Optimizing burn treatment in developing low- and middle-income countries with limited health care resources (part 1).

Abstract

In developing countries burn injuries are much more common than in the USA and Europe or other affluent developed countries, due to poverty, overcrowding, and illiteracy, and are associated with higher mortality rates. The high incidence makes burns an endemic health hazard in these countries. Over 90% of burn-related fatalities occur in developing or low- and middle-income countries (LMICs), with south-east Asia alone accounting for over half of fire-related deaths. Management of burns and their sequelae even in the well-equipped, modern burn units of advanced affluent societies remains demanding despite advances in surgical techniques and development of tissue-engineered biomaterials available to these burn centres. Undoubtedly, in a developing country with limited resources and inaccessibility to sophisticated skills and technologies, management of burns constitutes a major challenge. The present review of the literature analyses the challenges facing burn management in LMICs and explores probable modalities to optimize burn management in these countries. The review will be published in three parts. Part I will present the epidemiology of burn injuries and challenges for management in LMICs. Part II will be about management of burn injuries in LMICs and Part III will discuss strategies for proper prevention and burn care in LMICs.

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Management of burn injuries in low-
and middle-income countries
Burn management in developing countries encounters
huge problems at any stage.26Inadequate access to burn
care facilities and a poorly-equipped health care system
hinder optimal treatment.1With no formal infection con-
trol policy in most low- and middle-income country (LMIC)
burn units and limited aseptic techniques for wound care
management, due to nursing constraints and inadequate
limited facilities, high rates of burn-related mortality and
morbidity are still seen in developing countries.27,28This is
further complicated by the patients’ parents having to ap-
ply some of the dressings unsupervised, in less than ide-
al circumstances,27and by superstition,29religious rituals,30
and faith in alternative medicine.1,5,31
Service provision for burns in most LMICs is mainly
through the western system of care,1considered to be the
ultimate in patient care. The approach to burn manage-
ment, however, has to be radically different from that in
western countries.5Certain well-tested, cost-effective treat-
ment proceduresneed to be adopted to conserve resources5
and make the best of what it is realistically available. Over-
all poor conditions and lack of resources make excisional
surgery impossible for a large percentage of patients.26,32,33
Unfortunately, only a handful of studies evaluating burn
interventions in LMICs have been reported, possibly due
to lack of the funding necessary to conduct such studies
and partly due to lack of expertise in many of these LMICs.3
First aid, emergency care, and resuscitation
The severity of the burn wound and its clinical mani-
festation depends not only on the treatment regime at the
burn centre but also on first aid and initial management at
the burn site, at the emergency department, and during
transfer to the burn centre.32-36Few population-based stud-
ies have been conducted in LMICs about the first aid to
be provided and the subsequent healthcare-seeking for
burns, along with methods of burn treatment at home.3,37-39
Obviously, traditional values may determine the treatment
of burn injuries in the home setting.40,41Adequate immedi-
ate first aid following a burn appreciably determines out-
come and limits tissue damage and subsequent morbidity,
including the need for surgery.42,43Cool running water at a
temperature of between 10 and 15 °C for 20-30 min is
considered adequate burn first-aid treatment.32,33,40,42,44,45In
one study about burn treatment in LMICs, including all
countries in sub-Saharan Africa, Latin America, and the
Caribbean, the Middle East, India, and China, as well as
other countries in Asia and adjoining islands, cool water
was applied to the burned area as a first-aid therapy in a
third of the cases,3a ratio comparable to that observed in
some high-income countries (HICs).42Naturally, the avail-
ability of running water at the appropriate temperature, not
universally readily available, in addition to proper educa-
tion and knowledge, is an obvious limiting factor. Subse-
quently, since burn wounds are sterile immediately after
injury but liable to rapid bacterial colonization,40,46 the
OPTIMIZING BURN TREATMENT IN DEVELOPING LOW- AND
MIDDLE-INCOME COUNTRIES WITH LIMITED HEALTH CARE
RESOURCES (part 2)
Atiyeh B.,1Masellis A.,2Conte C.3
1General Secretary, Mediterranean Council for Burns and Fire Disasters – MBC, Plastic and Reconstructive Surgery, American
University of Beirut Medical Center, Beirut, Lebanon
2Burnet Project Manager, Plastic Surgery and Burns Therapy, Palermo Civic Hospital, Palermo, Italy
3Director, Plastic Surgery and Burns Therapy, Palermo Civic Hospital, Palermo, Italy
SUMMARY. The present review of the literature aims at analysing the challenges facing burn management in low- and middle-
income countries (LMICs) and exploring probable modalities to optimize burn management in these countries. In Part 1, the epi-
demiology of burn injuries and the formidable challenges for proper management due to limited resources and inaccessibility to
sophisticated skills and technologies in LMICs were presented. Part II will discuss the actual state of burn injuries management in
LMICs.

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190
wounds should be covered with a clean sterile sheet until
they are dressed.5,32,33
One-half to two-thirds of burned persons in LMICs are
reported to be taken to a health care facility for treatment
and a significant relationship is found between the size of
the burn sustained and subsequent healthcare seeking.3
Those who seek healthcare have significantly deeper burns
covering a wider TBSA or an infected burn previously
treated at home.3In the remaining cases that receive home
treatment, non-tested household remedies are commonly
used as a first-aid measure in developing countries.34,47,48 A
traditional preparation is usually applied in the form of
concoctions made of urine and mud, cow dung, beaten
eggs, or mud and leaves.3A significant relationship is al-
so found between the size of burn sustained and the type
of home-based treatment. Superficial burns and those cov-
ering a small body surface area are treated with gentian
violet, while more extensive burns are paradoxically treat-
ed with a traditional preparation.3,38In a report from Turkey,
after cold water and ice, raw egg white was most com-
monly used as first-aid treatment in addition to yogurt,
toothpaste, tomato paste, or sliced potato. Most of these
substances are harmful, seriously compounding the injury.40
Unfortunately, most people in Turkey as well as in other
LMICs still believe that this kind of medicine is safer and
less expensive than western medications and ointments.40
Early presentation and active resuscitation are the key
to successful management of severe burns. Among the
components of initial management, fluid resuscitation has
a crucial role in preventing complications and reducing the
death rate.32-34,49Initial care is in the line of the ABC of re-
suscitation. An adequate airway and respiration must be
ensured. All patients exceptthose with minor burns must
receive fluid resuscitation based on a simple formula us-
ing theParkland or Carvajal formulas for resuscitation.5,26
In some situations, intravenous fluid replacement must be
established prior to transfer to a burn centre - however,
time should not be wasted to set up an intravenous infu-
sion in the case of a short journey that is expected to take
no more than 1 h.32-34Unfortunately, such conditions may
not be possible to achieve in developing countries.34First,
a first-aid health care provider may not be available at the
scene of a burn accident; second, adequate resuscitation at
the scene may not be possible due to the considerable ig-
norance of health care providers about the correct and safe
initial management of burns; and third, early transfer of
patients may not be possible because of the lack of an
available ambulance or other means of transport.32-35A long
journey during the shock period is in any case challeng-
ing and risky, and delay for immediate urgent resuscita-
tion or the treatment of life-threatening problems is the
rule in most remote and rural areas and LMICs.
In fire disasters involving a large number of victims,
good triage is the cornerstone of effective burn disaster
management and should be performed at the disaster site
by staff with knowledge of burn treatment,32,33largely lack-
ing in most LMICs. Adequate triage must take into con-
sideration the total number of patients, bed availability,
and transportation capacity. Increased mortality rates as-
sociated with fire disasters in LMICs are due - in addition
to limited resources and adequate facilities - to the lack of
a proper burn disaster and rescue organization plan.32
Topical care and dressings
Local burn wound management is one of the most im-
portant aspects of burn therapy after the shock phase. Sev-
eral methods of burn wound management are available to-
day.50Conventional dressings necessitate, however, topical
antimicrobial ointments and creams that may be expensive
or not available, and require frequent dressing changes.50
The cost of these topical agents may even be prohibitive.51
Economics and logistics dictate that alternatives to the rel-
atively expensive burns dressings available in the devel-
oped world are required.27In a developing country with a
fairly large incidence of burns and with financial con-
straints and limited budgets where all medical resources
are stretched beyond practical limits, a major factor that
must be considered is how to reduce the cost of therapy
and reach a cost-effective management.50,52In LMICs an
extremely simple, convenient, economical but effective
dressing with a long shelf life is required. In addition treat-
ment should be on an outpatient basis as much as possi-
ble so that the load on hospital beds is reduced.5,52Pursu-
ing conservative burnwound management and using am-
nion as a biological dressing5,53seem to be an appropriate
burn management in developing countries.
Human amniotic membranes, used for many years in
the treatment of burns,54 are cost effective and on the whole
ideal as a burn wound cover.50,53They remarkably reduce
the cost of dressing changes and the period of stay in hos-
pital for the patient. They also significantly reduce nurs-
ing time and hence nursing costs.50,55The procurement and
storage of amniotic membrane is easy.50Amnion stored in
glycerol is reliable and effective for a long period of time.55
It may not be possible for a developing country to afford
the kind of “skin banks” that European countries have. But
certainly all hospitals in all developing countries can have
“amnion banks” providing sufficient and indeed unlimited
quantities of an easily available extremely economical bi-
ological dressing which can be preserved for a long peri-
od of time and which has almost all the qualities of an
ideal dressing.52,55The rate of wound infection is also sig-
nificantly low in membrane-treated patients, whether it is
fresh or preserved in glycerol.50Moreover, preserved mem-
branes are relatively free from transmitting bacterial or vi-
ral infections, especially HIV and HbSAg.55Human am-
nion as a temporary biological wound dressing is certain-

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191
ly inferior to allogenic skin but remains a beneficial and
cost-effective means of treating burns in developing coun-
tries.55-57
Due to the limited resources, traditional medicine still
plays a role in the management of a wide range of med-
ical and surgical conditions, including burns.27,57,58In the
absence of medical care, in rural Kenya burn wounds are
treated with plants and plant juices and covered with large
tropical banana leaves.59In other parts of Africa, traditional
first aid may also involve the application of gentian vio-
let, honey, Mentholatum, starch, and a variety of plants
and herbs. Particularly favoured by traditional healers are
plants such as bitter orange, coriander, grapefruit, lantana,
and blue tansy to soothe, treat, and bandage.59 In West
Africa more than 25 plants have been described specifi-
cally for the treatment of burns.27Papaya paste, readily
available and inexpensive, spread on gauze and then ap-
plied to the burn wound is a simple topical burn treatment
method and seems to be effective. Papaya applied by this
method is sufficient for the dressing to stick to the wound
and has the advantage of avoiding circumferential dress-
ings, which are uncomfortable in a tropical environment.27,59
Typically, the papaya paste is applied once a day, but oc-
casionally twice daily dressings for infected wounds may
be necessary. With limited theatre time and blood, and in-
herent risks to the patient, a major advantage is that top-
ical papaya obviates the need to debride burn wounds sur-
gically. Papaya appears to be effective in debriding necrot-
ic tissue, preventing burn wound infection, and providing
a granulating wound suitable for application of a split-
thickness skin graft. Possible mechanisms of action include
the activity of the proteolytic enzymes chymopapain,
leukopapain, and papain. Papaya also contains carpaine and
aglycones, which have a broad spectrum of antimicrobial
activity.27
Boiled potato peels and gauze bandages, onto which
they can be affixed and then applied over a thin layer of
5% silver sulphadiazine, have also been proposed as a sim-
ple low-cost easy-to-sterilize dressing for superficial par-
tial-thickness burn wound coverage in developing coun-
tries.60-62The application of potato peel dressing was shown
to reduce or eliminate desiccation, permit the survival of
superficial skin cells, and hasten epithelial regeneration.60-62
Boiled potato peel bandages (BPPB) may cause discom-
fort for some patients, however, and their preparation is
time-consuming.63An even cheaper alternative is banana
leaf dressing (BLD).63,64Its preparation is very simple and
can be easily taught to previously treated patients, rela-
tives of patients, and literate as well as illiterate individ-
uals.63Banana leaves are readily available in most cities,
towns, and villages in LMICs. It is even not difficult to
have a patch of land with a banana plantation within the
hospital premises in a busy burn unit. Banana leaf dress-
ing, being totally non-adherent, tends to slip. It thus needs
careful, firm bandaging.63 BLD is 11 times cheaper than
BPPB, 160 times cheaper than Sofratulle (Soframycin im-
pregnated gauze), 1750 times cheaper than Kollagen (col-
lagen sheet), and 5200 times cheaper than Skintemp
(biosynthetic dressing).63
The medicinal properties of honey and other hive prod-
ucts, e.g. pollen, royal jelly, propolis, and bee larvae, have
been well described for a variety of medicinal and nutri-
tional purposes, including treatment of burn wounds.65The
beneficial effects of honey include the cleansing of wounds,
absorption of oedema fluids, antimicrobial activity, pro-
motion of granulation tissue, epithelialization, and the im-
provement of nutrition.66,67In one study, honey dressing
was found to be superior to boiled potato peel dressings
as a cover for fresh partial-thickness burns regarding in-
fection control and healing time.68-71More recently, MEBO
(moist exposed burn ointment) (Julphar Gulf Pharmaceu-
tical Industries, UAE), a traditional Chinese burn ointment,
was reported to provide adequate moist environment for
optimal healing without the need of a cumbersome and ex-
pensive overlying protective dressing. Its main active com-
ponent is ß-sitosterol in a base of beeswax and sesame
oil.72,73MEBO has been found to be a useful alternative in
the treatment of partial-thickness burns because of its con-
venient method of application72,74and could be a valuable
treatment modality in LMICs.
Exposure therapy is often the method of choice as gauze
dressings are considered to be expensive. The exposure
method is particularly suitable for the treatment of paedi-
atric burn injuries, especially in a tropical climate where
patients are nursed under mosquito nets to keep flies and
other insects away from open burn wounds.59
Surgical excision and grafting
Increasingly aggressive surgical approaches with early
tangential excision and wound closure are nowadays stan-
dard practice in burn units and probably represent the most
significant change in recent years, leading to improvement
in mortality rates of burn victims at a substantially lower
cost.75-81Early excision of burned skin was first advocated
for small to moderate burns.51Subsequently, tangential ex-
cision in repeated but frequent interventions and immedi-
ate skin cover with skin auto- or homografts were recom-
mended for large burns.51By shortening hospital stay, ear-
ly burn wound closure reduces infective complications.
Faster healing decreases the severity of hypertrophic scar-
ring, joint contractures, and stiffness and promotes quick-
er rehabilitation.75,76However, lack of education in gener-
al and of health education in particular amongst the com-
mon people in the developing countries can hinder ac-
ceptance of this procedure and a lack of well-trained and
motivated burns surgeons can worsen the situation as well.81
If proper facilities are lacking, if blood and other resources

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such as dressings are not available, and if health care
providers are inadequately trained and prepared, such ag-
gressive therapy in burn victims can induce further trau-
ma and result in a less than optimal outcome.27,75More-
over, without adequate skin cover by autografts, homo-
grafts, or other substitutes, the early excision of burned
tissue is of no value.27,51“Delayed primary” is the second
best alternative to “early” burn wound excision and clo-
sure, with similar advantages of reducing the risk of sep-
ticaemia, mortality, morbidity, hospital stay, and cost of
treatment. It should be preferred to “secondary” skin-graft-
ing of granulating wounds. Thus, in the developing coun-
tries, indications of delayed primary burn surgery could
be: unstable patients or those unfit for surgery during the
first post-burn week;5delay in transfer;25delay in getting
patient’s consent for surgery;8major burns with no avail-
able skin substitutes;3and lack of operating time.7Con-
traindications for delayed primary surgery are any sign of
invasive sepsis or organ failure.60
Autografts from uninjured skin remain the mainstay of
treatment. Severe burn patients, however, invariably lack
adequate skin donor sites75and not infrequently a tempo-
rary coverage needs to be applied following early tangen-
tial excision. While in HICs it is possible to collect ho-
mografts from cadavers, and skin banks have been creat-
ed, in most LMICs this is not possible not only because
of lack of expertise and facilities but most commonly be-
cause of social, cultural, and religious objections and cer-
tainly because of cost. In India, for example, harvesting
cadaver skin is even forbidden by law.51Pig skin has been
recommended instead, but in Muslim countries or in coun-
tries with a large Muslim population the use of porcine
products is a sensitive issue, if not completely forbidden
as well.51Synthetic skin replacement products are far too
expensive to be of any value for management of severe
burns in LMICs.51BPPB have been developed as a sub-
stitute and though they are useful they are not compara-
ble to allografts. Amnion or collagen sheets may be used
instead.51Another alternative would be harvesting skin from
live donors - relatives in general. Though the idea seems
appealing in some situations, one must not forget that the
living donor will be another patient with partial-skin loss
requiring treatment, further taxing already stretched and
limited resources.
It must be stressed that xenografts, allografts, and oth-
er synthetic or tissue-engineered replacements are only a
temporary means of burn wound cover. True closure of
deep and full-thickness burn wounds is achieved only with
living autografts75,82provided for coverage of extensive burn
injuries by keratinocyte cultures (cultured epithelial auto-
graft [CEA]), largely unavailable in most LMICs for ob-
vious reasons. CEA is expensive to use and very sensitive
to infection. It requires meticulous wound care and more
professional time and effort than procedures with conven-
tional autografts.83,84Needless to say, even if the use of
confluent sheets of CEA for the treatment of extensive
third-degree burn wounds is considered to be definitely a
life-saving procedure, long-term results have been disap-
pointing and at present the true value of CEA is being
questioned in most HIC burn centres. Better long-term cov-
erage requires dermal replacement as well as epidermal re-
placement, which entails even more complex and expen-
sive technologies.83Early excisional surgery in most LMICs
is thus impossible for a large percentage of extensive burn
patients.5
Anaesthesia for burn patients and pain
management
The major improvements in quality and safety in anaes-
thesia over the last 30 years have resulted from advances
in technology, refinements in anaesthesia equipment and
drugs, and a focus on education and training. These all re-
quire significant resources,85 lacking in most LMICs. The
financial resources allocated to health are meagre and ac-
cess to even the most basic of facilities such as clean drink-
ing water remains a serious issue in these countries.85Elec-
tricity supplies are unreliable and many hospitals have nei-
ther a mains electricity supply nor a generator always avail-
able.85Local healthcare resources and international aid are
consumed by conditions such as HIV, malaria, and mal-
nutrition.85A study conducted in Uganda demonstrated that
23% of anaesthetists had the facilities to deliver safe anaes-
thesia to an adult, 13% to deliver safe anaesthesia to a
child, and 6% to deliver safe anaesthesia for a Caesarean
section.86The critical shortage of manpower is a further
barrier to progress.8,87In many African and Asian countries
the doctor/patient ratio is so low that the ideal of em-
ploying a physician specifically to provide routine anaes-
thesia is invariably out of the question.87Even though chil-
dren constitute more than half the population in many coun-
tries of the developing world, a paediatric anaesthesiolo-
gist per se is a luxury.87
Anaesthesia does not enjoy a high profile in develop-
ing countries and anaesthesia services are not considered
a major healthcare issue in LMICs.87Most anaesthesia is
provided by non-physicians and nurses under the direction
of a surgeon or unqualified personnel ‘trained on the job’
with little medical background.87The morbidity or mortal-
ity associated with different methods of anaesthesia in de-
veloping countries is not known, and the optimum equip-
ment and drugs for providing a service have not been de-
fined: these will vary according to the facilities available
locally.85Facilities considered mandatory for the surgical
care of children, such as the provision of adequate anal-
gesia, a recovery area for immediate post-operative obser-
vation, ventilatory support, and high-level care following
surgery, are inadequate or nonexistent in many parts of the

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Annals of Burns and Fire Disasters - vol. XXII - n. 4 - December 2009
193
developing world.87
Despite poor conditions, life-saving anaesthesia may be
provided.87In many areas anaesthesia remains largely ke-
tamine-based, particularly for children even when halothane
or ether is available.86,87This is dictated by its ease of use,
lack of airway equipment (e.g. tracheal tubes, facemasks,
or breathing circuits), and the perception that intravenous
access is not necessary or that intravenous cannulae are
simply not available.86,87Other drugs considered basic to
anaesthesia are seldom available in the developing world.
These include induction agents (propofol), neuromuscular
blocking agents, analgesics (morphine, pethidine), reversal
agents (neostigmine, naloxone), and long-acting local
anaesthetics (bupivacaine, ropivacaine). Moreover, the abil-
ity to deal with complications such as malignant hyper-
thermia is virtually impossible.87Ketamine and ether have
many positive features, and any recommendations for
changes in existing drugs, techniques, and equipment must
take account of all features of running a service in the lo-
cal environment.85
The availability of safe blood is a major factor divid-
ing the developed from the developing world. Fewer than
30% of developing countries have a nationally coordinat-
ed blood transfusion service, and storage of blood is diffi-
cult considering the unreliable and unpredictable electrici-
ty supply in many of the poorer countries. Many of these
do not even perform the most rudimentary tests for dis-
eases such as HIV or hepatitis B and C, because of finan-
cial constraints.80Patients, particularly children, in devel-
oping countries face the greatest risks from unsafe blood
and blood products.87Voluntary unpaid donors are hard to
come by in developing countries not only because of the
lack of resources but also because of traditional or religious
beliefs. In traditional Chinese culture, for example, blood
loss is detrimental to health and donation shows disloyal-
ty to one’s ancestors. In Africa blood donation is thought
to lead to impotency.87Many countries still rely on paid
donors or a family member to donate blood prior to sur-
gery.87
Pain management, particularly in children, is another
factor that divides the developed from the developing
world. Provision of pain relief in the face of limited re-
sources and, if available, a limited spectrum of analgesics,
as well as inadequately trained staff, is a challenge. Any
attempt to apply similar standards to those used in so-
phisticated units is fraught with difficulty. Illiteracy, mal-
nutrition, poor cognitive development, differing coping
strategies, and pharmacogenetic, cultural, and language dif-
ferences all add to the complexity of the problem.87Com-
plex techniques that offer the most benefit are seldom avail-
able to children in the developing world as they require a
minimum standard of monitoring and regular reassessment
to allow individualized titration of analgesia, the final
choice of which is unfortunately dictated by economic pres-
sure or by the facilities available rather than what would
be considered best for a burned child.87
RÉSUMÉ. Les Auteurs de cette revue de la littérature se sont proposés d’analyser les problèmes majeurs que les pays à revenu
faible ou intermédiaire (PRFI) doivent affronter dans la gestion des brûlures et d’explorer les modalités possibles pour optimiser
la gestion des brûlures dans ces pays. Dans la première partie ils ont considéré l’épidémiologie des brûlures et les énormes pro-
blèmes pour garantir leur gestion adéquate en raison des ressources limitées et de l’inaccessibilité des compétences et des techno-
logies sophistiquées dans les PFRI. La deuxième partie s’occupera de l’état actuel de la gestion des brûlures dans les PRFI.
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