Surgical Burn Care in sub-Saharan Africa: A Systematic Review

Abstract

Objective
Burn injuries are still one of the most common and devastating global health problems worldwide. The vast majority of burns occur in low- and middle-income countries, particularly in sub-Saharan Africa. A certain standard of surgical and anaesthesia care is essential to minimize morbidity and mortality. The aim of this study is to obtain baseline information on surgical burn care in sub-Saharan Africa and to determine how this can be improved.

Methods
A systematic review (PRISMA) was conducted. Data was extracted regarding study characteristics, patient and burn characteristics (aetiology of burn, total body surface area (TBSA), depth of burn), wound treatment and surgical care (type of wound dressing, surgery rate, skin graft rate, early vs. delayed) and outcome (mortality, wound infection, take of the grafts, length of stay, contracture formation).

Results
Forty-two studies from 12 different countries were included [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [40], [41], [42]. Most studies were case series (37). The mean TBSA was 17.3%. Of the included patients, 44.4% underwent some type of operation. Overall mortality was 13.1%. Only 13 studies reported on the number of patients with deep burn wounds in their population. In this group 89.4% was grafted, of which 25.4% was performed early (<10 days), 67.6% delayed and 7.0% not recorded.

Conclusion
Research on surgical burn care in sub-Saharan Africa is scarce and the quality is poor. Future studies should ensure uniform data collection to enable comparison between treatment strategies. The International Society for Burn Injuries (ISBI) guidelines for burns, published in 2016, provide a practical tool, not only for daily practice but also for research on different treatment protocols.

Full text

Surgical burn care in sub-Saharan Africa: A systematic review
M. Botman
a,b,1
, J.A. Beijneveld
a,b,
⇑
,1
, V.L. Negenborn
a
, T.C.C. Hendriks
a,b
, L.J. Schoonmade
c
,
D.P. Mackie
d
, P.P.M. van Zuijlen
a,d
a
Plastic, Reconstructive and Hand Surgery, VU Medisch Centrum, Amsterdam, The Netherlands
b
Global Surgery Amsterdam, Amsterdam, The Netherlands
c
Medical library, Vrije Universiteit, Amsterdam, The Netherlands
d
Burn Centre, Red Cross Hospital Beverwijk, the Netherlands
article info
Article history:
Received 20 May 2019
Received in revised form 19 July 2019
Accepted 20 July 2019
Available online 23 July 2019
abstract
Objective: Burn injuries are still one of the most common and devastating global health problems world-
wide. The vast majority of burns occur in low- and middle-income countries, particularly in sub-Saharan
Africa. A certain standard of surgical and anaesthesia care is essential to minimize morbidity and mortal-
ity. The aim of this study is to obtain baseline information on surgical burn care in sub-Saharan Africa and
to determine how this can be improved.
Methods: A systematic review (PRISMA) was conducted. Data was extracted regarding study characteris-
tics, patient and burn characteristics (aetiology of burn, total body surface area (TBSA), depth of burn),
wound treatment and surgical care (type of wound dressing, surgery rate, skin graft rate, early vs.
delayed) and outcome (mortality, wound infection, take of the grafts, length of stay, contracture
formation).
Results: Forty-two studies from 12 different countries were included [1–42]. Most studies were case ser-
ies (37). The mean TBSA was 17.3%. Of the included patients, 44.4% underwent some type of operation.
Overall mortality was 13.1%. Only 13 studies reported on the number of patients with deep burn wounds
in their population. In this group 89.4% was grafted, of which 25.4% was performed early (<10 days),
67.6% delayed and 7.0% not recorded.
Conclusion: Research on surgical burn care in sub-Saharan Africa is scarce and the quality is poor. Future
studies should ensure uniform data collection to enable comparison between treatment strategies. The
International Society for Burn Injuries (ISBI) guidelines for burns, published in 2016, provide a practical
tool, not only for daily practice but also for research on different treatment protocols.
Ó2019 The Authors. Published by Elsevier Ltd. This is an open accessarticle under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
1. Introduction
Remarkable improvements have been reached in global health
in the past decades but burn injuries continue to cause extensive
morbidity and mortality worldwide. Every year 11 million people
require medical attention and well over 200.000 patients die due
to injury caused by burns [43,44]. Globally, burn injuries are in
the top 15 causes of burden of disease and of all injuries caused
by burns, 95% occur in low resource settings [45]. Sub-Saharan
Africa is disproportionately afflicted by burns [46].
In the past safe surgical and anaesthetic care have been
neglected as a global health strategy. However, access to essential
surgical care is lacking for 5 billion people [47].
Surgical care is essential in the treatment of severe burn injuries
in minimizing morbidity, mortality and preventing complications
[48,49]. Despite this, research on surgical burn care in low resource
settings is sparse. The results of the few studies that have been
published give an impression of the need: Nthumba et al. (2016)
[46] for example, reported the epidemiology of burns in over
30,000 patients in 14 countries in sub-Saharan Africa and found
a mean age of 15.3 years with 80% of the patients aged 10 years
and below. This review reported a mortality of 17%. Gupta et al.
(2014) [50] determined burn management capacity in 458 hospi-
tals in 14 low-and middle-income countries including the presence
of surgeons (0.71 per hospital), presence of anaesthesiologists
(0.18 per hospital) and the capability of hospitals to provide skin
grafting of only 35.6%.
https://doi.org/10.1016/j.burnso.2019.07.001
2468-9122/Ó2019 The Authors. Published by Elsevier Ltd.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Abbreviations: TBSA, total body surface area; ISBI, International Society for Burn
Injuries.
⇑
Corresponding author.
E-mail address: n.beijneveld@gmail.com (J.A. Beijneveld).
1
M. Botman and J.A. Beijneveld contributed equally to this work.
Burns Open 3 (2019) 129–134
Contents lists available at ScienceDirect
Burns Open
journal homepage: www.burnsopen.com

ISBI guidelines
In 2016, the International Society for Burn Injuries (ISBI) pub-
lished guidelines for burn care, with special attention for low
resource settings [51]. These guidelines contain an extensive
description of the definitions, indications, advantages and disad-
vantages of various surgical techniques, type of wound dressings
and resuscitation methods. Where skin grafting is possible, one
of the difficult issues for low resource settings is the choice
between early or delayed excision and grafting. Early excision
and grafting is recommended when resources (i.e. experienced sur-
geons, anaesthetists, equipment, blood products, etc.) are present.
According to the guidelines, the choice of the wound dressing
technique in full thickness burns should be closely related to the
timing of eschar excision. When early excision is pursued, the rec-
ommended technique is the closed method, where dressings are
used to cover the wound. If resources for early excision are not avail-
able, the guidelines state that the open method could be used. The
wound is exposed to the air and no dressings are used for coverage
until the eschar loosens and can easily be removed. Evidence to sup-
port the expert opinion on this issue of the guidelines is limited.
A systematic literature overview on basic surgical burn care in
sub-Saharan Africa that includes timing of excision and grafting
in combination with wound dressing techniques is missing. The
aim of this review is to critically assess surgical care for burn inju-
ries in sub-Saharan Africa, to evaluate current treatments, to iden-
tify gaps in knowledge and provide recommendations for quality
improvements of burn in care in low resource settings. Research
on scar contracture release, that takes in a later stage after the burn
injury will not be taken into account in this review.
2. Methods
This systematic review is conducted in accordance with the Pre-
ferred Reporting Items for Systematic Reviews and Meta-Analysis
(PRISMA) statement (www.prisma-statement.org). A comprehen-
sive search was performed in the bibliographic databases PubMed,
Embase and the Cochrane Library (via Wiley) on July 6th 2016 and
was updated on May 11th 2017 and February 16th 2018, in collab-
oration with a medical librarian (LJS). Search terms included con-
trolled terms (Mesh in Pubmed, Emtree in Embase) as well as
free text terms. We used free text terms only in the Cochrane
Library. Search terms expressing ‘burn care’ were used in combina-
tion (AND) with search terms for all sub-Saharan African countries.
The full search strategies for all the databases are listed in the Sup-
plementary information (Appendix 1). Duplicate studies were
excluded. The search was not restricted to publication date or sta-
tus. All observational and experimental studies commenting on
surgical procedures in burn patients of all ages were considered.
All included studies were assessed on their level of evidence using
the OCEBM levels of evidence checklist. Studies reporting on
trauma patients and surgical procedures were excluded if specific
information on burn patients was missing.
- Studies were included when: considering surgical treatment of
burns of any aetiology in a group of admitted burn patients,
located in a country in sub-Saharan Africa, providing numerical
data on surgical interventions that allowed calculating
percentages.
- Studies were excluded when: the study population (n) con-
cerned less than 10 patients, only reporting on scar treatment
(e.g. contracture release), animal studies and studies published
in a language other than English.
A few dedicated researchers published several articles from the
same study setting: Agbenorku in Ghana, Asuquo in Nigeria,
Allorto, Rode and Hudson in South Africa and Mzezewa in Zim-
babwe. If the same patients were included in multiple studies,
we excluded the smallest study.
2.1. Study selection
Two independent reviewers (JAB and VLN) screened the titles
and abstracts of all records identified by the search to determine
eligibility. Full texts of eligible studies were subsequently screened
(JAB and VLN). In case of disagreement, a third reviewer was con-
sulted (MB).
2.2. Data collection process and data items
The following data was extracted by one author (JAB) and
checked by another (MB): study characteristics (data collection,
study type), epidemiological data (country, hospital, study popula-
tion), patient and burn characteristics (aetiology of burn, total body
surface area (TBSA), depth of burn) surgical care (surgery rate, skin
graft rate, early vs. delayed, type of wound dressing) and outcome
(mortality, wound infection, take of the grafts, length of stay, con-
tracture formation). Disagreements were resolved by discussion.
2.3. Definitions
The ISBI guidelines were followed to define early excision as the
removal of necrotic tissue within 10 days after burn injury and
delayed excision between 10 days and three weeks after burn
injury [51].
2.4. Summary measures
Descriptive statistics were used and percentages were calcu-
lated when possible. Meta-analysis was not performed due to the
heterogeneous or unclear methodology demonstrated among the
included studies.
3. Results
3.1. Study selection
In total, 2328 studies were identified through the literature
search. After adjusting for duplicates, 1663 studies were screened
on title and abstract. Forty-two studies were found eligible for
inclusion based on their full text (Appendix 2).
Study characteristics are listed in Table 1. All studies were
observational (37 case series, 3 cross-sectional and 2 cohort stud-
ies). Data collection was prospective in 14 studies, retrospective
in 21 studies and not recorded in 7 studies. This is corresponding
with Oxford CEBM level of evidence 3b and 4. Recommendations
of data analysis will therefore have a GRADE C. Thirty studies were
published after 2000, 12 studies were published before 2000. Stud-
ies contained data from 12 different countries in the sub-Saharan
African region.
3.2. Patient and burn characteristics
The basic characteristics of the included patients are given in
Table 2. The size (n) of the studies ranged from 14 to 1356 patients
with a mean of 271 patients. All together 11,375 patients were
included. In 28 studies, the age of the study population of the
included patients was reported showing mixed ages in 12, only
above 13 years old in six and only below 13 years in 10 studies.
Due to lack of detailed registration in many studies, it was
130 M. Botman et al. / Burns Open 3 (2019) 129–134

impossible to give overall percentages on certain age groups. How-
ever, the vast majority were children.
In some studies, only patients of a specific aetiology were
included (Table 4, Appendix 3).
This included burns due to hot water assaults [14], scalds [38],
kettle stove injuries [21], electricity [33,52], thermal injuries [7]
and explosions [17,42]. Noteworthy is the role of epilepsy in the
cause of burns: In 13 studies numbers of burn patients with epi-
lepsy were documented, with a mean of 13.5% of the population
in these studies (1–33%).
The overall mean total body surface area (TBSA) was 17.3%
ranging from 4 to 70% per study, recorded in 30 studies. If only
the median was available, this value was used to calculate the
overall mean. Findings showed that the depth of burn, the most
important indicator for surgery [53], was only clearly reported in
11.6% of the total study population.
3.3. Wound treatment and surgical care
Clear information on the type of dressing was found in few
studies. The following treatments were defined: closed wound
treatment,open wound treatment and both open and closed
with percentages as shown in Table 2.
The timing of skin grafting, defined as early or late, is also
shown in Table 2. Because of the differences in baseline character-
istics, further comparison of outcomes on dressing strategies or on
early and delayed grafting was not possible.
The following operations were included: escharotomy, exci-
sion (escharectomy) without grafting, amputation and grafting
Table 1
Study characteristics.
Author Year Country Patients (n) Inclusion period Method of data collection Study type Level of evidence
Agbenorku 2010 Ghana 826 Feb 2001–Jan 2006 prospective case series 4
Agbenorku 2013 Ghana 511 May 2007–Apr 2011 retrospective case series 4
Allorto 2009 South Africa 450 Sep 2006–Feb 2008 prospective case series 4
Allorto 2015 South Africa 490 Jan 2012–June 2013 retrospective case series 4
Asuquo 2008 Nigeria 59 Feb 2005–Jan 2008 prospective case series 4
Asuquo 2009 Nigeria 56 Feb 2005–Jan 2008 prospective case series 4
Cahill 2008 South Africa 67 Jan 1993–Jan 2007 retrospective case series 4
Chait 1975 South Africa 28 1974 NR case series 4
Chalya 2011 Uganda 130 Nov 2005–Feb 2006 prospective cohort 3b
Chalya 2011 Tanzania 342 Jan 2008–Dec 2010 NR cross-sectional 4
Chelidze 2015 Tanzania 211 Mar 2013–June 2014 retrospective case series 4
Chopra 1997 South Africa 88 Jan 1994–Dec 1994 retrospective case series 4
Cox 2011 South Africa 86 1971–2008 retrospective case series 4
Duminy 1993 South Africa 127 1985–June 1992 retrospective case series 4
Edwards 2011 Zambia 510 July 2002–June 2009 retrospective case series 4
Engelbrecht 1970 South Africa 354 Jan 1966–Dec 1966 NR case series 4
Fadeyibi 2009 Nigeria 39 Dec 2005, 31 prospective case series 4
Gallaher 2015 Malawi 905 June 2011–Aug 2014 prospective case series 4
Godwin 1997 South Africa 99 Jan 1993–June 1995 retrospective case series 4
Grudziak 2017 Malawi 1356 July 2011–May 2016 retrospective case series 4
Holmes 2012 South Africa 119 NR prospective case series 4
Hudson 1995 South Africa 240 1985–June 1992 retrospective case series 4
James 2003 Malawi 342 Apr 2000–Apr 2001 prospective case series 4
Kalayi 1996 Nigeria 84 Jan 1980–Dec 1989 retrospective case series 4
Kingu 2010 South Africa 66 Jan 2006 to July 2008 retrospective case series 4
Mabogunje 1987 Nigeria 429 1971–1980 NR case series 4
Manktelow 1990 Liberia 21 Oct 1987–Oct 1988 retrospective case series 4
Mulat 2006 Ethiopia 121 July 2001–Sep 2002 prospective cross-sectonal 4
Mzezewa 1999 Zimbabwe 451 Apr 1993–May 1996 prospective case series 4
Mzezewa 2004 Zimbabwe 51 NR prospective cohort 3b
Olaitan 2007 Nigeria 36 2000–2004 retrospective case series 4
Oluwasanmi 1969 Nigeria 229 1957–1966 NR case series 4
Opara 2006 Nigeria 24 Jan 1995–Dec 2004 retrospective case series 4
Otteni 2013 Kenya 269 Jan 2006–May 2010 retrospective case series 4
Ringo 2014 Tanzania 41 Oct 2011–April 2012 prospective cross-sectional 4
Rode 2016 South Africa 558 2013–2016 retrospective case series 4
Sharma 1979 Zambia 14 NR NR case series 4
Shonubi 2005 Lesotho 98 May 1997–April 2002 NR case series 4
Ter Meulen 2016 South Africa 884 Oct 2013–Sep 2014 retrospective case series 4
Tyson 2013 Malawi 454 June 2011–Dec 2012 prospective case series 4
Ugburo 2013 Nigeria 21 Jan 2004–Dec 2008 retrospective case series 4
Van Kooij 2011 Kenya 89 Jan 31, 2009 retrospective case series 4
NR = not recorded.
Table 2
Results – overall.
Mean Studies (n)*
Patients (n) 271 42
Male/female (%) 55.9/44.1 38
Flame/scald/unknown (%) 39.3/52.6/8.1 38
Epilepsy as cause of burn (%) 13.5 13
TBSA (%) 17.3 30
Timing of grafting 26
Early (%) 24.8
Delayed (%) 75.2
Wound treatment
Open (%) 1.0 2
Closed (%) 45.5 19
Both (%) 11.8 8
Unclear (%) 41.7 13
Length of hospital stay (days) 24.7 24
Infection (%) 32.5 15
Take of the graft (%) 82.2 4
Mortality (%) 13.1 37
*The number of studies describing the variable.
M. Botman et al. / Burns Open 3 (2019) 129–134 131

with or without excision. To calculate the incidence of these pro-
cedures, only the 13 studies that provided information on the
number of patients having deep partial or deeper burn wounds
were included, because only these wounds probably needed skin
grafting (Table 3).
3.4. Outcome
The outcomes are reported in Tables 2 and 3.Table 2 covers all
patients included in this review, while Table 3 provides the out-
comes for the patients with deep burns (this was only possible
when this group was clearly indicated in the studies). The total
number of patients with deep burns was 1322 from a total of
11375.
The overall mortality was 13.1%. Assuming that the mortality in
the group of patients reported to have only superficial burns is low,
we calculated that mortality in the deep burn wound group could
be as high as 27.9% (when all superficial burn patients would have
survived).
Wound infection was reported in 15 studies with a mean of
32.5% overall. When patients underwent skin grafting, there was
no clear information whether the infection occurred before or after
grafting.
The length of stay, documented in 24 studies, showed a mean
of 24.7 days for all patients.
It was not possible to compare different patient groups (depths,
TBSA, type of surgery) due to lack of detailed information in the
studies.
Only four studies provided data on the take of the graft with a
mean of 82.2% (range 72–95%) (Table 3). A difference in outcome
between early and delayed grafting was investigated in one study
[13]. The take of the graft was 84% in the early group and 86% in the
delayed grafting group.
4. Discussion
To improve surgical burn care it is critical to know on which cri-
teria the indication for surgery is based. These criteria are impor-
tant predictors of outcome. However, in almost all of the
included studies, the indications for amputations, escharotomy,
escharectomy and grafting were not clearly mentioned. It is very
important to realize, especially for future research, that the depth
of burn, the most important indicator for surgery [53], was only
reported in 11.6% of the total study population.It might be difficult
to distinguish between deep partial and full thickness burns, how-
ever, such information is of vital importance, as early skin grafting
of full thickness burns results in faster patient recovery and
reduces incidence and severity of contractures [9]. The fact that
eschar excision without skin grafting was performed in 6% of the
population shows a conservative approach, often because of lack
of resources. In the study of Chalya et al. (2011) [10] this discrep-
ancy becomes evident. Here, 28.7% had full thickness burns, but
only 8.5% underwent skin grafting. Referral to a better equipped
burn centre was often found to be problematic: in a burn facility
in a country like South Africa, which is officially not a low income
country according to the World Bank, patients were accepted for
transfer only in 3 out of 67 severe cases in need of more advanced
care [4].
4.1. Timing of excision and grafting
An aggressive approach of early excision and grafting in deep
partial thickness burns in high resource settings is often recom-
mended because it is associated with a reduction of mortality,
length of stay and cost [51]. Our findings show that only 24.8% of
the patients were grafted early and 75.2% were grafted after
10 days. Lack of resources was often reported as a limiting factor
for (early) excision [10,15,25,33,40,41].
There are some examples of positive results with early excision
and grafting: Mzezewa et al. [29] observed a reduction in length of
stay (from 42 to 17 days) and costs after implementing a daily
practice of early excision and grafting, set within the limits of
blood product availability. In a study on patients younger than
4 months old, Cox et al. [13] found a reduction of 25% in length
of stay as well as lower infection rates with early excision versus
delayed excision. However, in sub-Saharan Africa patients com-
monly arrive days or weeks after burn injuries occur, with heavily
infected wounds and in a poor overall condition [10,26]. These
patients are often malnourished, anaemic and are poor candidates
for immediate surgery [18,27]. This is supported by Grudziak et al.
[20], who found that malnourishment is a risk factor for post-
operative mortality. While associated with increased length of
stay, high infection rates and higher costs, delayed debridement
and grafting may still be the best option in this patient group
[4,25,28,29,38]. This supports the recommendation of the ISBI
guidelines that it might be necessary to take sufficient time to sta-
bilize patients and prepare them for surgery in low resource
settings.
An individual plan for staged excisions for a specific burn injury
in a specific setting might be the most appropriate approach in low
resource settings where resources and skills meet the minimal
standards for basic surgical burn care. Specific body parts, in par-
ticular areas like joint surfaces that benefit from early interven-
tions, starting with early excision may be advisable there. The
use of tourniquets and local anaesthesia with adrenaline where
possible, renders this approach more suitable [51].
4.2. Wound dressing
The ISBI guidelines stress the importance of the combination of
the dressing method and the timing of excision and grafting in full
thickness burns. They recommend (staged) early excision and
grafting combined with closed wound treatment when resources
permit, except for hands, perineum and the face. For the delayed
grafting strategy, the open method is recommended. In our review,
10 studies were analysed that reported on both methods
[4,10,13,16,25–27,32,37,38]. Many different treatment strategies
are described, but good comparative studies are lacking and follow
up was often limited. Some examples: Shonubi et al. (2005) [38]
used the open method in combination with delayed excision due
to a lack of resources and observed high infection rates (63%).
Kingu et al. (2010) [25] used closed dressings and enzymatic
creams until spontaneous eschar separation. If no separation had
occurred in the following 10 days, delayed escharectomy was per-
formed. This study showed a high mortality of 17% but many other
factors may have contributed to this outcome making it impossible
to draw conclusions.
Table 3
Surgical care – only the population with deep burns.
Mean (%) Patients (n) Studies (n)*
Only escharectomy 2.7 14 5
Escharotomy 2.9 16 3
Amputation 0.7 3 4
Skin graft 89.4 1183 13
Early 25.4 301 10
Delayed 67.6 800 10
Not recorded 7.0 81 3
Mortality Up to 27.9 190 11
Contracture formation 6.0 13 5
*The number of studies describing the variable.
132 M. Botman et al. / Burns Open 3 (2019) 129–134

Despite the recommendation of the ISBI guidelines to use open
wound treatment strategies in hands, perineum and the face, this
review found little information on treatment strategies for these
conditions in sub-Saharan Africa. Only two studies in our review
mentioned this strategy but without information on outcome
[1,26].
In general the type of dressing was not clearly indicated and no
uniform definition of traditional dressing was available. Future
studies should include timing of grafting in combination with
well-specified wound dressing techniques.
Follow-up on scar contracture formation was scarce. Only five
studies reported on both depth of the burn wound and contrac-
tures and showed that 6% of patients with deep burn wounds
developed contractures (Table 3). However information on the
follow-up of these contractures was very limited or not available
at all.
5. Limitations
There are several major limitations to the current literature
regarding surgical burn care in sub-Saharan Africa and it is inevita-
ble also true for this review. First and foremost, there is a severe
lack of evidence with few quality peer reviewed studies available.
The overall quality of available studies was moderate, with only
observational studies available. Furthermore, there is lack of uni-
formity in defining variables of the included studies, which makes
comparison between studies exceedingly complex if not impossi-
ble. It is possible that the mortality rate was underreported, con-
sidering the overall low level of documentation. Selection bias is
existent in this review, considering that included studies are those
capturing surgical burn care. It is likely that actual surgery rates
are much lower. An example is the absence of small clinics in
our included studies. Almost all hospitals are tertiary centres or
large regional hospitals. Thus, we can only draw limited conclu-
sions on the current state of affair in burn surgery in larger hospi-
tals. Lastly, South Africa, which currently is a high middle income
country according to the World Bank definition, is overrepresented
among included studies. But South Africa has one of the highest
inequality rates in the world and many South African studies, espe-
cially the older studies, showed a situation similar to other sub-
Saharan African countries. Excluding South Africa would not
change the message of this review.
6. Conclusion
This is the first systematic review that provides a critical over-
view of the available literature on basic surgical care of burn inju-
ries in sub-Saharan Africa, including timing of excision and grafting
and wound dressing techniques. To prevent mortality and disabil-
ity of burns, access to quality and timely surgical care is vital.
The lack of surgical burn care research in sub-Saharan Africa is
evident: only 42 studies reported surgical data and the level of evi-
dence of these studies is low (level 3–4). The information that
could be subtracted from these studies was therefore very limited.
A wide range of treatment strategies was observed and often
essential information on parameters such as depth of burns, TBSA,
timing of grafting and wound treatment were missing, indicating
the absence of standardized burn care.
Early excision has been shown to give better and quicker heal-
ing but circumstances might still favour delayed excision and
grafting in low resource settings. No clear conclusion for the best
strategy for grafting and type of wound dressing could be drawn
from research in sub-Saharan Africa. Evidence is too limited to
draw definitive conclusions.
Although limited resources complicate the delivery of surgical
burn care, with relatively minor investments in dedicated burn
teams major effects could be achieved for burn victims in sub-
Saharan Africa. National and regional treatment protocols should
be developed, based on a well-founded choice for either early or
delayed excision, depending on location and size of the full thick-
ness burn, patient characteristics and the available resources.
Efforts to elevate capacity building and training initiatives in surgi-
cal burn care should be stimulated. Timely essential surgical inter-
ventions performed under safe anaesthesia are needed to improve
the outcome of burn injuries. With better awareness of the ISBI
guidelines and improved training and capacity building of local
healthcare workers, a staged early excision strategy might be more
often a feasible option in sub-Saharan Africa.
Improving capacity in burn research should be promoted, par-
ticularly in rural areas. Future studies should aim to better under-
stand which approach results in the best outcomes. Studies are
required to include uniform definitions and parameters such as
depth of burns, TBSA, timing of grafting and wound treatment.
More extensive prospective research is needed to assess the effects
and safety of burn surgery in sub-Saharan Africa. Following this
benchmark review, an update of this review in 5 years is recom-
mended to evaluate the effects of the ISBI guidelines.
Acknowledgements
We are thankful to Esther Middelkoop and Marielle Jaspers for con-
tributions to this review.
Funding
Not applicable.
Declaration of Competing Interest
The authors declare that there is no conflict of interest.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.burnso.2019.07.001.
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