01. Injury Problem

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Internationally, burns are a grave public health problem.1 There are over 300,000 deaths each year from fires alone, with additional deaths from scalds, electrical and chemical burns, and other forms of burns, for which international data is currently unavailable.1,2

According to the WHO,


"Fire-related deaths alone rank among the 15 leading causes of death among children and young adults 5-29 years. Over 95% of fatal fire-related burns occur in low- and middle-income countries. South-East Asia alone accounts for just over one-half of the total number of fire-related deaths worldwide and females in this region have the highest fire-related burn mortality rates globally. In addition to those who die, millions more are left with lifelong disabilities and disfigurements, often with resulting stigma and rejection."1
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In many low- and middle-income countries, burns are often caused by stoves and lamps that are dangerous.3 This includes paraffin (kerosene) lamps and stoves that are predisposed to being knocked over resulting in either burning a person directly or initiating a house fire.8 Stove burst injuries can be devastating injuries that disproportionately affect people in developing countries. According to Ahmad et al (2007) "burns due to stove bursts are a major problem and continue to be a major environmental factor responsible for significant morbidity and mortality in developing countries."4

02. Magnitude and Trends

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Age at injury:

Burns due to stove bursts mainly affect young adults. The mean age of males is 32.2 years and for females it is 24.4 years. 5

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(Adapted from Ahmad et al. Experience of Burn Injuries at the Pakistan Institute of Medical Science, Islamabad, Pakistan. Ann Burns Fire Disasters. 2007 Mar 31;20(1):7-10. Figure 1.)

Gender:

Male to female ratio was 1/1.18. 5

Occupation:

Housewives are most frequently affected. 5

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(Adapted from Ahmad et al. Experience of Burn Injuries at the Pakistan Institute of Medical Science, Islamabad, Pakistan. Ann Burns Fire Disasters. 2007 Mar 31;20(1):7-10. Figure 2.)

Mortality:

Fire-related mortality rates are especially high in South-East Asia (11.6 deaths per 100,000 population per year).6 This compares with much lower rates of 1.0 deaths per 100,000 population per year in high-income countries.6 This is one of the biggest differences for any injury mechanism.6

According to the WHO report Burn Prevention and Care (2008),

"Differences in burn mortality rates vary across different age groups and between the sexes. For instance, fire-related burns are the sixth leading cause of death among 5-14 year olds and the eighth leading cause death among 15-29 year olds from low and middle-income countries. In terms of the sex differences, women are usually at higher risk of burns than men, especially in the younger age groups: death from fires is the sixth leading cause of death among females aged 15-29 years. The highest rates of fire-related deaths are recorded in females from South-East Asia, where rates are estimated to be as high as 16.9 deaths per 100 000 population per year. Burns are one of the few injury mechanisms that have a higher death toll globally among women than men."6

Morbidity:

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Burns are also a principal cause of disability and disfigurement.6 According to the WHO Global Burden of Disease Study of 2002, "burns rank second for women as a cause of unintentional injury and in South East Asia, the burden among women is double that from road traffic injury."7 It is projected that fire-related burns account for 10 million Disability Adjusted Life Years (DALYs) lost internationally each year.6 This estimate also includes people with burn wound contractures and other physical impairments which limits their functional abilities and thus the possibility of leading normal and economically industrious lives. This estimate does not include the impacts of deformities, which frequently results in social stigma and restriction in participation in society which is more difficult to measure.6


03. Types of Stoves Associated with Burn Injuries

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Two types of stoves are available in South Asia:

Gas Stoves

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Images Courtesy Malik N Khan

These mostly contain liquid petroleum gas.

Kerosene Stoves

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Images Courtesy Malik N Khan

These use liquid flammable kerosene.

04. Dowry Deaths

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Every year in nations like India, thousands of young women are burned to death or stricken with fatal burns. They are the casualties of dowry deaths. The husband and/or in-laws have ascertained that the dowry, a gift given from the daughter's parents to the husband, was insufficient and therefore attempt to murder the new bride allowing the husband to remarry or to punish the bride and her family.8

According to a report by Parvathi Menon published in the Indian magazine Frontline,

"Investigations by a women's group in Bangalore point to a high incidence of unnatural deaths among newly married women following dowry-related incidents. Many murders and forced suicides are often registered as stove burst injuries. When the cause of death in a majority of registered dowry death cases is due to burning, such a high rate of stove burst accidents involving daughters-in-law can hardly be regarded as natural or coincidental."8

05. Impact of Burns from Stove Bursts

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• Majority of patients have involvement of trunk and upper and lower limbs. 4
• Inhalation injury can be found in up to 23% of patients and acts as a factor in mortality. 5
• Total Body Surface Area involved in males on average is 27% and 39% in females. 6
• For every person who dies of burns, many more are left with lifelong disability and disfigurements. 9
• There is stigma, rejection and economic loss both for the burn victim and their family. 9

06. Risk Factors

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Some of the risk factors that need to be confronted include:
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• Use of cooking pots at ground level (that are easily knocked over and can cause scalds, especially among toddlers). 6
• Use of kerosene (paraffin) stoves and lamps that are easily knocked over and can then ignite. 6
• Wearing of loose fitting cotton clothing which can burn while cooking on an open fire. 6

07. Estimated Costs of the Injury Problem

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According to the WHO,
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"Little data exists of the medical costs of burns in low and middle income countries. However, the social and medical costs of burns are significant for societies and families. In the USA, the medical costs of primary health care with one inpatient with burns ranges from $3000 to $5000 a day. These expenses may account for only 23% of the total costs. The economic impact of burns also includes loss of wages and the costs relating to deformities resulting from burns, in terms of emotional trauma and loss of skills." 7

08. Factors that have limited progress

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The World Health Organization Plan for Burn Prevention and Care (2008) highlights certain barriers and challenges to the wider adoption of burn prevention.

Advocacy:

There is inadequate cognizance of the magnitude and cost of the burn problem among policy-makers and donors. According to the WHO, "An awareness that the current high rates of burn death, disability and disfigurement could be brought down by affordable and sustainable improvements in prevention care is also lacking." 6

Policy Development:

Several of the stratagems that have helped to decrease the burden of burns in high-income countries have been implemented through policy changes. Per the WHO Burn Prevention and Care report, "many low- and middle-income countries have not yet developed burns policies, nor have they put into place action plans, legislation or regulations to address the problem of burns. Even when burn policies exist, enforcement is often inadequate." 6

Data and Measurement:

It is generally accepted that accurate problem description is essential to planning effective interventions. However, in many less well-resourced countries, data on burns is limited and/or inaccurate. In some countries, a lack of reliable data on risk factors further hinders the promulgation and enactment of effective burn prevention strategies, while in others, inadequate reporting of burn events leads to under-assessment of the gravity of the public health problem. 6

Research and Prevention:

One of the barriers to greater implementation of burn prevention methods in low income countries is the lack of widely available information on what constitutes effective burn prevention strategies and programs.6 One challenge to this is that several of the burn prevention strategies used in high-income countries are not completely applicable. 6 In many low-income countries, especially in rural areas and among the urban poor, the epidemiological patterns for burns and the associated risk factors differ markedly from those in high-income countries.6 Hence, very different strategies are required. According to the WHO (2008), "Rigorous documentation of the effect of prevention efforts aimed at risk factors and various scenarios is, to date, very limited. Given that approximately two billion people worldwide cook on open fires or very basic traditional stoves - that in order to reduce the number of fire-related burn deaths worldwide, evidence-based strategies to address these particular risks are going to be needed." 6

09. Haddon's Matrix

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10. Haddon's Ten Basic Strategies

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1. Prevent creation of the hazard in the first place:

Not allowing the manufacture of hazardous gas and kerosene stoves.

2. Reduce the amount of hazard brought into being:

Require that safety features be present in these stoves to prevent burst injuries and burns.

3. Prevent release of the hazard that already exists:

Prevent manufacture of ground level stoves that can be less easily toppled over.

4. Modify the release of the hazard:

Promote the use of flame retardant fabrics to reduce burning rates.

5. Separate in time or space:

Use cooking units that children cannot reach or keep children out of the kitchen when cooking.

6. Separate with a physical barrier:

Use insulated firewalls in buildings.

7. Modify basic relevant qualities of the hazard:

Eliminate use of liquid kerosene in stoves.

8. Make what is to be protected more resistant to damage from hazard:

Improved general health condition of South Asian women, allowing for improved immunity to fight secondary bacterial infections from stove related burns.

9. First aid and emergency response:

Improve availability of first aid and emergency response teams for burn victims.

10. Stabilize, repair, and rehabilitate the object of the damage:

Improved access to burn centers, rehabilitation and community support.


11. Conclusions

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Burn injuries due to stove bursts are long lasting and more often than not preventable.4 Burn survivors can often be left with disability and disfigurements that hinder their return to a fulfilling and productive life. 3 Greater implementation of burn prevention strategies globally would go a long way towards attenuating the unacceptable burden of death and suffering from burns.3 There are many strategies that have proved to be effective, but have not been sufficiently disseminated internationally.3

Prevention is always the rule to be safe from burns but, once they occur, immediate and proper care should be given with aggressive treatment in order to minimize post-burn problems.1 According to Peck et al (2008), "Solving this substantial problem will depend on improved surveillance by means of formal epidemiologic studies, and the contributions and collaboration of international governmental and nongovernmental organizations."9 Implementing injury prevention strategies will involve enforcement (including legislation), education and engineering.83According to the WHO publication Burn Prevention Success Stories Lessons Learned (2011),


"One cannot stress enough the importance of monitoring and evaluation. This starts with a solid understanding of the burn problem in a given area or community, including knowledge of the epidemiological pattern of burns in the area (e.g. burden and major causes and risk factors). Once prevention activities are underway, care should be taken to document the effectiveness of these efforts, so as to know what efforts are effective and thus should be continued or even expanded. Likewise, it is important to know which efforts are not successful and hence should be adjusted or even discontinued, with resources shifted elsewhere."3

12. References

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1) http://www.who.int/violence_injury_prevention/other_injury/burns/en/index.html

2) Peck MD. Epidemiology of burns throughout the world. Part I: Distribution and risk factors. Burns. 2011 Nov;37(7):1087-100.

3) http://whqlibdoc.who.int/publications/2011/9789241501187_eng.pdf

4) Ahmad M et al. Burns from a Stove Burst: Analysis of 34 Cases. Ann Burns Fire Disasters. 2007 December 31; 20(4): 173-175.

5) Ahmad M et al. Experience of Burn Injuries at the Pakistan Institute of Medical Science, Islamabad, Pakistan. Ann Burns Fire Disasters. 2007 Mar 31;20(1):7-10.

6) http://whqlibdoc.who.int/publications/2008/9789241596299_eng.pdf

7) http://www.who.int/violence_injury_prevention/publications/other_injury/en/burns_factsheet.pdf

8) Dowry Deaths in Bangalore by Parvathi Menon. Frontline. 16(17) August 14-27,
1999. P. 64-73.

9) Peck M et al. Burns and fires from non-electric domestic appliances in low and middle income countries: Part I. The scope of the problem. Burns Volume 34, Issue 3, May 2008, Pages 303-311.