Epidemiology of burn injuries in the East Mediterranean Region: a systematic review

BMC Public Health Epidemiology of burn injuries in the East Mediterranean Region: a systematic review Nasih Othman 0 Denise Kendrick 0 0 School of Community Health Sciences, University of Nottingham , Nottingham , UK Background: Burn injuries remain one of the leading causes of injury morbidity and mortality in the World Health Organization's East Mediterranean Region. To provide an overview on the epidemiology of burn injuries in this region, a systematic review was undertaken. Methods: Medline, Embase and CINAHL were searched for publications on burns in this region published between 01/01/1997 and 16/4/2007. Data were extracted to a standard spreadsheet and synthesised using a narrative synthesis. No attempt has been made to quantitatively synthesise the data due to the large degree of clinical heterogeneity between study populations. Results: Seventy one studies were included in the review, from 12 countries. Burn injuries were found to be one of the leading causes of injury morbidity and mortality. The reported incidence of burns ranged from 112 to 518 per 100,000 per year. Burn victims were more frequently young and approximately one third of the victims were children aged 0-5 years. Hospital mortality ranged from 5 to 37%, but was commonly above 20%. Intentional selfharm burns particularly involving women were common in some countries of the region and were associated with a very high mortality of up to 79%. Conclusion: Burn injuries remain an important public health issue in the East Mediterranean Region therefore further research is required to investigate the problem and assess the effectiveness of intervention programmes. - Background The World Health Organizations (WHO) East Mediterranean Region (EMR) covers a population of over 500 million, spread over a wide area of relative cultural and geographical similarity extending from Morocco to Afghanistan. The EMR includes 22 countries; Afghanistan, Bahrain, Djibouti, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, United Arab Emirates and Yemen. Of these countries Kuwait, Qatar and United Arab Emirates are classified as high-income countries and the rest are classified as low-income or middle-income countries[1]. According to the WHOs International Classification of Diseases version 10(ICD-10), burn injuries are classified by site of injury in chapter XIX as burns and corrosions (T20-T32) and in terms of aetiology, they are classified as those caused by exposure to smoke, fire and flames (X00-X09), contact with heat and hot substances (X10-X19), exposure to electric current (W85-87), lightening(X33) and exposure to corrosive substances (X46, X49). Therefore burns include scalds as wells as injuries caused by heat from electrical heating appliances, electricity, flame, friction, hot air and hot gases, hot objects, lightening and chemical burns (both external and internal corrosions from caustic chemicals). Radiation-related disorders of the skin and subcutaneous tissue and sunburn are not included in this classification of burns [2]. Burn injuries are a major problem in the low-income and middle-income countries. The WHO estimates indicate that globally there were more than 7.1 million firerelated unintentional burns (X01-X09) in 2004 giving an overall incidence rate of 110 per 100,000 per year. The incidence in the EMR was 187 per 100,000 per year compared to the lowest incidence in the Americas which was 19 and the highest incidence in South East Asia which was 243 per 100,000 per year[3]. The WHO estimates that 310,000 people died in fires in 2004 across the world, the great majority being in low-income and middle-income countries with a global mortality rate amounting to 4.8 per 100,000 per year[4]. According to these WHO data, 29,000 deaths occurred in the EMR with a mortality rate of 5.6 deaths per 100,000 [4]. Published literature indicates that burn injuries remain a major health problem in the EMR countries, although there has been no published attempt to summarise this literature to date. In view of the cultural, economic and geographic similarities among the countries of this region, summarising the literature will describe the extent of the problem, and highlight common features and differences regarding the epidemiology of burn injuries. Such information will be useful for planning prevention strategies and identifying further research questions that need to be answered. Methods This systematic review was undertaken to describe the epidemiology of burns in the EMR between the years 1997 and 2007. All published studies relevant to the epidemiology of burns in the region were considered for inclusion in the review. The main outcomes included the incidence of burns, mechanism of burns and mortality. Inclusion/exclusion criteria Studies investigating the epidemiology of burns in the countries of the region were included if they were published between 1997 and 2007 using methodologies including cross sectional surveys, retrospective and prospective studies, systematic reviews and case-control studies. The following types of articles were excluded: 1) articles about specific aspects of burn management; 2) methodologies apart from those mentioned above e.g. case reports, editorials etc.; 3) military and war related burns and 4) articles repeating data from other articles already included. Search strategy Medline, Embase and CINAHL were searched for publication dates between 01/01/1997 and 16/4/2007. The search strategy included the following terms: burn*, scald*, thermal injur*, combined by OR; AND the names of all 22 countries of the region combined by OR. In addition a manual search was undertaken of the WHOs East Mediterranean Health Journal from its website. Articles in all languages were retrieved. Selection of the studies The search strategy retrieved 351 potentially relevant articles with abstracts (see figure 1). One researcher (NO) reviewed the abstracts and excluded studies which were not about EMR countries or the main topic was not about burns. The titles and or abstracts of the remaining 175 articles were assessed for inclusion independently by both researchers to select those relevant to epidemiology of burns. Eighty seven articles were selected and their full texts were obtained including some in French and Persian. Where these had English abstracts they were assessed for inclusion by 2 reviewers, otherwise they were assessed for inclusion and data were extracted by one reviewer who was fluent in these languages. Using the inclusion/exclusion criteria, the two researchers independently reviewed these articles and finally selected 71 studies for inclusion in the review. Any disagreement between the two reviewers about inclusion was settled by discussion. Data extraction Data were extracted from full copies of published articles using a standard data extraction spreadsheet. Data were extrac (...truncated)