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4
B. T. Stewart
declines in incidence in high-income countries are the result
of increasing socioeconomic status of specific population
groups, improved working conditions, national safety policies,
and awareness campaigns [3]. In addition to national income,
the incidence of burn injuries and deaths varies markedly by
age, gender, socioeconomic status, national income, region,
and several other factors.
Injuries Managed at Hospitals andBurn Centers
The incidence of people who seek care are admitted or die
from burn injuries represents the minority of injuries that
occur (Fig.1.1). However, people with burn injuries evaluated
at hospitals represent an opportunity to decrease preventable
morbidity and mortality with timely and effective service
delivery. Therefore, understanding the epidemiology of this
injury group can be used to guide optimal resource allocation
and reduce disability.
Fatal
injuries
Hospital &burn
center admissions
Emergencyservicecare
Primary&outpaentburn
Injuries treatedoutside of thehealth
Injuries that do notseek or need care
Unsafe condions, dangerousbehaviors,&near misses
care
system
F . Epidemiological pyramid of burn hazards and injuries
Chapter 1. Epidemiology
5
The incidence of burns managed in emergency departments
and outpatient clinics globally that require inpatient care for
their injuries is between 5 and 26 patients per 100,000
population [4]. This represents the minority of people with
burn injuries who require care and are admitted to a hospital,
particularly in regions where outpatient services are wellestablished. As example, a study from the United States
reported that 8% of burn-injured patients evaluated in an
emergency department were admitted or transferred to a
regional burn center [5]. However, the incidence of burns
that require hospital-based care are markedly higher in
many low- and middle-income countries due to both higher
incidence and less ability to provide outpatient burn care
(e.g., 8.0 per 10,000 children in Ethiopia, 6.3 per 10,000 children in Ghana) [4, 6].
Emergency departments and outpatient clinics in highincome and some regions within lower income countries (e.g.,
United States, United Kingdom) have witnessed a decrease
in the number of burn injury-related encounters for more
than two decades [7]. It is hypothesized that this is due to a
decreasing incidence and severity of injury due to systematic
prevention and control initiatives, as well as an increasing
availability of burn first aid and outpatient care resources [8].
The majority of people who have sustained a burn injury
and seek care can safely be managed as outpatients. In a
European review of 76 reports that involved 186,500 patients,
the annual incidence for burn injuries requiring admission to
a multidisciplinary burn center was 0.2 to 2.9 per 10,000
people [9]. In the Netherlands, the incidence approached 1
per 100,000 person years for burns ≥20% total body surface
area (TBSA). Other studies from high-income countries
including Australia, Singapore, and United States have
reported that burns ≥20% TBSA comprise less than 20% of
burn injuries requiring inpatient care [10, 11].
6
B. T. Stewart
Mortality
Between 100,000 and 350,000 people die each year from
burn injuries [1, 4, 12]. The overwhelming majority of burn
injuries and deaths occur in low- and middle-income
countries, which are frequently ill-equipped to successfully prevent and care for burns and where data are
sparse. As example, mortality to incidence ratios of lowand middle- income countries are multiple times higher
than those in high-income countries due to advances in
burn prevention (e.g., building codes, fire and smoke
alarms, safer cooking arrangements) and mature emergency and burn care systems [1]. Although data sources
are sparse, there may be a general decline in burn injuryrelated mortality globally.
The University of Washington (UW) Institute of Health
Metrics and Evaluation (IHME) Global Burden of Disease
Study (GBD) modeled the burden of fire, heat, and hot
substances in 2017 by updating key fatal and non-fatal data,
leveraging covariables to improve estimation in data-sparse
regions, and utilizing state-of-the-art spatiotemporal statistical modeling techniques [1, 3]. IHME models suggested
that the global age-standardized mortality rate was 1.6 per
100,000 injuries (95% UI 1.3 to 1.7), which equated to
120,632 deaths (95% UI 101,630 to 129,383) in 2017. Based
on these estimates, the world might have witnessed a 46.6%
(95% UI −49.7 to −38.8) decrease in age-standardized
mortality from 1990 to 2017. The greatest declines in mortality were witnessed by high-income countries and the
lowest by sub- Saharan Africa, South and Central Asia, and
Eastern Europe.
Although these estimates are encouraging, numerous
experts in burn prevention and control have suggested that
these reductions do not seem consistent with injury-related
mortality broadly, cluster-randomized community-based surveys of burn injury, and gains in burn prevention and care
capacity in low- and middle-income countries specifically.
Some of the limitations of these data include:
Chapter 1. Epidemiology
1. Relative absence of data from low- and middle-income
countries where incidence of injury, prevalence of disabil-
ity, and death are the highest
2. Patchwork of data from active and integrated surveillance
systems, hospital registries, re service records, mortuary
data, and community-based surveys
3. Differences in criteria for and behavior in seeking burn
center-level care have changed over time, making longitu-
dinal comparison challenging
4. Classication schemes of cause codes and injuries (e.g.,
burns, amputation, bodily harm) vary in operationalization
in registries across hospitals and countries
7
Global andLocal Inequities
As differences in the incidence, hospital admissions, and
mortality provided above demonstrate that the burden of
burn injuries are not equitably distributed globally. The
health, social, and financial burdens are unfairly carried
predominantly by people living in low- and middle-income
countries where prevention and control programs are
uncommon, and access to organized emergency, trauma, and
burn care systems is limited [13]. Burn injuries are a dramatic
example of the inequity of injury globally and even across
socioeconomic divides within countries.
As examples, about 90% of deaths from burn injuries
occur in low- and lower middle-income countries compared
to 7% in upper middle-income and 3% in high-income countries [1]. The rate of child injury death from fire and flames is
more than 10 times higher in low-income countries than in
high-income countries [4, 6, 14]. In high-income countries, the
child mortality rate from fire and flames is 3% of the rate of
death from unintentional injuries of all types; in low-income
countries, the child mortality rate is over 10% [15].
Burn injuries occur disproportionately to racial and ethnic
minorities and minoritized people in high-income countries. In
the United States, the proportion of Black infants who require
8
B. T. Stewart
hospitalization for burn injury is double the proportion of
Black infants in the general population [16–18]. In Canada, the
age-standardized mortality rate for fire-related mortality
among First Nations people was 4.3 times that of other races
combined [19]. This disparity has also been reported in the
United States, Greenland, and Australia [20–24].
The very low incidence of non-fatal burn injuries among
Hispanic people, in comparison to other people with other
ethnicities, treated in the United States suggests that many
Hispanic people living with burn injuries are being treated in
their homes, potentially in manners that are below standardof- care [4]. Even in countries with mature health systems and
surveillance programs, representative community-based surveys can play important roles. As example, community-based
surveys are needed in the United States to establish the
degree to which minoritized and undocumented patients utilize the healthcare system for treatment of burn injuries. Only
with an accurate appreciation of the burden and distribution
of burn injuries within a population can effective interventions and advocacy initiatives be created.
Risk Factors forFires andBurn Injuries
Major fire and burn injury risk factors include age, gender,
socioeconomic status, race and ethnicity, and comorbidities.
These risk factors often co-exist within people and populations
and act synergistically and exponentially exacerbating the
problem. Conversely, when risk factors and hazards co- exist,
they can be addressed simultaneously with targeted prevention
and control initiatives with minimal additional resources.
Age
Age is consistently and strongly associated with the etiology,
incidence, and mortality of burn injuries regardless of national
income. With markedly changing local and global population
Chapter 1. Epidemiology
9
structures, the epidemiology of burn injuries will too change.
Prevention professionals, policymakers, burn centers, and
health systems will need to anticipate these changes and
adapt their interventions and service delivery capabilities to
meet future demands.
Children
Infants and children aged <5years are at high risk of injury.
Infants commonly sustain scald injuries related to hot bottles,
being near mothers and older siblings who are cooking, and
spills. Toddler-aged children are newly mobile and curious
and have little inhibitions or prior knowledge and experience
with flame, scald, and electrical hazards. Beginning at six
months of age, children start reaching for objects and crawling and are fully mobile by 18 months. This escalation in
motor skills and activity increases the chances that children
will encounter hot liquids and solids, electrical cords, candles,
fireplaces, microwaves, treadmills, curling irons, ovens, cookstoves, chemicals, and other harmful agents. As example, the
majority of scald burns in the United States are children
between the ages of six and 36months from hot foods and
liquids (e.g., soup, tea, coffee) spilled in the kitchen or eating
area [25–28]. A major risk factor for toddler-aged burn injuries is lack of supervision [29–31]. The ability to supervise
infants is complex and related to maternal and child ages,
socioeconomic status, education level, social support, cooking
arrangement, home design, availability of older children,
household and societal norms, school availability, health promotion and awareness campaigns, and other reasons.
Interventions that aim to support child supervision and introduce protective barriers when supervision may be difficult
(e.g., home visits and education, distribution of playpens,
creation of community creches) reduce incidence and severity of multiple injury types, including burn injuries [30, 31].
Numerous other factors are associated with child burn injury
and death, including use of working smoke alarms, residential
fire sprinklers, fire-retardant chemicals in fabrics and uphol-
10
B. T. Stewart
stery, and healthcare systems that prioritize pediatric care
education and resources [4, 32]. Fire-related mortality rates
increase again after age 15 years, presumably related to
greater exposure to and severity of hazards, experimentation
with high-risk behaviors, and new employment. Fires and
burns are the third most common cause of unintentional
injury and death in children.
The majority of burns sustained by children are non-fatal.
The United States National Center for Injury Prevention and
Control reported that 90% of children who sustain burn
injury in the United States and evaluated in emergency
departments are not admitted to the hospital. Further, twothirds of children admitted to the hospital for burn injuries
were reported to have sustained burns <10% total body surface area (TBSA) [33]. Regardless, in countries with limited
burn care capacity or among populations with limited access
to care, even small injuries can result in significant disabilities
[34]. As example, a community-based survey of burn injuries
in four low- and middle-income countries found that 17% of
children with burn injuries experienced disability that lasted
>6 weeks, and 8% were anticipated to experience lifelong
disability due to their injury [35].
Elderly
Older people (i.e., age ≥60years) are also at high risk of burn
injury. Their susceptibility is related to deterioration in dexterity, coordination, balance, judgment, and cognition secondary to aging, medications, and comorbidities. Along with
infants, the elderly are at the highest risk of dying in structure
fires and being burned by hot baths and showers [4, 36, 37].
Unlike children, the elderly poorly tolerate even small and
shallow burn injuries, signaling the negative impacts of the
pathophysiological cascades that stem from injury and healthcare interventions, as well as burns being a symptom of frailty
and poor physiological reserve [38–40]. As a result, the
elderly have the highest mortality to incidence ratio of any
age-group. Age, alongside burn size and inhalation injury, is
Chapter 1. Epidemiology
one of the three factors most associated with in-hospital mortality after burn injury. Whereas the percentage of TBSA
burned at which 50% of patients will die (LA50) in highincome settings is over 90% in children aged <5years, the
LA50 for patients aged 70–79 is <40% TBSA, and for those
aged ≥80 years the LA50 is <20% TBSA. Data from the
United States National Burn Repository suggests that inhospital mortality is 9% for elderly in the seventh decade of
life, 16% for those in the eighth decade of life, and 25% for
those ≥80years. These mortality rates are particularly striking when compared to those of adults aged 18–49years (3%)
and children (<1%). A large proportion of the elderly who
lived at home prior to their injuries are discharged to skilled
nursing facilities or long-term acute care facilities following
hospitalization for burn care [41].
Several behaviors increase the inherent risks faced by
elderly. For instance, older individuals who smoke are more
likely to die of fire, smoke inhalation, and burns than younger
people who smoke [4]. Many elderly people also live in
households that do not have smoke detectors or may be
unable to maintain them (e.g., leave the home to purchase
batteries, climb on a step ladder to reach the detector, deploy
the dexterity to change the batteries) [42]. Similarly, many
elderly also suffer from energy poverty and may be exposed
to unsafe heating hazards, which have been documented to
be the most common reason for elderly residential fires in the
United States.
11
Gender
Burns, like other injuries, have significant gender-related
differences that appear soon after infancy. Boys are more
likely to be injured and about 25 to 70% more likely to die
from an injury than girls [4, 43]. Several explanations for
these differences have been proposed and validated in some
populations: boys are less likely to be supervised and allowed
to roam further from home with fewer limits; boys socialize
12
B. T. Stewart
differently and engage in higher risk behaviors more
frequently; and boys have higher activity levels and behave
more impulsively than do girls. Gender differences are also
observed in adults. Burn injury rates among people who seek
healthcare in the United States have been reported to be
about 50% greater among men than women (270 vs. 180 per
100,000, respectively) [44].
After infancy, differences in exposures to hazards like
unsafe cookstoves and cooking arrangements, household
work, and clothing between high- and low-income countries
are, in large part, responsible for women and girls experiencing a higher incidence and mortality rate from burn injuries
than men and boys. Clothing ignition is a common cause of
burn injuries, particularly in countries where the predominant attire worn by women is loose fitting and flammable, like
saris, chadarees, paranjas, and burqas (e.g., South Asia,
Central Asia, Middle East and North Africa, sub-Saharan
Africa). As a result and in contrast to the epidemiology in
high-income countries, the mortality rate among females is
more than twice that of males in many low- and middleincome countries, particularly in sub-Saharan Africa, Eastern
Mediterranean, South Asia, and Southeast Asia [1, 45, 46].
Cooking andCookstoves
About 90% of burn injuries occur in and around the home—
most of which are related to cooking [47]. In areas without
electrification, use of open flames and rudimentary cooking
arrangements (e.g., 3-stone fires, clay pots) are common [6,
48]. Further, cooking arrangements are often inside of the
home and on the ground, which is accessible to even small
children. Common fuels for such cookstoves include biomass
(e.g., wood, charcoal, leaves, dung), kerosene, and paraffin.
The risk of injury related to cookstoves is increased by a lack
of enclosure for open fires, cookstove instability, nearby storage of flammable fuels, flammable and loose-fitting clothing,
combustible household materials, insufficient smoke alarm
mechanisms, and lack of multiple exits.
Chapter 1. Epidemiology
Nearly half of the world’s population is exposed to harmful
levels of indoor air pollution and unnecessary fire and burn
injury risks from rudimentary cooking arrangements. More
than 4million children and adults die prematurely each year
from consequences of exposures to these cooking
arrangements, with upwards of 300,000 deaths per year from
cooking-related burns [49]. Transitioning households to
improved or liquid propane gas (LPG) cookstoves can save
lives, prevent disability, mitigate deforestation during the collection of solid biomass fuels, and promote social and gender
equity related to more efficient cooking arrangements.
However, as more households in resource-limited settings
move away from biomass and kerosene as a fuel source for
domestic stoves and heaters, there has been a subsequent
increase in the number of injuries sustained from the use of
natural gas and propane cookstoves [48]. While much research
and program development have gone into the design of
energy-efficient cookstoves and implementation of improved
and LPG cookstoves, little has been done to document and
improve key safety features in real-world settings (e.g., tip
ability, projection of flame, radiant heat, contact points) [50].
Developing safer cookstoves with policies and regulations
that facilitate their use is critically needed.
13
Occupation
Occupational exposure to hazards and work-specific
behaviors also exert differential burn injury risk within
populations. About 10–20% of burn injuries that present to
United States emergency departments are work related [44].
However, this is likely skewed upward due to pressure from
employers and workers’ compensation plans to present for
evaluations in burns that would otherwise be managed with
emergency care. Workers in the construction, welding, utilities,
concrete, transportation, mining, agriculture, and firefighting
fields are particularly at high risk of injury and being unable
to return to work after injury with dedicated vocational
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