Epidemiology of adults hospitalized with burns in Karachi, Pakistan

Copyright

BumsVo~.22,No.3,~~.225-229,1996 0 1996 Elsevier Science Ltd for ISBI. All rights reserved Printed in Great Britain 0305-4179196 $15.00+0.00

ELSEVIER

Epidemiology of adults Karachi, Pakistan D. Marsh’, A. Sheikh2, A Khalilz, S. Kamil’, and S. Eff endi

hospitalized

Jaffer-uz-Zaman2,

with

burns

in

I. Qureshi2, Y. Siraj2, S. Luby’

‘Department of Community Health Sciences,2Aga Khan University, Karachi and ‘DOW Medical College and Civil Hospital-Karachi, Karachi, Pakistan

Burns are a leading cause of adult death in Karachi slums, therefore we reviewed I year’s logged experience (November 1992 to October 1993) at Karachi’s two adull burn units for patienf age, sex, burn severity and outcome. Also 47 inpatients were interviewed regarding their circumstances of injury. We grouped these using Haddon’s Mafrix. The log identified 832 patients. Females (57 per cent) outnumbered males and were younger on average (2fr. 1 us 27.6 years, P= 0.002). Females had more severe burns than males (57 per cent us SO per cent total body surface area (TBSA) burn, P= 0.002). At the unit with outcome data (n= 556), the case fa&lily was 56 per cent. The estimated adult mortalify dueto burns in Karachi was 10.2/ 100 000,6.8/ 100 000 and 14. I/ 100 000 far menandwomen,respectively. Bums of interviewed pafients were mosf oftenassociated with flames (33/47), but stove bursts caused the most severe injury (52 per cent TBSA). These patients were predominantly younguneducated female houseworkers, clothed in loose attire who were injured duringdaylight at home around ,a floor-level stove, unaware of fire safety, andwho received no first aid. It was concluded that the high burn severity and case fatality rates demand: (1) preventive measures, such as kitchen sandbuckets, safer stovedesignand placement, and education onfire safety and first aid, and (2) risk factor analysis to refine interventions.

Bums,Vol. 22, No. 3,225-229,1996

occurred at home. Durrani also collected a large case series?of 2329 bums registered at Civil Hospital-Karachi as in- or outpatients. Hot liquids were the most common cause;however, sparking and bursting stoves causedthe most severebums, involving approximately 30 per cent of total body surface area (TBSA). Femalesaccounted for 44 per cent of outpatients and 65 per cent of admissions. Since 1971, the population of Karachi has tripled in size to an estimated 10000000, an estimated 40 per cent of whom reside in slumscharacterized by poverty, lack of education, a contaminated environment, political instability, ethnic violence and drug running6. The Aga Khan University pilots primary health care programmes in five such slums of approximate total population 48000. A recent analysisof adult deaths’between 1990 and 1993 in this population showed that bums was the fourth leading cause among women, at an average annual rate of 23/100000. Seventy-seven per cent of bum fatalities affected women. Indeed, under present conditions in these slums a IS-year-old girl has a 1.3 per cent chance of burning to death before her 60th birthday. Despite extensive experience in bums from Africaef9, the Middle East’“-12 and Asia13,especially India’4-‘6, we could find no peer-reviewed reports from Pakistan. To understand better the scope and the circumstances of severe bums, a descriptive study was undertaken in the city’s two bums units serving adults.

Introduction Bums account for 1.2 per cent of adult male deaths and 3.6 per cent of adult female deaths due to injury among the 56 countries which have vital registration systems, capturing at least 90 per cent of mortalityI. Reported national death rates per 100 000 among all females range from 0.2 (Switzerland) to 9.2 (Seychelles)and among all malesfrom 0.4 (Netherlands) to 10.8 (Bahamas)2. As countries develop, mortality due to injuries decreasesmore slowly than due to other causes3. In Karachi, Pakistan in 1971-72, Durrani conducted a city-wide survey4 of 3000 householdsidentifying 86 bums of varying severity with an incidence among males and females of 1.9 and 4.311000, respectively. Hot fluids caused61 per cent of bums, and 87 per cent of all bums

Methods Karachi hastwo bums units specializing in the care of adult patients: the 25-bed unit at Civil Hospital-Karachi and the 34-bed Abassi ShaheedHospital Unit. Both admit patients regardless of severity. Abassi Shaheed Hospital, a newer and less fully staffed unit, will infrequently transfer a patient to Civil Hospital when capacity is exceeded. We performed two investigations. First, we reviewed the patient log at each unit for admissionsbetween I November 1992 and 31 October 1993. Second, we interviewed 47 patients from the two units between 28 November and 12 December 1993. Measurements from the logs at each hospital included: age, sex, and severity aspercentage total body surfacearea

Bums: Vol.

226

burned (TBSA); the Civil Hospital log included hospital outcome (death, discharge or left against medical advice). Following Haddon’s frameworkl’, we sought hypothetical human, agent and environmental influences on the occurrence of the event, the injury and its severity. We interviewed patients or family members if the patient’s medical condition precluded direct interview. We used open- and closed-ended questions to determine sociodemographic factors, circumstances of bum and patterns of care seeking. We combined data from the two logs for age and sex analysis. We calculated the range of possible case fatality ratios (CFR) for the Civil Hospital patients according to differing assumptions for those leaving against medical advice: universal survival, universal death or mortality risk at the TBSA quintile-specific CFRs observed among patients with known outcome. Calculating the populationbased sex-specific mortality rate involved several assumptions: I. Civil Hospital patients leaving against medical advice experienced the same mortality by TBSA quintile as those for whom outcome was known. 2. The derived (observed and expected) sex-specific CFRs at Civil Hospital were applied to the admissions at Abassi Shaheed Hospital to determine their estimated contribution to mortality. 3. 10 per cent of Abassi Shaheed’s patients were transferred to Civil Hospital to avoid double counting (S. Mahdi, 1994, personal communication). 4. The estimated total population of Karachi (1994) is 9.5 million”, of which there are 2.67 million adult (15-54 years) males and 2.18 million adult females, based on the 1986 age-sex composition of urban Sindh ProvinceX9 of which Karachi is the principal city. (Pakistan has had no census since 1981). Univariate and bivariate analyses were conducted using Epi Info, version Szo, statistical software. We evaluated different frequencies and means between groups using chi-square and Student’s t-tests, respecitively, and the relationship between bum severity and survival using chi-square for linear trend ‘I. We considered a difference between frequencies or means to be not significant (NS) if the probability was > 0.05 that the difference was due to sampling error.

Results Log review (n = 832) The review of the two hospital logs showed that females, 477 (57 per cent), outnumbered males, 355 (43 per cent). Overall, the patients were young; 79 per cent were less than 35 years old (an estimated 66 per cent of urban adults in Sindh Province are less than age 35 yearslg). Women were younger than men, with a mean age 25.1 years vs 27.6 years (P~O.002). The combined admission rate averaged 69 patients per month, ranging from 48 in June to 86 in December. Both hospitals admitted patients with similar burn severity, age and sex. The mean TBSA of patients admitted to Civil Hospital was 53.7 per cent vs 55.0 per cent at Abassi Shaheed Hospital (NS). The Civil Hospital logs allowed for analysis of severity and outcome by sex among their 556 cases. At Civil Hospital the overall CFR was 56 per cent (Table I). Of those not leaving against medical advice, women were more likely than men to die

22,

No.

3,

1996

Table I. Outcome by sex*. Log review: Civil Hospital-Karachi, Bums unit, 1992-93 Died

Discharged

Total

LAMAt

Sex

No.

%

No.

%

No.

46

No.

%

Male Female

121 189

50 60

92 77

38 24

28 49

12 16

241 315

100 100

Total

310

56

169

30

77

14

556

100

*Of those who either likely than men to die were more likely than t Left against medical

l-19

20-39

Bum

severity

died or were discharged, women were more (P
40-59

(as % total body surface

al-79

80-100

acca bumed)

Figure I. Bum case fatality by severity and sex: Civil HospitalKarachi (November 1992 to October 1993). (71 per cent vs 57 per cent, RR= 1.25, 95 per cent CI = 1.09-1.44). Also, of those not dying in hospital, women were more likely than men to leave against medical advice (39 per cent vs 23 per cent, RR= 1.67, 95 per cent Cl = 1.13-2.46). Women were more severely burned than men: overall (57.0 per cent vs 49.5 per cent mean TBSA, P= 0.002) and among t-hose leaving against medical advice (42.3 per cent vs 32.7 per cent mean TBSA, P= 0.04). As expected, the CFR increased with severity as measured by TBSA quintiles. Among those with known outcome, the CFR was 5 per cent for < 20 per cent TBSA, 31 per cent for 20-39 per cenl TBSA, 64 per cent for 40-59 per cent, 88 per cent for 60-79 per cent TBSA and 99 per cent for > 80 per cent TBSA (Chi-square for linear trend = 197; P< 0.001). The overall CFR for major bums ( 2 20 per cent TBSA) was 70 per cent. There were no significant mortality differences by severity between sexes (Figure I). The overall CFR of 56 per cent was conservative, and assumed that all those leaving against medical advice survived. The final outcome of the 13.8 per cent who left against advice was, in fact, not known; however, they tended to be females (49177). Also these females were more extensively burned than their male counterparts leaving against advice. If they all died, the fatality ratio would have been 70 per cent. Applying the TBSA quintile-specific fatality ratios observed among patients with known outcome to those leaving against medical advice yielded an overall CFR of 62 per cent. Given fhat these two facilities handle most of Karachi’s hospitalized burned adults, an estimate of the public health burden due to bums can be derived. The annual mortality due to bums among adults 15-54 years of age was

Marsh et al.: Adult bums in Karachi

227

10.2/100000:6.8/100000 and 14.1/100000 formenand women, respectively. Additional financial and social costs included 6609 hospital days and 302 disfigured survivors overall, many of whom were likely to be disabled and possibly impoverished along with their families.

getfulness (leaving gas on), and perhaps injury proneness (previous bum). One patient with a seizure disorder had suffered an extensive previous bum also during a convulsion. Inexperience was a factor for one girl, who failed to close the stove’s pressure-release valve during her first pumping attempt. Several persons were injured when adding kerosene to an ignited stove or lantern, a practice that was prompted by lack of alternative illumination due to either power failures or insufficient electrification. Two patients were incapacitated due to convulsions from uncontrolled seizure disorders, and they had fallen into fires and were unable to extricate themselves. An additional six were unconscious and thereby suffering severe bums, The integrity of the equipment was in question in five cases (faulty gas line or stove wick). In at least five cases of burst pump stoves, there were no stove-pressure gauges. In all 11 cases involving stove flames, the stoves were placed at ground level thus creating two possible hazards. When the cook stooped to tend the stove or reached a shelf above it, his or her clothing came close to the flame. The time and place of occurrence was predominantly during the day and at home. The national dress consists of flammable, loose-fitting shZt.our and kameez (males and females), dupatta (females), sari (females) or dhoti (males). There were no smoke/fire detectors or extinguishers. The average time to extinguish the fire was 6 (SD 3) min. There was little knowledge of fire safety, no knowledge or practice of first aid, and no emergency medical transport system usage as the latter does not exist in Karachi.

Case series

Of the 59 patients admitted to the bum units during the study period, 10 died or left before they could be interviewed and two refused. The following analysis is restricted to the 47 on whom data were obtained. There were 19 males and 28 females of average age 30.8 and 26.5 years, respectively (NS). Unlike in the log review, there were no sex differences in bum severity (38 per cent TBSA for each group). Flames (70 per cent) and stove bursts (17 per cent) accounted for the majority of cases. Burst stoves caused the most severe bums (47 per cent TBSA) and hot objects the least (7 per cent TBSA). Flame injuries were of intermediate severity (34 per cent TBSA). Of the 33 flame bums, 11 involved stove flames; 11 involved flammable liquids, mainly kerosene, and six involved flammable gases. Stoves were ultimately responsible for 27 bums: through their normal flame (II), through catastrophic explosion (5), or through the unintentional ignition of their liquid (5) or gaseous (6) fuel outside the confines of the equipment itself. There was one case each of suspected attempted suicide and homicide and three cases of alleged assault with either acid or boiling water. Injury predominantly occurred in the home (38147). The females were mainly housewives or unmarried girl house workers (18 of 28 females). Males were divided among skilled workers (9), students (4) and other (6). The four workplace bums involved two episodes of assault and two mishaps with flammable liquid. Forty-two per cent of patients had had no formal schooling. The 12-cell Haddon matrix” (TiibleZI) was used to group prominent circumstances surrounding the most common bum injuries, those due to flames (33) and stove bursts (8). All cases had more than one factor. Human factors included lack of schooling, physical or mental disability, unawareness of a material’s flammability, for-

Discussion The profile of the typical hospitalized bum patient in this study was a young, uneducated woman, wearing loose clothing, injured in the kitchen, around a stove, who ignorant of fire safety, experienced prolonged contact with fire, received no first aid, was transported to the hospital in a common carrier, had 5 7 per cent TBSA burned, and died after 2 days. These bums were severe: we estimate that 62 per cent of admitted patients died. Women were more severely

Table II. Circumstances of bums due to flames and burst stoves (n = 41). Case seriesin two Karachi Bums Units (Nov.-Dec. Time

Human

factors

Pre-event

26 female 16 no schooling 17 (of 40) house worker 2 (of 34) unaware of flammable 4 disabled 2 left gas open 2 prior to burn

4 gas/fuel

Event

38 no fire safety 21 synthetic fabric 6 silk fabric 7 add kerosene to flame 2 incapacitated 1 first stove use

5 no stove gauge 1 bad stove wick

Post-event

33 no first aid 5 poor first aid 7 (of 40) unconscious 3 delayed hospitalization

EMS = emergency

medical

services.

Agent

factors leak

Physical Environment 37 home 33 daytime 7 one-room 6 electricity

factors

Sociocoltural environment median median

1993)

factors

household size: 6 income: Furl400

home failed

11 low stove 3 other burn victim 2 nearby flammables 0 fire/smoke alarms

33 shalwar kameez 16 dupatta 1 sari 4 dhoti 1 dupatta as potholder

0 EMS 23 taxi/van 12 ambulance 2 extensive fire 0 fire extinguisher

0 know first aid 4 extinguish with hands mean extinguish time: 6 min

228 burned than men, and they died disproportionately. The care women received once hospitalized was equivalent to that received by men, since there was no difference in mortality between sexes after controlling for bum severity. How serious is this problem? Comparative data from developing countries are rarely available, but the experience in the UK and Japan gives a perspective. In 1991, in the whole of UK and Japan, there were 23 and 35 deaths from bums to women between the ages of 15 and 34, respectivelyZz. Our log review of the one facility with outcome data yielded 164 deaths in a single year among women in this group who did not leave against medical advice. Our estimated bum-specific mortality rates per 100000 adult men and women (age 15-54 years) were eight and 39 times greater than the comparable UK and Japan 1991 rates of 0.84 and 0.36 per 100000, respectively. While bum-specific mortality rates cannot be definitely determined from facility-based data, our minimum estimated cause-specific annual adult mortality rate of 10.2/100 000 is high. Some patients may have come from outside the city, but they are likely to have been offset by uncounted fatalities among Karachi residents who never reached hospital care, who died in emergency wards, or who were admitted to one of the city’s 260 other hospitals without specialized bums units. Indeed, our estimate is consistent with the bum-specific rate of 15/100 000 in Bombay (1980) noted by Davies in his review of the problem of bums in India14. Furthermore. of adults hospitalized with bums at seven reporting facilities in India, 90 per cent were due to flames, two-thirds of which involved ignition of clothing from flaming kerosene usually following burst or knocked over stoves or lanterns. Data from the Office of the Registrar General, India presented in Murray et al.t3 highlight the importance of bums among adult women: in 1986 bum injuries caused 4.8 per cent of female and 1.0 per cent of male deaths among 15-54-year-old adults. Likewise, a 2-year case seriesz4 from Punjab, Pakistan reported that 17 of 51 total admissions for bums over 2 years involved stove bums to females of average age 21 years. In the 20 years since Durrani’s review* of 531 hospitalized bum patients at Civil Hospital in the early 197Os, the epidemiology of adult inpatient bums in Karachi has changed little. He reported that 65 per cent of patients were female (vs 60 per cent in our log review); the average percentage burn was 51 per cent (vs 54 per cent in log review); 41 per cent of victims were housewives (VS 45 per cent house workers in our interviewed patients); flames (63 per cent) and stoves (19 per cent) caused more bums (vs 70 per cent and 17 per cent in our interviewed patients); and 84 occurred at home (vs 81 per cent in our interviewed patients). There are some differences, however. Education has improved such that today only 47 per cent of victims in the case series had no schooling (vs 75 per cent in 1970s). On the other hand, this had no bearing on household response. Durrani noted that 14 per cent of patients received proper prehospitalization treatment (vs 2 per cent in case series). The greatest difference, however, involved outcome. Durrani reported a 24 per cent CFR (vs 56 per cent today) despite similar average severities. The present admission rate, 2.5 times that reported by Durrani, suggests that the health system may be overwhelmed by the numbers and severity of the cases. What is striking, however, is that

Bums: Vol. 22, No. 3, 1996 despite 20 years of development, the human suffering from bums appears unabated. This report has limitations:

1. It only considers

2.

3.

4.

5.

the experience of two facilities. Although they are believed to care for the majority of Karachi’s severely burned adults, there is no way of knowing without city-wide surveillance. Underreporting of attempted homicide or suicide was likely. Bums unit staff confided that death-bed anecdotes ultimately implicated foul-play in approximately 5 per cent of cases involving young women. A lengthy chart review in collaboration with hospital medicolegal officers could offer insight. Our case series was neither large nor random, nor did it include some of the most severe cases; however, the consistency of the retrospective log review with Durrani’s earlier findings support its general respresentativeness. The role of stove bursts may have been over-reported if the informant believed that such injuries would imply less negligence than those due to stove flames alone. However, the stove retains a central role. We have no reference group. But this descriptive study is a first step towards understanding the epidemiology of bums in our environment. Hypothesis testing studies will follow. Indeed, a LO-year literature search, 1984-94, failed to identify a single analytical study from the developing world. It would be interesting to hear others’ experience in studying risk factors for bums or bum severity, especially in South Asia.

‘The inability over 20 years to reduce the toll of bums demands fresh thinking. Given the extensive injuries incurred, additional bums units are unlikely to be as cost-effective as preventive measures.We have described common circumstancesin which bums occur. Additional research should analyse these and other possible risk factors. Bum units logs might be expanded to include the cause of bum, thereby allowing the calculation of a Bum Prevention Priority Index: {(bum severity due to cause A) x (fraction of bums due to cause A)}. Meanwhile, certain steps are worth considering a priori: fire safety (‘stop, drop and roV5, a bucket of sandin every kitchen; stove and lantern designs that preclude filling fuel reservoirs while lit; mandatory stove-pressure gauges; and dangerous agents painted red or marked with a culturally acceptable logo warning of flammability. More challenging steps,confronting culture and poverty, include higher placed stoves, safer clothing whilst cooking and first aid training.

Acknowledgement We would like to acknowledge the contribution of Dr Shahab Mahdi, Dr Kamran, Dr Faseehand Dr Aurangzeb of Abassi Shaheed Hospital; Dr Kaneez Fatima and Dr Ashraf Ganatra of Civil Hospital-Karachi; and Dr Joseph McCormick of Aga Khan University.

References 1 Murray CJL, Yang G, Qiao X. Adult mortality: levels, patternsandcauses. In: Feachem RGA, KjellstromT, Murray CJL, Over M, Phillips MA (eds)Health of Adults in the

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2 3

4 5 6

7

8 9 10

II

12

13

14

et al.: Adult

burns in Karachi

Developing World, New York: Oxford University Press, 1992; pp 3!?, 71. Handle Life with Care -prevent violence and negligence. Geneva: WH0/1/1993. Murray C]L, Yang G, Qiao X. Adult mortality: levels, patterns and causes. In: Feachem RGA, Kjellstrom T, Murray CJL, Over M, Phillips MA (eds) Health of Adults in the Developing World. New York: Oxford University Press, 1992; p 69. Durrani KM (ed). The Epidemiology of Burn Injuries. Karachi: Dow Medical College and Civil Hospital, 1974. Durrani KM. Incidence, Prevention, and Therapy of Burns. Karachi: Trade and Industry Publications, 1978. Bryant JH, Marsh DR, Khan KS, D’Souza RM, Husein K, Aslam A et al. A developing country university oriented toward health system development. Am 1 Pub Health 1993; 83: 1537-1.544. Marsh DR, Kadir M, Husein K, Siddiqui R, Khalid SB. Adult mortality in Karachi slums through community surveillance. 1 .Epidemiol Commun Health (submitted). Onuba 0, Udoidiok E. The problems and prevention ‘of bums in developing countries. Burns 1987; 13: 382-385. Courtright P, Haile D, Kohls E. The epidemiology of bums in rural Ethiopia. f Epidemiol Commun Health 1993;47: 19-22. Bang RL, Saif JKH. Mortality from bums in Kuwait. Burns 1989; 15: 315-321. Jamal YS, tirdawi MSM, Ashy AA, Merdad H, Shaik S14. Bum injuries in the Jeddah area of Saudi Arabia: a study Iof 319 cases. Burns 1989; 15: 295-298. Saleh S, Gadalla S, Fortney JA, Rogers SM, Potts DM. Accidental bum deaths to Egyptian women of reproductive age. Burns 1986; 12: 141-245. Subianto DB, Tumada LR, Margono SS. Bums and epileptic fits associated with cystercosis in mountain people of Irian Jaya. Trop Geograph Med 1978; 30: 275-278. Gupta RK, Srivastava AK. Study of fatal bums cases in Kanpur (India). Forens Sci Int 1988; 37: 81-89.

229 15 Datey S, Murthy NS, Taskar AD. A study of bum injury cases from three hospitals. Ind ] Pub Health 1981; 15: 117-124. 16 Davies JWL. The problem of burns in India. Burns 1990; (suppl I): Sl-S24. 17 Haddon W. Options for the prevention of motor vehicle crash injury. Isr J Med 1980; 16: 45-68. 18 United Nations, Population Division, Department for Economic and Social Information and Policy Analysis, ST/ESA/SER.A/147, Urban Agglomerations. New York: 1994. 19 Pakistan Statistical Yearbook 1986. Karachi: Federal Bureau of Statistics, Government of Pakistan, 1989; p II. 20 Dean AC, Dean JA, Burton AH, Dicker RC. @i-Info, version 5: a word processing database, and statistics program for epidemiology on microcompukrs. Stone Mountain, GA, 1990. 21 Schlesselman JJ. Case-control Studies. New York: Oxford University Press, 1982; pp 203-206. 22 World Health Statistics Annual 1992. Geneva: WHO, 1993; pp D-311, D-333. 23 Murray CJL, Yang G, Qiao X. Adult mortality: levels, patterns and causes. In: Feachem RGA, Kjellstram T, Murray CJL, Over M, Phillips MA (eds). Health of Adults in the Developing World. New York: Oxford University Press, 1992; u 81. 24 Zafar A, Cheema K, Latif S, Ahmed M. Fatal bum injury in females: oil stove is the main culprit. Rawal Med 11993; 21: 12-13. 25 Injury prevention: meeting the challenge. Am ] Prevent Med 1989; S(supp1): 154. Paper accepted

after revision

28 July 1995.

Correspondence should be addressed to: Dr David R. Marsh, Save the Children Federation (USA), 54 Wilton Road, Westport, CT 06880, USA.