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.

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.

A NEW TECHNOLOGY FOR PRODUCING DRINKABLE QUALITY WATER FOR SKIN AND WOUNDS

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.

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.

Microscopy, culture, and sensitive facilities were not available at the hospital.

RESULTS

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.

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).

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.

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