate, many of these relate to the maintenance of the airway, temperature control and blood loss. We have developed and published on a secure technique to stabilise an endotracheal tube during surgery. This is most useful when the patient undergoes frequent positional changes in theatre and in times when securing the tube poses a challenge such as for surgery to the face [25]. Blood loss during surgery may be substantial especially if the excision is delayed or the wound is infected. Preexsicional subeschar injection (clysis) of local anaesthetic (bupivacaine) and adrenaline to both the area for excision and the selected donor site/s is very effective in reducing blood loss by a factor of 50 % less blood loss [26]. The use of this technique that has now become routine, has reduced our transfusion rate by half and thus the associated costs. Inhalation injuries contributed significantly to morbidity and mortality amongst the children with major burns admitted to the ICU for initial stabilization. Risk factors indentified for developing pneumonia in our unit amongst 106 children were, fire burns, TBSA [30 %, young age and length of ICU stay. We have introduced remedial factors to reduce this high incidence including reducing the duration of ventilation, post-pyloric feeding, chlorhexidine mouth washed, head elevation and various staff factors such as hand washing and barrier nursing [27].
Ambulatory burn care With a large number of admissions and only 22 functional beds we have adopted a policy of ambulatory care for minor to moderate size burns changing inpatient care to outpatient treatment. The selection criteria are specific: partial thickness burns of\10 %TBSA, full thickness burns \5 % TBSA, fully resuscitated, stable condition, no evidence of infection and no co-morbidity. Patients are routinely followed up and if required re-admitted for day case surgery. Only patients with home circumstances permitting early discharge and those classified as ASA levels 1 or 2 are treated in such a manor. This policy has reduced the
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average stay in hospital to 4.3 days (range 3–6.7 days). As previously stated, many patients return to very poor home circumstances but despite this, we have not observed any additional adverse effects since this policy was adopted. HIV/AIDS and burns The impact of HIV infection on the pathophysiology of burns, complications, surgery and outcome is still to be determined. Sub-Saharan Africa is the epicentre of the epidemic with South Africa at the pinnacle with 2.9 % of children younger than 14 years infected. Routine HIV testing has not been a policy within the unit until recently. HIV testing was only done if the mother was on Highly Active Antiretroviral Therapy (HAART), or the child was exposed to or had clinical evidence of HIV or tuberculosis. Previously it was thought that only a few children with burns and concomitant HIV/AIDS are admitted annually and then usually with minor to moderate size burns. Anecdotally, over the last 4 years, staff in the unit has become aware of 23 children whose mothers were HIV positive. Of these, 8 were exposed to the virus in utero but were HIV negative, 12 were HIV positive and on HAART and 3 were HIV positive and not on treatment. Their average TBSA was 12 % (1–36 %) and 40 % needed surgery. Analysing these children there were no delayed wound healing or increased surgical complications, confirming the results amongst adults from the same geographical region [15, 28]. The burn wounds received standard care and anti-retroviral treatment was started if they were not already receiving HAART. Now that we have started to routinely test for HIV as a standard of care, it is noted that the HIV positive rate is indeed much higher than originally anticipated. It is our opinion that surgery should not be withheld or altered in the face of HIV infection. In cases with florid AIDS, children will be treated on merit, malnutrition and intercurrent infections treated, the child stabilised and the wounds treated as required. HAART has resulted, amongst surgical patients, in reduced morbidity and mortality by increasing the CD4 cell count and reducing the plasma viral load thus improving the nutritional states and immune function [29, 30].
Cost of burn care Health care for burns is one of the most expensive components of the allocated health care budget to the hospital. The financial cost is $1.14 million or 2.6 % of the annual total hospital budget. To reduce costs and without sacrificing the quality of care, the service has moved to the
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704 Table 1 Survival of burns exceeding 30 %TBSA at Red Cross War Memorial Children’s Hospital Burn Unit from 2000 to 2009
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Subject category
Proportion (%)
Mean age (years)
Flame burn
Scald
Mean burn size (%)
Mortality rate
All
117 (100 %)
4.3
64
53
48.5
27 (23 %)
Male
64
4.7
36
28
47
16 (25 %)
Female
53
3.6
32
21
49
11 (20.7 %)
30 B 45 %
73
3.2
30
40
37
7 (9.6 %)
45 \ 60 %
26
5.1
18
9
53
8 (30.7 %)
60 \ 75 %
9
5.1
8
3
71
7 (77.8 %)
[75 %
9
8.9
8
1
83
5 (55.6 %)
0\1
23
0.7
10
14
49
4 (17.4 %)
1B2 2B4
20 24
1.3 2.9
5 10
12 13
56 42
7 (35 %) 3 (12.5 %)
4B8
30
5.4
20
10
51
6 (20 %)
8 B 12
20
10.3
19
4
52
7 (35 %)
% TBSA
Age
utilisation of long-acting antiseptics and an ambulatory approach for minor to moderate size burns [31]. Currently 70 % of children are treated on this basis.
The dilemma of treating major burns The South African Medical Research Council has estimated that approximately 3.2 % of the South African population suffer from thermal injuries annually. The vast majority are from poor communities and only 6 % of patients are classified as private—those having sufficient income to pay for the burn management. The challenges facing South African burn surgeons are how to balance the current and future management of individual major burns in the face of the need of the greater majority. The question therefore is how do justify the enormous expenses required to treat an individual major burn against creating facilities that will make a substantative difference for minor to moderate size burns. The use of very expensive and highly specialised techniques for individual patients is ethically questionable when more accessible and cost-effective methods to serve the greater population of burn victims are needed [32].
African Region of 6.1/100,000 person years. Amongst children the highest mortality rates occur in the 0–2 and 3–6 year age groups and especially amongst young African children who have a 50 % higher mortality rate than other ethnic groups. Environmental circumstances contribute directly to this high mortality rate [35]. Our survival figures for burns exceeding 30 %TBSA are depicted in Table 1. The main causes for deaths in our unit were palliative care in 48 %, sepsis in 28 %, hypovolaemia in 10 %, inhalational injury in 7 % and aspiration in 3 %. Over many years of burn care experience with children, our unit has identified a subset of patients who, in our clinical situation, should only be offered quality end-of-life care due to the devastating outcome of their injuries. These patients include those with the probability of survival \10 %, the location and severity of the burn (destructive full-thickness facial and hand burns) that would result in severe disability, those with irreversible hypoxic brain damage and those with multi-organ dysfunction. These crucial decisions are made through open communication with support for the family including bereavement counselling, shared decisions and an end stage care plan [36].
Prevention Survival Accurate survival figures are not available for South Africa, but it is estimated that adult burns exceeding 40–50 % TBSA are unlikely to survive [33, 34]. The overall (adult and child) Cape Town burn mortality rate is 7.9/100,000 person years, which is higher than the world average of 5/100,00 person years, and even that of the
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There is not much evidence that house safety education without the provision of safety equipment reduces thermal injuries amongst children. In the developed world substantative improvements in burn prevention have decreased the incidence of burns substantially. This was brought about mostly by passive means such as smoke detectors, lowering geyser temperature, fire guards, flame retarding clothing for children, product design, legislation and the
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benefits of advances in burn care. Most of the mechanisms to prevent burns amongst our population are not easily modified due to the restraint of low socio-economic homes, overcrowding, unsafe appliances, multiple and complex daily demands on families and multiple psycho-social stressors contributing to material and social hardship [37]. Safety is also often considered by families as of secondary importance after other concerns of shelter, food stability, schooling, work security and clothing needs. These are insurmountable problems in a rapidly changing society [38–40].
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achieving universal primary education, promotion of gender equality and empowering of women and reducing child mortality rates. With the circumstances of rapid urbanization and poverty the only way to reduce the incidence of burns is to create an ‘‘enabling environment’’. As recognised by the Millennium Development Goals, interventions must be directed towards those factors that will make a substantial difference. Without alleviating poverty, developing minimum standards for entry-level housing, maternal education, safe appliances, products and legislation, we will not be able to reduce the ‘‘curse of poor people’’ and will continue to treat the consequences.
The future of the burnt child Burn injuries, especially amongst growing children, result in significant physical and psychosocial complications [41, 42]. Children are disfigured, visibly different and with negative self-perceptions and social consequences. How children emotionally cope with their burn injury is as important as the healing of a physical scar. Pre-morbid factors such as behaviour and other mental health problems as well as developmental delay have been found to predict functional outcomes in children at 6 months post-burn. Parent factors in the form of anxiety, depression extent of social support also contributed significantly to the variance in outcome of this group of children [42]. Given the fact that the majority of burn victims come from resource challenged environments it can be postulated that many of the above contributing factors exist in the children and their parents. The current rehabilitation program such as it is does not include a coherent psycho-social intervention which would deal with some of these problems. To address this caveat, we have started a psychotherapeutic intervention programme of reflective parenting. It is thus not surprising that in an environment with limited resources for an integrated rehabilitation program, low compliance and a 90 % drop-out rate after 1 year is noted. With a general acceptance of the inevitable and a sense of resignation, programs for rehabilitation are difficult to initiate and to maintain. This is one of the ‘‘Achilles Heel’s’’ of current burn care in the country. What has happened to the more than 1,000 children treated annually? They have mostly become incognito in our society. Many have accepted their disabilities and only seek remedial help if the disabilities are severe or restricting daily activities of living.
Conclusion At a United Nations Declaration Conference held in September of 2005 [43], key Millennium Development Goals were set. These goals include eradicating extreme poverty,
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