The burden of burns in Africa

Burns are unfortunately very common in Africa. There are many factors for this- cooking over an open fire is very common- also roadside cooking over an open fire. In many parts of Africa, the population also relies on gas cylinders for cooking. Many of these cylinders are stored indoors for security purposes. In case of fires in a house, these cylinders represent a considerable risk.

 

Burns occur mainly in the home and workplace. Children and women are usually burned in domestic kitchens from hot liquids, flames, or cookstove explosions. Men are most likely to be burned in the workplace due to fire, scalds, chemical, and electrical burns.

Our chapter on burns focuses mainly on mild-moderate burns, which are most commonly seen. It is not the purpose of WoundsAfrica to provide detailed information on burn care at, for example, an intensive-care unit. Instead, we want to focus on general burn care at the primary- care level and in clinics with low resources. 

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Figure 1  Cooking over an open fire is still one of the leading causes of burns in young children in Africa. Image. Shutterstock

There are several other risk factors for burns, including:

  • occupations that increase exposure to fire;

  • poverty, overcrowding, and lack of proper safety measures;

  • placement of young girls in household roles such as cooking and caring of small children;

  • underlying medical conditions, including epilepsy, peripheral neuropathy, and physical and cognitive disabilities;

  • alcohol abuse and smoking;

  • easy access to chemicals used for assault (such as in acid violence attacks);

  • use of kerosene (paraffin) as a fuel source for non-electric domestic appliances;

  • inadequate safety measures for liquefied petroleum gas and electricity.

Over half of the burn patients in Africa are children. It is estimated that about 1000 000 African children under five suffer from fire-related injuries or deaths. Furthermore, Fire related mortality rates in Africa (6.1 per 100 000 population) are much more common when compared to those seen in high-income countries (just 1.0 deaths per 100 000 population)

 

Due to accessibility and affordability of hospital treatment, reliance on traditional medicine, and high burns infection rates, many of these burns result in keloid scarring or contracture formation, in turn leading to significant physical impairment (18% in a study of 650 childhood burns in the Ashanti region in Ghana. 

 

The WHO collaborated with the International Society for Burn Injuries to create the Plan For Burn Prevention and Care (2008). This document aimed to catalyze burn prevention and care efforts globally. A link to this document is provided below.  

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Figure 2  If you are interested in reading more about burn prevention globally, click on the image above. This is a link to the WHO publication " A WHO Plan for Burn Prevention and Care," published in 2008. 

Some general principles of burns

  • A burn occurs when skin, a mucous membrane, or deeper lying tissues are exposed to high temperatures, radiation, or chemicals that lead to the damage and death of cells.  

  • Burns can be caused by open flames, hot liquids, hot surfaces, chemical substances, electrical accidents, and, more rarely, radioactive radiation.

  • Burns are classified according to how much area of the body is affected, depth, cause of the burn, and which areas of the body are affected. 

  • Concerning the depth of the damage, we classify burns into first, second, and third-degree burns. ( actually, there is also an entity called a fourth-degree burn - this is when the tissue is entirely charred)

  • Tissue damage already occurs at temperatures over 45 degrees Celcius. 

  • The main rule for cooling down burns in adults with running water is 20/20 - which means that we should cool down the burnt area for 20 minutes with approximately 20 degrees Celsius cold water. Because of the risk of severe hypothermia in small children, the 20/28 rule applies here: using 28 degrees Celcius water for 20 minutes. Whenever possible, the water should be running. 

Burns from flames

Burns from flames are the most common cause of burns in adults and are the most common cause of burns that need specialized health care. Typical causes are household fires, vehicles accidents, explosions due to improper storage of gas cylinders, faulty kerosene cookers, or accidents at the workplace. Deliberate cause of burns is unfortunately also a common cause of burns of flames in Africa. These are often life-threatening injuries that should be referred to the highest level of expertise available. 

Remember that there is a considerable risk of inhalation damage to the airways and severe intoxication due to toxic gases from smoke.

Burns from scalding

Burns from scalding accidents are the most common cause of burns in children. Cooking over an open fire within reach for toddlers is a common cause of burns in this age group. However, kettles and pans placed on regular household stoves are also common causes of scalding burns - these are usually within reach for older children. Scalding burns are also often seen in Africa when younger girls are placed in household roles like cooking and looking after even younger children. 

Sometimes scalding burns occur from too high temperatures in running water from faucets. As a general rule, scalding burns that are more extensive than the palm of the child's hand should be assessed by a healthcare worker. The severity of burns from scalding is sometimes underestimated. Scalding burns, which affect more than 15-20% of the body area, are potentially life-threatening. 

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Burns from touching hot surfaces

These burns are most commonly seen in children and are usually on the hands. Common causes are from touching hot surfaces like hot pans/kettles, oven plates, or hot rocks around open fires. The depth of the tissue damage will depend on the temperature of the object touched and the duration of the contact.

 

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Figure 3  Burns involving the hands are very common in children in Africa. Experienced healthcare workers should treat these to prevent complications like contractures that can lead to life-long disability whenever possible. Image: Franco Volpato, Shutterstock, editorial use only. 

Electrical burns

Electrical burns in a household setting are not common in Africa. Most serious electrical burns in Africa occur as work-related accidents. Some studies have also shown an increase in high voltage electrical accidents due to the theft of copper cables. The high price of copper globally has led to increased theft of high voltage cables in many African countries. In a report by the Chris Hani Baragwanath Burn Centre in South Africa, 7% of admitted burns were electrical burns. Of these, about 36% were theft-related accidents. 

 

Electrical burns are usually classified as those caused by low voltage ( <1000 Volt) and high voltage ( < 1000 Volt). The damage caused by electrical burns is often underestimated. The current traveling through the body can cause serious deep burns which are not visible from the outside. Electrical accidents also lead to cardiac arrhythmia, cardiac arrests, and neurological damage. 

Chemical burns

Serious chemical burns in a household setting are not common in Africa. Most serious chemical burns in Africa occur as work-related accidents. With the increasing industrialization on the continent, the number och chemical-related burns are on the rise. This is very often due to low adherence to safety measures when handling these chemicals. In some cases, workers are poorly trained. In other instances, employers do not offer the necessary measures to protect the workers from such accidents. 

 

Burns due to strong acids are most commonly seen. Burns from strong alkali bases are often underestimated as they usually do not cause pain at the start. Workers might not change the contaminated clothing when they have come into contact with a base because they do not feel any discomfort. First several hours or days later, the seriousness of the tissue damage may become apparent. Remember that alkali metals like lithium, potassium, and sodium can also cause chemical burns.  

 

In chemical burns, the contaminated clothing should be removed immediately. The skin should be rinsed with running water for extended periods, sometimes for more than an hour, depending on the chemical involved. As a general rule, all chemical burns should be assessed by healthcare personnel, ideally by someone who has experience with this type of injury. Serious chemical burns should always be admitted to a hospital. In many cases, deeper chemical injuries require debridement and skin transplants. 

 

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Figure 4  There are many online resources to improve the level of burn care in Africa. Like the Interburns training courses, many of these are available free of charge, and all you have to do is register. We have written a separate chapter," Information- and training resources in burn care," where we have collected many of these resources for you. Image copyright: Interburns.

1) Staff and surgeons at Korle Bu Plastic Surgery Unit.
(2) Agbenorku P, Akpaloo J, Farhat BF, Hoyte-Williams PE, Yorke J, Agbenorku M, Yore M, Neumann M (2010) Burn disasters in the middle belt of Ghana from 2007 to 2008 and their consequences JBurns  Epub ahead of print
(3) Forjuoh SN, Guyer B, Strobino DM (1995) Determinants of modern health care use by families after a childhood burn in Ghana JInjPrevention 1<: 31-34>
(5) WHO Injury A Leading Cause of the Global Burden of Disease (2000) http://whqlibdoc.who.int/publications/2002/9241562323.pdf
(6)A WHO plan for burn care and prevention (2008)http://whqlibdoc.who.int/publications/2008/9789241596299_eng.pdf
(7) Forjuoh SN (2006) Burns in low- and middle-income countries: A review of available literature on descriptive epidemiology, risk factors, treatment and prevention.
(8) Forjuoh SN, Guyer B, Ireys HT (1996) Burn-related physical impairments
and disabilities in Ghanaian children: prevalence and risk factors. AmJ Public Health 86:81–3.
(9) Papini R. (2004) ABC of burns. BMJ; 329 1