INTRODUCTION
Burns are defined as important lesions to the skin or organic tissue caused by
electricity, chemical, radioactive agents, friction or friction, exposure or
contact with extreme heat or cold. They can be classified, in terms of depth,
as
first-degree, when the lesions reach only the epidermal layer; second-degree,
when there is the involvement of the epidermis and the superficial or deep
dermis layer; and, third-degree, when there are lesions of all the skin
appendages1.
Factors associated with burn injuries are considered: low income, urban area,
home environment, and the handling of hot liquids2. Among children, the age of one to three years is more prevalent
in accidents associated with neuropsychomotor development and greater freedom
of
movement3. In elderly patients, in
addition to injuries that occur in the kitchen, they also happen in the
bathroom, related to excessively hot bath4.
Several complications can occur in burn patients, including infection of the
lesion, pneumonia, acute renal failure, shock, and sepsis5. Among the hospitalized patients, 35.8% develop skin
infections and 24.4% respiratory infections, with the elderly being the most
affected6.
Treatment of burn victims is costly for the state and the patient. The average
stay of major burns in a hospital environment is 41.5 days, with the body
surface burned directly related to gravity, causing a great economic and
emotional impact7. The final average cost
of this type of patient can reach R$ 26,386.22, including grafts, debridement,
and time spent in the Single Health System (SUS in Portuguese)8.
Patients face many challenges after hospital discharge, such as social stigmas
due to the injury, which reduces the possibility of the patient returning to
his
economic potential. Another difficulty is that the mobility of the affected
area, as the surface of the burned area can cause mobility difficulties in the
affected region with permanent sequelae9.
Currently, there is a trend in the world to decrease the incidence of burn cases,
the degree of mortality, the duration of hospital stays, and the severity10. In Brazil, the epidemiological profile
of the adult patient who suffers burns is predominantly male, with an average
age of 25 to 26 years, injured by flammable products in their own home. The
majority of incidents occur in the upper extremities, and most are either first
degree only or first and second degree combined. Second- and third-degree scald
burns predominate on children, mainly on the trunk and upper limbs11.
In the south of Brazil, there have been small variations in the rates of
hospitalization of burns in recent years (13.11 to 14.6/100,000 inhabitants),
being higher in males and the 0-19 age group (Favassa et al., in 2017)12. The state of Paraná stands out in the
region, which has higher rates compared to other states12. In Santa Catarina (SC), from 2006 to 2012, there was a
significant decrease in the rate (from 15 to 10/100,000 inhabitants). The group
most affected in the state is one to four years of age, with the hospitalization
rate inversely proportional to age13.
The accomplishment of a higher number of national scientific, technical studies
on the epidemiology of burns is necessary and desired14. The provision of new data, even public knowledge, but
through research, is essential for the responsible agencies to develop effective
prevention methods, based on the studied local population15. Therefore, this study’s objective was to analyze the
time series of hospitalization rates for burns in the state of SC, according
to
sex and age group, in order to provide peculiar and relevant information for
the
design of public policies. The purpose is to promote and protect collective
health concerning burns that are a significant cause of morbidity and mortality
in the Brazilian population.
OBJECTIVE
This study’s general objective is to analyze the time trend for hospitalization
due to burns in Santa Catarina from 2008 to 2018. The specific objectives are:
to identify the general rate of hospitalization due to burns and to evaluate
the
tendency of the time series according to sex and range age by sex.
METHODS
An ecological time-series study was carried out using data obtained in the state
of Santa Catarina in the public domain database of the Hospital Information
System of the Unified Health System (SIH-SUS)16.
The study population was extracted from SIH-SUS hospital admissions data for
burns in the state of Santa Catarina, which occurred from 2008 to 2018. Data
inclusion was performed considering the International Classification of Disease
ICD-10 in the case of burns and corrosion: T20 to T32. Hospitalization data with
ignored sex or age were excluded. During the study period, the estimated
population of burns was 4,480,073, according to SIH-SUS17.
Data collection was performed based on information in the public domain database
on the DATASUS website, from the SUS Hospital Information System (SIH-SUS),
available at http://tabnet.datasus.gov.br/cgi/tabcgi.exe?sih/cnv/niuf.def.
Hospital units affiliated with SUS sent data on admissions made through the
Hospitalization Authorization (AIH) to municipal and state managers. The data
were exported in Comma Separated Values (CVC) format and saved in an Excel
spreadsheet.
Population demographic information was taken from the Instituto
Brasileiro de Geografia e Estatística (IBGE) website, using the
2000 and 2010 censuses, and its inter-census estimates. The study’s dependent
variables referred to the rates according to male and female sex and age group
(0-4 years, 5-9 years, 10-19 years, 20-39 years, 40-59 years, 60 years or more)
by gender. The independent variable was the year 2008 to 2018
For each year of the studied period, the hospitalization rates for burns, grossly
and specifically, were calculated according to the dependent variables of
interest: age group and sex, calculated for every 100,000 inhabitants using the
total number of hospitalizations, divided by the general population of the
period (general, by sex and age group by sex). Standardized morbidity
coefficients and the simple linear regression method were used with the
Statistical Package for the Social Sciences (SPSS) version 18.0 to analyze the
temporal trends in burn morbidity. In this method, the standardized
hospitalization rates were considered as dependent variables, and the years of
the study calendar as independent variables, thus obtaining the model estimated
according to the formula Y = b0 + bI X, where y = standardized coefficient, b0
=
average coefficient for the period, Bi = average annual increase and X = year.
The results were presented in rates, r = correlation coefficient, b = slope,
and
p-value. P <0.05 was considered statistically significant.
RESULTS
In the period analyzed (2008-2018), there were 9,158 hospitalizations for burns
registered in public hospitals in Santa Catarina. The trend in the general rate
of hospitalization for burns is shown in Figure 1. The rate of hospitalization in 2008, at the beginning of the
period, was 12.06 hospitalizations per 100,000 inhabitants, ending the period
(2018), with the rate increasing to 17.07 hospitalizations per 100,000
inhabitants.
Figure 1 - Time trend of the general rate of hospitalization for burns in
the state of Santa Catarina between 2008 and 2018.
Figure 1 - Time trend of the general rate of hospitalization for burns in
the state of Santa Catarina between 2008 and 2018.
When stratifying the hospitalization rate by sex, it was noticed that in males,
it is higher (Figure 2). The male
hospitalization rate started at 14.52, ending the historical series with
22.51/100,000 inhabitants. In females, the initial rate was 9.52
hospitalizations per 100,000 inhabitants and, at the end of the period,
increased to 11.72 per 100,000 inhabitants. There were more variations in the
trend in males in the period, with a significant increase from 2013.
Figure 2 - Time trend of the hospitalization rate for burns in the state of
Santa Catarina between 2008 and 2018, according to sex.
Figure 2 - Time trend of the hospitalization rate for burns in the state of
Santa Catarina between 2008 and 2018, according to sex.
Figures 3 and 4 show the trend of the time
series according to the age group by sex. In Figure 3, which shows the time trend for hospitalization due to
burns in females, it can be seen that the most affected group is 0-4 years old,
with rates of 28, 86 at the beginning of the period, and 69.40 per 100,000 at
the end of the historical series. Besides, there is an increase in the rate in
the age group of 5 to 9 years in 2016 from 11.44 to 26.01 per 100,000
inhabitants.
Figure 3 - Time trend of the hospitalization rate for burns in the state of
Santa Catarina between 2008 and 2018, according to the female gender
by age group.
Figure 3 - Time trend of the hospitalization rate for burns in the state of
Santa Catarina between 2008 and 2018, according to the female gender
by age group.
The rate of hospitalization for burns in males by age group is shown in Figure 4. During the entire period, there is
an increase in the age group from 0 to 4 years, from 44.75 (100,000 inhabitants)
to 115.37 (100,000 inhabitants).
Figure 4 - Time trend of the hospitalization rate for burns in the state of
Santa Catarina between 2008 and 2018, according to the male gender
by age group.
Figure 4 - Time trend of the hospitalization rate for burns in the state of
Santa Catarina between 2008 and 2018, according to the male gender
by age group.
Table 1 shows the annual percentage
change, coefficient of determination (R2), the average annual change (β),
the p-value, and the trend stratified by sex and age group.
Table 1 - Temporal trend in hospitalization due to burns in the state of Santa
Catarina between 2008 and 2018, according to sex and age group by
sex
| |
Annual Percentage Variation (%) |
R2 |
Average Annual Variation (β) |
p-value |
Trend |
| General hospitalization rate Hospitalization rate
by sex
|
29.34 |
0.735 |
0.499 |
0.001 |
Increase |
| Female |
17.91 |
0.44 |
0.248 |
0.026 |
Increase |
| Male |
35.49 |
0.794 |
0.756 |
0 |
Increase |
| Hospitalization rate by age
group |
| Female |
|
|
|
|
|
| 0-4 years |
58.41 |
0.902 |
4.112 |
0 |
Increase |
| 5-9 years |
71.22 |
0.447 |
1.201 |
0.024 |
Increase |
| 10-19 years |
28.12 |
0.089 |
0.103 |
0.373 |
Stable |
| 20-39 years |
-97.71 |
0.346 |
-0.416 |
0.057 |
Stable |
| 40-59 years |
-39.15 |
0.042 |
-0.072 |
0.546 |
Stable |
| More than 60 years |
55.53 |
0.785 |
0.542 |
0 |
Increase |
| Male |
|
|
|
|
|
| 0-4 years |
61.21 |
0.858 |
6.788 |
0 |
Increase |
| 5-9 years |
70.38 |
0.311 |
1.795 |
0.074 |
Stable |
| 10-19 years |
50.54 |
0.372 |
0.498 |
0.046 |
Increase |
| 20-39 years |
-15.64 |
0.007 |
-0.042 |
0.802 |
Stable |
| 40-59 years |
1.01 |
0.093 |
0.202 |
0.362 |
Stable |
| More than 60 years |
42.5 |
0.526 |
0.737 |
0.012 |
Increase |
Table 1 - Temporal trend in hospitalization due to burns in the state of Santa
Catarina between 2008 and 2018, according to sex and age group by
sex
There was a 29.34% increase in the overall burn rate over the study period (2008
to 2018). Concerning sex, there is a significant upward trend for both men and
women, with an annual percentage change of 35.49% and 17.91%, respectively. When
analyzed by age group, there was a tendency to increase in ages between 0-4,
5-9, and over 60 years old in females. In males, there was a tendency to
increase in ages between 0-4, 10-19, and over 60 years
DISCUSSION
In the world, burns represent a significant cause of morbidity and mortality and
can lead to considerable economic and social impact7. These injuries are in fourth place as the most prevalent
type of trauma in the world, after traffic accidents, falls, and interpersonal
violence and they represent one of the biggest problems in global public health
due to the impact represented by the severity of their injuries18.
The data obtained in the present study demonstrated a time trend of increase in
the number of hospitalizations due to burns in the state of Santa Catarina in
the studied period (2008-2018). However, a similar study in the same state
between 1998 and 2012 showed a decrease in the number of cases13. The morbidity rate in 1998 was close to
16 hospitalizations per 100,000 inhabitants, decreasing in 2012 to less than
14
hospitalizations/100,000 and remaining constant14. Another study carried out in the southern region of Brazil,
between 2008 and 2016, found that the hospitalization rate for burns at the
beginning of the period was 13.11 per 100,000 inhabitants, ending in 2016 with
14.60/100,000 inhabitants and remaining constant14. When we analyzed these results, it was noticed that both are in
a temporal agreement since the hospitalization rates increased sharply from the
year 2015.
In Brazil in the period from 2000 to 2014 the general hospitalization rate was
14.56 per 100,000 inhabitants and, when comparing hospitalization rates in
Brazil by states, this longitudinal study found that the state of Goiás had the
highest overall hospitalization rate due to burns, reaching 28.8 per 100,000
inhabitants, a number significantly higher than that observed in the southern
states of Brazil19. This difference found
was not explained by the author of the work. It is relevant to note that this
type of epidemiological, ecological study does not often present enough
information to justify individual issues.
As for the sex of victims of burn hospitalization in Brazil, the present study
observed an increase in both sexes, and the highest rate of victims hospitalized
for burns was male patients. These data agree with results obtained in other
international studies, where countries such as Finland and Germany also have
a
predominance of male hospitalizations20,21. Even
compared with other studies in the national territory, it was observed that
there is a predominance of males8,11.
The triggering factor for the predominance of the male profile in hospitalization
rates, although not explicitly demonstrated, may be associated with the way men
relate to the work they do because epidemiologically, men are occupants of
professions with greater danger and that require more significant physical
effort and would subject them to more risk of accidents. The high hiring of male
professionals in chemical and oil industries in activities that require the
handling of mechanical and welding equipment, and professions that require
contact with flammable fuels, would be responsible for the increase in these
rates. As for the female sex, burn accidents would be most associated with
domestic accidents, domestic violence, and self-harm, as in suicide
attempts22.
The group that includes individuals from 0 to 4 years old stood out as the most
affected age group in both sexes. This finding agrees with other countries such
as Portugal, which presented a rate of 54.6 per 100,000 inhabitants in the same
age group, where scalding in the home environment was characterized as a
significant cause of burn23. Because they are still without the
cognitive integrity of discerning risk situations, younger children are more
exposed to accidents, intrinsically related to their parents’ knowledge about
preventing burns, and first aid24.
Children, aged between 5 and 9 years old, tended to increase hospitalizations in
women and stability in men. The possible accomplishment of housework can explain
this predominance as an assistant in the kitchen, the most commonplace of
accidents in schoolchildren and preschoolers3.
In the 10-19 age group, there was an increase in the trend in males and stability
in females. There was a scarcity of studies in the literature covering
adolescents. Serra et al., in 201225,
carried out a study with hospitalizations for burns between 12 and 18 years old,
in the period from 2007 to 2011, and the authors found that 33.33% of
hospitalizations were caused by alcohol and the most prevalent age was 17 years.
This fact can be justified by the ambivalence of interacting with the external
world in a freer way, without apparently having to assume the responsibilities
of adult life25. Besides, the male gender
in this age group starts to consume alcohol and drugs, leading to higher suicide
attempts and burn accidents. Concerning the age group of adults, in this study
between 20-59 years, there was a tendency towards stability.
The elderly, contained in the age group above 60 years, showed an increase in
both sexes during the period, suggesting a relationship with the increase in
longevity in recent years. This increase in hospitalizations can be explained
by
changes inherent to age, such as decreased sensory and cognitive functions,
predisposing a deficit in the preventing accidents and increasing the
possibility of thermal trauma. In the literature that male domestic accidents
are the most prevalent, this age group is related to worse clinical evolution,
weak recovery, and a higher number of days of hospitalization and hospital
cost4,26,27.
A recent study performed in the country showed that health professionals have
unsatisfactory knowledge with the first assistance to the burned individual28, which can cause a higher number of
complications and a more significant number of hospitalizations due to
negligence in the first care. Besides, the state of Santa Catarina has a high
level of notification concerning the rest of Brazil and a higher number of
notifications in recent years.
All scientific studies are subject to bias and limitations. As limitations in
this study, the fact that the data source was exclusively the DATASUS database,
thus excluding data from hospitalizations of private patients or financed by
health insurance, for this reason, there may be underreporting of
hospitalizations due to external causes29. In addition to the limitations, the possibility that hospitals that
are not accredited as being of high complexity can use codes other than burns
when issuing hospitalization to raise more resources for care, decreasing the
numbers in this study data. Despite this, DATASUS is still considered a good
source by WHO. It should be noted that more regionalized studies are needed to
observe better the factors associated with burns.
CONCLUSION
During the period studied, there were 9,158 hospitalizations due to burns,
corresponding to the rate of 14.52 hospitalizations per 100,000 inhabitants at
the beginning of the period and 22.51 hospitalizations per 100,000 inhabitants
at the end of the historical series.
When analyzing the general hospitalization rate, there is an increase of 29.34%
in the period. Both rates of hospitalization due to burns tended to increase,
with males being the highest throughout the study.
When observing the different age groups, the group that includes individuals from
0 to 4 years old stands out as the most affected in the state of Santa
Catarina.
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1. University Hospital, Florianópolis, SC,
Brazil.
2. Universidade do Sul de Santa Catarina, Palhoça,
SC, Brazil.
3. Federal University of Santa Catarina,
Florianópolis, SC, Brazil.
Corresponding author: Felipe Oliveira Duarte, Avenida Professor
Othon Gama D’Eça 900, Centro, Florianópolis, Santa Catarina, Brazil. Zip Code:
88015-240, E-mail: duarte.cirurgiaplastica@gmail.com
Article received: February 29, 2020.
Article accepted: July 15, 2020.
Conflicts of interest: none.
