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20%
16%
12%
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CHAPTER1 Incidence and epidemiology
Introduction toincidence and
epidemiology
Burns are a global public health problem. The World Health Organization
(WHO) estimated that 11million people worldwide required medical care
in 2004.1 Approximately 300,000 people die each year from re- related
burns (not including deaths from scalds, electrical injuries, chemical, and
other types of burns). The majority, over 95% of these burns, occur in
low- and medium- income countries (LMICs). Fire- related mortality is
11.6 deaths per 100,000 population per year in South East Asia, 6.4 in the
Eastern Mediterranean, and 6.1 in Africa, compared with approximately
one death per 100,000 population per year in the developed countries.
In the UK an average of 13,000 people each year are admitted to hospital with burn injures, while in the USA 410,000 burn injuries occurred
in 2008, with approximately 40,000 requiring hospitalization.3 The peak
age incidence (Fig. 1.1) is between 20 and 50years. In India over 1million
people are moderately or severely burned each year, while in Bangladesh,
Colombia, Pakistan, and Egypt, 18% of children with burns have a permanent disability. Causes of burns are tabulated in Table 1.1 showing that
the incidence of ame burns in LMICs is almost double that in developed
countries.
2
8%
4%
0%
0–.9
1–1.9
2–4.9
5–15.9
16–19.9
20–29.9
30–39.9
40–49.9
50–59.9
Total Female Male
Fig.1.1 Age category distribution of 163,771 patients in 91 hospitals in the USA
from 2001 to 2010. Y- axis is the percentage of the total burns.
Adapted with permission from 2011 National Burns Repository:Report of Data from 2001– 2010,
Figure6, p.19, Copyright © American Burn Association, National Burn Repository® 2011.
Version 7.0. All Rights Reserved Worldwide, available from http:// www.ameriburn.org/
2011NBRAnnualReport.pdf.
60–69.9
70–79.9
80+
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INTRODUCTION TOINCIDENCE AND EPIDEMIOLOGY
Table1.1 Burn aetiology
Type of burn USA
1
Flame burn 42% 37% 37% 77%
Scald burn 34% 28% 33% 14%
Contact burn 9% 19% 7% –
Electrical burn 4% 11% 5% 7%
Chemical burn 3% 3% 18% 2%
Source: Data from (1) ABA National Burn Repository. Report on data from 2005 to 2014,
Copyright © American Burn Association 2014, available from http:// www.ameriburn.org/ NBR.
php; (2)International Burn Injury Database. UK Burns Injur y Data 1986– 2007 Inc., UK National
Burn Care Group, Copyright © IBID 2008, available from http:// www.ibidb.org/ downloads/ cat_
view/ 913- ibid- reports; (3)Greenwood JE, et al. Increasing numbers of admissions to the adult
burns service at the Royal Adelaide Hospital 2001– 2004. ANZ Journal of Surgery 77(5):358– 63,
Copyright © 2007 Royal Australasian College of Surgeons; and (4) Ahuja RB, et al. Changing
trends of an endemic trauma. Burns 35(5):650– 6, Copyright © 2009 Elsevier Ltd and ISBI.
Published by Elsevier Inc. All rights reserved.
UK
2
Australia3India
4
3
4
90
Percent
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CHAPTER1 Incidence and epidemiology
Risk groups
Children
Over half of burned children are under the age of 5years and almost a third
are under the age of 2 years. In the under 1year olds, scald burns are the
most common thermal injury, followed by contact burns, with ame being
very uncommon. However, ame burns are the commonest type of burns
in children 10years or older (Fig. 1.2).
Elderly (>65 Years)
Elderly burned patients represented an average of 14% of hospital admissions in the USA from 1991 to 2005, data published from the US National
Burn Repository. As life expectancy in many of the developed countries
is over 80years (78.2 in USA and 80.1 in UK), there is an increased incidence of burns in elderly people, with female predominance over the age
of 75years. Flame burns in this age group are the most common, followed
by scalds. Burns mostly happened in the bedroom or the bathroom. The
80
70
60
50
40
30
20
10
0
0–1 2–4 5–9 10–14 15–17
Age (years)
Average scald Average re/ame
Average contact
Fig.1.2 Incidence of burns in children.
Reproduced from Kramer CB, etal. Variations in U.S.pediatric burn injury hospitalizations using the
national burn repository data. Journal of Burn Care Research 31(5):734– 9, Copyright © 2010 The
American Burn Association, with permission from Oxford University Press.
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average length of stay is 2.8days/ % total body surface area (TBSA) for the
65– 75 age group and 3.3 for the older patients. Half of patients aged 65– 75
were discharged home while only one- third of patients older than 75 were
discharged home. Likewise, 16% of 65– 75year olds died in hospital and
24% of older patients died in hospital.
The disabled
Underlying physical or cognitive disabilities because of medical conditions
such as epilepsy, peripheral neuropathy, cardiac dysrhythmia, or TIA (transient ischaemic attack) can lead to burns, especially in the elderly population. In addition, the presence of pre- existing comorbidity aects patients’
outcomes and mortality (Table 1.2).
The disadvantaged ‘socioeconomic factors’
In a study of a national cohort of 870,411 of burned patients in North
Korea, burn injury severity was signicantly aected by the socio- economic
status. Lack of family support especially in children has been shown to aect
post injury life re- adjustments.
Patients withpsychiatric disorders, alcohol, substance
abuse, or smoking
Psychiatric history and substance abuse has a two- way cause– eect relationship with burns. Two- thirds of all burn patients have at least one psychiatric
disorder. These patients have a longer length of stay and poor adjustment
following acute care. Smoking and substance abuse also increase the risk of
sustaining a burn more than six times the normal population. There is also
evidence of delayed wound healing as a result of stress.
Table1.2 Relationship betweencomorbidity, age, and outcome
No. of comorbidities
Characteristic 0 1 2 3+
Percentage of patients 73.6 15.0 7.1 4.3
Age (years) (mean) 40.4 47.9 54.5 60.3
Length of stay (days) (mean) 11.5 15.9 17.8 21.7
Died in hospital (%) 5.4 8.8 13.0 19.4
All dierences among groups dened by number of comorbidities are
signicant (P < 0.001).
Reproduced from Thombs BD, etal. The eects of preexisting medical comorbidities on mortality
and length of hospital stay in acute burn injur y:evidence from a national sample of 31,338 adult
patients. Annals of Surgery 245(4):629– 34, Copyright © 2007 Lippincott Williams & Wilkins, Inc.,
with permission from Lippincott Williams & Wilkins.
RISK GROUPS
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CHAPTER1 Incidence and epidemiology
Non- accidental burns
Non- accidental injuries include neglect and intentional injuries. This can affect children and vulnerable adults. In children, parental drug abuse, single
parent families, delay to presentation, and lack of rst aid were statistically
more prevalent in burns due to neglect. These burns are statistically more
likely to be deeper and require skin grafting. Intentional burns in children
vary between 1% and 3% of all paediatric burns admissions. Burns due to
child neglect were reported to be up to 8% of hospital admissions.4 The
care of almost half of these children was transferred to foster parents.
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MASS CASUALTIES
Mass casualties
Burn disasters during the twentieth and twenty- rst centuries, excluding
terrorist attacks, have shown a trend of reduced fatalities per disaster as
a result of strict preventative legislation. Historically, in most re disasters,
victims die immediately with fewer than 50 casualties with severe burns requiring hospitalization. Table 1.3 shows the distribution of burns victims in
selected terrorist attacks.
Table1.3 Selected terrorist attacks
Year Incident Location Injured Burns Fatalities
1982 Coal Mine Explosion, Cardowan 40 36 0
1982 Hyde Park Bombing, London 23 5 3
1983 Harrods Bombing, London 91 7 6
1984 Coal Mine Explosion, Abbeystead 44 44 16
1984 Renery Explosion, Pembrokeshire 16 16 4
1984 Oxford Circus Station Fire, London 15 15 0
1984 Putney Gas Explosion, London 10 10 8
1985 Ship Explosion, Milford
Haven,
1985 Stadium Fire, Bradford City 253 250 53
1985 Plane Crash, Manchester 137 2 52
1985 M6 Coach Crash, Lancashire 27 2 13
1987 Kings Cross Fire, London 45 24 29
1988 Piper Alpha Explosion, North Sea 25+ 25+ 165
1989 Car Bombing, Peterborough >100 2 1
1992 Castleford Chemical Plant, Yorkshire 18 3 2
1993 Littlewoods Store Fire, Chestereld 30 30 2
1994 Smitheld Cinema Fire, London 12 12 11
1998 Bombing, Omagh 336 7 29
1999 Soho Nail Bombing, London 81 Several 3
1999 Paddington/ Ladbroke
Grove Train Crash,
2001 Steel Plant Explosion, Port Talbot 15 Several 3
2005 Bunceeld Fuel Depot Fire, London 43 43 0
2006 July 7 Bombings, London 700 40 54
2009 Lakanal Tower Fire, London 20+ 20+ 6
2015 Shoreham Air Crash, West Sussex, 13 13 11
2017 Grenfell Tower Fire, London 64* 2* 72*
*est
Wales 13 13 3
London 447 >30 31
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CHAPTER1 Incidence and epidemiology
Further reading
Park JO, Shin SD, Kim J, Song KJ, Peck MD. Association between socioeconomic status and burn
injury severity. Burns 2009;35:482– 90.
Pham TM, Kramer CB, Wang J, Rivara FP, Heimbach DM, Gibran NS, Klein MB. Epidemiology and
outcomes of older adults with burn injur y:an analysis of the National Burn Repository. Journal of
Burn Care and Research 2009;30:30– 6.
References
1. WHO. Burns. Key facts. http:// www.who.int/ mediacentre/ factsheets/ fs365/ en/ . Accessed 21
September 2015.
2. WHO. Injury chartbook:a graphical overview of the burden of injuries. http:// www.who.int/ vio-
lence_ injury_ prevention/ publications/ other_ injury/ chartb/ en. Accessed 25 September 2015.
3. British Bur n Association. National burn care review 2001. http:// www.britishburnassociation.
org/ nbcr. Accessed 25 September 2015.
4. Chester DL, Jose RM, Aldlyami E, King H, Moiemen NS. Non- accidental burns in children— are
we neglecting neglect? Burns 2006;32:222– 8.
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Chapter2
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Burn prevention
Denition of burns 10
Haddon matrix categorizes risk factors 11
Categories of burn prevention countermeasures 12
Third dimension of Haddon matrix 12
Monitoring and evaluation 13
Examples of successful strategies 14
References 17
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CHAPTER2 Burn prevention
Definition ofburns
A burn is an injury to the skin or other organic tissue primarily caused by
thermal or other acute trauma. It 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 ames (ame burns). Injuries to the skin or other organic
tissues due to radiation, radioactivity, electricity, friction, or contact with
chemicals are also identied as burns.
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HADDON MATRIX CATEGORIZES RISK FACTORS
Haddon matrix categorizes risk factors
Burn injuries result from an interaction of the human host, the agent of
energy transfer, and the physical and social environment in which the event
occurs. Use of the Haddon matrix1 describes the factors responsible for
burns in terms of the time sequence of events (Table 2.1).
• Factors in the pre- event phase can be avoided using primary prevention
techniques that prevent the burn from occurring
• Factors in the event phase can be ameliorated using secondary
prevention techniques that minimize the damage caused by the energy
transfer
• Factors in the post- event phase can be amended using tertiary
prevention techniques that improve survival, functional, and cosmetic
outcomes from the burn injury
Table2.1 Haddon matrix applied torisk factors forresidential re burns
and death
Factorsl
Phasesd
Pre- event Smoking in
Event Lack of
Post event Ignorance of
Host (person) Agent
bed
Chronic
alcoholism
Debilitated
elderly
escape plan
Inappropriate
response to
alarms
appropriate
rst aid
Flammable
substances
stored in
house
Young children
with access
to matches or
lighters
Absence of
sprinkler
systems or re
extinguishers
Absence of
re retardants
in clothing and
household
materials
Physical
environment
Frayed
electrical wiring
Overcrowding
Absence of
functional
smoke alarms
Bars on
windows
No ladder for
upper story
rooms
Shortage of
emergency
medical
transportation
Socioeconomic
environment
Lack of
or poorly
enforced
building codes
Poverty,
unemployment,
illiteracy
Insucient
legislation or
enforcement
for smoke
alarm or
sprinkler
installation
Inadequate
community
infrastructure
for requesting
emergency
services
Inadequate
access to burn
centres for
treatment and
rehabilitation
Paucity of
community
support for
recovery
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