|Year : 2012 | Volume
| Issue : 1 | Page : 42-45
Epidemiology, treatment and preventive strategy in Diwali-related burns
Bhupendra Prasad Sarma
Senior Consultant Surgeon, NEMCARE Hospital, Guwahati, Assam, India
|Date of Web Publication||13-May-2013|
Bhupendra Prasad Sarma
Senior Consultant Surgeon, NEMCARE Hospital, Guwahati, Assam
Source of Support: None, Conflict of Interest: None
Introduction : Diwali is one of the most important festivals in India, but it also sees lots of people suffering from burns due to fire crackers. Methodology : This is a prospective study of 120 cases of Diwali-related burns in a period of 3 years. The data in the prescribed format were collected from two hospitals of Guwahati, the capital city of Assam. Results : There were 85 males and 35 females in the series. While 90 patients were directly involved in the use of the crackers, 30 were passersby or onlookers. The most common offending agent was the Flower pot (Kalgach) - 84 cases, while fire crackers were responsible for 23 cases, eight cases were due to chakari and five cases were due to the flame of earthen lamps. Majority of the cases (112) had burns between 2% and 6%, while six cases had 10-15% burns and two other cases sustained 45% and 60% burns. Seventy percent of the cases burnt their right hands, 10% burnt their left hand, 5% had burns in both the hands, 4% had burns of the trunk and limbs to a variable extent and 6% sustained facial burns. There were six cases (5%) of eye injuries. While 112 cases were treated as outpatients, 18 cases required indoor treatment. Most of the cases were treated with Collagen dry sheet dressing. A few cases (n = 5) were subjected to Early Excision and Grafting, while three cases required delayed grafting. Burn Prevention programs before Diwali were also undertaken in both the hospitals during the study period. The effect of the Burn Prevention Program on the incidence is also discussed in this paper. Conclusions : Awareness among the masses and strict implementation of government legislation may help in bringing down the incidence of Diwali-related burns.
Keywords: Diwali, fire cracker burns, prevention, treatment
|How to cite this article:|
Sarma BP. Epidemiology, treatment and preventive strategy in Diwali-related burns. Indian J Burns 2012;20:42-5
| Introduction|| |
Diwali is one of the most important Indian festivals and is celebrated on a mass scale by Indians not only in India but also all over the world. People celebrate the festival by lighting earthen lamps and candles and bursting crackers. Although the chances of having a serious accident may seem remote, hospitals and clinics are filled with people suffering from burn injuries caused by firecrackers during this festival. Although government regulation prohibits the bursting of crackers after 10 PM, especially those that produce a loud sound, hardly any heed is paid to these regulations during the festivities. As a result, patients with fire cracker burns continue to pour into the hospitals at odd hours during the festival days.
Although we do not have sufficient data on Diwali-related burns in India, a published study from Delhi has shown that the number of people reporting with fire cracker injuries during a period of 9 years from 2002 to 2010 have doubled from 0.81 to 1.51 per 100,000 population.  Burns of the hands, face and eyes are the most common injuries during Diwali.  Unfortunately, majority of the victims are children. They get injured while playing with the crackers unsupervised by the adults. There are instances of serious injuries caused by the fire crackers to the eyes, leading to loss of vision.  Many children or even adults injure their hands trying to ignite the "Flower pot" (popularly known as Kalgash in Assam) while holding it in their hands. These firecrackers, which should only emanate light and sparkles on ignition, often burst thus causing burn injuries.
NEMCARE Hospital, one of the leading multispecialty hospitals of the city of Guwahati, has a four-bedded Burn Unit under the banner of Burn Care Foundation, a trust that looks after the management, rehabilitation, research and prevention of burn injuries. It is the only referral center for burn-injured patients from all over the state of Assam and also the North Eastern region. The center receives a large number of burn-injured patients during the festival of Diwali. This study was carried out with the aim of analyzing the epidemiological data of Diwali-related burns, first aid measures undertaken in such cases, treatment methods applied and also to determine the effect of Burn Prevention Programs undertaken by the center.
| Materials and Methods|| |
The study was approved by the Ethical Committee of the hospital. This is a prospective study carried out over a period of 3 years (from October 2009 to November 2011) with the data collected from two hospitals of the city of Guwahati. Request for data on a predesigned format was sent to 15 hospitals of the city 2 weeks prior to Diwali. They were requested to fill up the format as soon as the patients arrived and to continue to fill the follow-up records. Only five hospitals responded and returned the filled up format 1 month after the festival. Three hospitals had no cases of burns during the festival. There were 120 cases of Diwali-related burns (patients attending within 1 week of the festival) in two hospitals, majority (108 cases) being in NEMCARE hospital. The data collected in the formats, which included age and sex of the patients, nature of injuries sustained, agents responsible, first aid given, treatment received and the results of treatment, were tabulated and analyzed. There were also questions on types of Burn Prevention Program undertaken by the hospitals.
The two hospitals, namely Guwahati Refinery Hospital and NEMCARE Hospital, wherefrom data were collected, had been conducting Burn Prevention programs, with emphasis on Diwali-related burns, since 2005. The Burn Prevention programs included School Education Programs, Awareness Programs for general people, erection of hoardings and banners at public places, publication of articles on burn prevention in newspapers and journals, television talks, discussions and telecasting of skits containing a message on burn prevention. We tried to analyze the effects of these programs on the incidence of burns and also on the awareness of first aid given to those victims.
| Results|| |
A total of 120 patients were treated in the hospitals during a period of 3 years. There was an increasing trend in the incidence of burns in the three successive years [Table 1]. There was a preponderance of males - 85 (71%) males, and 35 (29%) females omit in the series. While 90 patients were injured because of their direct involvement in the fireworks, 30 patients were either onlookers or passersby. Majority of the patients (n = 87) were young, between 11 and 40 years of age [Figure 1]. The youngest patient was 3 years old and the oldest patient was 73 years old. The most common offending agent was the flower pot (Kalgash) - 84 cases (70%), while fire crackers (bombs) were responsible for 23 cases (19.1%). Eight cases (6.6%) were due to ground spinners (chakari) and five cases (4.1%) were due to the flame of earthen lamps [Table 2].
Most of the cases (n = 112) had burns between 2% and 6% Total Body Surface Area (TBSA), while six cases had 10-15% TBSA burns and two other cases sustained 45% and 60% TBSA burns [Table 3]. Eighty-five (70%) cases burnt their right hands, 12 (10%) burnt their left hand, six patients (5%) had burns in both the hands, seven (6%) sustained facial burns and four patients (4.0%) had burns of the trunk and the limbs to a variable extent. There were six cases (5%) of eye injuries. While 104 patients sustained superficial burns, five patients had deep burns and 11 patients had mixed burns.
The types of first aids provided to the injured were: 65 patients (54.1%) poured water on the burn wounds, 26 patients (21.6%) applied ointments, 10 patients (8.3%) poured water and also applied ointments, six (5.0%) applied toothpaste, 10 patients (8.3%) poured water followed by application of toothpaste, two (1.6%) applied ghee and one patient (0.8%) applied grease over the burn wound as first aid [Table 4].
Majority of the injured (n = 112) were treated as out-patients. Eight patients, who had deep and extensive burns, were admitted. Seventy-one patients were treated with Collagen sheet dressing, 41 cases were dressed with 1% Silver Sulphadiazine with collagen (sore treat cream), five cases of deep burns underwent early excision and grafting and three cases required skin grafting at a later stage.
The results of treatment were classified on a subjective basis as felt by the patients and perceived by the Surgeon. They were as follows:
Eighty-one percent of the patients had excellent recovery, 14% had good recovery and 2% patients showed fair and poor results in our series [Figure 2].
- Excellent - Full functional and cosmetic recovery
- Good - Full functional and part cosmetic recovery
- Fair - Part functional recovery with gross depigmentation/mild scarring
- Poor - Minimal functional recovery with gross scarring and contracture.
Analysis of the results also revealed that there is no apparent decrease in the incidence of burns during the festival of Diwali in spite of intensive preventive campaigns done by the hospitals in the localities. However, awareness of first aid measures to be provided in case of burns has shown some improvement. Seventy percent of the patients have poured water on their burn wounds.
| Discussion|| |
Diwali-related burns are mostly due to fire cracker injuries. But, some patients get burn injuries due to careless handling of the earthen lamps or candles used during the festival. Lighting of the earthen lamps at the floor level and use of flowing garments by the victims were the causes of the disaster in such cases. We had five such cases, two of which culminated into 40% and 60% burns because of delay in dousing the fire.
Our study also reveals an increasing incidence of Diwali-related burns each year. This increase is seen in spite of the fact that Burn Prevention programs are being regularly organized by the Burn Care Foundation in the city of Guwahati. Our finding also conforms to the data of a study done in Safdarjung Hospital, New Delhi, where a steady increase in the incidence of burns during Diwali over a period of 9 years was reported.  Contrary to our findings, another study from Mumbai reported a steady decrease in the prevalence of fireworks injuries during Diwali over a period of 10 years. They attributed this to the mass awareness campaigns done there by government as well as non-government organizations. 
Fireworks are employed all over the world in different festivals and occasions throughout the year. Firecracker injuries in the USA affected approximately 10,000 persons annually from 1980 to 1989 as per the National Electronic Surveillance System.  Another statistics revealed 85,800 pediatric fireworks-related injuries in the USA over a period of 13 years (1990-2003).  In the UK, the number of fireworks-related injuries peaks during Halloween and Guy Fawkes Night.  A report from Denmark revealed 4447 cases of fireworks-related injuries over a period of 12 years. 
The preponderance of male and young patients in our study is in agreement with another study, where two-thirds of their firework-injured patients were males.  Unlike our findings, where majority of the injured were persons actively involved in lighting fireworks, a study reported that more eye injuries due to fireworks were found in persons who were bystanders.  Another study also reported that 66% of injured children were bystanders. 
Flower pot was the most common offending agent causing burn injuries in our study. This was also the most common cause (39%) of injury reported from Mumbai.  This device, although meant for emanating flare and lights only, frequently explodes, causing injuries.
Although most of the studies reported minor burns due to fire cracker injuries (like our study), involvement of the vital parts, like hands, faces and eyes, makes these injuries serious. As majority of these burns are superficial, treatment with collagen sheet dressing has given promising results. Similarly, early excision and skin grafting done in deep burns also showed gratifying results. We recommend Collagen sheet dressing in cases of superficial burns and early excision and skin grafting in deep burns if the patients report within 24 h.
We have not been able to reduce the incidence of Diwali-related burns in spite of our preventive programs. This may be due to the short length of our study and less number of people being covered by our programs. But, it is gratifying to note that more and more people have learnt to pour water on burns due to our mass awareness programs.
In order to bring down the incidence of Diwali-related burns, the Government should make adherence to the legislation regarding use of fireworks in the festival mandatory. The quality of the fire crackers sold in the market should also be standardized and the people in general should be encouraged to follow the precautions while celebrating the festival of lights.
| Conclusion|| |
There is an apparent increasing trend in the incidence of Diwali-related burns involving young children and adults. Although most of the burns sustained are minor, they involve vital body parts and hence call for effective preventive strategies. Awareness among the masses and strict implementation of government legislation in this regard may help in bringing down the incidence of Diwali-related burns.
| Acknowledgment|| |
The author acknowledges with thanks the support given by Dr. Hitesh Baruah, Managing Director, NEMCARE Hospital and Secretary, Burn Care Foundation, in collection of the data and preparing this paper. The author would also like to thank the office staff and the doctors and nurses of NEMCARE Burn Unit and the Emergency Department of NEMCARE Hospital for helping him in collection of the data.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]