Epidemiology, risk factors, and prevention of burn injuries

INTRODUCTION — Burn injuries are a major global public health problem given their high incidence and potentially devastating physical, psychosocial, and financial impacts on individuals, households, and communities [1-3]. Although there is suggestion from modeling initiatives that the global incidence of burn injury is decreasing, particularly in high-income countries, there has been little reduction in mortality rates outside of regions with sufficient multidisciplinary resources for burn injury care. More than 90 percent of the people who sustain burn injuries live in low- and middle-income countries and may not have access to well-planned and organized emergency and burn care systems [4,5]. As a result, the prevalence of people with preventable morbidity (eg, hypertrophic scars, contractures, amputations) is high in regions least able to provide rehabilitation and community reintegration services. However, the true epidemiology and trends in the burden of burn injuries globally is unclear, and there are marked differences in the estimates from modeling initiatives and results from population-proportional, cluster-randomized household surveys (ie, gold standard epidemiological studies). Regardless, given the critical role that systematic injury prevention initiatives and multidisciplinary burn care play in reducing preventable death and disability from burns, a detailed epidemiological understanding of the health, social, and economic burdens incurred is important as a foundation for advocacy, resource planning, and benchmarking interventions.

The epidemiology, risk factors, and prevention of burn injury are briefly reviewed. The classification and management of burn injury is reviewed separately. (See "Overview of the management of the severely burned patient" and "Overview of surgical procedures used in the management of burn injuries".)

EPIDEMIOLOGY — Burns from fire, heat, and hot substances are the fourth most common type of civilian trauma worldwide, following road traffic incidents, falls, and interpersonal violence [3,6]. It is estimated that there are between 7 and 12 million people (up to 33,000 each day) who sustain burn injuries that require medical care, lead to a prolonged absence from work or school, or result in death each year [7]. By comparison, the incidence of burn injuries is greater than that of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and tuberculosis combined and approaches the incidence of all malignant neoplasms [8,9].

Only with an accurate appreciation of the burden and distribution of burn injuries within populations can effective interventions and advocacy initiatives be created and implemented successfully. In the absence of systematic injury data collection and minimal burn injury surveillance activities in many areas of the world, much of the data available to estimate the burden of burn injuries or temporal trends have been gathered through hospital registries or aggregated reporting platforms, police and fire service reports, mortuary records, and isolated population-proportional, community-based surveys. Each of these modalities for data collection has specific strengths and limitations regarding ability to detect injuries and fatalities, bias related to differential abilities to access care, and infrastructure requirements. Even in countries with mature health systems and surveillance programs, representative community-based surveys can play an important role. As example, community-based surveys are needed in the United States to establish the epidemiology in specific subpopulations (eg, underrepresented and undocumented people, people who are unhoused) and the degree to which these individuals use the health care system for treatment of burn injuries.

As a result, the patchwork of data available makes it difficult to accurately, comprehensively, and longitudinally describe the burden of burn injuries globally [10]. The best data are available on people with burn injuries evaluated at hospitals. These data demonstrate the opportunity to decrease preventable morbidity and mortality with timely and effective service delivery. Therefore, understanding the epidemiology of this injury group can be used to estimate more frequent "near-miss" injuries, guide optimal resource allocation, and reduce disability.

Incidence of burn injuries managed at hospitals and burn centers — The global incidence of burn injuries seen in emergency departments and outpatient clinics that require inpatient care is between 5 to 26 patients per 100,000 population [8]. This likely represents the minority of people with burn injuries, particularly in regions where outpatient services are well established. Many people who sustain a burn injury and seek care can safely be managed as outpatients in well-organized systems.

In a European review of 76 reports that involved 186,500 patients, the annual incidence for burn injuries requiring admission to a multidisciplinary burn center ranged from 2 to 29 per 100,000 people [11]. In a study from the United States, 8 percent of burn-injured patients evaluated in an emergency department were admitted or transferred to a regional burn center [12]. In the Netherlands, the incidence of burns ≥20 percent total body surface area (TBSA) approached 1 per 100,000 person-years. Other studies from high-income countries including Australia, Singapore, and the United States have reported that burns ≥20 percent TBSA comprise less than 20 percent of people with burn injuries who require inpatient care [13,14]. The reported incidence of burns that require hospital-based care is markedly higher in many low- and middle-income countries due to both higher incidence and less ability to provide outpatient burn care (eg, 8 per 10,000 children in Ethiopia, 6.3 per 10,000 children in Ghana) [8,15].

Emergency departments and outpatient clinics in high-income countries (eg, United States, United Kingdom) and some regions within a predominance of low-income countries have seen a decrease in the number of burn injury-related encounters [16]. It is hypothesized that this is due to a decreasing incidence and severity of injury due to systematic prevention and control initiatives, as well as an increasing availability of burn first aid and outpatient care resources [17].

Mortality — Between 100,000 and 350,000 people die each year from burn injuries [5,7,8]. The overwhelming majority of these deaths occur in low- and middle-income countries, which are frequently ill-equipped to prevent burn injury or care for burns, and where data to inform prevention initiatives and drive high-quality care are sparse. As an example, mortality-to-incidence ratios in low- and middle-income countries are multiple times higher compared with high-income countries due to advances in burn prevention in high-income countries (eg, building codes, fire and smoke alarms, safer cooking arrangements) and mature emergency and burn care systems [7].

The University of Washington Institute of Health Metrics and Evaluation (IHME) Global Burden of Disease Study modeled the burden of injury by fire, heat, and hot substances by updating key data sources, leveraging covariables to improve estimation in data-sparse regions, and using state-of-the-art spatiotemporal statistical modeling techniques [7,18]. IHME models suggested that the global age-standardized mortality rate was 1.6 per 100,000 injuries (95% uncertainty interval [UI] 1.3 to 1.7), which equated to 120,632 deaths (95% UI 101,630 to 129,383) in 2017. Based on these estimates, the world might have witnessed a 46.6 percent (95% UI -49.7 to -38.8) decrease in age-standardized mortality from 1990 to 2017. The greatest declines in mortality were seen by high-income countries, and the lowest by sub-Saharan Africa, Southern and Central Asia, and Eastern Europe.

Although these estimates are encouraging, numerous experts in burn prevention and control have suggested that these reductions are not consistent with injury-related mortality broadly, cluster-randomized community-based surveys of burn injury, and gains in burn prevention and care capacity in low- and middle-income countries specifically [15,19-22].

Some of the limitations of these data include:

●Relative absence of input data from low- and middle-income countries where incidence of injury, prevalence of disability, and death are the highest by orders of magnitude.

●Patchwork of data from active and integrated surveillance systems, hospital registries or aggregated reporting platforms, fire service records, mortuary records, and community-based surveys.

●Differences in criteria for and behavior in seeking burn center-level care have changed over time, making longitudinal comparison challenging.

●Classification schemes of cause-codes and injuries (eg, burns, amputation, bodily harm) vary in operationalization in registries across hospitals and countries.

Global inequities — As differences in the incidence, hospital admissions, and mortality demonstrate, the burden of burn injuries are not equally distributed globally. Health, social, and financial burdens are carried predominantly by people living in low- and middle-income countries in which prevention and control programs are uncommon and access to organized emergency, trauma, and burn care systems is limited [23]. Burn injuries are a dramatic example of health-related inequity globally, and even across socioeconomic strata within countries.

Burn injuries occur disproportionately among underrepresented groups. As examples, in the United States, the proportion of Black infants who require hospitalization for burn injury is twice that of the general population [24-26]. In Canada, the reported age-standardized mortality rate for fire-related mortality among First Nations people was 4.3 times that of other races combined [27]. Equivalent disparities have also been reported in the United States, Greenland, and Australia [28-32]. In addition, approximately 90 percent of deaths from burn injuries occur in low- and lower middle-income countries compared with 7 percent in upper middle-income and 3 percent in high-income countries [7]. The rate of death among burn-injured children from fire and flames is higher in low-income countries compared with high-income countries (10 versus 3 percent) [8,15,19,33].

Specific populations — Risk factors for major fire and burn injury include age, gender, socioeconomic factors, and comorbidities. These risk factors often coexist within people and populations and act synergistically and can be addressed simultaneously with targeted prevention and control initiatives with minimal additional resources.

Because local and global population structures are continuously changing, the epidemiology of burn injuries also changes and, thus, prevention professionals, policymakers, burn centers, and health systems need to anticipate these changes and adapt their interventions and service delivery capabilities to meet future demands.

Age — Age is consistently and strongly associated with the etiology, incidence, and mortality of burn injuries regardless of national income.

Children — Children and young people are at highest risk of burn injury [34]. Numerous factors are associated with burn injury and death in children.

●Infants commonly sustain scald injuries related to hot bottles; being near mothers, other caregivers, or older siblings who are cooking; and spills.

●Toddler-aged children are newly mobile, curious, and have few inhibitions or little prior knowledge and experience with fire, flame, or scald or electrical hazards. Beginning at six months of age, children start reaching for objects and crawling and are fully mobile by 18 months. This escalation in motor skills and activity increases the chances that children will encounter hot liquids and solids, cookstoves, electrical cords, candles, fireplaces, microwaves, treadmills, hair curlers, curling irons, ovens, chemicals, and other harmful agents. As an example, the majority of scald burns in United States occur among children between the ages of 6 and 36 months and result from hot foods and liquids (eg, soup, tea, coffee) spilled in the kitchen or eating area [35-38].

●Fire-related mortality rates increase among older children, adolescents, and while transitioning to adulthood related to greater exposure to and severity of hazards, experimentation with high-risk behaviors, and new employment.

A major risk factor for younger children is lack of supervision [39-41]. The ability to supervise infants and young children is complex and related to the mother or other caregiver and child age, socioeconomic status, energy poverty, education level, social support, cooking arrangement, home design, availability of older children, household and societal norms, school availability, health promotion and awareness campaigns, and other reasons. Interventions that aim to support child supervision and introduce protective barriers when supervision may be difficult (eg, home visits and education, distribution of playpens, creation of community creches) reduce the incidence and severity of multiple injury types, including burn injuries [40,41]. Other factors related to burn injury in children include the availability of other prevention strategies such as the use of working smoke alarms, residential water sprinklers, fire-retardant chemicals in fabrics and upholstery, access to school-based prevention initiatives, and health care systems that prioritize pediatric care education and resources [8,42].

Most burns sustained by children are nonfatal. The United States National Center for Injury Prevention and Control reported that 90 percent of children who sustain burn injuries in the United States and are evaluated in emergency departments are not admitted to the hospital. Further, two-thirds of children admitted to the hospital for burn injuries were reported to have sustained burns <10 percent TBSA [43]. Regardless, in countries with limited burn care capacity or among populations with limited access to care, even small injuries can result in significant disabilities [44]. As example, a community-based survey of burn injuries in four low- and middle-income countries found that 17 percent of children with burn injuries experienced disability that lasted >6 weeks, and 8 percent were anticipated to experience lifelong disability due to their injury [45].

Older adults — Older adults (ie, age ≥60 years) are also at high risk of burn injury. Their susceptibility to burn injury is related to deterioration in dexterity, coordination, balance, judgment, and cognition secondary to aging, medications, and comorbidities. Older adults are at the greatest risk of dying in structure fires and being burned in hot baths or showers [8,46,47].

Older adults tolerate even small and shallow burn injuries poorly, signaling the negative impacts of the pathophysiological cascades that stem from injury and health care interventions, as well as burns being a symptom of frailty and poor physiological reserve [48-50]. As a result, older adults have the highest mortality-to-incidence ratio of any age group. Age, together with burn size (ie, TBSA) and smoke inhalation injury, is one of the three factors most associated with in-hospital mortality after burn injury. The percent TBSA at which 50 percent of patients will die (ie, lethal area 50 [LA₅₀]) in high-income settings is <40 percent for patients aged 70 to 79, and for those aged ≥80 years, the LA₅₀ is <20 percent TBSA [51]. By comparison, LA₅₀ is over 90 percent for children aged <5 years.

Further, data from the United States National Burn Repository suggest that in-hospital mortality is 9 percent for older adults in the seventh decade of life, 16 percent for those in the eighth decade of life, and 25 percent for those ≥80 years. These mortality rates are particularly striking when compared with those of adults aged 18 to 49 years (3 percent) and children (<1 percent). A large proportion of older adults who lived at home prior to their injuries are discharged to skilled nursing facilities or long-term acute care facilities following hospitalization for burn care [52].

Several behaviors increase the inherent risks faced by older adults. Older individuals who smoke are more likely to die of fire, smoke inhalation, and burns compared with younger people who smoke [8]. Many older adults also live in households that do not have smoke detectors or may be unable to maintain them (eg, leave the home to purchase batteries, climb on a step ladder to reach the detector, deploy the dexterity to change the batteries) [53]. Similarly, many older adults also suffer from energy poverty and may be exposed to unsafe heating hazards, which have been documented to be the most common reason for older adult residential fires in the United States.

Gender — Burns, like other injuries, have significant gender-related differences.

In the United States, burn injury rates among those who seek health care has been reported to be approximately 50 percent greater among men than women (270 versus 180 per 100,000, respectively) [54]. In addition, boys are more likely to be injured and approximately 25 to 70 percent more likely to die from an injury compared with girls [8,55]. Several explanations for these differences have been proposed and validated in some populations: boys may be less likely to be supervised and are allowed or encouraged to roam further from home with fewer limits and to play alone; boys may have higher activity levels and engage in higher-physical risk behaviors; and boys may behave more impulsively.

Exposures to hazards like unsafe cookstoves or other cooking arrangements, meal and tea/coffee preparation, household work, and clothing are responsible for women and girls experiencing a burn injury. Clothing ignition is a common cause of burn injuries, particularly when loose fitting and flammable attire is worn (eg, saris, chadarees, paranjas, and burqas). As a result, the mortality rate among women is more than twice that of men in many low- and middle-income countries, particularly in sub-Saharan Africa, Eastern Mediterranean, Southern Asia, and Southeastern Asia regions [7,56,57].

Comorbidities — Comorbidities that have been associated with a higher risk of burn injury include epilepsy, peripheral neuropathy, and other physical and cognitive conditions. In low- and middle-income countries in which access to medications for epilepsy and diabetes are often limited, these comorbidities are a common predisposing factor for burn injury.

●Epilepsy – Epilepsy in particular is a common cause of fires, severe burns, and burn-related fatalities since those suffering from the condition may fall into an open fire, onto a cookstove, or disrupt an ignition source during a seizure [58]. The risk and severity of injury is further exacerbated by stigma and traditional beliefs about epilepsy in many areas of the world. As an example, in some communities, the concerns about epilepsy being contagious prevents people from helping to put out the fire or lending first aid. Among people who practice religious fasting (may include medications), people with epilepsy are also at high risk and must be counseled about avoiding proximity to flames, chemicals, and hot substances while they are not consistently taking a seizure medication. In a prospective study of burns among people living with epilepsy in Saudi Arabia, 40 percent of injured patients sustained burns while fasting, in part because they did not take their medications [59].

●Neuropathic conditions – Burn injuries among people living with peripheral and central sensory neuropathies (eg, diabetes, leprosy, spinal cord injury) are common regardless of national income. Practices like soaking feet in "warm" water, warming feet in front of fires, and touching hot objects and substances without the sensation that generates a withdrawal response often causes severe burns in tissues with poor perfusion, which leads to infection, need for reconstruction, and/or amputations in many cases.

●Other conditions – Other physical and cognitive conditions have been associated with burn injuries, particularly those resulting from residential fires, scald, and contact injuries. With an aging population, including people without access to cardiovascular disease management in much of the world, cognitive conditions resulting from stroke, vascular dementia, Alzheimer disease, and age-related cognitive dysfunction are a major cause of burn injuries. Further, older adult patients with dementia tend to have worse outcomes despite smaller injuries, and rehabilitation is typically limited [46,52].

BURN INJURY MECHANISMS

Unintentional injuries — The majority of burns in the world are unintentional. Unintentional injuries are related to a variety of mechanisms. A review of 127,016 hospitalized burn patients between 1999 and 2008 from 79 United States hospitals reported that the most frequent known causes of burns were fire/flame (42 percent), scald (30 percent), contact with hot object (9 percent), electrical (4 percent), chemical (3 percent), and other (12 percent) [60].

Flames and scalds — Flame injuries and scalds are the most common causes of burns in children and adults worldwide [61-64]. Seventy percent of fire/flame burns and 81 percent of scald burns are sustained in the home [60].

There are age-related and regional differences for the most frequent cause of burns in children. Both the incidence and severity of scalds are inversely correlated with age [65]. Worldwide, scalds account for 60 to 80 percent of burn injuries for young children [66-72]. In the United States, the number of scalds far exceeds the number of flame burns in children aged 0 to 4.9 years [66]. However, flame burns outnumber scalds in all other pediatric age groups [60,73,74].

In some low- and middle-income countries, such as in China and Iran, flame burns and scalds occur at approximately the same frequency in children [61,75,76]. The relative frequency of flame and scald burns globally are typically related to energy poverty (eg, exposure to unsafe cooking and heating hazards), food and drink preferences (eg, exposure to boiling liquids for tea or noodle soups), and climate. Cooking, heating, and climate hazards are discussed below. (See 'Specific hazards and settings' below.)

Contact burns — In the United States, contact injuries represent approximately 10 percent of hospital admissions, are most often sustained by young children, and tend to occur in the home [77]. The hands and extremities are most often affected, and the injuries tend to be deceptively deep. Common etiologies include radiators/heaters, irons and curling irons, fireplaces and stoves, and other sources (eg, motorbike exhaust pipes, lighting).

Electrical injuries — Electrical injuries are a complex form of trauma that are often associated with high morbidity and mortality. The severity of the injuries depends upon the type of current, the voltage, and the resistance. Electrical injuries are most frequently related to household, occupational, or environmental exposures to an electrical current, including lightning discharge. (See "Electrical injuries and lightning strikes: Evaluation and management".)

There are four main types of injuries that occur from exposure to electricity: flash, flame, lightning, and true.

●Flash injuries are caused by an arc flash. Flash burns are typically relatively superficial burns, as no electrical current travels through the skin.

●Flame injuries occur when an arc flash ignites clothing or adjacent material.

●Lightning injuries involve extremely short but very high voltage electrical energy and are associated with an electrical current flowing through a person's entire body. 

●True electrical injuries involve a person becoming part of an electrical circuit. In true electrical injury cases, entrance and exit sites are usually found. True electrical injuries can also be associated with a myriad of internal injuries including injuries to the central and peripheral nervous system, cardiac conduction abnormalities and dysrhythmias, muscle necrosis, intestinal perforation, cataracts, and others.

Approximately 20 percent of electrical injuries occur in children. Among children, toddlers and adolescents have the greatest risk. In children, electrical injuries occur most often at home, whereas in adults, these injuries occur mostly in occupational settings and are the fourth-leading cause of workplace-related traumatic death [78]. Household injuries are caused by misuse or malfunction of lighting and appliances. Household electricity in the United States is set at 110 volts, though some high-power appliances may be set as high as 240 volts. Given that most household electrical current is low (ie, <240 volts and 250 amps), major injury is rare. However, serious electrical injury occurs with high voltage electrical injury (>1000 volts) with worse outcomes compared with lower voltage injury. In one review, mortality rates from electrical injuries was 5.2 percent for high voltage injury and 2.6 percent for low voltage injury [79]. Industrial and high-tension electrical power lines can be set at greater than 100,000 volts.

While the introduction and promulgation of electricity in low- and middle-income countries has reduced the risk of injury caused by exposure to unsafe cooking and heating sources, there has been an associated and dramatic increase in the risk of fires and burns from electricity related to nonstandard wiring techniques, unsafe practices, illegal poaching of power and scavenging copper from overhead lines, and inadequate barriers around high-voltage poles and towers [80].

Chemical injuries — Unintentional chemical injuries are relatively rare (ie, <5 percent of all burn-related hospitalizations) and occur most commonly from exposure to home, agricultural, and industrial products (eg, acids, bases, oxidizers, reducing agents, alkylating agents) [81]. Although chemical injuries are typically small and nonfatal, the deep tissue injury associated with prolonged chemical exposure often results in the need for surgical wound closure and the development hypertrophic scarring [82]. Intentional chemical injuries, including chemical assault (eg, acid attacks), are discussed below. (See 'Chemical assault' below.)

Specific hazards and settings

Cooking and cookstoves — Approximately 90 percent of burn injuries occur in and around the home, most of which are related to cooking [83]. Nearly half of the world's population is exposed to fire and burn injury risks related to their cooking arrangements, with upwards of 300,000 deaths per year from cooking-related burns [84]. In areas without electrification or liquefied petroleum gas (LPG) cookstoves, use of open flames and rudimentary cooking arrangements (eg, three-stone fires, clay pots) are common [15,85]. Furthermore, cooking arrangements are often inside of the home, on the ground, and accessible to small children. Common fuels for such cookstoves include biomass (eg, wood, charcoal, leaves, dung), kerosene, and paraffin. The risk of injury related to cookstoves is increased by a lack of enclosure for open fires, cookstove instability, nearby and unsecured storage of volatile and flammable fuels, flammable and loose-fitting clothing, combustible household materials, insufficient alarm mechanisms, and lack of multiple exits.

Transitioning households to improved or LPG cookstoves can save lives and prevent disability. However, as more households move away from biomass and kerosene as a fuel source for domestic stoves and heaters, there has been a subsequent increase in the number of injuries sustained from the use of natural gas and LPG cookstoves [85]. While much research and program development has gone into the design of energy-efficient cookstoves and implementation of improved and LPG cookstoves, little has been done to document and improve key safety features in real-world settings (eg, tip ability, projection of flame, radiant heat, contact points, tank testing requirements, use of nonstandard tubing, regulator quality standards) [86]. Developing safer cookstoves with policies and regulations that facilitate their safe use is critically needed.

Occupation — Occupational exposure to hazards and work-specific behaviors also exerts differential burn injury risk within populations. Approximately 10 to 20 percent of burn injuries that present to United States emergency departments are work-related [54]. However, this is likely skewed upwards due to pressure from employers and workers' compensation plans to present for evaluations with burns that would otherwise be managed without emergency care. Workers in the construction, welding, utilities, concrete, transportation, mining, agriculture, and firefighting fields are at particularly high risk for injury, as well as being unable to return to work after injury without dedicated vocational rehabilitation [87,88]. Additionally, homemakers and informal workers (eg, undocumented laborers, lawn maintenance workers, jacks-of-all-trades) are likely at high risk given their exposures to hazards and lack of formal protections, but data around injuries in these contexts are sparse.

Climate and seasonality — Colder and high-altitude climates are variably associated with increased risk of burn injury. Residential fires that occur in winter months and not associated with smoking or electrical faults are most often caused by heating appliances or cooking-related fires.

Energy poverty mandates the use of hazardous fuels, such as kerosene or open biomass (eg, wood) fires to maintain warmth. As an example, Nepal has an annual burn injury epidemic in the winter months, particularly among populations who live in mountainous and rural areas [57,89]. In Nepal, like in many cold-climate countries, older children and women are often responsible for lighting and tending to fires, managing cookstoves and lamps, and maintaining warmth. These practices significantly increase their risk of burn injury and burn-related death.

Although temperate climates are not protective, warmer climates in the United States do seem to have lower fire and burn-related mortality, as reported in Arizona (0.87 per 100,000) and Florida (0.84 per 100,000). In locations with significant seasonal variations of temperature, burns occur more frequently in the colder winter months. However, many colder regions of the United States have a lower fire and burn-related mortality rate (0.97 per 100,000) compared with the more temperate southeastern region (1.49 per 100,000) [8]. The fire and burn mortality rate of some of the coldest states in the United States are much lower than the average national rate (1.23 per 100,000). As examples, the fire and burn mortality rate in New Hampshire and Vermont is 0.5 per 100,000 population, and Minnesota is 0.7 per 100,000. However, Alaska has the highest fire and burn mortality rate in the United States (2.72 per 100,000).

Changes in climate are implicated in increases in extreme temperatures, wildfires, and natural disasters (eg, flooding or hurricanes that disrupt safe electricity infrastructure). Although poorly documented, burn centers and hospitals in affected areas are reporting increases of burn injuries associated with these changes (eg, frostbite or pavement contact burns among people who are unhoused, smoke jumper and wildland firefighter injuries) [90].

In some countries and during holidays (eg, Independence Day in the United States, Diwali in India and Nepal, Greek Orthodox Easter in Greece, Hari Raya in Malaysia, and New Year's celebrations globally), firework-related injuries become common, particularly among older boys [91]. Firework injuries often affect the hands, neck, face, and eyes and are not lethal. As a result, they exact a disproportionate morbidity for their incidence.

Intentional injuries — In the United States, assault (including child abuse) is responsible for approximately 2 percent of injuries admitted to burn centers [62].

Child abuse — Burns account for 10 percent of all cases of child abuse [92,93]. Children with unintentional trauma from burn injuries are almost always under age 10 years, and most are less than two years old. Scalds from immersion into hot baths or splashes are the most frequent burn injury. Contact with heated objects including cigarettes, irons, curling irons, hair dryers, and heated kitchen utensils are commonly used in abuse cases.

The medical evaluation of children who sustain burns includes seeking evidence of:

●Healed burns from prior injuries

●Multiple simultaneous burns

●Bruises shaped like hands, fingers, or objects that suggest burns, hits, or bite marks

●Sexual abuse

●Inconsistent history from parents or caregivers and physical examination

●Doughnut-shaped burn pattern on the buttocks

●Sparing of the soles of the feet

●Pattern of burn like a cigarette or other heated object

●Stocking or glove pattern burn

●Waterlines on skin

Furthermore, the TEN-4-FACES rule can help identify children who may have been abused; children rarely have normal bruising on their trunk, ears, and neck, and children less than four months of age rarely have normal bruising ("kids who don't cruise rarely bruise") [59].

Interpersonal and collective violence and self-harm — Assault-by-burning and self-immolation occurs worldwide, although they are more common in some regions and among specific populations [55]. Less than 1 percent of injuries admitted to burn centers in the United States are from self-immolation or attempted suicide [62]. Similar proportions have been reported from Europe and Taiwan [94].

Chemical assault — The use of acid or another caustic or corrosive substance or vitriol by one person against another with the intent to injure or disfigure has been perpetrated for centuries and is increasing in a number of communities [95,96]. High-profile attacks and advocacy campaigns have brought chemical assault to public attention, and survivors are seeking systematic change to the way chemical assault is viewed and controlled through legislation [96-98]. Although such attacks are thought to be more common in low- and middle-income countries, their incidence is on the rise in high-income countries [96,99]. However, little is known about the incidence and distribution of these events globally or the ways in which health systems and governments are addressing chemical assault [95].

In many cases, chemical assault occurs as a manifestation of gender-based or intimate partner violence. These motives in particular have inspired local, national, and global campaigns to address acid attacks and empower women and girls in communities with gender inequity [100,101]. Reports from several countries have described local efforts to limit access to corrosive substances, facilitate the prosecution of assailants, and increase support for victims [95,96,98,102]. A systematic review of legislation around chemical assault collated policies and regulations to propose a comprehensive legislative framework to prevent chemical assaults and mitigate their effects on victims and included five legislative priorities: apply a public health approach; adopt legal definitions specific to chemical assault; control chemical supply, sales, and procurement; facilitate justice; and support survivors [103].

The United Kingdom has a remarkably high incidence of chemical assault and acid violence that is predominantly perpetrated by men and boys against men and boys [104]. Unlike in other regions with high rates of chemical assault, the risk factors in the United Kingdom tend to be related to organized crime. Acid Survivors Trust International, a United Kingdom-based, international, nonprofit organization, is an exemplar in their use of epidemiological data to drive targeted interventions in different regions and populations, support advocacy initiatives, and generate evidence-based policy to prevent and control chemical assault.

Collective violence — Collective violence (warfare) and the complex humanitarian emergency that often ensues is another form of violence that generates burn injuries at rates far greater than those in safe societies. Most wartime burn injuries are related to explosive devices (eg, land mines, unexploded ordnances), breakdown of infrastructure (eg, electricity, formal housing), and poor fire prevention practices. A representative, cluster-randomized, community-based survey of civilians in postinvasion Baghdad, Iraq (2003 to 2014) determined that burn injuries occurred at a rate that was three times greater compared with the rate of burn injuries preinvasion (117 versus 39 per 100,000 population) [105]. Furthermore, burn injuries represented 10 percent of all injuries in Baghdad during the decade postinvasion. In the wake of turmoil, the lack of organized burn care led to a high mortality rate (16 percent). Additionally, 40 percent of burn-injured people were left with major disabilities, and approximately half experienced catastrophic health expenditure and/or food insecurity because of their injury. A report from Médecins Sans Frontières Operations Center Brussels described surgical care from projects in 15 countries over seven years [106]. Among 33,947 general surgical operations, 11 percent were for burns. People receiving surgical care at conflict relief projects had nearly twice the odds of having a burn operation compared with people requiring surgery in communities affected by natural disaster.

Explosive devices, including bombs, land mines, and cluster munitions, cause blast injuries. Blast injuries from high-order explosives manifest from multiple well-described mechanisms, including distortion of tissues from the primary blast wave, penetrating injuries from propelled fragments, displacement of the victim or blunt force injuries from propelled objects, burns and/or radiation, and other metabolic consequences of severe multisystem trauma. Chemical weapons (eg, mustard gas, white phosphorus) and ionizing radiation (eg, atomic weapons) have caused particularly horrific injuries in past and recent conflicts. Despite international regulations, treatises, and humanitarian law, chemical weapons continue to be used against both warfighters and civilians. The burden of disease from these weapons is unknown. Lastly, next-generation weapons, including high-power nonionizing directed energy (eg, microwave) weapons, are also known to cause burn and other injuries (eg, Havana Syndrome), but their effects and use in warfare have not been publicly characterized.

Self-immolation — Burning oneself (self-immolation) is a form of self-harm and suicide. Self-inflicted burns have significantly higher percent total body surface area, burn depth, inhalation injury, and mortality when compared with unintentional flame burns. Generally speaking, self-immolation accounts for less than 1 percent of suicide attempts [107-111]. However, nearly 30 percent of burn admissions in Nepal are for intentional injuries, of which 90 percent are self-inflicted and the remaining 10 percent are assaults. Patients with intentional burns are more likely to be female, married, and younger (between 25 and 30 years) [112].

The highest absolute number of deliberate self-burning cases and highest ratio of deliberate self-burnings to overall burn hospital admissions occur in Southern Asia, Middle Eastern countries, and Africa [107,113-115]. A review of 55 studies of deliberate self-burnings found that the most common motivations for self-harm were psychiatric illnesses (Western and Middle Eastern regions), personal (India, Sri Lanka, Papua New Guinea, and Zimbabwe), and political (India and South Korea) [107]. In high-income countries, 37 percent of deliberate self-burnings were associated with chronic mental illness and/or substance abuse [108].

BURN INJURY PREVENTION — With increasing awareness of the impacts of social determinants of health and health inequities more broadly, clear opportunities exist to prevent burn injury, particularly among historically disadvantaged populations [42,116]. Like other injuries, most burns can be prevented and their severity reduced through concerted prevention and control initiatives, which include investment in safer living conditions, awareness campaigns, legislation and building codes, and development of emergency, trauma, and burn care systems. Through a combination of prevention and care strategies, progress has been made reducing the incidence of burn injuries and burn severity and lowering rates of burn death and length of hospital stay, which is more evident in high-income countries [18,117-121].

Data for burn injury prevention and control — Given the enormous burden of burn injuries globally, prevention and control initiatives should be priorities of community organizations, burn centers, health systems, professional societies, and governments. Better data can inform burn injury prevention and control efforts, particularly data from community-based surveys, surveillance systems, and national and multinational registries.

The approach to injury prevention and control is broadly comprised of four core functions: surveillance, analysis, intervention, and evaluation. Within the intervention function, prevention experts think about the three E's: education, engineering, and effective legislation enforcement.

●Education is an active process that requires behavior modification. There is clearly a gap in understanding about risk and prevention of burn injuries in many communities [122-124].

●Engineering involves modification of agents (eg, cookstoves, flammable clothing, hot water tanks) or to the environment (eg, installation of smoke detectors).

●Enforcement involves the creation and implementation of guidelines, codes, and laws.

More specifically, injury prevention and control practitioners undertake a spectrum of activities to understand the problem, address hazards systematically and holistically, and reduce the burden of injury:

●Surveillance and data collection

●Strengthening individual knowledge and skills

●Educating health care professionals

●Changing practices of institutions and agencies

●Fostering coalitions and networks

●Mobilizing neighborhoods and communities

●Influencing policy and legislation

A precise understanding of the problem and factors that contribute to it are the basis for planning effective interventions. In much of the world, data regarding hazard distribution and burn injuries are scarce, inaccurate, or both. A lack of sufficient and high-quality data limits the development, implementation, and evaluation of potentially lifesaving and morbidity-reducing interventions.

The Haddon Matrix is a tool to conceptualize host-agent-environment factors that must be considered when collecting data for planning prevention and control interventions (table 1 and table 2) [125]. A third dimension has been added to the matrix that includes common causes of intervention success and failure (eg, equity, stigma, preferences, feasibility, cost) [126]. These issues can facilitate priority setting and decision making but only have value considering the epidemiological characteristics associated with burn injury in specific populations and communities.

There are exemplars of comprehensive national burn registries (eg, Australia and New Zealand, Taiwan, Norway) and a nascent, global, hospital-based burn registry supported (ie, Global Burn Registry [GBR]) and promulgated by the World Health Organization (WHO) [85,127]. These registries inform key burn injury prevention and control strategies. However, where these databases do not yet exist or are not used, active surveillance programs and representative community-based surveys are required to ensure that key risk factors and vulnerable populations that hide in the shadows of health systems are understood. Data and patterns from such surveys from Ghana, Bangladesh, Ethiopia, Iran, Nepal, Uganda, and Rwanda have taught us that hazards are not equally distributed within communities, countries of similar national incomes, or regions [15,19,22,128].

No one set of prevention and control interventions will be effective or cost effective without the use of easily collected and granular data. In response, WHO GBR uses a simple, standardized form to gather information about burns. The data give health facilities a clear picture of the major risk factors and populations at risk for burns in their setting, as well as how these compare with other settings. This information is key to identify and prioritize programs to prevent burn injuries. Data can be viewed online or exported for further analysis. More information about the GBR, as well as directions to participate in it or access its data, is available on the WHO GBR website.

Efficacy of prevention programs — Positive factors associated with burn prevention programs include improved housing, better supervision of children, proper regulation and design of products, proper storage of flammable substances, and overall improvement in the standard of living [1,129]. Selected measures are reviewed below [130-132].

Education programs — Based upon limited data, multipronged community-based interventions appear to be the most effective for reducing the risk of burn injuries [133,134]. The likely explanation is that the multifaceted community approach typically focuses on effective communication of preventive practices, which has been documented to improve outcomes such as the adoption and maintenance of healthy behaviors [135]. Injury prevention programs conducted in Israel between 1998 and 2000 were effective in reducing childhood burn-related hospitalizations from 1.39 to 1.05 per 1000 infants [133]. The effect was greatest among infants and toddlers, but there was no significant change in burn-related hospitalizations among school-aged children.

Although many resources are expended on community education, the beneficial effects are not clear [136]. Counseling and educational interventions had only a modest effect on the likelihood of owning a smoke alarm or having a functional alarm, but these effects were enhanced in the setting of primary child health care surveillance and counseling [136,137]. However, studies in low- and middle-income countries show that educational programs effectively reduce hazardous behaviors, the incidence of burns, morbidity, and mortality [138]. As an example, a multipronged initiative in Guwahati, India was designed and implemented to include education (context-specific hazard mitigation, fire extinguishing, first aid), public safety briefs (print media, radio, posters, talk shows), pre-Diwali campaigns, and social media blasts. A robust 10-year pre/post evaluation demonstrated that the incidence of burn-related hospitalizations was reduced 45 percent in Guwahati (exposed to the initiative) while hospitalizations increased 41 percent in other areas of Assam State where the initiative had less penetration [139]. Patients who did get injured reported greater use of safe extinguishing practices and first aid after the initiative.

The effectiveness of education programs for burn prevention may be enhanced by targeting specific at-risk groups with culturally appropriate teaching tools. Based on initial studies done in Amish communities, school-based tools including story boards, safety curriculum, and test questions were provided to schools in Amish communities in eight states in the United States [140]. Burn prevention knowledge significantly improved. Interburns created similar resources for school-aged children and adults in Nepal. Such resources can be used serially by schools, community health workers, health care providers, and outreach programs to improve awareness and reduce injuries.

In the rapidly evolving environment of social media, there may be novel opportunities for preventing burn injuries. In 2013, 21 videos were posted on YouTube with technically accurate content covering prevention and first aid treatment of childhood burns [141]. Due to the ease of access and wide audience reach (over 6 billion hours of video are watched each month on YouTube), there are exciting opportunities to use these platforms to raise public awareness of burn prevention and treatment. However, validation of content by qualified health care professionals remains a challenge.

Specific prevention interventions

Smoke detectors and alarms and sprinkler systems — Smoke detector installation is an effective and inexpensive strategy to reduce the risk of burn injuries in residential and commercial settings [142]. Smoke detectors serve as an early warning of fire and thus reduce the risk of burns by enabling occupants to escape the burning building. Both residential and commercial sprinkler systems reduce structural damage and offer passive protection of burns, which is important for young children, people with disabilities, and older individuals, who may not have sufficient mobility to escape a fire.

In 1975, the United States Building Officials and Code Administrators building code was amended to require a smoke detector protecting the bedroom area in each dwelling unit of new construction [143]. The rapid rate of smoke detector installation in United States homes (less than 5 percent in 1970 compared with 67 percent in 1982) was attributed to price reduction, intensive marketing, programs led by local fire departments, and building code modification and legislation [144]. The effectiveness of smoke alarm distribution projects was greatly enhanced by community canvassing programs that involved the local fire departments and community health workers [145]. Ninety-six percent of occupants of homes surveyed in the United States have at least one working smoke alarm [146,147].

The increased usage of smoke detectors has been associated with a decline in residential fire and flame deaths. The age-adjusted death rate in 1981 from residential fires was 2.28 per 100,000; by 1997, that rate was reduced by almost 50 percent [148]. The death rate per 100 reported home fires from 2003 to 2006 in the United States was twice as high when no working smoke alarm was present (eg, either no smoke alarm was present or an alarm was present but did not operate) compared with the rate with working smoke alarms (1.16 versus 0.59) [149]. Although smoke alarms contributed significantly to this reduction in mortality, other factors have been beneficial as well, including safer heating and cooking appliances; child-resistant lighters; flame-resistant mattresses, furniture, and clothing; and improvement in acute care of burn victims.

A major grassroots effort to strengthen the policies and regulations around residential sprinkler use in the United States began in the 1970s. The movement had gained major traction nationally by the early 2000s. However, between 2009 and 2011, 13 states passed legislation to extinguish the movement and sprinkler mandates. However, strategic reorganization and broadening of the coalition to include firefighter organizations, survivor groups (eg, Phoenix Society), and the National Fire Protection Agency, has since led to more than 360 ordinances, two state laws mandating residential sprinkler use in one- and two-family homes, and changes in the International Code Council [150].

Scald prevention — Hot tap water causes nearly 25 percent of all pediatric scald burns, and most of these occur in the bathroom. The damage caused by hot tap water burns tends to be more severe compared with other types of scald burns [151]. In an animal study, significant thermal injury occurred within three seconds of exposure to water at temperature of 140°F (60°C), but 10 minutes were required to cause skin burns at a temperature of 120°F (49°C) [152].

In 1977, 80 percent of homes in Washington state in the United States had tap water temperatures greater than 129°F (54°C). In 1983, a state law was passed requiring new water heaters to be preset at 120°F (49°C). Few people bothered to increase their water heater temperature after installation. Five years later, 77 percent of homes (84 percent of homes with postlegislation and 70 percent of homes with prelegislation water heaters) had tap water temperatures of less than 129°F (54°C). The average temperature in 1988 was 122°F (50°C) compared with 142°F (61°C) in 1977 [153]. The impact of this lower preset temperature was a 50 percent reduction in the number of patients treated for scald burns. Thermostatic mixing valves are now standard in hot water systems of high-income countries. Efforts to globalize this technology, including to systems that do not use hot water tanks, are critically needed.

Cookstove, heating, and lighting safety in communities with energy poverty — Many burn injuries in low- and middle-income countries are associated with the use of household appliances, particularly cookstoves, heating implements, and lamps. [113,154-159] The inevitable transition toward more sophisticated devices for cooking, heating, and lighting to reduce burn injuries in low- and middle-income countries is also not without hazard. As more households have moved away from biomass and kerosene as domestic fuel sources, there has been an increase in the number of injuries sustained from the use of natural gas (methane and ethane) and liquefied petroleum gas (LPG; eg, propane and butane) [160,161]. The majority of incidents are from gas leaks, either from the rubber tube or faulty regulator valve, representing an opportunity for intervention with programs that promote maintenance of equipment and safe practices [162,163]. Other causes include tipping of LPG stoves with surface cooktops, unprotected flame extrusion, poor regulations around refilling and pressure testing, and home adaptations.

Prevention of burns associated with cookstoves and lamps has included the following approaches:

●An educational approach teaches safe use and handling of kerosene lamps, including avoiding replenishment of the fuel reservoir while the wick is lit and providing a stable surface on which to place the lamp. One prospective study in low-income South African communities reported a significant increase in self-reported knowledge, safety practices, and recognition of injury risk within communities that received educational material about kerosene (ie, intervention community) compared with a control community that did not [156].

●Where oil lamps must be used, another approach is to use a safer lamp design. One such lamp is compact and heavy, so that it does not easily tip over, and has two flat sides that prevent it from rolling if it does tip over [164]. A screw-top lid prevents fuel spillage, and the thick slow-cooled glass used for construction is essentially unbreakable. Another approach is to use safer oils (eg, coconut oil, sesame oil). Unfortunately, these heavier oils do not perform as well as lighter fuels.

Fireworks safety — Fireworks are associated with national and cultural celebrations throughout the world and with an increased incidence of fires and burns [59].

●On Independence Day in the United States each year, more fires are reported than on any other day of the year [154]. Relaxation in fireworks laws in many states has allowed purchase of more powerful fireworks. These changes have had a modest effect on the incidence of related injuries and the age of the purchaser but have had a dramatic effect on the severity of the related injuries, resulting in more inpatient admissions and longer length of stay in the hospital [165].

●Reduction in fireworks-related injuries has been observed because of focused campaigns. Prohibiting the sale of the most dangerous types of fireworks through legislation has reduced the incidence of fireworks-related injuries [142]. Presumably because of the proliferation of fireworks legislation, the number of fireworks injuries in the United Kingdom decreased from 707 in 2001 to 494 in 2005 [166]. Conversely, after repeal of a law banning private fireworks in Minnesota, there was an increase in the number of children suffering fireworks-related burns [167].

●Educational interventions are not always successful. As an example, there was no effect on the use of fireworks, fireworks budget, making a bonfire, and the incidence in fireworks-related injuries among adolescent boys in Tehran, Iran following mailings to parents from schools discussing the risk of fireworks and limiting the fireworks budget, peer-to-peer education by trained students about the risks of fireworks, and distribution of safety brochures and a multimedia disk regarding injury victims [168].

●One of the more successful examples of firework-related injury prevention has roots in Chile. COANIQUEM, a Chilean nongovernmental organization, implemented a nationally represented burn injury registry in 1993 [169]. The group was able to demonstrate that fireworks were a major cause childhood injuries, disabilities, and costs to the health care system and society more broadly. They collaborated with legal groups and advertising agencies to draft legislation and create a toolkit for implementation and enforcement. As a result, Chile now has integrated community awareness campaigns (eg, radio, print media, social media) and school-based education and recently passed a retail firework ban. As a result of this multipronged effort, Chile has witnessed a reduction in firework-related injuries. COANIQUEM is now working with the Organization for American States to disseminate the toolkit to other Latin American countries.

Flame-retardant materials — The Flammable Fabrics Act was passed in the United States in 1953 to regulate the manufacture of clothing and amended in 1967 to expand coverage to internal furnishings. This legislation regulates the material construction of a broad range of consumer products (eg, carpets, night clothes, mattresses, upholstered furniture, tents, curtains, sleeping bags, and children's clothing) [142,144]. The National Fire Protection Association estimated that the enactment of the flammability standards for sleepwear in 1971 resulted in a 10-fold decrease in childhood deaths caused by ignition of sleepwear. Similarly, a retrospective study showed a decrease in the incidence of sleepwear-related flame burn in children admitted to the Shriners Burns Institute of Boston from 1969 through 1976 [170]. Prior to the development of flame-retardant clothes, the burn mortality rate of girls exceeded that of boys, which was attributed to loosely fitting, more easily flammable girls' nightgowns and dresses [171].

Halogenated flame retardants are used widely in textiles, carpets, and electronics, as well as other consumer products. However, concerns have been raised about the negative environmental and health-related effects. These compounds can seep into the environment, with particularly high concentrations recorded in marine mammals and fish. Some commercial brominated flame retardants, in particular polybrominated diphenyl ether (PBDE) mixtures and hexabromocyclododecane (HBCD), have been banned or phased out in some jurisdictions, and the possible use of alternative flame retardants continues to be investigated [172]. [173]

Smoking cessation — Discontinuation of cigarette smoking is recommended for a variety of reasons. Methods to help with smoking cessation are reviewed separately. (See "Benefits and consequences of smoking cessation" and "Cardiovascular risk of smoking and benefits of smoking cessation" and "Overview of smoking cessation management in adults".)

Cigarettes are responsible for 5 to 20 percent of fire-related burns in the United States and up to one-third of fire-related deaths and most nonfatal fire injuries in Europe [174,175]. Most fire deaths are associated with ignition of upholstered furniture, mattresses, and bedding by dropped cigarettes. One-fourth of fatalities from tobacco-related fires are other people, not smokers.

Consumer safety movements in the United States have focused on legislating mandatory production of fire-safe or reduced ignition propensity (RIP) cigarettes [176]. RIP cigarettes are made by using a paper wrapping that has thin bands of differing porosity, which lowers the ignition propensity of the paper. The bands are inserted at intervals down the length of the cigarette, causing the cigarette to extinguish if not repeatedly smoked [177-181].

Under RIP cigarette laws, a cigarette must burn out 75 percent of the time when not in active use [182]. All 50 states in the United States as well as Australia, Canada, Iceland, South Africa, and all European Union member states have adopted policies requiring RIP cigarettes [183-186]. Following enactment, fires related to smoking materials reduced by 57 percent from 1980 to 2006. Both the decline in cigarette consumption as well as standards and regulations that have made mattresses and upholstered furniture more resistant to ignition have contributed to this trend [174].

Reducing violence — Elimination of interpersonal violence requires a multitude of coordinated actions involving passage and enforcement of protective legislation, education of men and boys about appropriate behavior toward women, and resources and programs for women related to empowerment, shelter, and/or care [187,188]. An evidence-based comprehensive legislative framework to address chemical assault has been published and focused on five priorities with specific actions within each: apply a public health approach; adopt legal definitions specific to chemical assault; control chemical supply, sales, and procurement; facilitate justice; and support survivors [103].

The Acid Survivors Foundation (ASF) of Bangladesh is an effective program designed to reduce acid attacks on children and women. ASF has been raising public awareness, building institutional capacity and lobbying, and working with other nongovernmental organizations, the media, celebrities, and student groups to elevate community consciousness. It has also fostered advocacy and lobbying efforts with the government to ensure the passage and enforcement of laws and to create systems to provide service to acid survivors. As a result, the number of victims dropped from 490 in 2002 to 171 in 2008 [189]. Based on the success of ASF, similar organizations have been formed in Cambodia, India, Pakistan, and Uganda.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Care of the patient with burn injury".)

SUMMARY AND RECOMMENDATIONS

●Burn injuries globally – Burn injuries are a major global public health problem. The risk of burns is highest in low-income and lower-middle-income countries. Approximately 90 percent of all burn-related injuries and deaths occur in low- and middle-income countries, while 3 percent occur in high-income countries. In high-income countries, an increased risk of burns is found in marginalized populations and households with lower financial resources. (See 'Epidemiology' above.)

●Risk factors – Children and older adults are at the highest risk of unintentional burns. Flame/fire and scalds are the most common type of burn in adults and children. While most burns are unintentional, child abuse, deliberate self-burning, and interpersonal violence are common. (See 'Specific populations' above.)

●Burn prevention – Reduction in the number of burn injuries in high-income countries is attributed to legislation regulating installation of smoke detectors, hot water temperature, fireworks, and flammable sleepwear, and to engineer safer products for heating and cooking. Strategies to prevent injury from flames, scalds, and electrical injury are reviewed above. (See 'Burn injury prevention' above.)

•Education is an active process that requires behavior modification. Although many resources are expended on community education, the beneficial effects are not clear.

•Engineering (modification of agents or environment) and enforcement (creation and implementation of guidelines, codes, and laws) require more resources than education programs but also are more effective.

•Education programs and especially design changes and modification of the environment may be the best option for injury prevention. Passage of legislation in any country is often challenging, but enforcement is particularly difficult, particularly in low- and middle-income countries.

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Michael D Peck, MD, ScD, FACS, who contributed to earlier versions of this topic review.