By Manasi Jiwrajka
I recently completed a surgical placement with a Burns Unit, and was drawn to a recent case report on Global Health describing the appalling effects of severe paediatric burns. The Devastating Effects of a Fire Burn in a Child (1) is about a 2-year old boy with 40% burns to his head and arms. He was not seen immediately after the burn, instead, he presented 1 month later to an eye clinic in Hakkari, Turkey. By then he was blind.
This case raises two main issues:
- “Accidental house fires cause nearly half (49%) of the injuries resulting in death” (1). How could these be prevented?
- Delayed presentation without adequate first aid led to a poor outcome for the child. Would the outcome have been different if the patient had better access to healthcare?
“Burn injuries represent a significant public health concern in both developing and developed countries” (1). Specifically, the WHO estimates that 265 000 deaths occur each year from fires alone, with more than 96% of deaths occurring in low and middle-income countries. Mortality due to burns is over 10 times higher in low and middle income than in high income countries (2). Many studies have found a correlation between socioeconomic deprivation and the incidence and severity of burn injury (3-5). The socioeconomic factors including crowding, poverty and poor maternal education pose as significant risk factors for paediatric burns (6).
Causes of burns
The relevance of this case in Hakkari, in Turkey is that “the incidence of childhood fire burns in Turkey is unknown because of inadequate records.” (1). “In Turkey, tea is made using two narrowly based containers that are stacked on top of each other”; these may easily topple (7). Globally, most burns occur at home, especially in the kitchen. Paediatric burns often occur when parents leave their children alone (even for a moment). His mother “left [her] baby at home sleeping near the electric heater” (1, 8, 9).
Worldwide, open flame burns are the most common, followed closely by scalds. Ignition of clothing is a common cause of burns in low and middle income countries including Ethiopia, India and Papua New Guinea. In Ethiopia, it was found that 93% of burn injuries in rural areas were due to open fires inside homes causing the ignition of clothing. In India, saris catching fire whilst cooking on kerosene stoves are a cause of deaths due to burns amongst adults. Similarly, 50% of hospitalizations due to burn injuries in Papua New Guinea are due to ignition of grass skirts (10-13). In Mexico, Ghana and Taiwan, boiling liquids and hot baths were found to cause scalds among children (2, 14-16).
Global Health Issues
There are several socio-economic factors that play a role. The authors write:
“Socio-demographic factors linked to an increase incidence of burns include low household income, living in a deprived are, living in rented accommodation, young mothers, single-parent families and children from ethnic minorities. The parental educational level, parent occupation and the type and size of accommodation are also important.”
The issue of access to healthcare is two-fold: (i) access to treatment and (ii) access to prevention. This patient’s mother quotes, “because we are poor and have no health insurance, I could not take the child to the hospital right away. It was only one month later that I was able to take the child to an ophthalmologist” (1). Access to a reliable electrical supply precludes the use of open fires.
Burn care costs comprise preventative measures, emergency response, and treatment and follow-up. In Turkey, Sahin et al. showed that the mean cost associated with per percent of burn area was $368 (compared to $927 per percent burn in New Zealand), and each percent burn corresponded to 2 days in the hospital. In the case of the 2 year old patient with 40% burns, the total cost would be about $15000 with 80 days in the hospital. This overall cost of burn management is higher than other medical problems such as stroke and HIV/AIDS (17, 18). In comparison, cost analysis of burns management in Australia showed that management of burns patient was not significantly higher than other patients in ICU receiving a similar level of care. The only difference, however, was in physiotherapy, dressing and medication costs (19). This lack of discrepancy in Australia could be attributed to overall increased healthcare costs rather than specifically for burns, similar to the high cost in New Zealand. In low and middle-income countries, including Turkey, the costs associated with HIV/AIDS and cardiovascular issues is lower than burns due to the availability of knowledge, resources and medical specialists compared to burns management that requires highly specialised care. A lack of specialist burn services is, therefore, an important factor not only in burn care, but also in healthcare funding.
Interventions to prevent burn injuries can be divided into education programs, engineering programs and enforcement, and include “improvement in socioeconomic status, improved housing, provision of basic amenities (eg, water), proper regulation and design of industrial products (eg, kerosene stove), proper storage of flammable substances, and supervision of children” (20).
Education is also fundamental to long-term awareness of burn injuries. The authors suggest “the establishment of a national programme would help ensure sufficient funds are available and allow coordination of the efforts of district, regional and tertiary care centres.” Others suggest the need for public education, broadcasting programmes, and the implementation of stringent government regulation (7).
- Istek Ş. The devastating effects a fire burn in a child. BMJ Case Reports. 2015;2015.
- Agbenorku P, Agbenorku M, Fiifi-Yankson PK. Pediatric burns mortality risk factors in a developing country’s tertiary burns intensive care unit. International Journal of Burns and Trauma. 2013;3(3):151-8.
- Edelman LS. Social and economic factors associated with the risk of burn injury. Burns : journal of the International Society for Burn Injuries.33(8):958-65.
- Cubbin C, Smith GS. Socioeconomic Inequalities in Injury: Critical Issues in Design and Analysis. Annual Review of Public Health. 2002;23(1):349-75.
- Park JO, Shin SD, Kim J, Song KJ, Peck MD. Association between socioeconomic status and burn injury severity. Burns : journal of the International Society for Burn Injuries. 2009;35(4):482-90.
- Delgado J, Ramírez-Cardich ME, Gilman RH, Lavarello R, Dahodwala N, Bazán A, et al. Risk factors for burns in children: crowding, poverty, and poor maternal education. Injury Prevention. 2002;8(1):38-41.
- Nursal TZ, Nursal TZ, Yildirim S, Tarim A, Caliskan K. Burns in Southern Turkey: Electrical Burns Remain a Major Problem. Journal of burn care & rehabilitation. 2003;24(5):309-14.
- Forjuoh SN. Burns in low- and middle-income countries: A review of available literature on descriptive epidemiology, risk factors, treatment, and prevention. Burns : journal of the International Society for Burn Injuries. 2006;32(5):529-37.
- Rossi LA, Braga ECF, Barruffini RdCdP, Carvalho EC. Childhood burn injuries: circumstances of occurrences and their prevention in Ribeirão Preto, Brazil. Burns : journal of the International Society for Burn Injuries. 1998;24(5):416-9.
- Sawhney CP. Flame burns involving kerosene pressure stoves in India. Burns : journal of the International Society for Burn Injuries. 1989;15(6):362-4.
- Kalayi GD. Burns in children under 3 years of age: the Zaria experience. Annals of tropical paediatrics. 1996;16(3):243-8.
- Barss P, Wallace K. Grass-skirt burns in Papua New Guinea. Lancet. 1983;1(8327):733-4.
- Peck MD. Epidemiology of burn injuries globally. 2015. In: UpToDate [Internet]. Waltham, MA: UpToDate.
- Hijar-Medina MC, Tapia-Yanez JR, Lozano-Ascencio R, Lopez-Lopez MV. [Home accidents in children less than 10 years of age: causes and consequences]. Salud publica de Mexico. 1992;34(6):615-25.
- Tung KY. A seven-year epidemiology study of 12,381 admitted burn patients in Taiwan–using the Internet registration system of the Childhood Burn Foundation. Burns : journal of the International Society for Burn Injuries. 2005;31 Suppl 1(1):S12-7.
- Forjuoh SN. Childhood burns in Ghana: epidemiological characteristics and home-based treatment. Burns : journal of the International Society for Burn Injuries. 1995;21(1):24-8.
- Sahin I, Ozturk S, Alhan D, Açikel C, Isik S. Cost analysis of acute burn patients treated in a burn centre: the Gulhane experience. Annals of Burns and Fire Disasters. 2011;24(1):9-13.
- Lofts JA. Cost analysis of a major burn. The New Zealand medical journal. 1991;104(924):488-90.
- Patil V, Dulhunty JM, Udy A, Thomas P, Kucharski G, Lipman J. Do burn patients cost more? The intensive care unit costs of burn patients compared with controls matched for length of stay and acuity. Journal of burn care & research : official publication of the American Burn Association. 2010;31(4):598-602.
- Peck MD. Prevention of fire and burn injuries. 2015. In: UpToDate [Internet]. Waltham, MA: UpToDate.