- Email: [email protected]
Pediatric burns in Israeli natives versus asylum seekers living in Israel: Lessons learned
burns 44 (2018) 1322 –1329
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Pediatric burns in Israeli natives versus asylum seekers living in Israel: Lessons learned Sivan Zissman 1 , Matan Orgil 1 , Oded Ben-Amotz, Eyal Gur, Ehud Arad, David Leshem * Pediatric & Craniofacial Plastic Surgery Unit, Department of Plastic and Reconstructive Surgery, Tel-Aviv Sourasky Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
article info
abstract
Article history:
Background: Burn injuries are one of the leading causes of morbidity and mortality in the
Accepted 22 February 2018
pediatric population. In early childhood, burns have a wide range of adverse long-term consequences ranging from functional impairment to psychological implications. Children from low-income and middle-income countries are at a higher risk of suffering from
Keywords:
burn injuries. In the last 10 years the population of asylum seekers from low-income
Burn injuries
countries in Israel has increased dramatically.
Pediatric population
About 25,000 or 60% of asylum seekers are living in the Tel Aviv area, making up roughly 6% of
Israeli native
the city’s total population (about 405,000).
Asylum seekers gender
Aim: A retrospective study aimed to profile the pediatric burn injuries treated at the Tel Aviv
Casualty
Sourasky Medical Center over the last 9 years in an effort to examine the distinct characteristics
Total body surface area (TBSA)
of African asylum seekers who suffer burn injuries in comparison with Israeli nationals.
Depth of burn and patient outcome
Patients & Methods: Medical records of 876 patients under the age of 18 years presenting
Hospitality stay & rate
between 2007–2015 were retrospectively reviewed. The parameters collected included gender, causality, total body surface area (TBSA), burn depth and patient outcome. Conclusions: There was no significant difference regarding: age; male-female ratio; scaldtypes burns; limb involvement. However, hospitalization and length of hospital stay were significantly higher among asylum seekers, as was family burden. Questions may be raised regarding prevention, education & social support. Our research provides a small glimpse into the world of asylum seekers in Israel. We hope it will serve as a window into the much grander problems that this population faces on a daily basis. © 2018 Published by Elsevier Ltd.
1.
Introduction
Burn injuries are one of the leading causes of morbidity and mortality in the pediatric population [1]. Every day, more than
300 children ages 0–19 are treated in emergency rooms for burn-related injuries and two children die as a result of being burned in the United States alone [2].
* Corresponding author at: Pediatric & Craniofacial Plastic Surgery Unit, Department of Plastic and Reconstructive Surgery, Tel Aviv Sourasky Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, 6 Weizmann Street, Tel Aviv 64239, Israel. E-mail address: [email protected] (D. Leshem). 1 Denotes equal contributors. https://doi.org/10.1016/j.burns.2018.02.027 0305-4179/© 2018 Published by Elsevier Ltd.
burns 44 (2018) 1322 –1329
Young children are more prone to burns for a variety of reasons, among them: total dependence of adults, inability to comprehend potential danger and lack of preventive education [3,4]. In early childhood in particular, burns can have a wide range of adverse long-term consequences ranging from functional impairment to psychological and social issues [5]. The younger the age of a child at the time of injury, the greater the effect later on [6]. Studies performed around the world show that pediatric burns occur more frequently in developing countries, and are more prevalent among children from low-to middle-income countries [7]. While Israel is a first-world country, over the past ten years, the number of asylum seekers living here has been rising steadily [8]. As of April of 2016, there were 42,147 refugees and asylum seekers living in Israel, of which 92% are from Eritrea or Sudan (30,595 and 8232 respectively). Roughly 25,000 or 60% of asylum seekers are living in Tel Aviv area, making up 6% of the city’s total population (about 405,000) [9]. Growing numbers of African natives were forced to leave their homes and their countries to seek asylum in Israel due to local persecution, civil war, and genocide, among other things [10]. Research from around the world has identified several socioeconomic risk factors that might explain the increased incidence of burns in groups of lower socio-economic status, among them: low rate of literacy within the family, overcrowded living conditions, poor supervision of children, a lack of laws and regulations relating to building codes, low prevalence of smoke detectors and wearing of flammable clothing [10]. The objective of our study was to provide recent epidemiological data on pediatric burn injuries at our institution over the last decade in order to identify characteristics unique to asylum seekers in comparison with Israeli nationals in order to improve to prevention, education and social support.
2.
1323
Patients and Methods
A retrospective review was performed of all pediatric patients who sustained acute burn injuries from 2007 to 2015. The inclusion criteria were patients aged 0–18 who sought medical treatment due to burn injuries at the Tel-Aviv Sourasky Medical Center. The clinical data collected focused on patient age, gender, casualty, degree of burn, area of impact, total body surface area (TBSA), number of admissions and duration of hospitalization. The demographics and clinical data were compared between the Israeli natives and asylum seekers.
3.
Results
We identified 876 patients, of which 792 were Israeli natives and 84 were asylum seekers, ranging in age from 0 to 18 years who were admitted to the Tel Aviv Sourasky Medical Center. We categorized the data into five age groups; Fig. 1. The majority of the patients who sustained burn injuries were between the ages of 0–4 years old. 82% (n = 69 out of 84) of the injuries among asylum seekers and 46% (n = 365 out of 792) of the injuries among native Israelis at the time of admission. Another peak appeared among native Israelis between the ages of 16-18 years old, with 20% of the injuries (n = 160 out of 792). There were more males than females who sustained burn injuries, however the gender distribution between the groups was very similar. The number of incidents among the asylum seekers was 56% (n=47) males and 44% (n=37) females, and among native Israelis it was 55%(n=433) and 45% (n=359), respectively.
Fig. 1 – Age Distribution.
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burns 44 (2018) 1322 –1329
Fig. 2 – Etiology of burn.
The mechanism of injury included nine main categories: bathing (2 cases), chemicals (24 cases), open flames (29 cases), heating devices (15 cases), hot objects (152 cases), spilled hot substance (547 cases), sun (22 cases), electricity (2 cases) and unknown (83 cases). Similarly, in our study the primary cause of injury was the spilling of hot liquids, making up 73% in the asylum seekers group and 62% in the native group. Contact with hot objects were the second leading cause of burns, causing about 19% in the native group and about 6% of the cases in the asylum seekers group. Both the spilled hot substance and contact with hot objects concluded 80% of total injuries. Comparison
characteristics between the native and asylum seekers are summarized in Fig. 2. Burns are classified according to the depth of tissue injury: superficial or epidermal (first-degree), partial-thickness (second degree), full thickness (third degree), and burns extending beneath the subcutaneous tissues and involving fascia, muscle and/or bone (fourth degree). The majority of burns identified in our patient populations were second degree: about 80% (n=67) of the cases in the asylum seekers group and about 64% (n=505) in the native group. The large number of second degree burns correlates with the leading cause, spilled hot substances, and its
Fig. 3 – Burn Extent.
burns 44 (2018) 1322 –1329
1325
Fig. 4 – Total percentage of body surface area.
mechanism of damage to the tissue. The comparison is shown on Fig. 3. The extent of burns is expressed as the total percentage of body surface area (TBSA) calculated based on Wallace rule of nines [11]. We divided the data into six categories: 0%–2%; 2%– 4%; 4%–6%; 6%–8%; 8%–10%; >10%. Most of the burns in both groups covered between 0%–4% of the total body surface, about 34% of the native cases and about 52% of the asylum seekers cases. 460 cases in the native group and 23 cases in the asylum seekers group were excluded from our study due to lack of sufficient data. The comparison is shown in Fig. 4. The most common burn areas were the upper limbs, lower limbs, chest, and face respectively. Most of the burns were to
the extremities, which were involved in 68% of the native group and 45% in the asylum seekers group. The four main burn areas were involved in 94% of the native burns incidence and 72% of the asylum group cases. The comparison is shown in Fig. 5. Our findings demonstrated that the hospitalization rate at our center among the native Israeli patients was 19% (n=149) in comparison with a hospitalization rate of 35% (n=29) among asylum seekers (p=0.63; chi-square test). While this result was not statistically significant, the relatively small number of asylum seekers seeking treatment for pediatric burn injuries was a limiting factor statistically. The trend, however, remains, and continued monitoring of the rate of hospitalization in this unique population may prove to offer statistically
Fig. 5 – Burn area.
1326
burns 44 (2018) 1322 –1329
Fig. 6 – Hospitalization Rate.
significant results in the long term. Despite the lack of clear statistical significance, the nearly double rate of hospitalization among asylum seekers indicates the presence of an alarming trend that may be attributed to the general lack of community services for this unique population. The comparison is shown in Fig. 6. In our evaluation of the relative durations of hospital stays among our two study groups, the hospitalization duration was statistically significantly longer in the asylum group, with an average hospital stay of 5.5days in comparison with an average of 2.4days of hospitalization among patients in the native group (SD 6.5; 5.6; p=0.004; chi-square test). Comparison data is shown in Fig. 7. Much like the elevated rate of hospitalization among asylum seekers, the statistically
significant increase in total number of days of hospitalization may be representative of the limited access to communitybased health services for asylum seekers. The repercussions of this finding include loss of work and therefore loss of income among parents of these children, something that can have serious, long-term impact on the children and the families as a whole. Efforts to reduce this discrepancy may require multidisciplinary involvement, including social services, and improved access to medical care in the community. According to the data we gathered there was an increase in total number of cases and hospitalization since the year of 2012. In the native group, the distribution is quite similar and the rise may be explained by increased awareness. However, in the asylum seekers the rise is more significant and may be
Fig. 7 – Hospitalization Duration.
burns 44 (2018) 1322 –1329
1327
Fig. 8 – Distribution of cases by years among the Natives group.
Fig. 9 – Distribution of cases by years among the Asylum seekers group.
explained by increased immigration in the recent years. The comparison data is shown in Figs. 8 and 9. Analysis of the data regarding seasonal distribution did not show any significant changes between summer and winter. Moreover long-term outcome is missing due to loss of follow-up.
4.
Discussion
The increasing numbers of asylum seekers in Israel has generated a growing number of admissions in our hospital for a range of diagnoses. It is important to keep in mind that
although the number of asylum seekers has increased they still make up only a small percentage of Tel Aviv population (6%) though they represent about 10% of the burn cases between the years of 2007–2015. The majority of asylum seekers arrived in Israel between 2006 and 2012, with a peak from 2010 to 2012 [12]. In 2010, Israel began building a border wall along sections of its border with Egypt to reduce the influx of refugees from African countries. Construction was completed in January 2013 resulting in a dramatic decrease in illegal immigrations into Israel [13]. Despite this change, our study did not demonstrate any linear correlation between the population influx rate and the rate of hospitalization for pediatric burn injuries in this population.
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burns 44 (2018) 1322 –1329
In Israel, where healthcare and education are public services provided by the government, lack of documentation (which can be difficult for refugees to procure) can preclude appropriate designation of resources. As a result, there has been a particularly alarming trend, which made national news in 2015 when five young refugee children died due to overcrowding in refugee daycares. The facilities are undocumented and most often fail to adhere to the most basic requirements of childcare facilities established by the Municipality and the Ministry of Health. An investigation into the matter revealed sub-par conditions, often with a 40-to-1 ratio of children under the age of 2 to caregivers [14]. With untrained staff, overcrowding, and unsanitary conditions, these facilities are both a breeding ground for illness and potential trauma, as well as an indication of the socioeconomic stress this population faces. It is important to note that our medical center does not have an official burn unit. Still, minor burn injuries are treated at our facility. These include partial thickness burns of more than 23% TBSA, full thickness burns, burns involving the face, hands, feet, genitalia and electrical burns. Worldwide, scald injuries account for 60–80% of burn injuries among young children [15–17]. In our comparison of burn characteristics between natives and asylum seekers, we found that both populations were similar with regards to most variables — gender distribution, scald-type burns, second degree was the majority of injuries and limbs are the most commonly burned area. We did, however find some differences in the following parameters: In both groups, the highest risk age for burn injuries was between 0–4 years old, while in the native group there was another peak between the ages of 16–18 years old. This data may be explained by the high socioeconomic status among native Israelis, who typically enjoy direct access to medical care and medical facilities in comparison with asylum seekers who often do not seek medical treatment due to lack of insurance and low socioeconomic status. While many of the parameters we examined bore limited significance due to relatively small numbers of patients, there was a clear trend of increased hospitalization and length of hospital stay among asylum seekers in comparison with native Israelis. Efforts to explain this using medical reasoning (e.g. more severe burns or burn injuries requiring longer hospital care) failed to prove fruitful. Instead, we looked at socio-economic factors that might contribute to our findings. The asylum seekers suffer from a low socioeconomic status that increase their risk of burns and decrease their chance of having access to a satisfactory environment for healthy recovery outside the hospital setting [18]. They usually do not have health insurance and they cannot afford to sacrifice time or money required to gain access to adequate treatment for burn injuries outside the hospital setting. It is reasonable to believe that burns that could easily be treated at home are treated in the hospital when the patients are children of asylum seekers. Those reasons along with their crowded residential area and poor living conditions can result in the need for more hospitalization and a longer duration of stay in the hospital [19]. This may correlate with poverty and an unsafe domestic environment. Parents of children who suffer seemingly minor burn injuries that would otherwise require at-home care only after
an emergency room visit do not have the resources or the time to stay at home with their children and care for them, and certainly cannot afford private childcare for the duration of the child’s invalidity. Hospitalization is therefore likely a compassionate measure to assist these families. The long term benefit of this sort of expense, however, is questionable, and there is little doubt that reallocation of resources to improve childcare conditions would likely more drastically help these children than longer, unnecessary hospital stays. Efforts to improve the conditions for asylum seekers and their children in Israel are widespread and include the TEREM Public Health Clinic — a humanitarian clinic located in South Tel Aviv staffed with healthcare workers, many of whom are volunteers, as well as translators, in an effort to improve health care as well as health education in the refugee population [20]. In addition, Unitaf, which is supported by the Tel Aviv Municipality, has received extensive public grants and private donations over the past few years in order to provide day care and after-school programs for children from the refugee population. Despite their efforts, however, the problems are still rampant and require more attention [14]. This information raises questions regarding future prevention, education and social support for this at-risk population. One method for prevention may be family physician qualification in order to offer better treatment and follow-up outside the hospital setting. It is clear to us that efforts to improve healthcare in this unique population must begin with population education in order to implement preventative measures and avoid injury whenever possible. In addition, provision of translation services may likely improve at-home care significantly, allowing for shorter hospital stays and less detriment to the income on which this population so heavily relies.
5.
Study limitations
There are a number of limitations to our study. First, the number of asylum seekers with burns is relatively lower compared to the number of Israeli natives with burn injuries. This can, of course, be explained by the relatively small population of asylum seekers in comparison with the number of native Israelis living in the Tel Aviv area. In addition, the fact that many asylum seekers do not have medical insurance likely prevents them from seeking treatment at the hospital, particularly for illegal immigrants who fear legal repercussions and deportation. Another limitation to our study is the lack of follow-up care among members of the asylum-seeking population as they rarely, if ever, return for follow-ups at the clinic. This can be explained by lack of adaptive communication and language barriers, as well as insurances issues.
6.
Conclusion
Israel is facing a new reality in which growing numbers of asylum seekers settle in an already heavily populated area. This population has different cultural, environmental and socioeconomic status and suffers from lack of proper safety education, which may subject them to a higher risk of burns. Although the asylum seekers represent just 6% of the population of Tel Aviv,
burns 44 (2018) 1322 –1329
we found that they represent 10% of the pediatric burn victims. While the burn characteristics were similar between the two groups we examined, there was a trend towards higher hospitalization rate and duration of stay among the asylum seekers. If anything, this highlights the need for implementation of measures for prevention, education, and accessible and affordable treatment in this high-risk population. Our research provides a small glimpse into the world of asylum seekers in Israel. We hope it will serve as a window into the much bigger problems that this population faces as they struggle to raise their children in a foreign environment.
Conflict of interest The authors declare that they have no conflict of interest. REFERENCES
[1] Peden M. World report on child injury prevention addresses burn prevention. Burns 2009;35(6):907–8. [2] National Center for Injury Preventions and Control. https:// www.cdc.gov/safechild/burns/index.html. [3] Ojo P, Palmer J, Garvey R, Atweh N, Fidler P. Pattern of burns in child abuse. Am Surg 2007;73:253–5. [4] Lindblad BE, Terkelsen CJ. Domestic burns among children. Burns 1990;16:254–6. [5] Bakker A, Maertens K, Van Son M, Van Loey N. Psychological consequences of pediatric burns from a child and family perspective: a review of the empirical literature. Clin Psychol Rev 2013;33(3):361–71. [6] Werneck GL, Reichenheim ME. Paediatric burns and associated risk factors in Rio de Janeiro, Brazil. Burns 1997;23:478–83. [7] Forjuoh S. Burns in low- and middle-income countries: review of available literature on descriptive epidemiology, risk factors, treatment, and prevention. Burns 2006;32(5):529–37.
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[8] Home | ASSAF — Aid Organization for Refugees and Asylum Seekers in Israel [Internet]. 2017 Assaf.org.il. Available from: http://assaf.org.il/en/node/2. [Cited 22 March 2017]. [9] The geographical distribution of infiltrators and asylum seekers in Israel. Knesset, Israel: Information and research center; 2012 Available from: https://www.knesset.gov.il/ mmm/data/pdf/m03052.pdf. [10] Delgado J. Risk factors for burns in children: crowding, poverty, and poor maternal education. Inj Prev 2002;8(1):38–41. [11] Carlsson A, Udén G, Håkansson A, Karlsson ED. Burn injuries in small children, a population-based study in Sweden. J Clin Nurs 2006;15(2):129. [12] Data regarding illegal aliens in Israel. Ministry of Population and Immigration; 2017. p. 1–12 April. https://web.archive.org/ web/20170608194739/https://www.gov.il/BlobFolder/reports/ foreign_workers_report_q1_2017/he/ foreign_workers_stats_q1_2017.pdf. [13] Israel completes bulk of Egypt border fence. Reuters; 2013 [Retrieved 2 January 2013]. [14] David Ariel. Who Will Save the Refugee Children of Tel Aviv? Haaretz.com. 10 Jan., www.haaretz.com/israel-news/. premium-1.650425. [15] Tse T, Poon CH, Tse KH, Tsui TK, Ayyappan T, Burd A. Paediatric burn prevention: an epidemiological approach. Burns 2006;32(2):299. [16] Al-Shehri M. The pattern of paediatric burn injuries in Southwestern, Saudi Arabia. West Afr J Med 2004;23(4):294. [17] Monafo. Initial management of burns. N Engl J Med 1996;335 (21)1581 Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA. [18] Reimers A, Laflamme L. Neighborhood social and socioeconomic composition and injury risks. Acta Paediatr 2007;94 (10):1488–94. [19] Peck M. Epidemiology of burns throughout the world. Part I: distribution and risk factors. Burns 2011;37(7):1087–100. [20] Center – The Humanitarian Clinic: For Patients Who Do Not Have Official Standing (Not for Tourists). Emergency Medical Centers – “Terem Lev El Lev”, TEREM, www.terem.com/ ClinicID.aspx?TeremClinicId=21&teremRegionId=5&lang=2.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Pediatric burns in Israeli natives versus asylum seekers living in Israel: Lessons learned Sivan Zissman 1 , Matan Orgil 1 , Oded Ben-Amotz, Eyal Gur, Ehud Arad, David Leshem * Pediatric & Craniofacial Plastic Surgery Unit, Department of Plastic and Reconstructive Surgery, Tel-Aviv Sourasky Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
article info
abstract
Article history:
Background: Burn injuries are one of the leading causes of morbidity and mortality in the
Accepted 22 February 2018
pediatric population. In early childhood, burns have a wide range of adverse long-term consequences ranging from functional impairment to psychological implications. Children from low-income and middle-income countries are at a higher risk of suffering from
Keywords:
burn injuries. In the last 10 years the population of asylum seekers from low-income
Burn injuries
countries in Israel has increased dramatically.
Pediatric population
About 25,000 or 60% of asylum seekers are living in the Tel Aviv area, making up roughly 6% of
Israeli native
the city’s total population (about 405,000).
Asylum seekers gender
Aim: A retrospective study aimed to profile the pediatric burn injuries treated at the Tel Aviv
Casualty
Sourasky Medical Center over the last 9 years in an effort to examine the distinct characteristics
Total body surface area (TBSA)
of African asylum seekers who suffer burn injuries in comparison with Israeli nationals.
Depth of burn and patient outcome
Patients & Methods: Medical records of 876 patients under the age of 18 years presenting
Hospitality stay & rate
between 2007–2015 were retrospectively reviewed. The parameters collected included gender, causality, total body surface area (TBSA), burn depth and patient outcome. Conclusions: There was no significant difference regarding: age; male-female ratio; scaldtypes burns; limb involvement. However, hospitalization and length of hospital stay were significantly higher among asylum seekers, as was family burden. Questions may be raised regarding prevention, education & social support. Our research provides a small glimpse into the world of asylum seekers in Israel. We hope it will serve as a window into the much grander problems that this population faces on a daily basis. © 2018 Published by Elsevier Ltd.
1.
Introduction
Burn injuries are one of the leading causes of morbidity and mortality in the pediatric population [1]. Every day, more than
300 children ages 0–19 are treated in emergency rooms for burn-related injuries and two children die as a result of being burned in the United States alone [2].
* Corresponding author at: Pediatric & Craniofacial Plastic Surgery Unit, Department of Plastic and Reconstructive Surgery, Tel Aviv Sourasky Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, 6 Weizmann Street, Tel Aviv 64239, Israel. E-mail address: [email protected] (D. Leshem). 1 Denotes equal contributors. https://doi.org/10.1016/j.burns.2018.02.027 0305-4179/© 2018 Published by Elsevier Ltd.
burns 44 (2018) 1322 –1329
Young children are more prone to burns for a variety of reasons, among them: total dependence of adults, inability to comprehend potential danger and lack of preventive education [3,4]. In early childhood in particular, burns can have a wide range of adverse long-term consequences ranging from functional impairment to psychological and social issues [5]. The younger the age of a child at the time of injury, the greater the effect later on [6]. Studies performed around the world show that pediatric burns occur more frequently in developing countries, and are more prevalent among children from low-to middle-income countries [7]. While Israel is a first-world country, over the past ten years, the number of asylum seekers living here has been rising steadily [8]. As of April of 2016, there were 42,147 refugees and asylum seekers living in Israel, of which 92% are from Eritrea or Sudan (30,595 and 8232 respectively). Roughly 25,000 or 60% of asylum seekers are living in Tel Aviv area, making up 6% of the city’s total population (about 405,000) [9]. Growing numbers of African natives were forced to leave their homes and their countries to seek asylum in Israel due to local persecution, civil war, and genocide, among other things [10]. Research from around the world has identified several socioeconomic risk factors that might explain the increased incidence of burns in groups of lower socio-economic status, among them: low rate of literacy within the family, overcrowded living conditions, poor supervision of children, a lack of laws and regulations relating to building codes, low prevalence of smoke detectors and wearing of flammable clothing [10]. The objective of our study was to provide recent epidemiological data on pediatric burn injuries at our institution over the last decade in order to identify characteristics unique to asylum seekers in comparison with Israeli nationals in order to improve to prevention, education and social support.
2.
1323
Patients and Methods
A retrospective review was performed of all pediatric patients who sustained acute burn injuries from 2007 to 2015. The inclusion criteria were patients aged 0–18 who sought medical treatment due to burn injuries at the Tel-Aviv Sourasky Medical Center. The clinical data collected focused on patient age, gender, casualty, degree of burn, area of impact, total body surface area (TBSA), number of admissions and duration of hospitalization. The demographics and clinical data were compared between the Israeli natives and asylum seekers.
3.
Results
We identified 876 patients, of which 792 were Israeli natives and 84 were asylum seekers, ranging in age from 0 to 18 years who were admitted to the Tel Aviv Sourasky Medical Center. We categorized the data into five age groups; Fig. 1. The majority of the patients who sustained burn injuries were between the ages of 0–4 years old. 82% (n = 69 out of 84) of the injuries among asylum seekers and 46% (n = 365 out of 792) of the injuries among native Israelis at the time of admission. Another peak appeared among native Israelis between the ages of 16-18 years old, with 20% of the injuries (n = 160 out of 792). There were more males than females who sustained burn injuries, however the gender distribution between the groups was very similar. The number of incidents among the asylum seekers was 56% (n=47) males and 44% (n=37) females, and among native Israelis it was 55%(n=433) and 45% (n=359), respectively.
Fig. 1 – Age Distribution.
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burns 44 (2018) 1322 –1329
Fig. 2 – Etiology of burn.
The mechanism of injury included nine main categories: bathing (2 cases), chemicals (24 cases), open flames (29 cases), heating devices (15 cases), hot objects (152 cases), spilled hot substance (547 cases), sun (22 cases), electricity (2 cases) and unknown (83 cases). Similarly, in our study the primary cause of injury was the spilling of hot liquids, making up 73% in the asylum seekers group and 62% in the native group. Contact with hot objects were the second leading cause of burns, causing about 19% in the native group and about 6% of the cases in the asylum seekers group. Both the spilled hot substance and contact with hot objects concluded 80% of total injuries. Comparison
characteristics between the native and asylum seekers are summarized in Fig. 2. Burns are classified according to the depth of tissue injury: superficial or epidermal (first-degree), partial-thickness (second degree), full thickness (third degree), and burns extending beneath the subcutaneous tissues and involving fascia, muscle and/or bone (fourth degree). The majority of burns identified in our patient populations were second degree: about 80% (n=67) of the cases in the asylum seekers group and about 64% (n=505) in the native group. The large number of second degree burns correlates with the leading cause, spilled hot substances, and its
Fig. 3 – Burn Extent.
burns 44 (2018) 1322 –1329
1325
Fig. 4 – Total percentage of body surface area.
mechanism of damage to the tissue. The comparison is shown on Fig. 3. The extent of burns is expressed as the total percentage of body surface area (TBSA) calculated based on Wallace rule of nines [11]. We divided the data into six categories: 0%–2%; 2%– 4%; 4%–6%; 6%–8%; 8%–10%; >10%. Most of the burns in both groups covered between 0%–4% of the total body surface, about 34% of the native cases and about 52% of the asylum seekers cases. 460 cases in the native group and 23 cases in the asylum seekers group were excluded from our study due to lack of sufficient data. The comparison is shown in Fig. 4. The most common burn areas were the upper limbs, lower limbs, chest, and face respectively. Most of the burns were to
the extremities, which were involved in 68% of the native group and 45% in the asylum seekers group. The four main burn areas were involved in 94% of the native burns incidence and 72% of the asylum group cases. The comparison is shown in Fig. 5. Our findings demonstrated that the hospitalization rate at our center among the native Israeli patients was 19% (n=149) in comparison with a hospitalization rate of 35% (n=29) among asylum seekers (p=0.63; chi-square test). While this result was not statistically significant, the relatively small number of asylum seekers seeking treatment for pediatric burn injuries was a limiting factor statistically. The trend, however, remains, and continued monitoring of the rate of hospitalization in this unique population may prove to offer statistically
Fig. 5 – Burn area.
1326
burns 44 (2018) 1322 –1329
Fig. 6 – Hospitalization Rate.
significant results in the long term. Despite the lack of clear statistical significance, the nearly double rate of hospitalization among asylum seekers indicates the presence of an alarming trend that may be attributed to the general lack of community services for this unique population. The comparison is shown in Fig. 6. In our evaluation of the relative durations of hospital stays among our two study groups, the hospitalization duration was statistically significantly longer in the asylum group, with an average hospital stay of 5.5days in comparison with an average of 2.4days of hospitalization among patients in the native group (SD 6.5; 5.6; p=0.004; chi-square test). Comparison data is shown in Fig. 7. Much like the elevated rate of hospitalization among asylum seekers, the statistically
significant increase in total number of days of hospitalization may be representative of the limited access to communitybased health services for asylum seekers. The repercussions of this finding include loss of work and therefore loss of income among parents of these children, something that can have serious, long-term impact on the children and the families as a whole. Efforts to reduce this discrepancy may require multidisciplinary involvement, including social services, and improved access to medical care in the community. According to the data we gathered there was an increase in total number of cases and hospitalization since the year of 2012. In the native group, the distribution is quite similar and the rise may be explained by increased awareness. However, in the asylum seekers the rise is more significant and may be
Fig. 7 – Hospitalization Duration.
burns 44 (2018) 1322 –1329
1327
Fig. 8 – Distribution of cases by years among the Natives group.
Fig. 9 – Distribution of cases by years among the Asylum seekers group.
explained by increased immigration in the recent years. The comparison data is shown in Figs. 8 and 9. Analysis of the data regarding seasonal distribution did not show any significant changes between summer and winter. Moreover long-term outcome is missing due to loss of follow-up.
4.
Discussion
The increasing numbers of asylum seekers in Israel has generated a growing number of admissions in our hospital for a range of diagnoses. It is important to keep in mind that
although the number of asylum seekers has increased they still make up only a small percentage of Tel Aviv population (6%) though they represent about 10% of the burn cases between the years of 2007–2015. The majority of asylum seekers arrived in Israel between 2006 and 2012, with a peak from 2010 to 2012 [12]. In 2010, Israel began building a border wall along sections of its border with Egypt to reduce the influx of refugees from African countries. Construction was completed in January 2013 resulting in a dramatic decrease in illegal immigrations into Israel [13]. Despite this change, our study did not demonstrate any linear correlation between the population influx rate and the rate of hospitalization for pediatric burn injuries in this population.
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In Israel, where healthcare and education are public services provided by the government, lack of documentation (which can be difficult for refugees to procure) can preclude appropriate designation of resources. As a result, there has been a particularly alarming trend, which made national news in 2015 when five young refugee children died due to overcrowding in refugee daycares. The facilities are undocumented and most often fail to adhere to the most basic requirements of childcare facilities established by the Municipality and the Ministry of Health. An investigation into the matter revealed sub-par conditions, often with a 40-to-1 ratio of children under the age of 2 to caregivers [14]. With untrained staff, overcrowding, and unsanitary conditions, these facilities are both a breeding ground for illness and potential trauma, as well as an indication of the socioeconomic stress this population faces. It is important to note that our medical center does not have an official burn unit. Still, minor burn injuries are treated at our facility. These include partial thickness burns of more than 23% TBSA, full thickness burns, burns involving the face, hands, feet, genitalia and electrical burns. Worldwide, scald injuries account for 60–80% of burn injuries among young children [15–17]. In our comparison of burn characteristics between natives and asylum seekers, we found that both populations were similar with regards to most variables — gender distribution, scald-type burns, second degree was the majority of injuries and limbs are the most commonly burned area. We did, however find some differences in the following parameters: In both groups, the highest risk age for burn injuries was between 0–4 years old, while in the native group there was another peak between the ages of 16–18 years old. This data may be explained by the high socioeconomic status among native Israelis, who typically enjoy direct access to medical care and medical facilities in comparison with asylum seekers who often do not seek medical treatment due to lack of insurance and low socioeconomic status. While many of the parameters we examined bore limited significance due to relatively small numbers of patients, there was a clear trend of increased hospitalization and length of hospital stay among asylum seekers in comparison with native Israelis. Efforts to explain this using medical reasoning (e.g. more severe burns or burn injuries requiring longer hospital care) failed to prove fruitful. Instead, we looked at socio-economic factors that might contribute to our findings. The asylum seekers suffer from a low socioeconomic status that increase their risk of burns and decrease their chance of having access to a satisfactory environment for healthy recovery outside the hospital setting [18]. They usually do not have health insurance and they cannot afford to sacrifice time or money required to gain access to adequate treatment for burn injuries outside the hospital setting. It is reasonable to believe that burns that could easily be treated at home are treated in the hospital when the patients are children of asylum seekers. Those reasons along with their crowded residential area and poor living conditions can result in the need for more hospitalization and a longer duration of stay in the hospital [19]. This may correlate with poverty and an unsafe domestic environment. Parents of children who suffer seemingly minor burn injuries that would otherwise require at-home care only after
an emergency room visit do not have the resources or the time to stay at home with their children and care for them, and certainly cannot afford private childcare for the duration of the child’s invalidity. Hospitalization is therefore likely a compassionate measure to assist these families. The long term benefit of this sort of expense, however, is questionable, and there is little doubt that reallocation of resources to improve childcare conditions would likely more drastically help these children than longer, unnecessary hospital stays. Efforts to improve the conditions for asylum seekers and their children in Israel are widespread and include the TEREM Public Health Clinic — a humanitarian clinic located in South Tel Aviv staffed with healthcare workers, many of whom are volunteers, as well as translators, in an effort to improve health care as well as health education in the refugee population [20]. In addition, Unitaf, which is supported by the Tel Aviv Municipality, has received extensive public grants and private donations over the past few years in order to provide day care and after-school programs for children from the refugee population. Despite their efforts, however, the problems are still rampant and require more attention [14]. This information raises questions regarding future prevention, education and social support for this at-risk population. One method for prevention may be family physician qualification in order to offer better treatment and follow-up outside the hospital setting. It is clear to us that efforts to improve healthcare in this unique population must begin with population education in order to implement preventative measures and avoid injury whenever possible. In addition, provision of translation services may likely improve at-home care significantly, allowing for shorter hospital stays and less detriment to the income on which this population so heavily relies.
5.
Study limitations
There are a number of limitations to our study. First, the number of asylum seekers with burns is relatively lower compared to the number of Israeli natives with burn injuries. This can, of course, be explained by the relatively small population of asylum seekers in comparison with the number of native Israelis living in the Tel Aviv area. In addition, the fact that many asylum seekers do not have medical insurance likely prevents them from seeking treatment at the hospital, particularly for illegal immigrants who fear legal repercussions and deportation. Another limitation to our study is the lack of follow-up care among members of the asylum-seeking population as they rarely, if ever, return for follow-ups at the clinic. This can be explained by lack of adaptive communication and language barriers, as well as insurances issues.
6.
Conclusion
Israel is facing a new reality in which growing numbers of asylum seekers settle in an already heavily populated area. This population has different cultural, environmental and socioeconomic status and suffers from lack of proper safety education, which may subject them to a higher risk of burns. Although the asylum seekers represent just 6% of the population of Tel Aviv,
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we found that they represent 10% of the pediatric burn victims. While the burn characteristics were similar between the two groups we examined, there was a trend towards higher hospitalization rate and duration of stay among the asylum seekers. If anything, this highlights the need for implementation of measures for prevention, education, and accessible and affordable treatment in this high-risk population. Our research provides a small glimpse into the world of asylum seekers in Israel. We hope it will serve as a window into the much bigger problems that this population faces as they struggle to raise their children in a foreign environment.
Conflict of interest The authors declare that they have no conflict of interest. REFERENCES
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