Analysis of 1089 burn patients in province of Kurdistan, Iran

Burns 28 (2002) 569–574

Analysis of 1089 burn patients in province of Kurdistan, Iran Bahram Groohi, Reza Alaghehbandan, Abdolaziz Rastegar Lari∗ Department of Microbiology, Iran University of Medical Sciences, P.O. Box 14515-717, Tehran, Iran Accepted 17 April 2002

Abstract Burn injuries still produce a significant morbidity and mortality in Iran. This study was carried out to analyze the epidemiology, mortality, and current etiological factors of 1089 burn patients in the province of Kurdistan in the west of Iran during the 6 years from 21 March 1994 to 20 March 2000. There were two burn centers in Kurdistan, serving 1.4 million people in an area of 28,000 km2 . The incidence rate of burn hospitalization was 13.5 per 100,000 person-years. The median age was 18 years with 58% of the patients under 20 years. The median Body Surface Area (BSA) burned was 40%. Incidence rate of burns for females was 18 per 100,000 person-years and 9.1 per 100,000 person-years for males (P(2) < 0.000001). Also there was a statistically significant association between mortality rate and age groups/gender/BBS (P(2) < 0.000001). Flame was the most common type of burn (694/1089, 63.7%). There was also a significant correlation between the age groups and types of burn (P(2) < 0.000001). Ninety-one percent (991/1089) of the burns were unintentional (12.3 per 100,000 person-years), while suicide attempts by burning for the population aged 13 and older accounted for 12.7% (98/771) (2 per 100,000 person-years). The mortality rate was 4.5 per 100,000 person-years. The study results provide a valuable baseline by which to assess future efforts directed toward the prevention of burn injuries in Kurdistan. © 2002 Elsevier Science Ltd and ISBI. All rights reserved. Keywords: Burns; Epidemiology; Suicide; Kurdistan; Iran

1. Introduction Burns by fire, hot liquids, and contact with hot surfaces have been recognized as significant hazards for centuries. Notwithstanding the decreases in burn mortality in economically developed countries, burn injuries continue to be a major public health problem in other countries, including economically developing countries [1]. Epidemiology identifies the incidence and prevalence of disease and injury, including burn injury. However, if burn injury is to be reduced, characteristics of high-risk persons, together with risk factors in the environment, must also be identified to provide a basis for planning effective prevention. There are a few published studies about burn injuries in different regions in Iran. However, the nature and extent of this problem is still unknown [2–5]. In this respect, a simple description of the epidemiological data of patients treated in our burn centers would be of great benefit for the region. Unfortunately, educational programs focusing on the prevention of this type of accident have not been implemented in Kurdistan for many years. Epidemiological studies can underpin the development of such programs. Thus, the present ∗

Corresponding author. Tel.: +98-21-827-8510; fax: +98-21-805-4355. E-mail address: [email protected] (A.R. Lari).

study was carried out to analyze the epidemiology, mortality, and current etiological factors of burn injuries in Kurdistan in order to develop effective burn prevention programs.

2. Materials and methods The province of Kurdistan is located in the west of Iran. The population is 1,346,383 people, living in 28,203 km2 . There are only two burn units in Kurdistan, located at Tohid and Shahid Beheshti hospitals, in the cities of Sanandaj and Ghorveh. Because of their designation as the burn referral centers for the province, all significant burn cases in Kurdistan are referred to these burn units, making these units a good model for epidemiological research. Data were obtained by analysis of the medical records of patients hospitalized in the two burn units from 21 March 1994 to 20 March 2000. During this 6-year period, 33,168 burn patients were seen in the hospitals, at the primary rural and urban health care centers, and clinics in Kurdistan. Of the 33,168 burn patients, 1089 were hospitalized (giving an admission percentage of 3.3%). In this study, burn patients treated as outpatients and patients admitted for later reconstructive surgery were excluded. The inclusion criteria for admission into our burn units are:

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1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Children <2 years. Children with total body surface area (TBSA)
10%. Adults with TBSA
15%. Localized deep burns of 2% TBSA or greater. Facial burns. Burns of hands, feet, and perineum. Suspected inhalation injury. Chemical or electrical burns. Associated fractures or chronic illness. Suspected criminal or suicide burns.

Data collected included age, gender, percentage of burn in terms of body surface, etiology, and the outcome of treatment. The percentage of burned body surface (BBS) was estimated by the method of Nine’s Role. Burn incidence rates were estimated by relating the numbers of burns to the number of person-years of observation, as estimated from the 1996 population census [6]. Differences between various groups were evaluated using the Chi-square test. The level of significance was set at 0.05. 3. Results During the time period under review, 33,168 burn patients were seen in the hospitals, at the primary rural and urban health care centers, and clinics in Kurdistan. The overall incidence rate of burns including outpatients and inpatients was 410.6 per 100,000 person-years. Of the 33,168 burn patients, 1089 were subsequently admitted to our burn units. The incidence rate of burn hospitalization was 13.5 per 100,000 person-years. The distribution of the 1089 patients according to age group and gender is shown in Table 1. The mean and median ages of the patients were 20.6 and 18 years, respectively, age ranged from <1 month to 90 years, with a standard deviation of 15.1 years of age. Six hundred thirty-one patients (57.9%) were under 20 years of age (54% of the population in Kurdistan is under the age of 20), and 81% (882/1089) Table 1 Distribution of patients and incidence rate by age and gender Age (years)

0–5 6–10 11–15 16–20 21–25 26–30 31–40 41–50 51–60 61–90 Total a

Males and females (IR)a

213 75 124 219 148 103 101 54 26 26

(22.3) (5.9) (10.2) (24) (20.3) (16.8) (11.5) (8.8) (7.3) (5)

1089 (13.5)

Number of patients (IR)a Males

Females

126 39 45 46 26 20 39 21 5 8

87 36 79 173 122 83 62 33 21 18

(25.5) (5.9) (7.3) (10.1) (7.1) (6.6) (8.9) (6.8) (2.7) (2.8)

375 (9.1)

(18.8) (5.8) (13.2) (37.8) (33.5) (26.8) (14.1) (10.6) (12.1) (8)

714 (18)

Numbers within parentheses are incidence rates (no. of burns per 100,000 person-years).

were younger than 30 years of age. The mean and median ages of the patients who died were 22.4 (±13.7) and 20 years versus 19.4 (±15.7) and 17 years among those who survived, respectively (P(2) = 0.02 for the comparison of mean ages). The burn incidence rates were the highest for age groups
5 and 16–20 years, and the lowest for elderly patients (>60 years) (Table 1). Also the incidence rate of burns among children <1 year old was 13.1 per 100,000 person-years, while for the age group of 2–5 years, it was 29.3 per 100,000 person-years (P(2) < 0.000001). Of the admissions, 714 (65.6%) were females and 375 (34.4%) were males. The overall female to male ratio was 1.9:1, but a ratio of 0.69:1 was found among
5 age group. The incidence rate of burns for females was 18 per 100,000 person-years, which significantly (P(2) < 0.000001) higher than 9.1 per 100,000 person-years for males. The mean age of the female patients was older than that of the male patients; 22.4 compared to 16.9 years (P(2) < 0.000001). The BBS of the burns ranged from 4–100% with a mean and median of 48.2 and 40%, respectively. The extent of the burn was <40% of the BBS in 53.1% (579) of the patients (Table 2). In 30.4% of the patients, the BBS was >60%. The mean BBS of the female patients was significantly higher (52.2%) than that of the male patients (32.6%) (P(2) < 0.000001). There were statistically significant differences between the mean BBS for children under 11 years of age and age group 11–30 years (P(2) < 0.000001). Furthermore, there was statistical significant differences between the mean BBS for age group 11–30 years with the older age group (31–90 years) (P(2) < 0.000001). Mean BBS in different age groups is shown in Table 3. The mean and median of BBS among those who died were 73.4% (±21.4) and 80 versus 33% (±16.7) and 30% for those who survived, respectively (P(2) < 0.000001). Six hundred thirty-six patients (58.4%) were residents of urban area that account for 15 per 100,000 person-years. The remaining of 453 patients were residents of rural area (11.8 per 100,000 person-years). Both urban and rural populations had the same access to the burn units. There was Table 2 Distribution of patients by BBS BBS (%)

Number of patients (%)a

Number of deaths (%)a

≤10 11–19 20–29 30–39 40–49 50–59 60–69 70–79 80–89 90–100

36 180 183 180 104 75 85 86 89 71

– 5 11 22 28 39 51 65 76 67

a

(3.3) (16.5) (16.8) (16.5) (9.6) (9.6) (7.8) (7.9) (8.2) (6.5)

(2.8) (6.1) (12.2) (26.9) (52) (60) (75.6) (85.4) (94.4)

Numbers within parentheses are percent and refer to the patients’ columns.

B. Groohi et al. / Burns 28 (2002) 569–574 Table 3 Distribution of died patients and mortality rate by age and gender Age (years)

Number of deaths (MR)a

Number of deaths (MR)a

0–5 6–10 11–15 16–20 21–25 26–30 31–40 41–50 51–60 61–90

37 10 46 103 62 39 35 14 10 8

24 5 6 11 7 4 9 2 2 1

Total

364 (4.5)

(3.9) (0.8) (3.8) (11.3) (8.5) (6.3) (4) (2.3) (2.8) (1.6)

Males (4.9) (0.8) (1) (2.4) (1.9) (1.3) (2.1) (0.6) (1.1) (0.3)

72 (1.7)

Females 13 5 40 92 55 35 26 12 8 7

(2.8) (0.8) (6.7) (20.1) (15.1) (11.3) (5.9) (3.9) (4.6) (3.1)

292 (4.4)

571

Table 5 Distribution of patients and cause-specific mortality rates by types of burns

Mean BBS (%) 32.5 31.8 55.8 60.5 54.2 53.1 46.2 47.6 52.9 38.9

Type

No. of deaths (cause-specific MR)a

Flame Gas explosion Boiling water Hot liquids Electrical Chemical Others a

48.2

a

Numbers within parentheses are mortality rates (no. of deaths per 100,000 person-years).

a statistically significant difference between incidence rate of burns in urban and rural populations (P(2) = 0.000077). The incidence rate of burns in urban population for male and female was 10.2 and 20.1 per 100,000 person-years (P(2) < 0.000001). Also incidence rate of burns in rural population for male and female was 7.9 and 15.7 per 100,000 person-years (P(2) < 0.000001). There was a statistically significant difference between incidence rate of burns between female patients in urban and rural populations (P(2) = 0.0009). Also a statistically significant difference was found between incidence rate of burns for male patients in urban and rural populations (P(2) = 0.013). Burn type by gender and other characteristics is shown in Table 4. Flames burn accounted for 63.7% (694/1089) of all burns, 72.2% (516/714) of all burns to females, and 82.7% (301/364) of the fatal burns. The most common flammable liquid for patients with flame burns was kerosene (492/694, 70.9%) followed by gas explosion (122/694, 17.6%), gasoline (58/694, 8.3%), and tar (22/694, 3.2%). Scalds including boiling water and hot liquids accounted for 23.7% of all burns and 35.2% (132/375) of all burns to males. One hundred thirty-nine of 213 children <5 years were burnt by boiling water and hot liquids (65.2%). There were statistically significant differences between mean age and type of

301 29 28 3 – – 3

(3.7) (0.4) (0.3) (0.04)

(0.04)

No. of patients (gender-specific MR)a Males (MR)a

Females (MR)a

52 4 14 – – – 3

171 25 15 3 – – –

(1.3) (0.1) (0.3)

(0.07)

(6.3) (0.6) (0.4) (0.07)

Mortality rates (no. of deaths per 100,000 person-years).

burn (P(2) < 0.000001) and also between mean BBS and the type of burn (P(2) < 0.000001) (Table 4). Cause-specific incidence and mortality rates are shown in Tables 4 and 5. Ninety-one percent (991/1089) of burns were unintentional (12.3 per 100,000 person-years). These were more common in females than males (63.2 versus 36.8%). Frequency rate of suicide attempts by burning for the population aged 13 and older was 12.7% (98/771). The incidence rate of self-inflicted burns was 2 per 100,000 person-years (for population aged 13 and older), with a female to male ratio of 8.8. The incidence rate of self-inflicted burns (for population aged 13 and older) in male and female were 0.4 and 3.7 per 100,000 person-years, respectively (P(2) < 0.000001). Suicide attempts for all patients
13 years were the cause of 17.3% (88/507) of the burns involving females and of 3.8% (10/264) of the burns involving males. Self-inflicted burns occurred predominantly in the age group 16–25 years (60/98, 61.2%) (Table 6). The case fatality rate for patients with self-inflicted burns (76.5%, 75/98) was significantly higher than the 29.2% (289/991) rate observed for unintentional burns (P(2) < 0.000001). The overall case fatality rate among patients admitted to our burn units was 33.4% (364/1089). This represents a mortality rate of 4.5 per 100,000 person-years. The case fatality rate in male patients was 19.2%, while in female patients it was 40.9% (P(2) < 0.000001). Also the mortality rate for male and female patients was 1.7 and 4.4 per 100,000 person-years, respectively (P(2) < 0.000001). The mortality

Table 4 Distribution of patients and cause-specific incidence rate by types of burns Type

Flame Gas explosion Boiling water Hot liquids Electrical Chemical Others Total

Overall cause-specific IRs

694 102 230 28 12 4 19 1089

(8.6) (1.3) (2.8) (0.3) (0.1) (0.05) (0.2)

Gender-specific IRs Males

Females

178 32 117 15 12 4 17

516 70 113 13 0 0 2

375

(4.3) (0.8) (2.8) (0.4) (0.3) (0.1) (0.4)

714

(13) (1.8) (2.8) (0.3) (0) (0) (0.05)

Mean age (years)

Mean BBS (%)

23.2 27.7 10.9 11.5 18.4 32.5 20.5

56.2 43.7 31.5 24.5 29 40 46.6

20.6

48.2

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Table 6 Distribution of patients with self-inflicted burns by age and sex Age (years)

Number of males and females

13–15 16–20 21–25 26–30 31–40 41–50 ≥51

13 30 30 9 6 4 6

Total

98 (2)a

Number of patients Males

Females

0 4 3 1 0 2 0

13 26 27 8 6 2 6

10 (0.4)a

88 (3.7)a

a

Numbers in the parentheses are incidence rates (number of self-inflicted burns per 100,000 person-years).

rate for females was significantly (P(2) < 0.000001) higher than males in all age groups with the exception of age group 10 years. Table 2 shows BBS according to case fatality rate. Case fatality rate for patients with BBS <40% was 15.2% (38/579) while in patients with BBS ≥40% was 63.9% (326/510) (P(2) < 0.000001). The mean and median length of hospital stay were 13.1 and 9 days and ranged between 1 and 65 days. Six hundred nineteen patients (56.8%) stayed <10 days in hospital, while only 8.5% (92/1089) of patients stayed for >30 days. Median length of hospital stay in survived and died patients according to age is shown in Table 7. There was statistical significant difference between median length of hospital stay in died patients and age groups (P(2) = 0.0018). However, no statistically significant difference was found between median length of hospital stay in survived patients and age groups (P(2) = 0.051). Burns requiring hospitalization were common during winter months (27.3%), followed by spring (27%), autumn (26.5%) and summer (19.2%). The following factors were identified as strongly predisposing to death: suicidal burns, BBS
40%, flame burns, age
15 years. Details of factors predisposing to death are shown in Table 8.

Table 7 Median length of hospital stay in survived and died patients according to age Age (years)

≤10 11–20 21–30 31–40 41–50 51–60 61–70 71–80 81–90

Median length of hospital stay (days) Survived patients

Died patients

9.5 15 14 13 16 22 14 9 32

7 7 8 5 6 2 8 4 2

4. Discussion The overall death and hospitalization rates due to burn injuries in Kurdistan were 4.5 and 13.5 per 100,000 person-years, respectively. Few such data have been reported from Iran [2–5]. In this respect, Panjeshahin et al. [4] reported death and hospitalization rates of 4.6 and 13.4 per 100,000 person-years in Fars province Iran which is similar to our results. The maximum burn incidence rates were observed in age groups 5 and 16–25 years. It is comparable with other reports from Iran and other economically developing countries such as Egypt, Saudi Arabia, Kuwait, Nepal [2–5,7–12]. Also the incidence rate of burn among children aged 2–5 years was significantly higher than children aged 1 year and less (P(2) < 0.000001). This may be explained by the following factors: • There is not any barrier or platform to prevent children from accidentally touching and/or tipping the burner or kettle. • The stove burner is often close to the fuel supply and/or stored fuel making catastrophic accident more likely. Females were burnt more frequently than were males (P(2) < 0.000001). Also other studies have reported a

Table 8 Predisposing factor to death among burn patients Factor

Variable

No. of patients

No. of deaths

Relative risk

P(2) -value

BBS

≤40% >40%

579 510

38 326

9.7

<0.000001

Type of Burns

Others Flame

395 694

62 302

2.8

<0.000001

Cause of Burns

Unintentional Suicidal

991 98

289 75

2.6

<0.000001

Gender

Male Female

375 714

72 292

2.1

<0.000001

Age (years)

≤15 >15

412 677

93 271

1.7

0.00002

B. Groohi et al. / Burns 28 (2002) 569–574

preponderance of burnt females [7,13–15]. However, most studies have reported that males were the victims of burns more frequently than females [11,15–22]. Among children ≤10 years of age, that more male children are burnt than females, ones has also been reported in other studies of childhood burns [20,23–25]. The female patients had greater mean size of burns and higher mortality rate, reflected in a female to male risk of death ratio of 4 which is higher than other studies [4,25,26]. The traditional style of Kurdish women’s clothing has two specificities, which contribute to accidental burn: 1. The volume of the clothes is high and in the case of an accidental fire women cannot get the clothes off quickly. 2. Most of the material in the clothing is nylon or silk and highly flammable. In our review, flame was the most common type of burns, followed by scalds which the same findings reported by other authors [2–4,8,16,17,27]. This may be explained by the fact that flammable liquids such as kerosene and gas were nearly the most frequent domestic fuel in Iran. Flame was the most common type of burn in adults (P(2) < 0.000001). On the other hand, scalds was the leading type of burn among children (P(2) < 0.000001) which agrees with other reports [2,8,19,20,27,28]. There was also significant association between the type of burn and gender (P(2) < 0.000001). There were more female patients with flame burns versus more male patients with scalds. Furthermore, there was a significant correlation between BBS and types of burn (P(2) < 0.000001). There was higher BBS among patients with flame in comparison with other types of burn such as scalds. In this respect, mortality rate among flame-burns patients was significantly higher than scalding-burn patients (P(2) < 0.000001) that is in agreement with other reports [2–4,29]. Therefore, it seems that flame is a significant determinant of the prognosis of burn patients as established in the literature [3,4,27,29]. The age of burn patients is another important factor for prognosis. In our series, the mortality rate increased in a direct proportion with age, with 22.6% values for patients aged ≤15 years and 40% for patients aged 15 years and older. However, this was due to the children having a smaller number of flame burns and a lower BBS involved than the adult. The mortality rate among females was significantly higher than males (P(2) < 0.000001). This was due to the females having a large number of flame burns and a higher mean age and BBS involved than the males. Therefore, it suggests that female gender in Kurdistan is one of the risk factors. Prognostic factors for survival in our series were similar to those reported in the medical literature [2–4,16,30]. BBS affected was the best prediction of survival. There is a general consequence that mortality is extremely high when BBS exceeds 70% [3,29]. In this respect, our study showed that there was significant correlation between BBS and mortality rate (P(2) < 0.000001). The case fatality rate for the

573

burns >40% in our patients was 63.9% which is higher than many studies [2,10,16,18,28,31,32] and clearly lower than what was reported by others [4,7,18]. The recent literature has reported a tendency towards increased frequencies of self-inflicted burns among men and women [32], with mortality rates of 18–84% [4,32,33–44]. In the present study, we report one of the highest values in the literature in the terms of frequency of burns due to attempted suicide among women, with a mortality rate of 76.5% similar to the values reported in the literature [23,33,38,41,42]. The high incidence rate of suicide by burning specially among women may be explained by the following factors: • No perspective of solution of individual problems. For example they did not find a way to solve their family problems such as lack of understanding with the spouse, lack of interest in the family affairs, addiction of the spouse, difference of age, and polygamy. • Low socioeconomic class. • Easy access to inflammable agents. Due to the high mortality rate of patients who attempted suicide compared to patients with accidental burns, we suggest that the motive of the burn is a determinant factor in the clinical outcome of the patients. The overall case fatality rate in the Kurdistan province is 33.4% which is higher than many reports [2,3,7,10,13,16,27,45]. This may be explained by a great number of patients with high BBS who were admitted in our burn units. High resistance of microorganisms to many available antimicrobial agents and also unavailability of preferred antibiotic choices may be considered as other factors in this matter. Winter was the most common season for burns, followed by spring. However, there is no significant seasonal variation noted in the present report; similar findings have been described by others [3,4,45,46].

5. Conclusions The highest incidence rates of burns were in the children and young age groups. Burn injuries were more frequent and larger with higher mortality in females than in males. Flame was the major cause of burns. Self-inflicted burns were noted mainly in young women and resulted in 76.5% mortality. It is necessary to implement programs for health education relating to prevention of burn injuries by means of broadcast flashes on television or the radio, showing risk situations together with epidemiological data about burn accidents and sentences to call attention to strategies to prevent burn accidents.

Acknowledgements This work was completed in the Kurdistan University of Medical Sciences, Sanandaj, Kurdistan, Iran.

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