JBUR-4250; No. of Pages 10 burns xxx (2014) xxx–xxx

Available online at www.sciencedirect.com

ScienceDirect journal homepage: www.elsevier.com/locate/burns

A study of energy-related injuries from hospital admissions among children and adults in South Africa A. Gevaart-Durkin a,*, D. Swart b, Z. Chowdhury a a b

Graduate School of Public Health, San Diego State University, San Diego, CA, United States Research and Education, Paraffin Safety Association of Southern Africa, Cape Town, South Africa

article info

abstract

Article history:

Introduction: Burn and ingestion injuries are common in developing countries because of

Accepted 17 December 2013

poor access to safe energy sources, crowded living conditions, and insufficient knowledge of

Keywords:

injuries due to various energy source usages in South Africa.

Burn injury

Methods: Patients at 16 regional hospitals throughout South Africa presenting with an

potential risks. The purpose of this study is to understand the scope of burn and ingestion

Ingestion injury

energy-related injury between 2006 and 2012 were interviewed to obtain demographics

Paraffin

and injury characteristics.

Kerosene

Results: A total of 12,443 patients were included in this study. Children aged 1–2 years

South Africa

predominantly experienced burn and ingestion injuries (21%). Liquid burns (30%) were more

Unintentional injury

common than flame burns (14%). Chi-squared tests show that age was significantly related to degree of burn, type of burn, and severity of burn ( p < 0.001). Non-intentional injuries (45%) were more frequent than self-inflicted or assault injuries. Temporal and seasonal injury trends reflect usage patterns. Burn injuries result in longer hospital length of stay than ingestion injuries. Conclusion: Non-intentional liquid burns and ingestions to infants and babies were most common in this study, with many injuries also occurring among young adults. It is advised that interventions targeting low-income communities be conducted to increase awareness of burn and ingestion injuries. # 2014 Elsevier Ltd and ISBI. All rights reserved.

1.

Introduction

Unintentional injuries remain one of the leading causes of death in the world, with burns accounting for a large portion of mortality; a disproportionately high percentage (over 95%) of these injuries occur in developing countries [1]. Africa in particular has a high prevalence of burn injuries due to poverty, overcrowding in housing communities, and poor living conditions [2]. The proportion of deaths among children due to burns is twice the level in low-income countries than it

is in high-income countries, and infants in Africa specifically experience burns three times more than the world average [3]. While South Africa is viewed as one of the more developed African countries, rates of unintentional injuries such as burns and ingestions, remain high. Many African countries utilize unsafe energy sources and lack infrastructure, putting them at even greater risk for injury [2]. Energy source usage refers to the pattern and combination of materials used in the home for cooking, heating, and/or lighting purposes. These usage patterns differ greatly between electrified and non-electrified homes. Examples of common

* Corresponding author at: Graduate School of Public Health, San Diego State University, Hardy Tower 119, 5500 Campanile Drive, San Diego, CA 92182, United States. Tel.: +1 425 218 5185. E-mail address: [email protected] (A. Gevaart-Durkin). 0305-4179/$36.00 # 2014 Elsevier Ltd and ISBI. All rights reserved. http://dx.doi.org/10.1016/j.burns.2013.12.014 Please cite this article in press as: Gevaart-Durkin A, et al. A study of energy-related injuries from hospital admissions among children and adults in South Africa. Burns (2014), http://dx.doi.org/10.1016/j.burns.2013.12.014

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energy sources include electricity, paraffin, firewood, candles, and gas [4]. South Africa in particular does not follow a typical energy ladder scheme in which higher income homes climb the ladder, but instead utilizes a mix of multiple energy sources [4]; the reason for this is multifactorial. Human factors such as knowledge of fuel source and appliances, physical environment setting such as dwelling size and escape points, and cultural practices all affect energy source usage [5]. Perhaps the biggest determinant of energy source usage is level of poverty; this affects the choice and quality of fuels, appliances, dwellings and frequently forces children to be left unattended [5]. Many South African low-income homes turn to paraffin (also known as kerosene) as their primary fuel source due to its lower cost and ease of accessibility for many families [6]. Paraffin, not to be confused with paraffin wax, is a hydrocarbon fuel created through the distillation of petroleum and is used most commonly for cooking and boiling water, however it is also used for lighting and heating purposes [7,8]. As many as 92% of homes in South African informal settlements use paraffin on a daily basis [6]. Studies have found trends in injury patterns, commonly depending on age, gender, and race. Allorto and colleagues (2009) found that among pediatric burn patients aged 0–12 years, the median patient age is 3 years, but among burn patients over 12 years of age, the median patient age is 40 years [2]. Additionally, adults were found to sustain deeper burns to the skin than were children [2]. Children are at greater risk for experiencing a burn injury due to their reduced mobility, undeveloped risk perception, long sleeping hours, greater likelihood to sleep deeply, smaller surface area to body volume ratio, and physiological immaturity; these characteristics also put them at higher risk of experiencing adverse outcomes [8]. Generally speaking, population risk factors of childhood burn injury are low literacy and income levels, overall health status, and household crowding, with further risk associated when there is low socio-economic status (SES) of the family, low education level of the mother, and stress in the family [9]. More injuries likely occur in South Africa as a result of higher rates of poverty and unsafe use of paraffin [10]. While a number of studies have attempted to present the scope of energy-related burn and ingestion injuries in South Africa, none have been published with data from the number of hospitals and length as this study. Much of the literature has focused primarily on a small cohort or geographic region, however this study hopes to give a more inclusive view of the problem in South Africa. Current research also tends to focus on only one injury type—either burns or ingestions—but rarely focus on both of them [11–13]. Burns are any thermal injury that damages skin cells by hot liquid (scalds), hot solids (contact burns), flames (flame burns), electricity, friction, or radiation [14]. While burns have a higher incident rate overall, it is important to remember that ingestion injuries occur from paraffin and other fuels as well. Paraffin is considered a poison if ingested [12]. Paraffin enters the body through ingestion into the stomach or by inhalation of fumes and smoke [8]. The fatality rate is low, but can result due to respiratory failure from aspiration of paraffin into the lungs [7]. Because poisoning incidence among children is poorly documented, especially in developing countries [11],

this study hopes to add to this documentation. It has also been noted that accurate and thorough injury surveillance and analysis is crucial in the planning of interventions, and that the lack of such data is a major problem in the battle against burn injuries [14]; this study seeks to strengthen this knowledge base. Overall, the objective of this study is to establish the scope of the problem of paraffin and other energy-related burn and ingestion injuries among children and adults in South African townships by determining demographic distribution of injuries, investigating when injuries occur, and analyzing characteristics of these injuries.

2.

Methods

2.1.

Settings and participants

Sixteen regional hospitals throughout South Africa were chosen for participation in this study if surrounding areas were known to have high incidence of energy-related injuries, which typically corresponded to areas of densely populated lowincome housing. Participants were then selected from these institutions upon presentation of an energy-related injury from both hospital and emergency admissions. According to the 2011 South African Census, approximately 7 million people live in informal settlements [15], which were originally the result of post-Apartheid labor migration when men moved to cities looking for work [16]. Today, these housing areas commonly lack basic amenities such as access to clean water, electricity, and sanitation facilities [16]. These homes, or shacks as they are commonly called, are densely populated and built close together, often out of materials such as tin, wood, and other scrap supplies, many of which are highly flammable [6]. Shacks that have access to electricity frequently do so through an illegal connection, further increasing the risk of injury [6]. Home interiors are small and cramped with little space for using stoves and candles safely or storing poisonous items [17]. Children have little room to play and in the event of a fire, it spreads quickly from one shack to another due to their close proximity [17]. While it cannot be assumed that everyone in this study lived in an informal settlement, it is likely that the majority of individuals resided in a similar environment given the hospital locations and the populations they serve.

2.2.

Data collection

Paraffin Safety Association of Southern Africa (PASASA) research assistants located at each institution collected the data used in this study (see Fig. 1 for institution information). Upon presenting with an energy-related injury, patients were verbally asked in their native language for consent to be interviewed and to obtain access to their medical records (verbal consent was obtained due to low literacy among the sample population). Once participants gave consent, research assistants captured patient data on the Household EnergyRelated Morbidity and Mortality Surveillance Data Capture Form created by PASASA for the purpose of this study, which includes information on gender, race, age, cause of injury, energy source involved, location and activity when injury occurred, intentionality, injury characteristics (including burn

Please cite this article in press as: Gevaart-Durkin A, et al. A study of energy-related injuries from hospital admissions among children and adults in South Africa. Burns (2014), http://dx.doi.org/10.1016/j.burns.2013.12.014

JBUR-4250; No. of Pages 10 burns xxx (2014) xxx–xxx

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Fig. 1 – Geographical distribution and demographics of study institutions.

severity and depth), and outcome. Patient names were not recorded during this process, however identification numbers were used to track patients. Following completion of the patient interview, patient medical records were retrospectively viewed to obtain information on treatment outcomes. PASASA research assistants then uploaded data via cellphones to the database. The PASASA Senior Project Manager of Research & Education confirmed data validity by visiting institution locations and checking research assistants’ performance, in addition to crosschecking data capture forms with the database. Once data were received for this analysis, a cleaning of the dataset was done in Microsoft Excel. Invalid entries were corrected (i.e. spelling errors) or replaced and marked as unknown (i.e. if it was not possible to determine the intended classification). Children were defined as aged 0–14 years and adults were defined as aged 15+ years. Hospitals were excluded from this study if they declined participation, or if they contributed less than 50 patients because we felt that they did not meet participation requirements (four institutions). No cases were excluded due to missing information; missing variables were marked as unknown so as to preserve other variable data. The Institutional Review Board at San Diego State University approved this analysis (vIRB Number 1132087).

2.3.

Fig. 2 shows the distribution of injuries by gender and age, as well as by injury type. Forty-seven percent were male. There were 5608 children with a mean age of 4.8 years (SD  3.8 years). The mean age of an adult was 31.3 years (SD  13.7 years). Black Africans comprised 77% of the population injured, followed by coloureds at 10% (‘‘coloured’’ is an accepted ethnic category in South Africa to indicate mixed ethnicity). Table 1 also shows the frequency distribution of injuries, segregated by gender and age. Flame and liquid burns each comprised 40% of adult burns, however liquid burns accounted for 70% of burns received by children; 1275 1–2 year old children received liquid burns (see Fig. 2a). Adults sustained more superficial and full thickness burns (46% and 14%, respectively), while children sustained more partial thickness burns, representing 56% of burn injuries to children. Burn severity was reported predominantly to be minor/ superficial for both adults and children (59% and 60%, respectively). Using a chi-squared test of independence, age was significantly related to the degree of burn, the type of burn, and the severity of burn in this study ( p < 0.001). There were 268 burn fatalities, however this figure is likely an under representation of the actual number of burn deaths. The likely reason for this is that victims found dead are taken straight to a mortuary and are never seen at a hospital.

Data analysis 3.2.

All descriptive statistics and frequencies were determined using IBM SPSS Statistics version 20. Tables and figures were also generated using SPSS, as well as Microsoft Excel. Variables analyzed were age, gender, race, incident cause, energy source, total body surface area burnt (TBSA), burn severity, length of stay (LOS), degree of burn, intentionality, and time. A chi-squared test of independence was used to determine relatedness between age and degree of burn, type of burn, and severity of burn.

3.

Results

3.1.

Burn injuries

Adults had more ingestion injuries than children, however it is worth noting that children (mostly boys) were poisoned much more by paraffin than adults were, and that the majority of adult ingestions came from other chemicals (Fig. 2c and d). Almost all ingestion injuries to children were non-intentional, whereas nearly all ingestion injuries were self-inflicted by adults aged 15–44, particularly among females. A closer look at adult ingestions reveal that non-paraffin chemicals were ingested 10 times more for each age group than paraffin.

3.3.

Between 2006 and 2012, 12,443 patients presented with an energy-related injury at 16 regional hospitals in South Africa.

Ingestion injuries

Intentionality

As seen in Table 2, 45% of injuries were non-intentional, 20% were self-inflicted, and 30% of injuries had unknown intentionality. Females had more self-inflicted injuries than

Please cite this article in press as: Gevaart-Durkin A, et al. A study of energy-related injuries from hospital admissions among children and adults in South Africa. Burns (2014), http://dx.doi.org/10.1016/j.burns.2013.12.014

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Fig. 2 – Distribution of cases by age and gender by (a) total injuries, (b) all burn injuries, (c) all ingestion injuries, and (d) all injuries resulting from paraffin.

males. In total, females account for 65% of self-inflicted burn injuries and 73% of self-inflicted ingestion injuries. Conversely, males presented with burn injuries from assault more often than females (64% versus 33%). Non-intentional injuries were seen more commonly in children (distribution mode of 2 years), whereas assault and self-inflicted injuries were seen more often in adults (assault distribution mode of 26 years for both males and females, self-inflicted distribution mode of 27 years for males and 17 years from females). Assault injuries resulted in the longest LOS with a median stay of 9 days (95% CI: 0–61 days).

3.4.

Activity, location, and energy source used

Playing/recreation was the most common activity at the time of injury, accounting for 40% of all cases. Fighting/moments of anger was the second most common activity, accounting for 10% of cases. About 80% of all injuries occurred in the home.

Electricity use was reported by 25% of cases and was the most frequently used energy source at the time of injury in this study. Paraffin use was also common at the time of injury with 19% of cases reporting this source; other and unknown sources accounted for 47% of energy sources used at the time of injury. Liquid burns were the predominant injury type, as illustrated in Table 1. Flame burns and other ingestions also comprised a large portion of injury type.

3.5.

Temporal and seasonal trends

The most burn injuries occurred during the month of July with 730 cases, as seen in Fig. 4. The fewest burn injuries occurred in February and March with 400 and 401 cases, respectively. Ingestion injuries peaked in January with 354 cases and were at their lowest in June, with 126 cases. The most number of injuries occurred during the hour of 6 pm to 7 pm, followed closely by the hour of 10 am to 11 am. Not surprisingly, these

Please cite this article in press as: Gevaart-Durkin A, et al. A study of energy-related injuries from hospital admissions among children and adults in South Africa. Burns (2014), http://dx.doi.org/10.1016/j.burns.2013.12.014

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Patient age group (years) 1–2

10% 11–20% 21–30% >30%

234 61 21 4

144 29 18 9

748 183 78 45

514 142 53 23

257 62 30 23

152 59 26 21

246 50 26 22

200 65 21 27

133 19 17 21

139 14 10 13

127 13 12 25

184 23 9 7

178 41 33 41

223 34 26 17

405 101 74 85

318 51 40 37

257 73 39 42

156 54 34 23

136 40 27 26

106 20 16 24

59 17 14 12

54 16 13 13

34 9 8 12

62 12 7 9

Degree of burn

Full thickness Partial thickness Superficial thickness

15 184 112

8 111 78

57 543 424

32 396 284

23 223 123

12 158 88

25 187 138

23 176 112

24 92 73

12 84 85

22 74 89

13 59 152

31 127 115

22 97 179

101 288 266

49 149 252

71 166 157

36 110 121

39 107 74

31 47 81

15 48 27

20 39 32

24 24 13

20 33 36

Type of injury

Flame burn Food burn Liquid burn Contact burn Other burn Paraffin ingestion Other ingestion Chemical burn paraffin Chemical burn other Asphyxiation Multiple causes Unknown

30 10 233 10 10 19 19 0 4 0 25 11

19 9 147 5 3 15 14 3 1 2 17 11

65 48 734 34 44 237 109 3 12 0 102 63

52 44 510 27 34 164 100 1 4 0 89 34

64 14 225 15 21 62 82 3 7 0 37 21

44 10 153 12 14 40 61 3 4 0 36 9

86 14 156 27 17 18 49 2 14 1 50 23

62 15 188 8 16 12 36 3 3 1 34 14

69 12 71 14 14 17 26 2 6 0 18 8

39 15 88 6 6 13 131 0 9 1 28 7

54 9 65 7 11 12 93 0 7 0 28 15

31 16 72 8 34 53 422 2 17 1 46 17

98 14 83 14 27 19 128 1 6 1 44 15

64 22 84 13 42 51 357 2 17 2 55 20

240 25 220 15 41 20 182 7 20 1 112 30

108 29 148 17 41 39 305 6 15 1 70 24

149 18 138 13 37 9 66 4 4 0 59 21

74 9 104 4 22 12 133 8 7 0 43 13

83 10 78 4 15 0 27 1 2 0 34 12

57 14 48 5 10 1 48 2 2 0 32 4

41 3 30 4 7 0 14 2 2 3 10 2

35 3 30 1 5 0 28 2 0 0 15 4

43 0 11 0 4 0 5 1 1 0 9 2

37 2 31 3 2 3 6 0 2 1 17 6

Burn severity

Minor/superficial Moderate Severe Fatal Inhalation burn

180 128 4 8 8

114 76 5 6 7

732 384 20 27 26

511 290 11 10 30

256 147 12 12 16

177 109 3 8 6

232 128 9 7 9

202 111 16 7 5

131 58 11 9 6

179 58 0 7 14

140 66 5 8 16

338 80 2 21 26

207 112 4 18 18

368 82 5 20 30

425 259 26 31 22

413 129 17 17 25

217 152 21 20 18

224 97 9 18 7

105 93 12 23 3

107 49 5 19 9

44 42 3 9 5

47 29 4 13 3

14 26 8 12 2

39 37 1 17 2

a

burns xxx (2014) xxx–xxx

Please cite this article in press as: Gevaart-Durkin A, et al. A study of energy-related injuries from hospital admissions among children and adults in South Africa. Burns (2014), http://dx.doi.org/10.1016/j.burns.2013.12.014

Table 1 – Frequency distribution segregated by gendera and age for injury description.

M, male; F, female.

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– – –

4.1.

Burn injuries

Burn injuries were the predominant injury type in this study. Length of stay is an important indicator when looking at burn injuries as it can convey information on the gravity of the injury. Higher TBSA is associated with greater LOS in hospital as seen in Table 2. Length of stay peaks at 21–30% TBSA with a median stay of 13 days (95% CI: 0–62 days), and then decreases for >30% TBSA burns, possibly because patients are not surviving such severe burns. This finding is much shorter than what has been reported in other studies, which found the mean LOS to be 68 days [2]. Superficial and partial thickness burns reported cover 30% comprising a larger portion of these burns (Fig. 3). Burn injuries occurred most commonly among children aged 1–2 years as seen in Fig. 2 and Table 1. Injury incidence decreased after age two perhaps due to greater risk awareness, however the number of cases increased in patients in their 20 s, but then decreased again as they continued to get older. This injury peak in the later adolescent years corresponds to greater assault and self-inflicted injuries, which occur most commonly is this age group. Interestingly, this pattern is consistent across all four graphs of Fig. 2.

4.2.

26 1 1

16

28

27

17

Discussion



– –

4.

16

25

21





30 16

Ingestion injuries

26 2 Age, years (mode)

2

9

10

29

The routine storage habit of paraffin in many homes greatly increases the risk of ingestion injury for children [13]. There is little storage space in cramped, crowded living spaces

Age, years (median)

436 (53.1)

384 (46.8)

13 (50.0)

247 (51.2)

233 (48.3)

13 (50.0)

535 (26.9)

1425 (73.1)

2

2

156 140 104 180 183 220 720 284 1684 425 196 177

are common meal times when people are most likely using a variety of energy sources to prepare food.

M, male; F, female. a

Ingestions, n (%)

30% TBSA, n

1272 340 127 113

193 71 27 31

97 42 19 14

140 5 3 15

299 5 13 10

866 189 159 149

618 148 117 93

5 11 10 7

5 12 16 8

F

156

M

284

F

7 7

M F

109 (64.9) 55 (32.7)

M F M

1028 (41.5)

F

1420 (57.3)

M

250 (63.9) 1543 (41.7)

F M

2026 (54.7)

Non-intentional

129 (33.0)

Unknown Self-inflicted Assault

Intentionality Table 2 – Injury intentionality by gendera, type of injury, age, and LOS.

Burns, n (%)

Range Median

Length of stay

burns xxx (2014) xxx–xxx

Fig. 3 – Degree of energy-related burns and total body surface area burned.

Please cite this article in press as: Gevaart-Durkin A, et al. A study of energy-related injuries from hospital admissions among children and adults in South Africa. Burns (2014), http://dx.doi.org/10.1016/j.burns.2013.12.014

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forcing families to keep paraffin on the floor within easy reach of small children [7]. Since there are no regulations dictating packaging or labeling that would indicate paraffin as a poison in South Africa, paraffin is frequently put into old beverage bottles [13,18]. Children will commonly mistake a reused milk jug or cold-drink bottle full of paraffin as water during the warm summer months and subsequently drink the contents, resulting in poisoning from paraffin ingestion or inhalation of fumes [8]. In a 1994 article on paraffin poisoning in children in South Africa, it was reported that as many as 61–82% of poisonings to children were from paraffin [18]. Paraffin ingestions are typically non-intentional among children. When adults present with an ingestion injury, it is commonly self-inflicted and they have ingested something other than paraffin. An interesting point made in a Zimbabwean paraffin study was that due to the low incidence of intentional ingestion of paraffin by adults, parents may not identify paraffin as a poison and therefore do not feel the need to store paraffin out of reach of their children; this exemplifies the need for proper education about the risks of paraffin [19]. Because of this mindset, nearly 600 children experienced a non-intentional paraffin ingestion, which represents just over 10% of all children presenting with an energy-related injury in this study. Male children were especially likely to experience paraffin ingestion poisonings. Fortunately when treated paraffin ingestions are usually not serious. Paraffin ingestion typically results in respiratory symptoms [12]. The most common complications include pneumonitis, pneumomediastinum, pneuchemical mothorax, and subcutaneous emphysema as a result of paraffin aspiration into the lung; this occurs either upon ingestion, or when parents induce vomiting thinking it is the correct course of action for a paraffin ingestion [20]. This is very dangerous as paraffin alters the production and function of surfactants in the lung, leading to the aforementioned conditions; this can be fatal, although is not a common outcome [12]. Symptoms include inflammation of lung tissue, hemorrhaging of lung tissue, edema, hyperanemia, bronchial necrosis, and vascular necrosis [12]. Treatment often includes oxygen supplementation and antibiotics [12]. Length of stay is often much shorter for ingestion injuries (as opposed to burn injuries) with a mean LOS of only two days [11]; consistent with previous findings, ingestion injury patients in this study had a similar median LOS of three days (95% CI: 0–7 days). Paraffin poisoning is difficult to identify, so if children cannot yet speak and inform an adult that they ingested something, it is possible that many ingestions are going untreated [18]. This situation is exacerbated by the fact that parents are away at work and children are unattended or left in the care of older siblings [21]. Even more worrisome is that children may wander into the homes of neighbors, resulting in an increased exposure to paraffin; these neighbors, particularly if they do not have children of their own, may not take the proper precautions to prevent paraffin-related injuries [17].

4.3.

Vulnerability of children

The World Health Organization (WHO) states that burns are the only category of childhood unintentional injury that girls

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experience more frequently than boys [1]. Additionally, it has been found that boys are more commonly burnt by flames, whereas girls are more commonly burnt by liquids [22]. However, Balan and Lingam found that there is a higher prevalence of burn injuries among boys in South Africa and that this is likely due to the fact that boys take more risks than girls and are typically given more freedom as children [23]. In this study, boys experienced both flame and liquid burn injuries more than girls, as well as more ingestion injuries among young boys, which is inconsistent with the WHO information. It is likely that the findings of this study are more consistent with that of Balan and Lingam in which the boys in South Africa exhibit behaviors that increase their risk of burn and ingestion injury. Children aged 1–2 years experienced a large portion of injuries in this study. As mentioned above, Fig. 2 shows that with each injury type, children in this age category experienced more injury than any other age group. Liquid burns were the predominant cause of injury. Children just beginning to walk may be left unsupervised and unaware of dangers inherent to energy usage. They frequently have hot water, soups, or paraffin spilled upon them by accident, resulting in this high percentage of burn injuries. This age group is especially vulnerable because their bodies are still developing, resulting in devastating injuries. Children with such severe burns experience discrimination and stigmatization throughout their lives that keeps them trapped in the cycle of poverty, in addition to a painful physical recovery that may last years [24].

4.4.

Institution and regional differences

Most institutions reported more burn injuries than ingestion injuries. However, Themba Hospital, Kimberley Hospital Complex, and RK Khan Hospital observed in some cases almost 10 times more ingestion injuries than burn injuries. While it is difficult to identify trends that resulted in this pattern since they are not geographically clustered, it is interesting to note that these three institutions saw more female patients, whom are more likely to self-inflict ingestion injuries than males. Each of these three institutions, especially the Kimberley Hospital Complex, saw an increase in the number of injuries during the late teens to mid-twenties—an age when most self-inflicted injuries occur. Furthermore, when looking at intentionality of each institution, it is found that these three have the highest number of self-inflicted injuries among all institutions. It would be recommended that the motivations for this behavior be explored in these areas to better inform interventions and help these women. The only institution representing Cape Town and the whole Western Cape is a pediatric hospital, which is unlikely to accurately reflect all burn and ingestion injury patterns for this region. When looking at the data from Red Cross Children’s Hospital, there were slightly more boys than girls with 157 male patients and 98 female patients; 129 of them were aged 1–2 years. Interestingly however, almost all of their injuries were burns. This may suggest that families in this area, which is more urbanized, have a greater understanding of the dangers of paraffin and take greater precautions to prevent ingestion injuries, whereas other areas of South Africa

Please cite this article in press as: Gevaart-Durkin A, et al. A study of energy-related injuries from hospital admissions among children and adults in South Africa. Burns (2014), http://dx.doi.org/10.1016/j.burns.2013.12.014

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may not have this knowledge. As would be expected among pediatric patients, almost all injuries were non-intentional. While this hospital may not be representative of the Western Cape, there is some applicability of this sample to all children in that mostly boys received injuries, they were predominantly aged 1–2 years, and they received more burn injuries than ingestion injuries. This pattern is seen across all institutions for pediatric patients. According to a 2012 Residential Sector study conducted by the South African Department of Energy, significantly more low-income homes do not have access to electricity (72%), compared to medium and high-income homes (7% and 0%, respectively) [4]. Homes that do have formal electricity are using electricity as their predominant energy source, however unlike many other developing countries, South Africa does not follow the traditional unidirectional movement ‘‘up’’ the energy-ladder; many electrified homes still use other energy sources due to cost or barriers to energy-switching [4]. In homes that are not electrified however, candles, paraffin, and firewood are still the primary energy sources used. Candles, firewood, and paraffin represent 70% of the energy sources used in low-income homes. It was also determined that paraffin is almost universally used in all non-electrified informal settlements [4]. Notably, the Eastern Cape and Kwazulu-Natal provinces have lower electrification rates, resulting in higher usage patterns of alternate energy sources, such as paraffin and firewood, and similar patterns are seen in rural, low-density homes, which are even harder to electrify [4].

4.5.

Fig. 4 – Burn and ingestion injury distribution by month.

Temporal and seasonal patterns

Burn and ingestion injury patterns differ from one another throughout the year. Ingestion injuries were more likely to occur in January during the summer, whereas burn injuries were more likely to occur in July during the winter (Fig. 4). As mentioned above, there are no requirements for the labeling or packaging of paraffin. As a result, children searching for a cool beverage in the summer heat might drink paraffin unintentionally since it looks similar to water and is in an unmarked, reused container [6]. In the cooler winter months people cook and heat their homes more often, thus increasing the likelihood of a burn injury from flames or liquids [9]. Similar to seasonality, there were daily temporal trends of when injuries occurred, as shown in Fig. 5. The highest peaks were seen in the morning hours between 8 am and 10 am and again in the evening between 6 pm and 8 pm. This is not surprising as these are common meal times when people are most likely to be using various energy sources to prepare meals. Other studies support these findings [11,25]. There is another peak, although not as high as during meal times, between 1 and 2 am. Due to South Africa’s known drinking culture, it is possible that inebriated individuals returning home from the shebeen, or bar, are not as careful when handling cooking or heating objects, resulting in an unintentional injury or fire. Similarly, when people return home intoxicated they may be more likely to engage in argumentative behaviors that lead to assault injuries, which also occurred during this hour. Many more burn injuries occurred during this time, rather than ingestion injuries.

Fig. 5 – Injury by hour of occurrence, all injuries.

4.6.

Strengths and limitations

This study is predominantly descriptive. While there are many hospitals included in this study, they are not equally distributed geographically and are clustered on the eastern side of South Africa. The only participating hospital on the western side of the country is a children’s hospital, so there is a lack of information about adult injuries for this area. The Western Cape was underrepresented when hospitals were selected because it is a well resourced province with two burn units (one for adults at Tygerberg Hospital and one for children at Red Cross Memorial Children’s Hospital). Additionally, it has been found that different regions of South Africa have different energy use patterns. In the Western Cape, only 26% of homes use paraffin compared to nearly 72% of homes that use paraffin in the Eastern Cape (the highest usage rate of all provinces); it was thus a presumption that the Eastern Cape

Please cite this article in press as: Gevaart-Durkin A, et al. A study of energy-related injuries from hospital admissions among children and adults in South Africa. Burns (2014), http://dx.doi.org/10.1016/j.burns.2013.12.014

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would have a higher incidence of paraffin injuries so more hospitals were chosen in this region [4]. However, this is a very large dataset spanning a number of years. Although the geographic distribution is not uniform, there are hospitals from the most populated areas within South Africa. This study contributes substantial data about burn and ingestion injuries resulting from a variety of energy sources, which strengthens the existing knowledge of unintentional injury in South Africa and can be used to help inform policy and interventions.

4.7.

Recommendations

Besides the difficult and complex task of eliminating poverty, policy changes and educational interventions may be helpful to reduce injuries in the meantime. Educational campaigns have so far been conducted with much success, suggesting that widescale interventions have the potential to greatly reduce injuries. A randomized controlled trial by Odendaal and colleagues (2009) found their home visitation program reduced hazards associated with burn injuries by 50% [21]. Caregivers were made aware of how to safely use energy sources, including placement of appliances as well as consumption of fuel, and how to reduce the risk of poisoning by instructing caregivers to keep poisonous substances out of reach of children [21]. Another study by Schwebel et al. found that a home visitation train-the-trainers model was successful in educating the community about paraffin safety, practice, and perception of risk [17]. Upon final analysis, intervention community members knew more about paraffin safety and had better safety practices in the home than those in the control community [17]. If more interventions are conducted in high risk areas and policies are put in place to protect appliances and fuel distribution, it is likely these types of injuries will decline in frequency.

5.

Conclusion

Burn and ingestion injuries are still a relatively common occurrence in low-income areas of South Africa. The results of this study show that very young children are sustaining a large percentage of these injuries (21% of injuries are to children aged 1–2 years) and that liquid burns are the most common injury type; nearly 70% of injuries to children 15 years or younger experience a liquid burn and they comprise 30% of the injuries in this study overall. Children burn a greater percentage of their body than adults do, experience a greater depth of burn to their skin, but show similar patterns in burn severity to adults. Although adults had more ingestion injuries, children ingest paraffin more frequently. More data is needed to understand the risk factors for these injuries. Interventions educating on the safe use of paraffin and other household energy sources may prove beneficial for families living in these environments. Additionally, it is advised that stricter safety regulations regarding the production and distribution of energy sources be enforced so as to protect these individuals further. Ultimately the reduction of poverty would provide the best solution to preventing energy-related injuries.

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Conflict of interest The authors declare no conflicts of interest.

Acknowledgements The authors would like to thank the Paraffin Safety Association of Southern Africa for the use of their dataset. The authors would also like to thank the research assistants who collected data over the years, all participating health institutions, and patients and their families for participating in this study. Finally the authors would like to thank Sumaiyah Docrat for her assistance in the initial phases of this manuscript.

references

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Please cite this article in press as: Gevaart-Durkin A, et al. A study of energy-related injuries from hospital admissions among children and adults in South Africa. Burns (2014), http://dx.doi.org/10.1016/j.burns.2013.12.014

A study of energy-related injuries from hospital admissions among children and adults in South Africa.

Burn and ingestion injuries are common in developing countries because of poor access to safe energy sources, crowded living conditions, and insuffici...
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