ReviewEpidemiology of burns throughout the world. Part I: Distribution and risk factors
Introduction
Injury is the physical damage that results when a human body is suddenly subjected to energy in amounts that exceed the threshold of physiologic tolerance [1]. As a significant cause of disability and death, injury is a public health problem; one out of every ten deaths worldwide results from injury [2]. In high-income countries (HIC), the incidence of injuries is decreasing at a slower rate than the incidence of illness. In low- and middle-income countries (LMIC), both death and disability from injuries is increasing very rapidly. In the LMIC of the Americas, Europe, and the Eastern Mediterranean, among men aged 15–44 years, more than 30% of disability-adjusted life years (DALYs, the loss of the equivalent of one year of good health) due either to death or disability was from injury [2].1
Fire-related burns are among the leading causes of DALYs lost in LMIC [2]. For example, approximately 6% of all unintentional injuries in children less than 15 years of age come from burns of under 20% total body surface area (TBSA) [2]. Worldwide injuries are thus the most common cause of loss; in 2004 these injuries accounted for 17% of DALYs lost in adults aged 15–59 [2].
As defined by the International Society of Burn Injuries, a burn is an injury to the skin or other organic tissue primarily caused by thermal or other acute trauma. A burn occurs when some or all of the cells in the skin or other tissues are destroyed by hot liquids (scalds), hot solids (contact burns), or flames (flame burns). Injuries to the skin or other organic tissues due to radiation, radioactivity, electricity, friction or contact with chemicals are also identified as burns.
Globally in 2004, the incidence of burns severe enough to require medical attention was nearly 11 million people [2] and fourth in all injuries, behind road traffic accidents, falls, and interpersonal violence—this is higher than the combined incidence of tuberculosis and HIV infections, and just slightly less than the incidence of all malignant neoplasms. Burns under 20% TBSA occur to 153 per 100,000 population of children aged 0–15 years, making them the fifth most common cause of non-fatal childhood injuries after intracranial injury, open wounds, poisoning, and forearm fractures [2]. In Nepal, 5% of disabilities occurring at all ages are from burns and scalds [3].
Risk factors for burns are multivariate and interrelated, and much of the impact of burns is emotional, psychological and spiritual. Both retrospective and prospective studies done at US burn centers regarding recovery from burn clearly show that that the ability to adjust following injury is less dependent on the physical characteristics of the burn (such as burn size, burn depth or location), and more dependent on the status of the burn victim's pre-injury level of adjustment. Coping skills, family and community support, and general psychological health have more impact on recovery from burns than the characteristics of the burn itself [4].
In HIC, this means that burn survivors from struggling family backgrounds are likely to have problems re-assimilating into school and community. In LMIC, the consequences are direr, with isolation from or even abandonment by the family, social segregation, unemployment, and extreme poverty. Although burn victims from affluent families in LIC have a chance of recuperation, the vast majority of burn survivors will start from living situations that deny them the opportunity to recover from even a small burn.
Additionally, the sequelae of non-fatal burns are often severe enough to cause permanent disability. In the Global Childhood Unintentional Injury Surveillance pilot study conducted among children (0–12 years of age) in Bangladesh, Colombia, Egypt and Pakistan, 17% of survivors had long term (greater than six weeks) temporary disability, and 8% had permanent disability [5]. The incidence of long-term temporary disability was highest in children surviving burns and traffic injuries. Only near-drowning victims had a higher rate of permanent disability. Permanent disability was eight times more common in burn survivors than in those children recovering from falls.
Thus comes the wisdom of one of the founding fathers of burn care in India, Dr. M.H. Keswani: “The challenge of burns lies not in the successful treatment of a 100% burn, but in the 100% prevention of all burn injuries” [6].
Section snippets
Epidemiology
Knowledge of the epidemiology of burns comes from studies including national and regional public health registries, hospital and/or burn center registries, and community surveys (self report). This knowledge is affected by the sources of data and the differences in methodologies used. Here is discussed the incidence of burns and fires and their sequelae in communities.
Risk factors for fires and burns
Risk factors include those related to socioeconomic status, race and ethnicity, age, and gender, as well as those factors pertaining to region of residence, intent of injury, and comorbidity. All risk factors combine and overlap, exponentially exacerbating the problem.
Conclusions and recommendations
Given the extent of burns worldwide, prevention is a first priority. Better research, including special surveys and registries will support preventive efforts, as will better models of effective preventive systems.
The approach to injury prevention includes four stages: surveillance, analysis, intervention and evaluation. Precise description of the problem(s) is the basis to planning effective interventions, yet in many LMIC, data on burns are scarce, inaccurate, or both. In some countries, a
Acknowledgements
The author wishes to express his gratitude to the following: Ken Dunn for his provision of data from the UK National Burn Injury Database; Peter Brigham for his insight on burn epidemiology in the US; and Andrea Sattinger for her editorial contributions.
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