Hospitalized
Burn
Injuries
in
Massachusetts:
An
Assessment
of
Incidence
and
Product
Involvement
ANNETTE
MACKAY
ROSSIGNOL,
SCD,
CATHERINE
M.
BOYLE,
MPH,
JOHN
A.
LOCKE,
MPH,
AND
JOHN
F.
BURKE,
MD
Abstract:
We
assessed
the
frequency
of
hospitalized
burn
injuries
in
Massachusetts,
and
product
involvement
in
causing
bums,
by
reviewing
the
hospital
inpatient
records
and
emergency
room
logbooks
for
240
of
New
England's
256
acute-care
hospitals.
Chil-
dren
less
than
two
years
of
age,
males,
and
Blacks
experienced
higher
bums
rates
than
did
older
individuals,
females,
or
Whites.
Products
frequently
associated
with
burn
injuries
included
those
involved
in
food
preparation
and
consumption,
flammable
liquids,
and
clothing.
(Am
J
Public
Health
1986;
76:1341-1343.)
Introduction
Burns
are
the
fourth
leading
cause
of
injury
death
in
the
United
States,
accounting
for
approximately
6,000
deaths
each
year.'
An
additional
90,000
people
are
hospitalized
annually
for
the
treatment
of
burns.2
The
epidemiology
of
hospitalized
burns
in
well-defined,
regional
populations,
however,
is
not
well-known
because
few
large-scale
studies
have
been
undertaken.-"
In
addition,
few
studies
have
identified
the
role
of
products
in
causing
burn
injuries.7
The
objectives
of
this
study
were
to
assess
the
frequency
of
hospitalized
burn
injuries
in
the
State
of
Massachusetts
with
respect
to
the
age,
sex,
and
race
of
the
victims
and
to
gauge
the
contribution
of
consumer
and
industrial
products
in
causing
burn
injuries.
Methods
The
New
England
Regional
Burn
Program
(NERBP)
was
one
of
six
projects
within
the
National
Burn
Demonstration
Project
established
under
contractual
agreements
with
the
Division
of
Emergency
Medical
Services
of
the
US
Depart-
ment
of
Health
and
Human
Services
(then
the
Department
of
Health,
Education,
and
Welfare)
to
collect
data
on
burn
injuries
occurring
over
a
26-month
interval,
May
1978
to
June
1980.8
Among
the
NERBP's
data
collection
efforts
was
identi-
fication
of
persons
admitted
to
any
of
240
of
New
England's
256
acute-care
hospitals
for
treatment
of
a
new
burn
injury.
Patients
were
identified
primarily
by
review
of
hospital
inpatient
records
and
emergency
room
logbooks.
Types
of
injuries
included
in
the
effort
were
scald,
flame,
flash,
contact,
electrical,
chemical
(ICDA
codes
983.0,
983.1,
983.2
and
phosphorus
in
983.9),
and
ultraviolet
radiation
burns.
Demographic
information
and
information
regarding
the
nature
of
the
burn
injury
and
products
involved
were
ob-
tained
by
review
of
the
medical
record
for
each
case.
Product
involvement
was
summarized
using
a
four-digit
"victim
Address
reprint
requests
to
Annette
MacKay
Rossignol,
ScD,
Assistant
Professor,
Department
of
Civil
Engineering,
Tufts
University,
Medford,
MA
02155.
Ms.
Boyle
is
a
Biostatistician/Epidemiologist,
Trauma
Services
and
Data
Analysis
Development
at
Massachusetts
General
Hospital,
and
Dr.
Burke
is
Chief,
Trauma
Services
at
the
hospital
as
well
as
Helen
Andrews
Benedict
Professor
of
Surgery,
Harvard
Medical
School;
Mr.
Locke
is
Director
of
Public
Health,
City
of
Brookline,
MA.
This
paper,
submitted
to
the
Journal
January
24,
1986,
was
revised
and
accepted
for
publication
April
14,
1986.
©
1986
American
Journal
of
Public
Health
0090-0036/86$1.50
activity
code"
that
discriminated
among
the
various
types
of
bums
and
sequences
of
events
that
result
in
burn
injury.
Use
of
the
victim
activity
code
was
unique
to
the
New
England
site
of
the
National
Burn
Demonstration
Project.
The
present
study
is
based
on
a
subset
of
the
NERBP
data.
The
subset
consists
of
information
for
inpatients
who
were
Massachusetts
residents
on
the
date
of
the
burn
injury
and
who
were
burned
between
July
1,
1978
and
June
30,
1979.
The
approximately
30
burn
victims
who
died
before
hospi-
talization
are
not
included
in
the
present
study.
In
addition,
residents
of
12
Massachusetts
cities
and
towns,
representing
5
per
cent
of
the
total
population
of
Massachusetts,
are
not
included
in
the
analysis
because
three
hospitals
primarily
serving
these
communities
did
not
participate
in
the
NERBP.
The
demographic
characteristics
of
these
residents
are
sim-
ilar
to
the
characteristics
of
the
Massachusetts
residents
included
in
the
study.
We
calculated
crude
and
age-,
race-,
and
sex-specific
incidence
rates
by
relating
the
number
of
inpatient
burns
in
each
category
to
the
number
of
person-years
during
which
the
burns
were
observed
to
occur.
The
numbers
of
person-
years
used
to
calculate
these
rates
were
based
on
data
reported
in
the
1980
United
States
census
for
Massachusetts,
minus
the
data
for
the
12
Massachusetts
communities
not
included
in
the
study.9
Results
A
total
of
1,237
burn
injuries
were
identified
among
Massachusetts
residents
for
the
one-year
period,
July
1,
1978
to
June
30,
1979,
yielding
a
burn
incidence
rate
equal
to
22.7
hospitalized
burns
per
100,000
person-years.
Children
less
than
two
years
of
age
experienced
the
highest
burn
rates
for
both
males
and
females
(143.8
and
110.4
hospitalized
burns
per
100,000
person-years,
respectively).
The
overall
rate
for
males
was
2.6
times
higher
than
the
rate
for
females.
The
burn
rate
for
the
Black
population
was
3.1
times
the
rate
for
the
White
population,
and
2.3
times
the
rate
for
the
remaining
racial
groups
in
Massachusetts
combined.*
Table
1
summarizes
the
data
for
type
of
burn
according
to
age
categories
and
sex
of
the
victims.
Scalds
were
the
most
frequent
type
of
burn
for
children
less
than
five
years
of
age
for
both
sexes,
and
for
females
for
all
age
categories
except
five
to
14
years.
Flame
and
flash
burns
predominated
among
males
aged
five
years
or
older.
Products
associated
with
food
preparation
and
consump-
tion,
the
most
common
sources
of
scald
injury
for
both
non-work-
and
work-related
scalds,
were
involved
in
48
per
cent
of
all
scalds
(Table
2).
Flammable
liquids
were
involved
in
87
per
cent
of
the
non-structural
flame
or
flash
burns
that
were
work-related,
and
in
42
per
cent
of
non-structural
flame
or
flash
burns
overall.
Clothing
ignition,
motor
vehicles,
and
stoves
or
ovens
were
involved
in
36,
12,
and
14
per
cent
of
all
non-structural
flame
or
flash
burns,
respectively.
*Tabulationsof
burn
rates
for
these
subgroups
are
available
by
request
to
Dr.
Rossignol.
AJPH
November
1986,
Vol.
76,
No.
11
1341
PUBLIC
HEALTH
BRIEFS
TABLE
1-Burn
Incidence
Rates
by
Type
of
Burn,
Sex,
and
Age
of
Inpatients,
Massachusetts
Residents,
July
1,
1978-June
30,
1979
Type
of
Burn
Flame/Flash
Scald
Other
All
Types
Age
Category
Incidence
Number
Incidence
Number
Incidence
Number
Incidence
Number
Sex
(years)
Rate*
of
Burns
Rate*
of
Burns
Rate*
of
Burns
Rate*
of
Burns
Male
<5
8.6
14
59.9
98
25.7
42
94.1
154
5-14
13.9
56
8.9
36
4.7
19
27.5
111
15-54
14.7
221
11.0
166
7.8
117
33.4
504
-55
8.7
45
6.2
32
4.5
23
19.4
100
All
Ages
13.0
336
12.8
332
7.8
201
33.6
869
Female
<5
6.4
10
47.0
73
15.4
24
68.9
107
5-14
2.1
8
1.5
6
2.8
1
1
6.5
25
15-54
3.8
60
3.9
61
2.2
34
9.8
155
.55
4.2
31
5.2
38
1.6
12
11.1
81
All
Ages
3.8
109
6.2
178
2.8
81
12.9
368
Both
Sexes
<5
7.5
24
53.6
171
20.7
66
81.8
261
5-14
8.1
64
5.3
42
3.8
30
17.2
136
15-54
9.1
281
7.4
227
4.9
151
21.4
659
.55
6.1
76
5.6
70
2.8
35
14.5
181
All
Ages
8.2
445
9.4
510
5.2
282
22.7
1,237
*Number
of
burns
per
100,000
person-years.
TABLE
2-Products
Frequently
Involved
in
Scald
Injuries
by
Work-relatedness
among
Inpatients,
Massachusetts
Residents,
July
1,
1978-June
30,1979
Work-relatedness
Non-work
Work
Both
Categories
Per
Cent
of
396
Number
Per
Cent
of
114
Number
Per
Cent
of
All
Number
Product
Involvement
Non-work-related
Scalds
of
Scalds
Work-related
Scalds
of
Scalds
510
Scalds
of
Scalds
Food
Preparation
and
Consumption
55
216
25
28
48
244
Motor
Vehicle
Radiator
8
33
7
8
8
41
Bathroom
Tub
or
Shower
9
37
0
0
7
37
Industrial
Process
0
0
14
16
3
16
Tar
or
Asphalt
0
0
1
1
12
2
12
Home
Medical
Remedy
3
12
0
0
2
12
Molten
Metal
0
0
10
11
2
11
Other
Product
13
52
12
14
13
66
Unknown
12
46
22
25
14
71
Total
100
396
100
114
100
510
Discussion
The
epidemiology
of
hospitalized
burn
injuries
in
Mas-
sachusetts
is
similar
to the
epidemiology
reported
for
other
geographic
regions3-
with
respect
to
the
higher
burn
rates
for
children
less
than
two
years
of
age
than
for
older
individuals,
for
males
compared
with
females,
and
for
the
Black
popu-
lation
compared
with
the
White
population.
In
addition,
the
frequent
involvement
of
products
associated
with
food
prep-
aration
and
consumption,
flammable
liquids,
clothing,
and
motor
vehicles
in
burn
injuries
is
consistent
with
the
findings
of
these
same
studies.
Of
the
total
of
1,237
burns,
23
per
cent
(289
burns)
were
known
to
involve
products
associated
with
food
preparation
or
consumption.
Cups
were
involved
in
34
per
cent
(99
of
289
burns)
of
these
burns;
stoves
or
ovens
were
involved
in
20
per
cent
(59
of
289
burns)
of
such
burns.
Clearly,
engineering
and
administrative
control
strategies
could
prevent
such
burn
injuries.
Such
strategies
include
improved
design
of
cups
to
prevent
easy
spillage,
and
stove
and
oven
designs
that
discourage
users
from
reaching
across
burners
to
gain
access
to
control
knobs.
1342
Similarly,
strategies
are
needed
to
control
flame
or
flash
burns
from
flammable
liquids.
Such
strategies
include
the
placing
of
unambiguous
warning
labels
on
containers
of
flammable
liquids,
motor
vehicle
carburators,
and
industrial
equipment
or
processes
that
use
flammable
liquids,
and
the
elimination
of
ignition
sources,
such
as
lighted
cigarettes,
from
areas
in
which
flammable
liquids
are
being
used.
Because
of
the
frequent
involvement
of
products
in
causing
burn
injuries,
increased
instruction
of
engineers
and
engineering
students
about
the
relations
between
product
design
and
burn
hazards
seems
warranted.
ACKNOWLEDGMENTS
The
authors
gratefully
acknowledge
the
cooperation
of
the
hospitals
participating
in
the
New
England
Regional
Burn
Program,
and
the
excellent
data
management
skills
of
Cynthia
Tolkov.
This
research
was
supported
in
part
by
grant
GM21700-10
and
by
Contract
No.
4510-9027
from
the
Office
of
Emergency
Medical
Services,
Department
of
Public
Health,
Boston,
MA.
REFERENCES
1.
Accident
Facts.
Chicago:
National
Safety
Council,
1982.
2.
Haupt
BJ,
Graves
E:
Detailed
Diagnoses
and
Surgical
Procedures
for
Patients
Discharged
from
Short-stay
Hospitals:
United
States,
1979.
DHHS
Pub.
No.
(PHS)
82-1274-1.
Washington,
DC:
Dept
of
Health
and
Human
AJPH
November
1986,
Vol.
76,
No.
11
Services,
1982.
3.
Barancik
JI,
Shapiro
MA:
Pittsburgh
Bum
Study.
National
Technical
Information
Service
Report
No.
PB250-737.
Springfield,
VA:
NTIS,
1975.
4.
Clark
WR
Jr,
Lerner
D:
Regional
burn
survey:
two
years
of
hospitalized
bum
injury
in
central
New
York.
J
Trauma
1978;
18:524-532.
5.
Feck
G,
Baptiste
M,
Greenwald
P:
The
incidence
of
hospitalized
bum
injury
in
upstate
New
York.
Am
J
Public
Health
1977;
67:966-967.
6.
Feck
G,
Baptiste
MS:
The
epidemiology
of
burn
injury
in
New
York.
Public
PUBLIC
HEALTH
BRIEFS
Health
Rep
1979;
94:312-318.
7.
Injury
in
America.
Washington,
DC:
National
Academy
Press,
1985;
28.
8.
Burke
JF,
Locke
JA:
Final
Report
of
the
New
England
Regional
Bum
Program.
Rockville,
MD:
Dept
of
Health
and
Human
Services,
Health
Services
Administration,
Bureau
of
Medical
Services,
Division
of
Emer-
gency
Medical
Services,
1980.
9.
Bureau
of
the
Census:
General
Population
Characteristics-Massachusetts
1982.
Washington,
DC:
US
Dept
of
Commerce,
PC80-1-B23.
The
Delivery
and
Uptake
of
Nicotine
from
an
Aerosol
Rod
DANIEL
W.
SEPKOVIC,
PHD,
STEPHEN
G.
COLOSIMO,
MS,
CARYN
M.
AXELRAD,
MS
JOHN
D.
ADAMS,
BS,
AND
NANCY
J.
HALEY,
PHD
Abstract:
Nicotine
aerosol
rods
were
assessed
for
their
possible
usefulness
as
substitutes
for
cigarettes.
Under
standard
FTC
condi-
tions,
the
per
puff
delivery
of
the
aerosol
rod
averaged
0.3
,ug
nicotine/puff
after
10
puffs
and
6.4
,ug
nicotine/puff
after
60
puffs.
After
puffing
on
the
rods,
no
nicotine
was
detected
in
the
plasma
or
urine
of
seven
subjects.
(Am
J
Public
Health
1986;
76:1343-1344.)
Introduction
Nicotine
addiction
accounts,
in
part,
for
the
continuation
of
cigarette
smoking
in
spite
of
well
recognized
risks
it
imposes
on
the
smoker.
15
A
variety
of
alternatives
to
smoking
can
deliver
nicotine
to
the
subject
and
yet
eliminate
the
other
tobacco
specific
compounds
that
have
been
impli-
cated
as
agents
of
disease.
These
alternatives
include,
nasal
nicotine
solutions,
transdermal
and
intravenous
nicotine
administration,
and
oral
nicotine
delivery
in
the
form
of
nicotine
gum'
9
A
nicotine
aerosol
delivery
method
was
marketed
in
the
Fall
of
1985
in
Texas
for
use
by
smokers
and
others
who
desire
nicotine.
The
possibility
exists
that
nicotine
supple-
mentation
by
inhalation
of
nicotine
as
an
aerosol
could
alter
smoking
behavior
patterns
and
reduce
the
uptake
of
other
toxic
and
carcinogenic
tobacco
smoke
constituents.
For
this
reason,
we
became
interested
in
the
nicotine
aerosol
rod
as
a
substitute
source
of
nicotine
for
smokers
who
were
trying
to
reduce
their
smoking
habit.
Methods
The
aerosol
rods
were
first
examined
under
standard
FTC
(Federal
Trade
Commission)
machine
smoked
condi-
tions.
Nicotine
was
trapped
on
a
Cambridge
filter
pad
and
quantitated
by
gag
chromatography.10,11
We
measured
the
physiological
uptake
of
nicotine
in
three
non-smokers
and
four
smokers
who
were
asked
to
abstain
for
at
least
12
hours
prior
to
reporting
to
each
session.
An
indwelling
catheter
was
inserted
into
the
antecubital
vein
of
the
right
forearm
and
an
automatic
blood
pressure
cuff
was
placed
on
the
left
arm
according
to
previously
described
methodology.
12
Three
puffs
of
aerosol
were
taken
every
two
minutes
for
six
minutes.
Plasma
and
urinary
nicotine
and
cotinine
concentrations
were
determined
by
a
modification
of
the
radioimmunoassay
From
the
American
Health
Foundation,
Naylor
Dana
Institute
for
Disease
Prevention,
Divisions
of
Nuttition
and
Endocrinology
and
of
Environmental
Carcinogenesis,
Dana
Road,
Valhalla,
NY
10595.
Address
reprint
requests
to
D.
W.
Sepkovic
at
that
address.
This
paper,
submitted
to
the
Journal
February
18,
1986,
was
revised
and
accepted
for
publication
April
23,
1986.
C
1986
American
Journal
of
Public
Health
0090-0036/86$1.50
AJPH
November
1986,
Vol.
76,
No.
11
TABLE
1-Nicotine
Yield
of
Nicotine
Aerosol
Rod
under
Standard
Ma-
chine
Smoked
Conditions*
Average
Nicotine/Puff
Total
Nicotine
Puffs
(Fg)
(6g)
1-10
0.3
3
11-20
1.8
18
21-30
3.5
35
31-40
4.4
44
41-50
5.8
58
51-60
6.4
64
Total
Nicotine
222
'Srnoked
on
a
H.
Borgwaldt
single
port
piston
smoking
machine
(1
puff/min,
35
ml
volume
of
2
sec
duration).
Nicotine
was
trapped
on
a
Cambridge
fifter
pad
and
quantitated
by
gas
chromatography.
developed
by
Langone,
et
al.
3
The
inter-
and
intra-assay
variation
of
the
nicotine
and
cotinine
assays
is
6
per
cent.
Results
Under
standard
FTC
conditions,
the
average
nicotine
delivery
of
the
rod
increased
with
the
number
of
puffs
taken
from
0.3
,ug/puff
in
the
first
10
puffs
to
6.4
jig
of
nicotine
after
60
puffs
(Table
1).
No
nicotine
was
observed
in
the
plasma
or
urine
of
smokers
or
non-smokers
after
using
the
aerosol
rod.
Smok-
ers'
plasma
cotinine
concentrations
remained
constant
be-
fore
and
after
using
the
aerosol
rod.
No
cotinine
was
detected
in
the
plasma
of
nonsmokers.
Urinary
cotinine
was
assessed
daily
for
four
days
after
aerosol
rod
use
in
nonsmokers.
No
urinary
cotinine
was
detected.
Discussion
We
theorize
that
the
amount
of
nicotine
delivered
per
puff
was
the
equivalent
of
a
hypothetical
0.01
mg
nicotine
content
cigarette
which
would
provide
per
puff
deliveries
too
small
for
nicotine
absorbed
to
be
detected
in
the
plasma.
Only
after
a
total
of
60
puffs
could
this
rod
approximate
the
nicotine
delivery
of
a
0.2
mg
nicotine
content
cigarette.
The
results
of
the
study
lead
us
to
believe
that
in
its
present
form
the
nicotine
aerosol
rod
will
not
provide
a
suitable
vehicle
for
nicotine
delivery.
The
absence
of
nicotine
or
cotinine
in
plasma
or
urine
of
both
subject
groups
indicates
that
nicotine
concentrations
of
these
rods,
on
a
per
puff
basis,
does
not
approximate
the
nicotine
yield
of
a
cigarette.
The
most
frequently
used
cigarettes
based
on
sales
weighted
averages
in
the
United
States
deliver
nicotine
in
the
0.7-1.0
milligram
range.14
Conceptually,
the
aerosol
rod
represents
an
ideal
nico-
tine
delivery
system
that
mimics
the
route
of
absorption
of
nicotine
in
cigarette
smokers
who
inhale.
Puffing
on
the
1343
