Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/burns
Acute burn care in resource-limited settings:
A cohort study on treatment and outcomes in a
rural regional referral hospital in Tanzania
, M. Botman
, J.J. Binnerts
, G.S. Mtui
, A. Meij-de Vries
, H.A.H. Winters
, P.P.M. van Zuijlen
Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC (location VUmc), Amsterdam,
Global Surgery Amsterdam, The Netherlands
Department of Surgery, Haydom Lutheran Hospital, Haydom, Tanzania
Amsterdam Public Health Research Institute, The Netherlands
Department of Surgery, Red Cross Hospital, Beverwijk, The Netherlands
Burn Center, Red Cross Hospital, Beverwijk, The Netherlands
Pediatric Surgical Centre, Emma Children’s Hospital, Amsterdam UMC, Amsterdam, The Netherlands
Burn Center, Martini Hospital, Groningen, The Netherlands
Association of Dutch Burn Centers, The Netherlands
Hanze University of Applied Sciences, Research Group Healthy Ageing, Allied Health Care and Nursing,
University of Groningen, University Medical Center Groningen, Department of Human Movement Sciences,
Department of Plastic, Reconstructive and Hand Surgery, Red Cross Hospital, Beverwijk, The Netherlands
Accepted 18 January 2022
Available online xxxx
Background: Only a few papers are published on the safety and effectiveness of acute burn
care in low-income countries. A cohort study was therefore carried out to determine such
Methods: The study was conducted in a rural Tanzanian hospital in 2017–2018. All patients
admitted with burns were eligible. Complications were scored during admission as an
indication for safety. Survivors of severe burn injuries were evaluated for time of
0305-4179/© 2022 The Author(s). Published by Elsevier Ltd.
Abbreviations: LMIC, (Low- and Middle-income Country); HIC, (High-Income Country); HLH, (Haydom Lutheran Hospital); QoL, (Quality
of Life); PROM, (Patient-Reported Outcome Measure); NGO, (Non-Governmental Organizations); RLS, (Resource-Limited Settings); ISBI,
(International Society for Burn Injuries); WHODAS 2.0, (World Health Organization Disability Assessment Schedule version 2.0); EQ-5D-
3L, EuroQoL-5D-3 L questionnaire; TBSA, (Total Body Surface Area); IQR, (interquartile range); WHO, World Health Organization
Correspondence to: Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, location VUmc, Amsterdam, the
Netherlands De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
E-mail address: email@example.com (T.C.C. Hendriks).
burns xxx (xxxx) xxx–xxx
Please cite this article as: T.C.C. Hendriks, M. Botman, J.J. Binnerts et al., Acute burn care in resource-limited settings: A
cohort study on treatment and outcomes in a rural regional referral hospital in Tanzania, Burns, https://doi.org/10.1016/
reepithelialization, graft take, disability (WHODAS2.0) and quality of life (EQ5D-3L) up to 3
months post-injury, as an indication of effectiveness.
Results: Patients presented on average at 5 days after injury (SD 11, median 1, IQR 0–4).
Three patients died at admission. The remaining 79 were included in the cohort. Their
median age was 3 years (IQR 2–9, range 0.5–49), mean TBSA burned 12% (SD10%) and
mortality rate 11.4%. No surgery-related mortality or life-threatening complications were
observed. Skin grafting was performed on 29 patients at a delayed stage (median 23 days,
IQR 15–47). Complications of skin grafts included partial (25% of procedures) and complete
graft necrosis (8% of procedures). The mean time to reepithelialization was 52 (SD 42) days
after admission. Disability and quality of life improved from admission to 3 months after
injury (p < 0.001, p < 0.001, respectively).
Conclusion: In this resource-limited setting patients presented after a delay and with
multiple complications. The mortality during the rst two weeks after admission was high.
Surgery was found to be safe and effective. A signicant improvement in disability and
quality of life was observed.
© 2022 The Author(s). Published by Elsevier Ltd.
Major advances in acute burn care have been made over the
past decades. Optimalization of the prevention, acute man-
agement, infection control, and wound closure have sub-
stantially decreased the incidence, morbidity and mortality
of severe burn injuries . In High-Income Countries (HICs)
patients present early after a burn injury, and mortality is
reported to be as low as 1.5% [2–8]. Because of the optimali-
zation of burn care in HICs, attention and resources have
gradually shifted towards the prevention and treatment of
the long-term physical [9,10] and psychological con-
sequences of burns. Important outcomes currently are scar
quality [11–13] functionality [10,14] post-traumatic stress
syndrome  and health-related Quality of Life (QoL) [16,17].
Such advances in burn care have not been observed in
Low and Middle-Income Countries (LMICs) [18–20], although
the vast majority of all burn injuries worldwide occur in these
countries . Existing studies show that poor populations
are predominantly at risk of sustaining burns, and that up to
70% of patients are children [19,22–24]. Populations that are
geographically and economically disadvantaged have limited
access to safe burn care . Due to this lack of care, the
mortality in LMICs is high. Ninety-ve percent of all mortality
caused by re-related burns worldwide occurs in LMICs.
The risk of child mortality due to burns is currently estimated
to be over seven times higher in LMICs than in HICs .
Those patients who survive burns, risk developing burn scar
contractures. Burn scar contractures may impair joint func-
tion, disability-free survival and QoL .
In response to the need for safe and timely burn care
worldwide, the International Society for Burn Injuries (ISBI)
published practice guidelines tailored to Resource-Limited
Settings (RLS) in 2016 [27,28]. The current evidence on the
safety and effectiveness of burn care in resource-limited
settings is scarce and of limited quality, as shown in our re-
cent systematic review on burn care in sub-Saharan Africa
. To improve our understanding of burn care, the World
Health Organization (WHO) called for efforts to collect data
and promoted research on this topic.
To guide future improvements of burn care of under-
served populations in LMICs, insight into current treatment
and its outcomes is of vital importance. Therefore, this
single-center prospective study aimed to evaluate the early
outcome of burn care provided in an resource-limited setting
up to three months after injury.
2.1. Study setting
This prospective cohort study was conducted in 2017–2018 at
Haydom Lutheran Hospital (HLH), a remotely located regional
referral center for the two million people living in Manyara
province in Tanzania. HLH has a 250-bed capacity and provides
primary and secondary burn care, delivered by the surgical
team. The team consists of accredited surgeons, registrars,
nurses and anesthesia-associates. The team participates in a
twice yearly burn care training. Training is provided by accre-
dited surgeons of Doctors of the World, and consists of on-the-
job training (e.g. surgery), off-the-job training (e.g. workshops),
lectures and has a duration of two weeks. The hospital has
essential laboratory facilities, a physiotherapy team and a
surgical theater with essential surgical equipment, including
basic surgical sets, a humbey knife, an electric dermatome
(Aesculap® Acculan 3Ti) and an anesthesia machine for me-
chanical ventilation. The hospital has pediatric burn ward with
an 8-bed capacity and dressing room.
HLH utilizes a cost-sharing model, where patients and the
hospital share treatment costs. To be eligible for elective sur-
gery, the patient fee must be paid prior to surgery. Of all burn
patients, 25% had their costs covered by a healthcare in-
surance. HLH attempts to provide nancial support for pa-
tients who cannot afford treatment and might face potential
catastrophic expenditure. It should be noted that nancial
related issues can attribute to a delay in treatment and wound
closure. However, it was beyond the scope of this article to
elaborate on the affordability of the burn care provided. In
another study the timeliness, affordability and the surgical
capacity of burn care is assessed into more detail .
2 burns xxx (xxxx) xxx–xxx
2.2. Study participants and follow-up
During 2017–2018 all pediatric and adult patients admitted to
Haydom Lutheran Hospital with a burn injury were eligible
for participation in this study. Written informed consent was
obtained from all the patients who were included in the
study. For children below the age of 18 years consent was
obtained from their caregivers. A subgroup of patients who
survived and for whom split-skin grafting was indicated were
also eligible to participate in the assessments regarding ef-
fectiveness. The wounds that required skin grafting were
considered ‘severe’ burns. In this study severe burns are de-
ned as deep partial-thickness burns and full-thickness
burns – the wounds that did not show reepithelialization
after 14 days – which involved at least 5% of total body sur-
face area (TBSA). This denition was chosen because deep
burn wounds with more than 5% TBSA is a signicant burn in
a resource-limited setting, which can cause substantial se-
qualae among burn victims. It should be noted that this is not
similar to the denition of severe burns for High-Income
Countries, which use a higher percentage of TBSA burned.
The selection to follow-up patients with severe burns was
made to ensure a high follow-up rate in this resource-limited
setting. Patients with minor burns with no indication for skin
grafting, who had less risk of burn wound complications,
were not included in the subgroup as they would be less in-
clined to go through the time and economic burden of
All the patients were assessed from admission to dis-
charge. In addition, the subgroup of patients who required
skin grafting were also assessed at 1.5- and 3-months post-
injury for disability and QoL. In this subgroup, some of the
patients remained admitted, and others were already dis-
charged and assessed as outpatients. To ensure a high follow-
up rate of the outpatients, they were compensated for their
traveling expenses and were counseled by telephone and
Where possible, we tried to provide treatment in accordance
with the Emergency Management of Severe Burns and ISBI
guidelines for Resource-Limited Settings (RLS) . As this
study was conducted in a rural and resource-limited setting,
it was not possible to achieve a 100% guideline adherence.
Guideline adherence was documented and is specied under
data collection. Treatment was provided after counseling and
agreement of relatives for both adult and pediatric patients.
Initial management was provided at admission. Adults
with > 15% and children with > 10% TBSA burned, pre-
senting within 48 h post-injury had an indication for uid
resuscitation (Appendix 1). An escharotomy was performed
in deep circumferential burns of the extremities if the blood
ow to the distal parts was or might be threatened. Anti-
biotics were available and indicated for infected burn wounds
or sepsis. Infected burn wounds were diagnosed clinically
(i.e., pus, erythema, edema, fever, sepsis). A limited supply of
fortied nutrition and blood transfusions were available, and
when available, were provided to cases with malnutrition
and anemia. Antithrombotic treatments were not available.
Escharotomies were performed within 6 h post-injury. If pa-
tients presented later, escharotomies were still performed if
the extremities were viable to improve perfusion of the af-
fected extremities. If patients presented in a delayed fashion
with gangrene of the extremities, escharotomy was not per-
formed, and the surgical team discussed the option of an
Wound care consisted of daily wound cleansing in luke-
warm water with normal saline. Silver-sulfadiazine was ap-
plied to burn wounds. An occlusive – i.e., closed method –
wound dressing was applied, using conventional petroleum
jelly gauzes covered by dry gauzes. Facial injuries received an
open wound treatment with silver-sulfadiazine applied three
times daily. Anesthesia during wound care was only available
to a limited extent and consisted of oral and intramuscular
medication. Due to limited anesthesia staff and equipment
and the cost of treatment, ketamine anesthesia was only
available for children with burns of more than 20% TBSA
burned. To limit loss of range of motion, all patients received
physiotherapy during admission, which consisted of mobili-
zation and instructions for active and active-assisted range of
All wounds smaller than 1% were treated conservatively.
In larger wounds, surgery was performed if no adequate re-
epithelialization had occurred between 14 and 21 days after
admission. Staged delayed grafting was the predominant
approach: spontaneous eschar separation was awaited to
limit the surgical excision of eschar. Please see Fig. 1. for an
example of delayed skin grafting. This allowed stabilization
of patients prior to surgery, and limited the necessity of blood
products. We aimed to debride wounds at day 14, debriding
as minimally as possible to obtain a clean wound without
eschar, and if possible, to perform immediate subsequent
grafting with autologous split-skin. In extensive wounds
multiple grafting procedures were performed: during each
operation, approximately 5–10% of the wound was grafted.
An electric dermatome was used to harvest grafts of 0.2 mm
thickness, which were meshed by hand in a 1:1.5 ratio.
Postoperatively, wounds were dressed with tetracycline and
petroleum jelly gauzes, covered by dry gauzes. Tetracycline
was used as topical antibacterial ointment and ensured that
gauzes were non-adhesive. Splints were used over joints of
the extremities to protect the grafts during the rst week.
Inspection was performed at day 3–5, depending on whether
there was clinical suspicion of wound infection. After in-
spection, grafts sites were left open. The donor site was left
dressed when wounds were clean until complete re-
epithelialization had occurred. Finger, toe and below-the-
knee amputation was performed in burn patients who had
developed dry gangrene after demarcation.
2.4. Study design
2.4.1. Data collection
At admission, burn characteristics, e.g. etiology, %TBSA
burned, burn depth and localization were documented, as
well as basic patient characteristics including gender, age,
hemoglobin, weight and comorbidity. Comorbidities such as
neurological complications (seizures, epilepsy) or diabetes
were documented. The type of initial treatment (e.g.
3 burns xxx (xxxx) xxx–xxx
administration of uids and antibiotics), wound care (e.g.,
method of dressing and topical therapy) and length of stay
were documented. Surgical interventions were documented,
specically the type and timing of the intervention.
Compliance with guidelines was documented regarding uid
resuscitation and antibiotic administration.
2.4.2. Patient safety
To determine safety, ‘timeliness’, was documented (dened
as the time from burn injury to presentation (i.e. patient
delay)) as were complications, including complications of
burns and treatment-related complications. Infectious com-
plications concerned wound infection, sepsis, urinary tract
infection and pneumonia. Wound infection was diagnosed
clinically (see above). Signs of sepsis were fever < 36.5 ⁰C
to > 39 ⁰C, tachycardia (> 110 b.p.m.), tachypnoea (> 25
breaths/min), thrombocytopenia (< 100,000 μl), hypergly-
cemia in the absence of diabetes, or inability to continue
enteral feeding. A patient was considered septic if at least
three of the previous criteria were met . Multi-organ
failure was dened as the presence of a systemic in-
ammatory response and dysfunction of at least two organs.
Urinary tract infection was diagnosed by dipstick, pneu-
monia was diagnosed clinically in combination with chest x-
ray. Cultures were not performed as microbiology resources
were only available to a limited extent and costs were high.
Other complications related to burn injury concerned dehy-
dration, diarrhea, severe facial edema, anemia, severe acute
malnutrition (weight-for-length below 3 STD), gangrene of
digits, and cardiovascular, pulmonary and renal failure
(acute renal failure).
Treatment-related complications involved anesthesia and
surgery and had to occur within 30 days post-surgery.
Examples of surgical complications included hemorrhage,
surgical site infections, graft necrosis, donor site morbidity,
and pulmonary complications. Partial graft necrosis was a
graft take between 30% and 80%, complete graft necrosis was
a graft take below 30%. Anesthesia-related complications in-
cluded cardiovascular or mechanical ventilation-related
Burn care was considered safe when no major complica-
tions occurred. Major complications were dened according
to the Clavien-Dindo Classication [31,32]. Major complica-
tions include life-threatening complications, such as single or
multi-organ dysfunction (Grade IV), or patient death (Grade
2.4.3. Effectiveness of treatment
The effectiveness of treatment was assessed in the subgroup
of burns survivors who required split skin grafting. This in-
cluded assessments of the timing of completed re-
epithelialization, graft take, disability-free survival and QoL.
Graft take was assessed in the second week postoperatively.
Disability was assessed with the validated World Health
Organization Disability Assessment Schedule version 2.0
(WHODAS 2.0, 12-item), in the Kiswahili language [33,34]. The
questionnaire consists of 12 questions regarding disability in
different domains of daily life, scored on a 5-point Likert
scale. A total score is calculated, ranging between 0 and 1,
where a higher value represents greater disability. A score
Fig. 1 – Example of delayed skin grafting. Photo release consent was provided by the patient and the caregivers after extensive
counseling. 1a. debridement. 1b. harvesting skin with the electrical dermatome. 1c. meshing by hand. 1d. suturing mesh.
4 burns xxx (xxxx) xxx–xxx
lower than 0.25 is classied as “disability-free survival”, ac-
cording to Shulman et al. . This questionnaire has been
validated to assess disability in patients aged 18 years of age
and older [35,36]. For patients under 18 years of age, parents
were asked to ll in the questionnaire by proxy .
2.4.5. Quality of Life
Patient QoL was assessed using the EuroQoL-5D-3L ques-
tionnaire (EQ-5D-3L), which is interculturally validated for
this purpose [38–40]. The questionnaire consists of ve
questions, scored on a 3-point Likert scale. A total score is
calculated, ranging between 0 and 1, where a higher score
represents a higher QoL. The questionnaire is available for
adults and pediatric patients aged between 8 and 18 year of
age (the EQ-5D-Y) [41–43]. Parents were asked to ll in the
questionnaire for patients younger than 8 years of age .
2.4.6. Data analysis
Descriptive data analysis was performed to describe the
outcomes. Continuous data were presented as the mean with
standard deviation (SD), non-continuous variables as the
median with interquartile range (IQR), and categorical data as
percentages (n, [%]). Kaplan-Meijer curves were analyzed and
created using GraphPad Prism 8.3.1 (GraphPad Software, San
Diego, CA, USA). The statistical differences in mean disability
and mean QoL at admission and at follow-up were calculated
and analyzed with paired t-tests using IBM SPSS Statistics
version 22.0 (IBM Corp., Armonk, NY, USA).
In 2017–2018, 82 patients with burn injuries were admitted at
Haydom Lutheran Hospital. Three patients died within 12 h
after admission and did not provide informed consent. All
the remaining 79 patients provided informed consent. Of all
the patients included, 45 had severe burns. Of those patients,
36 survived and were analyzed in a subgroup.
3.1. Patient and burn wound characteristics
The median age of all patients was 3 years (IQR 2–9, range
0.5–49 years). The vast majority of patients included were
children aged below 14 years (62/79, 78%) (Table 1). Males and
females were evenly affected. The mean BMI of adult patients
was 17.6 kg/m
(STD 2.8). One pediatric patient presented
with malnutrition with a weight-for-length below 3 STD.
Epilepsy (16%) and mental retardation (11%) were the most
prevalent comorbidities. The most common cause of burn
injury was scalds (58%). The mean TBSA burned was 12%
(STD 10). Of all the patients, 63% suffered from deep dermal
or subdermal burns. The patient and wound characteristics
of subgroups are presented in Table 1.
In all patients, the median patient delay was 1 day post-
injury, and the mean delay was 5 days (IQR 0–4, STD 11, range
0–58). In the subgroup of severe burn survivors, the median
patient delay was 3 days, and the mean delay was 7 days (IQR
0–7, STD 12, range 0–47).
Guideline adherence was limited regarding uid and anti-
biotic administration. Fluid resuscitation at admission was
indicated in 44% of all the cases. Compliance with the ISBI
guidelines was achieved in 78% of these. All patients (100%)
received antibiotics at admission, whereas only 25% of the
wounds were classied as infected at admission. Patients
that come in after a delay are stabilized at the emergency
department and sepsis, dehydration, malnutrition are
treated. Almost all the patients (97.5%) received occlusive
wound dressing, which was according to the local protocol.
Facial injuries received an open wound treatment. In total, 36
patients were eligible for the subgroup of patients with se-
vere burns which required skin grafting. Escharotomy was
performed in four patients. Seven patients refused auto-
logous skin grafting due to fear of costs, lack of trust in the
healthcare providers, or health illiteracy. Skin grafting was
thus performed in 29 patients (81%). The vast majority of
grafting was performed at a delayed stage (90%), i.e., > 10
days post-injury (median 23 days post-injury, IQR 15–47)
(Fig. 2). In 9 patients, several grafting procedures were ne-
cessary (ranging from 2 to 4 procedures), totaling 41 proce-
dures. Amputation was performed in ve cases, including
ngers, toes and below-the-knee amputation.
3.3. Patient safety
Patient safety was considered unsatisfactory in the rst two
weeks after admission, based on the Clavien-Dindo classi-
cation. Patients presented with life-threatening complica-
tions on admission and the mortality rate was high in the
rst two weeks after admission.
Clearly, many complications in the rst two weeks related
to the situation at admission. In all patients, 87 burn wound-
related complications were observed on admission. Major
complications (i.e. grade IV complications) included sepsis
(11%), severe acute malnutrition (6%), and acute kidney
failure (6%). The most common minor complications present
on admission were dehydration (35%) and burn wound in-
fection (25%). No inhalation injuries were observed during
admission. A possible explanation might be that the vast
majority of burns took place in the open air. The complica-
tions of the subgroups are presented in Table 2.
Of all patients included, 9 died during admission, com-
prising a total in-hospital mortality of 11.4% (n = 9/79). The
majority of deaths occurred within the rst two weeks post-
admission. In the subgroup of patients who died, the median
time from admission until death was 10 days (IQR 2–17),
ranging from 0 to 73 days. Two patients died within 24 h after
admission (2/9 = 22%), three between 1 and 4 days (3/
9 = 33%), and three between 4 and 14 days (3/9 = 33%) and one
between 14 and 73 days (1/9 = 11%) (Table 2 and Fig. 3). Shock
due to sepsis (44%) or hypovolemia (22%) were the most
common causes of death. In the subgroup of patients who
died (n = 9), the mean patient delay was signicantly longer
(14 vs. 5 days, p = 0.0377) compared to the total study popu-
lation (n = 79). Likewise, the mean TBSA% burned (21% vs.
12%, p = 0.0262) was higher. Deep burns were more prevalent
5 burns xxx (xxxx) xxx–xxx
in the group of the patients who died (77% having deep burns
vs. 63%, p = 0.408); however, there was no signicant differ-
ence compared to the total study population (n = 79).
The safety of anesthesia and surgical procedures was sa-
tisfactory according to the Clavien-Dindo classication. Seventy
procedures were performed, including 41 skin grafts and no
surgery-related life-threatening complications and mortality
were observed (Table 3). The most predominant complications
of skin grafts were partial (22%) and complete necrosis (7%). Two
patients died who underwent escharotomy procedures; how-
ever, they died of multi-organ failure due to the severity of their
burn injuries. One patient died who underwent a below-the-knee
amputation; however, she died due to complications of epilepsy,
more than 60 days after amputation. None of the patients who
died had received debridement or skin grafting.
3.4. Effectiveness of treatment
Thirty-six patients with severe burns had clinical indications
for split-skin grafting. Seven patients refused surgery and 29
patients underwent skin grafting (see ‘treatment’). The mean
TBSA% of all burn wounds that needed grafting was 10.2%
(SD 9), with a mean TBSA% covered by skin grafting of 8.9%
(SD 7). The mean graft take was 79% (SD 24). The mean time
to reepithelialization was 52 days post-admission (SD 42,
median 45, IQR 25–60) and a mean of 60 days post-injury (SD
41, median 58, IQR 34–67) (Table 3). In the subgroup of pa-
tients with severe burns who refused surgery (n = 7), the
mean time to reepithelialization was not available as they
left the hospital before complete reepithelialization had oc-
Table 1 – Patient and burn wound characteristics.
Variable All patients Deaths Severe burn survivors
N 79 9 36
Male/female, n 43/36 2/7 19/17
Median age, years 3 (IQR 2–9) 4 (IQR 3–11.3) 5.0 (IQR 2–22)
Mean age, years 9 (STD 13) 10 (STD 14) 13 (STD 16)
Weight-for-length, n Known in 59 patients Known in 6 patients Known in 24 patients
> 0 SD 18 (31%) 0 6 (25%)
0 to − 1 SD 21 (36%) 3 11 (46%)
-1 to − 2 SD 15 (25%) 3 4 (17%)
-3 to − 2 SD 4 (7%) 0 3 (13%)
> −3 SD 1 (2%) 0 0 (0%)
Mean BMI, kg/m
17.6 (STD 2.8) 14.5 (N = 2) 18.5 (STD 2.6)
Comorbidity, n (%)
Epilepsy 13 (16%) 1 (11%) 9 (25%)
Mental retardation 9 (11%) 2 (22%) 5 (14%)
Diabetes 1 (1%) 1 (11%) 0 (0%)
HIV 1 (1%) 0 (0%) 1 (2%)
Heart failure 1 (1%) 0 (0%) 0 (0%)
Median Hb, g/dL 11.5 (IQR 10.1–13.7) 11.2 (IQR 8.8–12.5) 11.4 (IQR 9.9–14.4)
Burn wound characteristics
Etiology, n (%)
Scalds 46 (58%) 4 (44%) 11 (31%)
Fire 32 (38%) 4 (44%) 23 (64%)
Contact 3 (4%) 1 (11%) 2 (5%)
Mean %TBSA 12 (STD 10) 21 (STD 17) 14 (STD 10)
Median %TBSA 10 (IQR 5–16) 20 (10–28) 10 (IQR 7–17)
Mean %TBSA full thickness 13 (STD 8) 22 (STD 20) 10 (STD 9)
Median %TBSA full thickness 8 (IQR 5–16) 20 (IQR 6–32) 8 (IQR 5–12)
Deepest burn depth, n (%)
Supercial partial-thickness 29 (37%) 2 (22%) 0 (0%)
Deep partial-thickness 13 (16%) 1 (11%) 5 (14%)
Full-thickness 29 (37%) 4 (44%) 25 (69%)
Full-thickness and vital structures below 8 (10%) 2 (22%) 6 (17%)
Body part affected, n (%)
Head/neck 20 (25%) 3 (33%) 9 (25%)
Trunk 41 (52%) 7 (78%) 17 (47%)
Buttocks 20 (25%) 2 (22%) 8 (22%)
Genitalia 7 (9%) 1 (11%) 3 (8%)
Upper extremity 38 (48%) 6 (67%) 20 (56%)
Lower extremity 42 (53%) 6 (67%) 21 (58%)
Time to wound closure, days
Mean (STD, range) 25 (STD 33, range 0–203) N/A 52 (STD 41, range 6–203)
Median (IQR) 10 (IQR 6 −29) N/A 45 (IQR 25–60)
6 burns xxx (xxxx) xxx–xxx
In the subgroup of patients with severe burns the mean
patient disability score was 0.63 (n = 34, SD 0.23) at admis-
sion. At 1.5 months post-injury, this improved to 0.35 (n = 31,
SD 0.23, p < 0.001) and at 3 months to 0.20 (n = 32, SD 0.2,
p < 0.001) (Fig. 4). The number of patients with disability-free
survival at admission were 2 out of 34 (6%), which improved
to 9/31 (29%) at 1.5 months, and to 22/32 (69%) at 3 months
post-injury. Similar results were observed in the subgroup of
patients who received skin grafting: at admission the mean
disability score was 0.64 (n = 27, SD 0.25), at 1.5 months it was
0.36 (n = 26, SD 0.24, p < 0.001), and at 3 months it was 0.21
(n = 25, SD 0.16, p < 0.001).
In the subgroup of patients with severe burns the mean
QoL score was 0.25 at admission (n = 34, SD 0.25). At 1.5
months post-injury, this score improved to 0.53 (n = 33, SD
0.27, p < 0.001), and at 3 months it had further improved to
0.73 (n = 30, SD 0.26, p < 0.001) (Fig. 4). None of the 34 patients
reported a full QoL score at admission, 2/33 patients (6%)
reported a full score at 1.5 months, and 8 (8/30, 27%) reported
a full score at 3 months post-injury. Similar results were ob-
served in the in subgroup of patients who received skin
grafting: at admission the mean QoL score was 0.22 (n = 29,
SD 0.26), at 1.5 months the score was 0.53 (n = 29, SD 0.30,
p < 0.001), and at 3 months the score was 0.70 (n = 26, SD
0.702, p < 0.001). Please see Fig. 5 for an example of delayed
According to the World Health Organization (WHO), the
burden of burn injuries is high in low- and middle-income
countries. There is currently a lack of understanding of burn
treatment and burn care outcomes in these settings.
Therefore, the WHO called for efforts to collect data and
promoted research on this topic. In an answer to this call,
this is the rst study performed in a rural area in a resource-
limited setting that evaluated the outcomes of acute burn
care by assessing the safety and effectiveness of burn care,
including the use of validated Patient-Reported Outcome
Measures (PROMs). Our results showed that patients often
presented after a prolonged delay at the emergency room
with life-threatening complications. Patients had a high risk
of in-hospital mortality in the rst two weeks after admis-
sion. The safety of surgical procedures was considered sa-
tisfactory since no surgery-related mortality or life-
threatening complications were observed. This study also
demonstrated that delayed skin grafting was effective by
achieving reepithelialization at a mean of 60 days post-injury
without major complications. Partial graft necrosis (25%) was
a predominant complication. During follow-up patients re-
ported a reduction of disability and an improvement of QoL.
The in-hospital mortality reported in our study (11.4% for
all burns) is in line with the literature dealing with similar
resource-limited settings. A recent systematic review of burn
care in sub-Saharan African countries by our group showed
an overall mortality of 13.1% for all, and 27.9% for severe
burns . However, individual studies presented a widely
varying mortality of 1–39% [45–53]. This diversity may be at-
tributed to differences in study methods, quality of follow-up
and differences in healthcare settings with different levels of
burn care available [29,47,48].
Compared to HICs, the mortality reported in LMICs is
considerably higher. Large burn registries report a mortality
rate of 3.3% in the United States [2,3], 4.1% in The Nether-
lands [1,4], and a mortality rate from severe burns (dened as
burns > 15% TBSA burned) of 15.7% in Australia . In the
literature these vast differences are partially explained by the
limitations in access to, and the quality of, burn care services
in LMICs [22,23].
Our ndings suggest that a delayed grafting technique
was safe and effective in a resource-limited setting. Patients
with burns who survived the rst two weeks after admission
were able to undergo skin grafting at a median of 23 days
post-injury, and reepithelialization was achieved without life-
Several approaches have been proposed in the literature
to optimize burn care in low-income countries. Regarding
surgery, studies suggest that early eschar excision and
grafting within 72 h improve the outcome of burn wound
treatment by reducing bacterial wound colonization, infec-
tion and length of hospital stay [55,56]. However, controversy
remains as to whether early excision or a more conservative
approach is the preferred technique in resource-limited set-
tings [8,27]. The few studies available reached different con-
clusions . Three studies supported early excision and
grafting [57–59]. On the other hand, Gallaher et al. showed
that early excision and grafting were associated with in-
creased mortality compared to delayed grafting after burn
day ve . Apart from the safety considerations, our ex-
perience is that patient delay, the condition of the patient at
admission, out-of-pocket payments and the limited avail-
ability of supplies and products (e.g. blood products) con-
tribute to the delay in surgery. These factors should be
considered when discussing the optimal timing of wound
closure in a resource-limited setting.
Fig. 2 – Surgical interventions performed in patients with
severe burns and timing of grafting procedures.
7 burns xxx (xxxx) xxx–xxx
The ISBI guidelines were challenging to apply regarding
uid management and antibiotic usage. Fluid management
was not performed according to the guideline in 22% of the
cases. This was due to various shortcomings: medical doctors
were not aware of the current international guidelines, uids
were temporarily not available, or uids were not provided
due to shortages of staff. The guidelines recommend the
avoidance of prophylactic use of antibiotics; however, 100%
of our population received oral antibiotics at admission while
only a quarter of the patients presented with an infected
burn wound and even fewer presented with septicemia. This
inappropriate antibiotic usage has been described earlier in
the setting of Tanzania [61,62]. Clinicians may have thought
it likely that infection prevention and hygiene control could
not yet match the high standards of High-Income Countries
and therefore prescribed prophylactic antibiotics. The above
Table 2 – Patient safety: complications and mortality.
Variable All patients Deaths Severe burn survivors
Complications of burns
Mean (STD, range) 5 (STD 11, range 0–58) 14 (STD 20, range 0–58) 7 (STD 12, range 0–47)
Median (IQR) 1 (IQR 0–4) 3 (IQR 1–23) 3 (IQR 0–7)
Minor complications at admission, n (%)
Dehydration 28 (35%) 3 (33%) 25 (69%)
Burn wound infection 20 (25%) 2 (22%) 16 (44%)
Anemia 8 (10%) 1 (11%) 7 (19%)
Other 9 (11%) 3 (33%) 6 (17%)
Major complications at admission, n (%)
Sepsis 9 (11%) 2 (22%) 7 (19%)
Severe acute malnutrition 5 (6%) 3 (33%) 1 (3%)
Acute kidney failure 5 (6%) 2 (22%) 3 (8%)
Compartment syndrome 3 (4%) 2 (22%) 1 (6%)
Minor complications during admission, n (%)
Pneumonia 2 (3%) 1 (11%) 2 (5%)
Anemia 8 (10%) 2 (22%) 6 (17%)
Diarrhea 7 (9%) 2 (22%) 4 (11%)
Dry gangrene 3 (4%) 0 (0%) 3 (8%)
Decubitus 2 (3%) 0 (0%) 1 (3%)
Facial edema 2 (3%) 1 (11%) 0 (0%)
Dehydration 21 (27%) 3 (33%) 18 (50%)
Other 3 (4%) 0 (0%) 3 (8%)
Major complications during admission, n (%)
Severe hypovolemia 2 (3%) 2 (17%) 0 (%)
Sepsis 11 (14%) 4 (44%) 7 (19%)
Acute kidney failure 6 (8%) 1 (8%) 2 (6%)
Severe acute malnutrition 6 (8%) 3 (33%) 1 (3%)
Coma due to progressive epilepsy syndrome 1 (1%) 1 (11%) 0 (%)
Electrolyte imbalance 3 (4%) 2 (22%) 0 (0%)
Respiratory failure 2 (3%) 1 (11%) 1 (3%)
Number of deaths, n (%) 9 (11%)* 9 (100%)* 0 (%)
Mean time to death since admission, days 16 (STD 23, range 0–73) 16 (STD 23, range 0–73) NA
Median time to death since admission, days 10 (IQR 2 -17) 2 (IQR 2 -17) NA
Mean time to death since injury, days 29 (STD 36, range 0–111) 29 (STD 36, range 0–111) NA
Median time to death since injury, days 17 (IQR 4–38) 17 (IQR 4–38) NA
Death within 24 h of admission, n (%) 2 (3%) 2 (22%) NA
Cause of death, n (%)
MOF due to septic shock 4 (5%) 4 (44%) 0 (0%)
MOF due to distributive shock 2 (3%) 2 (17%) 0 (0%)
MOF with acute kidney failure 1 (1%) 1 (8%) 0 (0%)
Respiratory failure due to tetanus 1 (1%) 1 (8%) 0 (0%)
Sudden Unexpected Death in Epilepsy (SUDEP) 1 (1%) 1 (8%) 0 (0%)
Fig. 3 – Survival of patients admitted with burns. Days
elapsed since admission.
8 burns xxx (xxxx) xxx–xxx
ndings show that there is room for improving guideline
adherence, and thus potentially outcome.
Furthermore, more advanced techniques of burn wound
treatment were not yet available in our setting. Enzymatic
debridement of eschar with Bromelain (Nexobrid©) is effec-
tive and reduces the need for blood products, surgical exci-
sions and skin grafting; however it requires adequate
regional anesthesia and is not cost-effective in low-income
countries [55,63,64]. Cerium-ammazine is a relatively ex-
pensive topical therapy that needs to be applied soon after
injury. It prevents bacterial wound colonization, reduces the
risk of sepsis, and helps to safely postpone surgery until pa-
tients are stabilized [8,65–69]. However, before considering
these techniques for use in resource-limited settings, patient
delay, availability of regional anesthesia, costs and cost-ef-
fectiveness should be addressed rst.
This is the rst study on burns which shows the value and
feasibility of applying validated PROMs in a resource-limited
setting. Our ndings seem to be in line with existing studies
from High-Income Countries on the effects of burns on dis-
ability and quality of life [17,40]. These studies have shown
that the impact of burns on disability and QoL diminishes
shortly after injury, but can be persistent in a small group of
patients, particularly those with severe burns that require
multiple surgeries [17,40]. Our study shows that standardized
assessments of PROMs on disability and QoL can be applied
in a LMIC setting. These PROMs may aid the improvement of
burn care quality in LMICs .
Globally, no consensus exists as to which patient-reported
outcome measures (PROMs) should be used in burn survivors
to determine effectiveness . Burn-specic PROMs are
available, such as the Burns Specic Health Scale-Brief (BSHS-
B) , or the BOQ
for pediatric populations . However,
these PROMs are specied for populations and their beha-
viors in HICs. Therefore, we chose PROMs that were generic,
feasible and applicable to our study population and cultural
Our study indicates that patients present after a delay
with signicant morbidity and have a high risk of mortality.
Based on these ndings, the most promising rst step to
improve burn care in resource-limited settings is to improve
timely access to safe burn care in areas of underserved po-
pulations. The few studies available have suggested several
barriers to access to burn care [22,23,73–75]:
• Socio-economic barriers, e.g. lack of insurance and out-of-
• Geographical barriers, e.g. the limited number of facilities
providing burn care services.
• Limitations of the surgical workforce, e.g. the lack of
adequately trained medical personnel.
•Limitations in resources, e.g. the lack of infection pre-
vention, monitoring, intensive care and mechanical ven-
tilation, or surgical equipment.
To improve access to burn care these barriers should be
addressed [22,23,73]. Examples of possible initiatives include
awareness and prevention projects , initiatives that limit
out-of-pocket payments and ensure nancial protection of
patients , or training of local healthcare workers
Table 3 – Surgical interventions, safety and
Interventions n %
Patients that refused grafting 7 19%
Patients that underwent grafting 29 81%
Total procedures 70 100%
Split skin grafting 41 59%
- Early excision & grafting (0–10 days) 4 10%
- Delayed (> 10 days) 37 90%
Debridement 18 26%
Escharotomy 4 6%
Amputation 5 7%
Muscle ap 1 1%
Transposition ap 1 1%
Patient safety: surgical complications n %
Partial graft necrosis 9 22%
Complete graft necrosis 3 7%
Burn wound infection 5 12%
Donor site infection 3 7%
Hemorrhage 2 3%
Wound infection 1 1%
Skin grafts: effectiveness
%TBSA in need of grafting
Mean % 10%
Timing of rst skin graft, days
Mean (STD) 39 (STD 43)
Median (IQR) 23
Time from admission to
Mean (SD) 52 (42)
Median (IQR) 45 (25–60)
Time from injury to
Mean (SD) 60 (41)
Median (IQR) 58 (34–67)
Mean graft take
Mean % take (STD) 79 (24)
percentage of total skin grafts (total skin grafts = 41)
Fig. 4 – Patient-reported outcomes on disability and QoL.
9 burns xxx (xxxx) xxx–xxx
[22,23,73]. Essential requirements of such initiatives are that
they should have a needs-driven approach, are tailored to the
local settings and communities , and are based on ex-
isting burn care guidelines and protocols . LMIC actors
should include leading organizations in burn care such as
national burn care centers. HIC organizations should colla-
borate with these organizations. Potential actors from HICs
include burn care specialists who aim to strengthen the
surgical capacity, academics that empower the local aca-
demic culture and non-governmental organizations that
generate awareness and mobilize resources.
The strengths of this study are the high follow-up rate and
the evaluation of disability and QoL using validated PROMs. It
is the rst study to answer the call of the WHO to improve our
understanding of burn care in resource-limited settings.
This study has limitations. It is a single-center study without
a control group, thus limiting its generalizability. Given our
setting, several parameters, such as burn wound depth and
burn wound infection, were solely based on clinical diagnosis
and therefore have limited accuracy. Due to the nature of this
observational study, it was not possible to compare different
treatment approaches, e.g. early escharectomy and grafting
versus delayed skin grafting, and its effect on the safety or
effectiveness on wound closure and improving QoL. It should
also be noted that disability and QoL were observed over
time, rather than a sole outcome of the burn care provided.
This study dened deep burns of at least 5% of total body
surface area (TBSA) as severe burns. We note that this is a
Fig. 5 – Example of an 8-year-old patient who sustained a burn on the back. Photo release consent was provided by the
patient and the caregivers after extensive counseling. 5a. Admission post-injury day 4. 5b. post-injury day 18. 5c. First skin
graft post-injury day 26. 5d. Second skin graft day post-injury day 55. e). third skin graft post-injury day 90. 5f. result at 9
10 burns xxx (xxxx) xxx–xxx
different denition of severe burns in HICs, which use a
higher percentage of TBSA burned. Caution is needed when
comparing outcomes of this study whit studies that apply a
different denition of severe burns. A nal limitation is that
patients with minor burns who did have spontaneously
wound healing within 14–21 days and who did not have an
indication for skin grafting, were not included for follow-up.
It should be noted that a number of these patients might
have developed disability or QoL related issues, which are
potentially missed by this study.
This study on burn care performed in a rural area in a low-
income country showed that patients present with burn in-
juries after a substantial delay with life-threatening compli-
cations. The in-hospital mortality is high (11.4%). The vast
majority of patients with severe burns who survived, re-
ceived surgical treatment which was found to be safe. The
burn care was effective in achieving reepithelialization, re-
ducing disability and improving Quality of Life over time.
First experiences with the ISBI guideline showed that it is
indeed an appropriate and useful tool to guide burn care in a
resource-limited setting. Overall adherence to the ISBI
guideline can be improved, particularly regarding appro-
priate antibiotic usage and uid resuscitation. To improve
burn care worldwide, we recommend improving timely ac-
cess to safe burn care in areas of underserved populations in
Ethics approval and consent to participate
Ethical clearance was obtained from the National Institute of
Medical Research, Tanzania (NIMR/HQ/R.8a/Vol.IX/2652).
This research is supported by the Dutch Burns Foundation,
Otto Kranendonkfonds and Doctors of the World.
CRediT authorship contribution statement
TH and MB designed the study, supervised by EN, HW, MN
and PvZ. TH, JB and GM collected and analyzed the data. TH,
JB, MB and GM wrote the paper, and TH, MB, JB, GM, EN, AdV,
HW, MK and PvZ critically revised it through an iterative
process and all the authors approved the nal manuscript.
Data are presented in the manuscript. The database is
available upon reasonable request.
Declaration of Competing Interest
The authors declare that they have no competing interests.
We would like to thank Haydom Lutheran Hospital and its
staff for their assistance with the study.
Consent for publication
Patient consent was obtained.
Appendix 1. Fluid resuscitations in patients
with burns at HLH
Adults with > 20% and children with > 10% TBSA are re-
suscitated with uids according to the international guide-
lines. During the rst 24 h, patients are resuscitated with
NaCl 0.9% according to their body weight and %TBSA burned
using the Parkland formula (3 ml × body weight [kg] × %TBSA
burned=total amount of uids). The rst half is administered
in the rst 8 h, beginning from the time of the burn injury.
The other half is administered during the consecutive 16 h.
To prevent hypoglycemia in children up to 30 kg, main-
tenance uids is added (glucose 2.5% + NaCl 0.45%) evenly
spread over the rst 24 h. Calculate as follows; 100 ml/kg/24 h
(< 10 kg), plus 50 ml/kg/24 h (10–20 kg), plus 20 ml/kg/24 h
(20–30 kg). In children, IV uids are continued beyond the
rst 24 h post-injury, if required. This is done when oral in-
take cannot be monitored properly. However, it is switched to
oral intake when it is considered to be safe.
To assess the efcacy of uid resuscitation urine output is
measured using an indwelling urinary catheter (IDC). The
urine output for various ages should be as follows; infants:
1.0–2.0 ml/kg/hour. Children: 1.0–1.5 ml/kg/hour. Adults:
0.3–0.5 ml/kg/hour. If the urine output is inadequate, admin-
ister extra uids via boluses of 5–10 ml/kg and/or increase the
volume of uid to be administered within the next hour to
150% of the planned volume.
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