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ABSTRACT: In rural Africa, wound and skin care is often undertaken within very limited resources and staff have little access to evidence-based information on which to base clinical decisions. There is a shortage of appropriate products for wound and skin care. This article investigates the use of PUR(TM)-a product that, without the use of fuel or expensive equipment, converts even the most contaminated water into drinking quality that may also be used for wound care. The article highlights discrepancies in the standards of care between developed and developing countries and shows the need for further research.
The management of wounds and skin that is both cost effective and research based is a huge challenge for those in the developing world.
Wound and skin care in clinics and hospitals is often undertaken with very limited resources and without up-to-date and evidence-based information available to make clinical decisions. In many rural hospitals, staff have little access to textbooks and journals and little or no access to the Internet. Because of this, there is a general lack of knowledge regarding wound management and skin care. There is also commonly a scarcity of suitable products to manage skin and wounds including a lack of appropriate dressings, as well as skin and wound cleansing agents and emollients. Antiseptics such as chlorhexidine gluconate lotion and hydrogen peroxide are expensive and scarce. Intravenous fluids are sometimes used to clean wounds at great cost, and dry skin is often left untreated.
There is a growing body of evidence that water that is of drinking quality is suitable for cleaning wounds and may therefore be used to clean vulnerable or compromised skin. In 2008, a Cochrane review analyzed 11 randomized and quasirandomized studies (Fernandez & Griffiths, 2008). Trials on burns and dental procedures were excluded. The trials, which were of variable quality, assessed the effects of drinkable quality tap water compared with other wound cleansing solutions. The other solutions used were normal saline, procaine spirit, distilled water, and boiled water. The studies were undertaken in various settings including hospitals and the community. The patient's ages ranged from 2 to 95 years. The review concluded that using tap water to cleanse acute wounds in adults did not increase the infection rates. The reviewers concluded that, where tap water is of drinkable quality, it may be as good as the other methods, such as sterile water or saline, and more cost effective. It is now extensively used in the United Kingdom for managing wounds.
However, obtaining water that is fit for drinking in a resource-poor country is no easy matter. Water obtained from bore holes, wells, rivers or lakes, and ponds has to be boiled and filtered because it is likely to be grossly polluted by animal and human waste and/or by chemicals and heavy metals. Almost 884 million people in the developing world live without access to safe drinking water (UNICEF, 2011). With the population in many developing countries projected to rise significantly, these numbers are set to increase significantly. In Tanzania in 2010, for example, in a population of almost 49 million, the number of households connected to a source of drinking water was only 8% (World Health Organisation [WHO], 2012). Because water is not piped into individual houses, it has to be carried from its source over long distances several times a day often by children and women. In rural areas, this scarce water is primarily used for drinking and cooking. Using it for washing is a low priority. Where water is used for cleaning the skin, it is likely to be grossly contaminated, giving rise to skin and wound infections.
Boiling water uses expensive fuels such a gas and electricity. For most of the population, these fuels may not be available or affordable. Even charcoal is beyond the reach of most poor people. Wood has to be gathered, which is both time-consuming and labor intensive. It also results in trees being cut down for firewood and burnt with the resultant pollution and deforestation.
Because of the lack of access to drinkable quality water in many parts of the developing world and where there are natural disasters such as earthquakes, there is a need for easily portable and effective methods for cleaning water. In response to this, a technology called PUR has been developed, which produces drinkable quality water from even the filthiest water without the use of fuel or expensive equipment. PUR(TM) is produced by Procter & Gamble (a global company that provides consumer products in the areas including pharmaceuticals and personal care), who have been distributing it as a humanitarian aid for several years to provide safe drinking water, primarily for dehydrated babies and those with AIDS. It has recently been made available for trials in wound management. PUR(TM) is ideally suited in providing "water fit for drinking" for washing at risk or compromised skin in developing countries where there are often scarce or contaminated water supplies.
PUR(TM) is a flocculant (a substance that brings about contact and adhesion in which the particles of a dispersion form larger-size clusters) of ferric sulfate with additional polymers, which removes particulate microbes and pollutants from water including heavy metals such as arsenic. Each small 4G sachet, when added to 10 L of filthy water, thoroughly stirred, and then filtered, produces clear clean water within 30 minutes. PUR(TM) provides significant decrease in bacterial load (>8.0 log reduction), viruses (>5.0 log reduction), and chlorine-resistant cysts (e.g., giardia, cryptosporidium; >3.0 log reduction) and is also effective in removing or reducing to below WHO guidelines heavy metals (e.g., arsenic and lead), pesticides, and organics (Souter et al., 2003). It has a small amount of chlorine included to eradicate any bacteria escaping from filtration of the flocculant and its entrapped contents. This residual chlorination means that water will retain microbial stability for about a day, although purified water can be maintained longer using simple techniques, such as storing in a clear plastic container and placing in direct sunlight throughout the day.
The International Foundation for Dermatology and the International Skin Care Nursing Group have recently signed a Memorandum of Understanding for its use in skin care projects. There are publications concerning the use of PUR to provide drinking water, and projects are due to take place in Ethiopia, South Africa, and Tanzania to confirm how it should be best used for washing (Matts & Ryan, 2010; Souter et al., 2003).
PUR water was used to cleanse the wounds of patients in the surgical ward of a 160-bed district hospital in Uganda (Brooks, 2011). The hospital used expensive products such as sterile intravenous normal saline, chlorhexidine gluconate of variable dilutions, and hydrogen peroxide for cleansing wounds and burns.
Approval was obtained from the medical director, and teaching sessions were provided for the trained clinical staff in the hospital. PUR water was made by a trained member of the pharmacy staff. Initially, it was made up daily, but later, this changed to alternate days. The surplus each day was stored in the refrigerator. The water was made up in a clean, large labeled container. PUR was added to tap water, which came from the hospital's bore hole. Analysis of this water has revealed that it contains too many microorganisms to count but no coli-form bacteria. There are no data regarding any possible chemical pollution.
The water containing PUR was stirred continually for 10 minutes and then allowed to settle for 10 additional minutes before being strained through a clean piece of cotton cloth into another clean labelled container. This was in line with recommended practice. The used cloths were thoroughly washed in hot soapy water after each use, rinsed, and dried. The resulting water was poured into clean, 0.5-L labeled containers. Each day, at least 1.5 L of water was delivered to the surgical ward. Any remaining water was used by the children's ward to reconstitute oral hydration fluids, and in the last 2 weeks of the trial, 1.5-2 L/day was used for wound cleansing in the minor operations theater.
In the surgical ward, the water was used to clean the wounds of 32 patients over a 6-week period. The patients were of both genders and all ages, with the youngest being 14 months and the oldest being 73 years. The types of wounds included burns (Figure 1); necrotic wounds on babies caused by poor injection practices; trauma wounds; surgical wounds of various types including those resulting from incised abscesses and hematomas; surgical amputations; surgically debrided necrotic wounds, which were the result of injections of paraffin; and surgical wounds from abdominal operations for peritonitis, some of which developed multiple fistulae. It was used for cleansing superficial wounds as well as for irrigating very deep and extensive sinuses. Some of the wounds were dressed twice a day, whereas others were dressed daily or less, depending on the amount of exudate and the general condition of the wound. The longest it was used on any one patient was for 29 days. All the wounds were dressed by the author of the studies.
Microscopy, culture, and sensitive facilities were not available at the hospital.
The water was easily prepared by a member of the pharmacy staff. It was readily accepted as a cleansing agent by the nursing staff and the doctors. There was no noticeable rise in infection rates of wounds as measured by clinical signs. Wounds that started clean remained clean. Infected wounds were treated with intravenous antibiotics, and all burns were treated with silver sulfadiazine cream.
The biggest change was the savings on the use of chlorhexidine gluconate, hydrogen peroxide, and intravenous normal saline, which ceased to be used during the trial. Normally, in a 4-month period expenditure on wound cleansing, these are the products in the surgical ward:
The exchange rate was calculated at 3,000 Ugandan shillings to [pounds]1(2010 rate). This saving equated to approximately [pounds]417/$641 per annum. In a resource-poor country where a newly qualified nurse is paid approximately [pounds]45 per month or [pounds]540/$830 per year, these savings are significant.
If the water was also used for wounds in the maternity ward and the minor operating theater, the savings would be even greater (Brooks, 2011).
On October 14, 2010, the WHO published its first report on neglected tropical diseases. Over 50% of the 17 diseases identified in the report affect the skin. They include Buruli ulcer (mycobacterium ulcerans infection), Chagas disease (American trypanosomiasis), leishamaniasis, leprosy (Hansen's disease), lymphatic filariasis, onchocerciasis, trachoma, and yaws. Three other neglected conditions were also identified including the skin condition podoconiosis. Aside from these "neglected skin diseases," there are other more common skin diseases occurring in the developing world such as psoriasis, eczema, acne, favus, fungal infections, scabies, pyoderma, and infected sores (Figure 2).
Analyses of the prevalence of skin disease in the rural areas of developing countries have been undertaken to indicate levels of skin disease between 50% and 80%, depending on whether there is a local endemic disease, such as scabies and tinea capitis, but because of underreporting due to insufficient knowledge among both health workers and the public, these studies are almost certainly an underestimate (Hay & Fuller, 2011). Washing in clean water is an important therapy for the skin, improving barrier function and reducing contamination by bacteria, irritants, and allergens.
The use of PUR to produce drinkable quality water on the skin is now the focus of a PhD research study at the University of Hull, United Kingdom. The study will focus on those with podoconiosis. Podoconios is sometimes known as mossy foot, which is a nonfilarial, noninfective blockage of the lymphatics almost always affecting the lower limbs and, especially, the feet. It first becomes symptomatic in the early teens, causing nocturnal leg and foot pain. It is most prevalent in Africa and, especially, in the higher altitude regions in the eastern and central part of the continent (Ethiopia, Rwanda, Burundi, Cameroon, and Tanzania).
A review of podoconiosis and its epidemiology, pathology, and management by Davey, Tekola, and Newport (2007) indicated high levels of stigma against those with the disease. Those with the disease are often excluded from schools and churches and from marrying unaffected individuals. The total financial cost of podoconiosis per annum has been calculated to exceed [pounds]10 million/$16 million (Tekola, Mariam, & Davey, 2006). The review also suggested that the progression of the disease can be averted by strict hygiene methods, which include daily washing with soap, antiseptics, and emollients. But there is currently no evidence regarding the use of PUR water for washing the skin, nor is there an information on the amount of emollient required to hydrate the skin of those with podoconiosis.
The study will focus on the use of PUR water to clean the skin, which will be used in combination with glycerine as an emollient.
It is envisaged that this study may provide evidence supporting the use of accessible and easy-to-use low-cost solutions, which will provide optimum skin management to those in the developing world.
Brooks J. (2011). Water fit for drinking is fit for washing wounds! A case study at a Ugandan Hospital. Journal of Community Dermatology, 7, 17-32. [Context Link]
Davey G., Tekola F., Newport M. J. (2007). Podoconiosis: Non-infectious geochemical elephantiasis. Transactions of the Royal Society of Tropical Medicine and Hygiene, 101, 1175-1180. Available at http://www.sciencedirect.com[Context Link]
Fernandez R., Griffiths R. (2008). Water for wound cleansing. Cochrane Database of Systematic Reviews, 1. Art. no.: CD003861. doi: 10.1002/14651858.CD003861.pub2. [Context Link]
Hay R. J., Fuller L. C. (2011). The assessment of dermatological needs in resource-poor regions. International Journal of Dermatology, 50, 552-557. [Context Link]
Matts P. J., Ryan T. J. (2010). Water and the skin: Skin carers collaborative with industry in a new initiative and humanitarian drive. Unpublished paper. [Context Link]
Souter P. F., Cruickshank G. D., Tankerville M. Z., Keswick B. H., Ellis B. D., Langworthy D. E., Perry J. D. (2003). Evaluation of a new water treatment for point-of-use household applications to remove microorganisms and arsenic from drinking water. Journal of Water and Health, 1 (2), 73-84. [Context Link]
Tekola F., Mariam D. H., Davey G. (2006). Economic costs of endemic non-filarial elephantiasis in Wolaita Zone, Ethiopia. Tropical Medicine & International Health, 11, 1136-1144. [Context Link]
UNICEF. (2011). Water, sanitation and hygiene. Retrieved from http://www.unicef.org/wash/index_43084.html[Context Link]
World Health Organisation. (2012). Joint Programme for Water Supply and Sanitation. Estimates for the use of Improved Drinking-Water Sources. United Republic of Tanzania. Retrieved from http://whqlibdoc.who.int/publications/2012[Context Link]
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