Epidemiology of burn injuries in Sulaymaniyah province of Iraq

Background Sulaymaniyah is one of the three provinces of the Kurdish region in northern Iraq with a population of 1,700,000. Burn injuries remain a major concern for health authorities in this region where published data on the nature and size of the problem are scarce. The objectives of this PhD project were to investigate the epidemiology of burn injuries, burn mortality, intentional self-harm burns and risk factors for burns in pre-school children. Methods This project involved three main studies; an incidence and outcome study, a three-year admissions study and a case-control study. In the incidence and outcome study which was undertaken prospectively from 3rd November 2007 to 2nd November 2008 at the only burns centre in Sulaymaniyah, all patients attending for a new burn injury were included whether admitted or treated as an outpatient. Patients admitted for intentional self-harm within this study were separately analysed. In the three-year admissions study, all acute burn admissions of 2006-2008 were included. The case-control study investigating risk factors for burns in children aged 0-5 years, involved incident burn cases and controls admitted for other conditions. The risk factors for death, for self-harm and for childhood burns were analysed using multiple logistic regression. Results The incidence and outcome study: A total of 2975 patients were recruited (male 52%, female 48%; median age 18 years). The all-age incidence of burns was 389 per 100,000 per year and the highest incidence was in preschool children (1044 per 100,000 per year). The mechanisms of injury included scalds (53%), flame (37%), contact (7%), chemical (1%), electrical (1%) and explosives (1%). Most burns occurred at home (83%; male 68%, female 96%). There were 884 admissions during the year amounting to an admission rate of 40.4 (males 34.6, females 46.2) per 100,000 per year with the highest rate being in preschool children (82.3 per 100,000 per year). Flame injuries accounted for most women admissions (91%) and scalds for most child admissions (84%). The mortality rate was 9.1 (males 2.5, females 15.6) per 100,000 per year. The median total body surface area (TBSA) burnt was 18% and median hospital stay was 8 days. In¬hospital mortality was 28%. Adjusted odds ratios for death were 36.4 (95% confidence interval 15.9-83.3) for TBSA burnt ≥ 40%; 5.4 (1.7-18.5) for age of 60 and over; 3.6 (1.7-7.3) for inhalation injury; 5.6 (2.5-12.9) for self-inflicted burns and 3.0 (1.3-6.8) for autumn season. Regarding self-harm burns, there were 197 cases of intentional self-harm burns during the year (male 6%, female 94%) amounting to an incidence rate of 8.4 (male 1.2, female 15.5) per 100,000 per year. The median age of patients was 20 years, the median TBSA burnt was 74%, the median hospital stay was 4 days and in-hospital mortality was 88%. The adjusted odds ratios for the risk factors for self-harm were 13.8 (6.9-27.4) for female sex; 3.9 (2.2-7.0) for young age of 11-18 years; 2.5 (1.2-5.5) for lower levels of education; 2.4 (1.3-4.4) for spring season; and 2.7 (1.4-5.2) for small family size of 1-3 members. The three-year admissions study: There were 2829 acute burn admissions from 1st January 2006 until 31st December 2008 with an in-hospital mortality rate of 27%. There was similar number of patients in each year with no significant differences in terms of sex, median age, median TBSA burnt, and in-hospital mortality. The case-control study: The case-control study included 248 cases & 248 controls. 79% of cases were scalds, 17% contact and 4% flame injuries. Burns most commonly occurred in sitting rooms (53%) and in the kitchen (36%) and were most commonly caused by tea utensils (42%) and kerosene stoves (36%). The adjusted odds ratios for risk factors for burns were 5.4 (2.6-11.7) for poor living standard; 5.3 (3.4-8.5) for child activity score; 2.8 (1.5- 5.2), for family history of burns; 1.3 (1.0- 1.7) for a one unit increase in presence of home hazards; 0.4 (0.2- 0.7) for presence of a second carer; and 0.14 (0.03-0.6) for presence of disabilities. Conclusion Burns are an important public health problem with high incidence and mortality rates. Morbidity is highest in pre-school children and mortality is highest in young females. Suicide by self-burning is common and mostly affects adolescents and young women. Collective action is required from the health authorities and their partners to address these issues through developing prevention strategies incorporating further research to the situation, improvement of service delivery to those affected and preventive interventions particularly addressing burns in pre-school children and intentional self-harm burns in women.