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Defining the global burden of burn injuries: a 29 year review of data from 196 countries

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Defining the global burden of burn injuries: a 29 year review of data from 196 countries

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Content Defining the Global Burden of Burn Injuries:
A 29 Year Review of Data from 196 Countries
by
Zachary Jonathan Collier, MD
A Thesis Presented to the
FACULTY OF THE USC KECK SCHOOL OF MEDICINE
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF SCIENCE
(CLINICAL AND BIOMEDICAL INVESTIGATIONS)
May 2022
Copyright 2022 Zachary Jonathan Collier

ii
Table of Contents
List of Tables ................................................................................................................................. iii
List of Figures ................................................................................................................................ iv
Abbreviations .................................................................................................................................. v
Abstract .......................................................................................................................................... vi
Introduction ..................................................................................................................................... 1
Methods........................................................................................................................................... 3
Data Source: The Global Burden of Disease 2019 ..................................................................... 3
Data Modeling Methodology of Global Burden of Disease 2019 .............................................. 3
Data Organization by SDI Rank and Geographic Region........................................................... 4
Data Formatting, Stratification, and Analysis ............................................................................. 6

Results ............................................................................................................................................. 7
Summary ..................................................................................................................................... 7
Incidence ..................................................................................................................................... 8
Deaths ........................................................................................................................................ 11
Disability-Adjusted Life Years (DALYs) ................................................................................. 15
Gender Strata ............................................................................................................................. 19
Age Strata .................................................................................................................................. 22
Mortality Ratio .......................................................................................................................... 28

Discussion ..................................................................................................................................... 29
Global Burns and the Impact of Socio-Demographic Index ..................................................... 30
The Regional Distribution of Burn Morbidity and Mortality ................................................... 32
Prioritizing Global Burn Care Using A Global Surgery Approach .......................................... 36
Study Limitations ...................................................................................................................... 39

Conclusions ................................................................................................................................... 41
References ..................................................................................................................................... 42

iii

List of Tables
Table 1: SDI Ranks ......................................................................................................................... 5
Table 2: Geographic Regions.......................................................................................................... 6
Table 3: Summary of Burn Incidence, Deaths, & DALYs ............................................................. 8

iv

List of Figures
Figure 1: Yearly Burn Incidence Rates ........................................................................................... 9
Figure 2: Burn Incidence by Country, 2019 ................................................................................. 11
Figure 3: Yearly Burn Death Rates ............................................................................................... 14
Figure 4: Burn Deaths by Country, 2019 ...................................................................................... 15
Figure 5: Yearly DALY Rates ...................................................................................................... 17
Figure 6: Burn DALYs by Country, 2019 .................................................................................... 19
Figure 7: Gender-Stratified Burn Incidence ................................................................................. 20
Figure 8: Gender-Stratified Burn Deaths ...................................................................................... 21
Figure 9: Gender-Stratified Burn DALYs .................................................................................... 22
Figure 10: Age-Stratified Burn Incidence by SDI Rank ............................................................... 23
Figure 11: Age-Stratified Burn Incidence by Region ................................................................... 24
Figure 12: Age-Stratified Burn Deaths by SDI Rank ................................................................... 25
Figure 13: Age-Stratified Burn Deaths by Region ....................................................................... 26
Figure 14: Age-Stratified Burn DALYs by SDI Rank.................................................................. 27
Figure 15: Age-Stratified Burn DALYs by Region ...................................................................... 28
Figure 16: Mortality Ratios for SDI Ranks & Geographic Regions, 2019 ................................... 29

v

Abbreviations
All listed abbreviations are alphabetized.
Abbreviation Definition
DALY Disability-Adjusted Life Years; sum of YLD and YLL
GBD Global Burden of Disease
GHDx Global Health Data Exchange
HIC High-Income Country
IHME Institute for Health Metrics and Evaluation, Seattle, Washington
LAC Latin America and the Caribbean
LMIC Low- and Middle-Income Country
MENA Middle East and North Africa
MR Mortality Ratio = burn death rate / burn incidence rate
SDI Socio-Demographic Index
SSA Sub-Saharan Africa
WHO World Health Organization
YLD Years of Life with a Disability
YLL Years of Life Lost
(F) Female
(M) Male

vi

Abstract
Introduction: Globally, more than nine million burns and 120,000 burn-related deaths occur
yearly. Despite burn care improvements decreasing mortality rates by more than 70% in high
income countries, there remains a significant yet poorly defined disparity in the quality of care
provided in lower socioeconomic regions with studies suggesting more than 90% of the burn
morbidity and mortality burden exist within Low- and Middle-Income Countries. In order to
improve our ability to address the significant impact of burns on the individual, community,
national, and global levels, we set out to better define the global burn burden as well as the
socioeconomic, age, and gender disparities to identify specific regions that would benefit most
from targeted interventions to enhance burn care.

Methods: Data was acquired from the 2019 Global Burden of Disease (GBD19) database of the
Global Health Data Exchange (GHDx), which is maintained by the Institute for Health Metrics
and Evaluation (IHME). Data from the GBD19 which incorporated 136,320 data sources from 204
countries and territories over a 29-year period (1990-2019) was used to estimate burn incidence,
deaths, and Disability-Adjusted Life Years (DALYs) across time, geography, age, and gender
stratifications. Summative statistics were calculated for burn incidence, deaths, DALYs, and
mortality ratio (burn deaths:incidence, %) with respect to year, gender, age strata, and socio-
demographic index (SDI). Geospatial mapping was also performed to identify regions and
countries with high burn burden.

Results: From 1990 to 2019, an estimated 251,871,087 burns occurred with 3,605,749 deaths and
248,934,130 DALYs. In 2019, 78% of all burns, 89% of deaths, and 89% of all global DALYs

vii

occurred in Low-to-Middle SDI countries with Asia accounting for 55% of the burn burden and
76% of DALYs. All burn metrics decreased by 20-40% during the 29-year period although lower
SDI countries had two-to-three times higher death and DALY rates. Women and children from
Low-to-Middle SDIs had greater rates of burn incidence, deaths, and DALYs as well as higher
mortality ratios with Asia, Sub-Saharan Africa, and the Middle East accounting for most of this
morbidity and mortality. The lowest death and DALY rates were seen in High SDI countries within
North America and Europe.

Discussion: This 29-year analysis of 196 countries highlights the significant burn disparities that
exist throughout the world. The majority occur in lower SDI regions and more prominently impact
women and children. Although all indicators improved throughout the study period for all SDI
regions, they were consistently worse in the lower SDI groups for both genders and all ages. This
initial global analysis of GBD19 data highlights socioeconomic and geographic regions with the
greatest burn burden which will help guide further field analyses to identify ideal programmatic
targets for healthcare system strengthening, capacity building, workforce training, and
sustainability efforts throughout the world.

1

Introduction
In 2015, the Lancet Commission on Global Surgery (LCoGS) determined that more than
five billion people worldwide lack access to safe, affordable, and timely surgical, obstetric, and
anesthesia (SOA) care.
1
According to the LCoGS key messages, low- and middle-income
countries (LMICs) are disproportionately affected by this deficit with more than 95% of
individuals living in LMICs lacking access to life-saving surgical care that results in nearly 17
million deaths from untreated surgical conditions. Although LMICs account for 84% of the global
population, only 6.3% of all worldwide procedures are performed within these countries.
Therefore, it is imperative to increase access to quality surgical care in LMICs through evidence-
based approaches and community-driven solutions that address the significant burden of unmet
surgical need – a global initiative championed by the World Health Organization as part of their
Sustainable Development Goals 2030 agenda.
An essential factor to overcoming the global burden of untreated surgical disease is
improving access to burn care given the significant impact that burn injuries have on medical and
surgical healthcare systems as well as the severe psychosocial and economic ramifications for
individuals who receive suboptimal burn care. An estimated 9 million burns and 110,000 burn-
related deaths occur yearly with LMICs accounting for as much as 92% of the global burn
burden.
2–6
While burn care disparities have noticeable implications at the health systems level,
substandard care for burn survivors results in many life-altering sequelae due to disfigurement and
disability which often leads to mental illness, social isolation, economic hardship, and chronic
pain.
5,7–9
As a result, burns in LMICs are major contributors to years lived with disability (YLD)
and years of life lost (YLL) – both of which are accounted for in DALYs. They impair the ability
of burn survivors to re-integrate and contribute to their societies and economies, which results in

2

an annual accumulation of more than 18 million disability-adjusted life years (DALYs) within
these countries.
2,4,9,10
The DALYs arising from burns in LMICs account for 94% of the total global
burden of burn-related disability which highlights the degree to which impaired access to burn care
alters burn survival, recovery, and rehabilitation.
2,7
As a result of these significant disparities and
their impact on overburdened healthcare systems, we must improve our understanding of the
geographic distribution of burns, their socioeconomic risk factors, and the barriers to accessing
care so that we may create more effective solutions that will reduce the impact of burns on
individuals, communities, healthcare systems, and economies.
Despite the pervasive understanding that individuals from LMICs are more frequently and
severely burned, have greater difficulties accessing high quality care, and subsequently have more
prolonged complications that impact reintegration; there is a significant deficit in country-wide
epidemiological data from LMICs that could be used to facilitate efforts aimed at identifying and
overcoming barriers to accessing and receiving essential burn care. This data deficit most often
arises from LMICs lacking resources and capacity to maintain national registries, systems for
tracking outcome metrics, and up-to-date census data on burn trauma.
10–13
Without these data, it is
difficult to establish well-targeted and sustainable improvements in burn prevention, care, and
rehabilitation that are appropriately contextualized to unique regional needs.
While there has been a lack of reliable global epidemiological data on burn injuries, the
recent inclusion of thermal injuries in the Global Burden of Disease (GBD) database may help
overcome this deficit to facilitate more accurate analyses of the global burden of burns and their
distributions across geographic, sociodemographic, and economic borders.
14
As a result, we
utilized the most recent GBD database iteration, Global Burden of Disease 2019 (GBD19), to
acquire large-scale, modeled ecological data on burn injuries to perform regional and country-level

3

assessments while also investigating age and gender-related disparities. The current study seeks to
provide an important foundation for our understanding of the global burden of burn injury to enable
future development of strategic plans that will reduce burn morbidity and mortality through
prevention, community outreach, workforce expansion, and capacity building programs at the
regional, national, and community levels.

Methods
Data Source: The Global Burden of Disease 2019
All data utilized for this study were acquired from the Global Burden of Disease 2019
(GBD19) database which is maintained by the Global Health Data Exchange (GHDx).
15
The
GHDx – a dynamic, open-access, and internationally supported database encompassing 204
countries and territories – is maintained by the Institute for Health Metrics and Evaluation (IHME)
out of the University of Washington, Seattle, Washington, USA. Its creation and maintenance are
supported by the World Health Organization (WHO) as well as the Bill and Melinda Gates
Foundation. The GBD19 report, which was compiled by over 5,000 international collaborators
from 152 countries, incorporated 136,320 data sources from 204 countries and territories to predict
with meta-regression modeling the incidence, deaths, and Disability-Adjusted Life Years
(DALYs) of 369 diseases by year, gender, age, and location from 1990 to 2019.
16

Data Modeling Methodology of Global Burden of Disease 2019
The numbers generated by GBD19 are based on a multifaceted amalgamation of literature
studies, survey results, census and surveillance data, inpatient admission records, outpatient visit
records, and health insurance claims. The data from these sources are entered into the GBD’s

4

Disease Modeling MetaRegression 2.1 (DisMod-MR 2.1) program, a Bayesian mixed-effects
meta-regression modeling tool created to facilitate ecological level analyses. DisMod-MR
2.1initially generates numbers at the global level but then sequentially tapers the predictions down
to the national and subnational levels using the above-mentioned data sources that provide
increasingly detailed information relative to time, gender, age, and geography.

Data Organization by Sociodemographic Index (SDI) Rank and Geographic Region
All data points regarding fire, heat, and hot substance-related injuries were compiled from
this database using the GBD-designated Global average, Socio-Demographic Index (SDI) Ranks,
and Geographic Regions as the primary cohorts for analyses. The SDI is a computationally derived
indicator of a country’s developmental status which has been shown to strongly correlate with
country-specific health outcomes.
17
It was calculated by GBD researchers on a scale of 0 to 1 using
the following parameters: mean education for those ages 15 and older, lag distributed income per
capita, and total fertility rate under the age of 25. These values were then stratified into Low, Low-
Middle, Middle, High-Middle, and High SDI categories by the GBD. The countries assigned to
each SDI Rank are shown in Table 1. A total of 36 countries were considered Low SDI with an
average of 382 data sources available for modeling per country, 40 were Low-Middle SDI with an
average of 474 data sources per country, 44 were Middle SDI with an average of 635 data sources
per country, 41 were High-Middle SDI with an average of 646 data sources per country, and 35
were High SDI with an average of 1,406 data sources per country.
17
On average, higher SDI
countries had more data sources available for modeling with the respective source numbers shown
in parentheses next to each country in Table 1.

5

Table 1: SDI Ranks

SDI Ranks: The 196 countries included in this study are listed by their Socio-Demographic Index (SDI) [Low, Low-Middle,
Middle, High-Middle, High] and in parentheses next to each country is the number of data sources (e.g., registries, census reports,
publications, surveys, etc.) used to model the data for each country. Next to each SDI Rank header in parentheses is the average
number of available data sources per country for that SDI rank as well as the total number of countries in that category.

All included countries were also stratified according to geographic region as defined by the
GBD 2019 database. These 6 regions as well as all the countries within each designation are listed
in Table 2. There were 49 countries in the Asia region, 47 in Sub-Saharan Africa (SSA), 33 in
Latin America and the Caribbean (LAC), 22 in the Middle East and North Africa (MENA), 43 in
Europe, and 2 in North America.
15

Low SDI (382; n = 36) Low-Middle SDI (474; n = 40) Middle SDI (635; n = 44) High-Middle SDI (646; n = 41) High SDI (1406; n = 35)
Afghanistan (250) Angola (265) Albania (351) Antigua and Barbuda (200) Andorra (162)
Benin (366) Bangladesh (924) Algeria (356) Argentina (911) Australia (2117)
Bhutan (168) Belize (301) Armenia (454) Bahamas (241) Austria (957)
Burkina Faso (564) Bolivia (405) Azerbaijan (390) Bahrain (291) Belgium (1013)
Burundi (242) Cabo Verde (220) Botswana (284) Barbados (298) Brunei Darussalam (249)
Central African Republic (204) Cambodia (368) Brazil (2628) Belarus (409) Canada (1891)
Chad (222) Cameroon (545) China (3709) Bosnia and Herzegovina (418) Cyprus (463)
Comoros (132) Congo (267) Colombia (779) Bulgaria (643) Czechia (894)
Côte d'Ivoire (460) Democratic People's Republic of Korea (103) Costa Rica (599) Chile (944) Denmark (1644)
Democratic Republic of the Congo (409) Dominican Republic (437) Cuba (469) Croatia (718) Estonia (873)
Djibouti (129) El Salvador (439) Ecuador (734) Dominica (201) Finland (1678)
Eritrea (105) Eswatini (200) Egypt (823) Georgia (539) France (2386)
Ethiopia (964) Ghana (721) Equatorial Guinea (217) Greece (1102) Germany (1877)
Gambia (319) Guatemala (530) Fiji (314) Hungary (842) Iceland (731)
Guinea (226) Honduras (367) Gabon (245) Israel (901) Ireland (1062)
Guinea-Bissau (215) India (3621) Grenada (189) Italy (2767) Japan (2166)
Haiti (259) Kenya (1358) Guyana (230) Jordan (403) Kuwait (421)
Liberia (281) Kiribati (148) Indonesia (1224) Kazakhstan (305) Latvia (728)
Madagascar (380) Kyrgyzstan (410) Iran (1240) Lebanon (283) Lithuania (822)
Malawi (465) Lao People's Democratic Republic (271) Iraq (339) Libya (232) Luxembourg (641)
Mali (503) Lesotho (180) Jamaica (423) Macedonia (517) Monaco (120)
Mozambique (442) Maldives (238) Mexico (1419) Malaysia (708) Netherlands (1951)
Nepal (545) Marshall Islands (150) Moldova (359) Malta (565) New Zealand (1378)
Niger (331) Mauritania (206) Namibia (197) Mauritius (356) Norway (1595)
Pakistan (842) Micronesia (144) Nauru (159) Montenegro (190) Qatar (358)
Papua New Guinea (363) Mongolia (356) Panama (498) Niue (173) San Marino (200)
Rwanda (328) Morocco (427) Paraguay (414) Oman (340) Singapore (889)
Senegal (517) Myanmar (319) Peru (795) Palau (210) Slovenia (773)
Sierra Leone (305) Nicaragua (360) Philippines (941) Poland (1411) South Korea (1099)
Solomon Islands (152) Nigeria (1536) Saint Lucia (225) Portugal (1069) Sweden (2547)
Somalia (225) Palestine (329) Saint Vincent and the Grenadines (230) Romania (723) Switzerland (1061)
South Sudan (383) Sao Tome and Principe (190) Samoa (193) Russia (901) Taiwan (938)
Togo (306) Sudan (502) South Africa (1119) Saint Kitts and Nevis (244) United Arab Emirates (337)
Uganda (821) Tajikistan (347) Sri Lanka (595) Saudi Arabia (786) United Kingdom (4604)
United Republic of Tanzania (1003) Timor-Leste (141) Suriname (227) Serbia (333) United States of America (8590)
Yemen (309) Tuvalu (149) Syria (291) Seychelles (233)
Vanuatu (145) Thailand (1157) Slovakia (688)
Western Sahara (427) Tonga (185) Spain (2365)
Zambia (448) Tunisia (423) Trinidad and Tobago (339)
Zimbabwe (459) Turkmenistan (296) Turkey (1100)
Uruguay (522) Ukraine (583)
Uzbekistan (356)
Venezuela (616)
Vietnam (721)

6

Table 2: Geographic Regions

Geographic Regions: The 196 countries included in this study are listed by their geographic regions [Asia, Sub-Saharan Africa,
Latin America and the Caribbean, Middle East and North Africa, Europe, and North America] as designated by the Global Burden
of Disease 2019 database. Next to each Region header in parentheses is the total number of countries in that region.

Data Formatting, Stratification, and Analysis
Data were acquired from the GBD19 in two formats – rate and number. The rates were
reported as follows: burn cases per 100,000 person-years for Incidence, burn-related deaths per
100,000 people for Deaths, and the sum of years living with disability (YLD) and years of life lost
(YLL) due to burn injury per 100,000 people for Disability-Adjusted Life Years (DALYs).
15,16,18

Predicted numbers for Incidence, Deaths, and DALYs are reported as absolute numbers for each
Asia (49) Sub-Saharan Africa (47) Latin America & Caribbean (33) Middle East & North Africa (22) Europe (43) North America (2)
Armenia Angola Antigua & Barbuda Afghanistan Albania Canada
Australia Benin Argentina Algeria Andorra United States of America
Azerbaijan Botswana Bahamas Bahrain Austria
Bangladesh Burkina Faso Barbados Egypt Belarus
Bhutan Burundi Belize Iran Belgium
Brunei Darussalam Cabo Verde Bolivia Iraq Bosnia & Herzegovina
Cambodia Cameroon Brazil Israel Bulgaria
China Central African Republic Chile Jordan Croatia
Fiji Chad Colombia Kuwait Cyprus
Georgia Comoros Costa Rica Lebanon Czechia
India Congo Cuba Libya Denmark
Indonesia Côte d'Ivoire Dominica Morocco Estonia
Japan Democratic Republic of the Congo Dominican Republic Oman Finland
Kazakhstan Djibouti Ecuador Palestine France
Kiribati Equatorial Guinea El Salvador Qatar Germany
Kyrgyzstan Eritrea Grenada Saudi Arabia Greece
Laos Eswatini Guatemala Syrian Arab Republic Hungary
Malaysia Ethiopia Guyana Tunisia Iceland
Maldives Gabon Haiti Turkey Ireland
Marshall Islands Gambia Honduras United Arab Emirates Italy
Mauritius Ghana Jamaica Western Sahara Latvia
Micronesia Guinea Mexico Yemen Lithuania
Mongolia Guinea-Bissau Nicaragua Luxembourg
Myanmar Kenya Panama Macedonia
Nauru Lesotho Paraguay Malta
Nepal Liberia Peru Moldova
New Zealand Madagascar Saint Kitts & Nevis Monaco
Niue Malawi Saint Lucia Montenegro
North Korea Mali Saint Vincent & the Grenadines Netherlands
Pakistan Mauritania Suriname Norway
Palau Mozambique Trinidad & Tobago Poland
Papua New Guinea Namibia Uruguay Portugal
Philippines Niger Venezuela Romania
Samoa Nigeria Russia
Seychelles Rwanda San Marino
Singapore Sao Tome & Principe Serbia
Solomon Islands Senegal Slovakia
South Korea Sierra Leone Slovenia
Sri Lanka Somalia Spain
Taiwan South Africa Sweden
Tajikistan South Sudan Switzerland
Thailand Sudan Ukraine
Timor-Leste Tanzania United Kingdom
Tonga Togo
Turkmenistan Uganda
Tuvalu Zambia
Uzbekistan Zimbabwe
Vanuatu
Viet Nam

7

respective category rounded up to the nearest whole integer. Trends in burn incidence, deaths, and
DALYs were assessed using age-standardized, gender-stratified (male or female), and age-
stratified (<5 years, 5-14 years, 15-49 years, 50-69 years, ≥70 years) cohorts for all 29 years from
1990 to 2019. Numbers from the GBD19 model for the age-standardized rates for burn incidence,
deaths, and DALYs were used to calculate the relative contribution of each SDI Rank and
geographic region to the global burn burden and represented as a percentage of the total number.
These numbers were also used to calculate the burn mortality ratios for the Global, SDI Rank, and
Geographic Regions by dividing the number of burn-related deaths by the total number of burn
cases (i.e., burn deaths/burn incidence). Mortality Ratios were presented as percentages. All data
aggregation, statistical analyses, and data visualizations were performed in Excel (Microsoft
Corporation, Washington, USA).

Results
Summary
Over the 29 years, an estimated 251,871,087 burns occurred with 3,605,749 deaths and
248,934,130 DALYs. As of 2019, 78% of the burns, 89% of deaths, and 89% of all global DALYs
occurred in Low to Middle SDI countries (Table 3). From 1990 to 2019, the global burn incidence,
death, and DALY rates decreased by 26%, 38%, and 44%, respectively. The 2019 rates were as
follows: 116 burns per 100,000 person-years, 1.4 deaths per 100,000 people, and 96 years of
disability and life lost per 100,000 people. Using these global rates for 2019, it is estimated that
there were 8,326,493 burns, 124,037 deaths, and 9,218,639 DALYs that occurred that year
amongst the 196 countries.

8

Table 3: Summary of Burn Incidence, Deaths, & DALYs

Summary of Burn Incidence, Deaths, & DALYs: The incidence, deaths, and DALYs are listed for the first year of data, 1990,
and most recent year, 2019, as age-standardized rates per 100,000 persons (absolute numbers in parentheses). The ∆ column shows
the percent change from 1990 to 2019 for rates. The Range and Mean columns represent their respective statistical descriptors for
the entire 29-year period for each category. SDI = Socio-Demographic Index; DALYs = Disability Adjusted Life Years; SSA =
Sub-Saharan Africa; LAC = Latin America & Caribbean; MENA = Middle East & North Africa

Incidence
The greatest reduction in burn incidence was seen in the High-Middle SDI group (-30%)
followed by High SDI (-28%) with the Low SDI group having the least reduction in burn incidence
(-13%). While the High-Middle and High SDIs had the greatest reductions in burn incidence, they
still had the highest incidence rates in 2019 at 138 and 160, respectively (Table 3). With respect
to regions, North America had the largest decrease in burn incidence (-32%) whereas Sub-Sharan
Africa saw the least improvement with only a 12% reduction over the 29 year period. Despite this,
SSA had the second lowest burn incidence rate in 2019 at 122 after MENA’s 71. Despite having
the second greatest improvement in burn incidence, LAC had the great incidence rate at 290 which
was significantly higher than the other geographic regions with Europe second at 198.
Figure 1 provides the yearly burn incidence for both the SDI Ranks (Figure 1.a) and
Geographic Regions (Figure 1.b) from 1990 to 2019. Throughout the entire 29-year period, the
High-Middle and High SDI groups had the highest burn incidence, averaging 25% above the global
average during that time despite the greatest improvement relative to the other SDI ranks. Low
and Middle SDIs were similar throughout this time and close to the global average whereas the
Low-Middle SDI rank was farthest below the global average at all time points. For the regional

9

groups, LAC was the highest during this time averaging more than 2.5 times the global average
and 4 times MENA’s rate of around 90 to 100 burn cases per 100,000 person-years. Europe
mirrored the average between LAC and the Global trend line while MENA had the lowest
incidence rate of all regions despite the second lowest rate of improvement.

Figure 1: Yearly Burn Incidence Rates

Yearly Incidence for Global Average, SDI Ranks, & Geographic Regions: The yearly incidence from 1990 to 2019 is listed as
an age-standardized rate of burn cases per 100,000 persons controlling for age and gender relative to SDI Rank (A) and Geographic
Region (B). The Global trend line represents the average for all countries. The relative contributions as a percentage of the total
global burden are shown for the SDI Ranks (C) and Geographic Regions (D). See Tables 1 and 2 for the complete list of countries
in each SDI and geographic region. SDI = Socio-Demographic Index; SSA = Sub-Saharan Africa; LAC = Latin America &
Caribbean; MENA = Middle East & North Africa

10

In addition to the incidence rates, Figure 1 shows the overall contribution of each SDI
Rank (Figure 1.c) and Region (Figure 1.d) to the total number of global burn cases to better
understand their respective contributions to the overall burn burden. For SDI ranks, Low and Low-
Middle SDIs accounted for 25% of burn cases with the Middle and High-Middle ranks contributing
25-30% each. High SDI countries only accounted for 20% of all global burns. From a regional
perspective, Europe (12%; n=1,481,049) and North America (5%; n= 606,377) only accounted for
17% of all cases with the remaining 83% coming from MENA (3%; n= 368,845), LAC (15%; n=
1,880,116), SSA (10%; n= 1,302,178), and Asia (55%; n= 6,990,550).
Figure 2 shows the country-level data for burn incidence rate in 2019 using a choropleth
map where red represents the highest rates and green the lowest. Azerbaijan (405), Bahamas (370),
Turkmenistan (363), Cuba (350), and Haiti (344) had the highest burn incidence with the greatest
regional clusters in Central Asia, the Caribbean, and Central America. In contrast, Pakistan (40),
Bangladesh (45), Afghanistan (45), Taiwan (46), and Nepal (50) had the lowest rates as mirrored
by the dark green clusters in MENA and South Asia.

11

Figure 2: Burn Incidence by Country, 2019

Burn Incidence in 2019 by Country: The choropleth map shows the 2019 burn incidence rates (cases per 100,000 person-years)
across all 196 countries included in the study. The color legend shows the relative scale from green (lowest rate) to red (highest
rate).

Deaths
Over the 29-year period, death rates across all SDI ranks and geographic regions decreased
by at least 30%. Both the Low and Middle SDI groups improved the most with a 43% drop from
1990 to 2019. This was followed by the High SDI group (-40%) and Low-Middle SDI (-39%) with
High-Middle SDI showing the smallest reduction (-33%). Geographically, MENA (-49%) and
North America (-48%) improved the most whereas Europe (-30%) and SSA (-36%) saw the lowest
reduction in the rate of burn deaths.
The global rate dropped from 2.3 to 1.4 deaths per 100,000 people with Low SDI (2.1) and
SSA (2.5) representing the highest death rates in 2019 and averaging 43% and 71% above the
global rate, respectively. High SDI and North America had the lowest rate of death due to burn

12

injury at 1 death per 100,000 people indicating that people in Low SDI countries and the SSA
region, specifically, die from burns more than twice as often (Table 3). Asia, LAC, and MENA
all had similar death rates around 1.5 burn-related deaths per 100,000 people.
Figure 3 displays the yearly death rates for both the SDI Ranks (Figure 3.a) and
Geographic Regions (Figure 3.b) from 1990 to 2019. All SDI Ranks except the High-Middle
cohort saw consistent reductions over time with the Low-Middle SDI group closely following the
global trendline whereas the Low SDI group’s death rate remained at least 40% above the global
average at all time points. The Middle and High SDI groups were always below the global average
whereas the High-Middle SDI countries showed a 15-25% jump from 1993 to 2010 before
normalizing around the global average for the remaining 9 years. From a regional perspective, the
LAC, MENA, and Europe regions closely followed the global trendline whereas SSA and North
America were respectively above and below the global average throughout all 29 years. Asia
averaged 20% above the global average for most of the study period but in 2000 there was a
noticeable spike to a rate of 6.2 from 2.5 the year prior, a 148% increase, that then returned to a
rate of low two’s for the remaining 19 years. No other regions shared this spike in 2000 although
Europe did have a 25-30% increase from 1992 to 2010 that then decreased back to the global
average. This spike appears to be an artifact of the model rather than a true findings as no
identifiable mass casualty burn event occurred during this time to account for such a significant
increase.
The relative percent contribution of the SDI Ranks and Geographic Regions to the global
burden of burn deaths are displayed in Figure 3.c and 3.d, respectively. Nearly 70% of all burn
deaths occurred in the lower SDI countries with Low (16%; n=19,296), Low-Middle (24%;
n=29,853), and Middle (28%; n=34,878) SDI countries accounting for 84,027 deaths. The High

13

SDI countries only represented 11% or 13,800 of the 124,037 deaths that occurred in 2019. From
2002 onward, the relative contributions of the Low to Middle SDI countries increased as death
rates dropped in High-Middle and High SDI regions.
Regionally, nearly half of all burn deaths occurred in Asia (47%; n=58,601). Another 33%
of deaths were seen in SSA (17%; n=20,828), LAC (7%; n=8,458), and MENA (9%; n=11,350).
Only 20% of deaths occurred in Europe (15%; n=19,034) and North America (5%; n=5,633)
despite these two regions having higher burn incidences than all other regions except LAC.
Starting in 2002, the relative contribution of Europe to global burn deaths decreased relative to the
other regions, whereas North America remained stable.

14

Figure 3: Yearly Burn Death Rates

Yearly Deaths for Global Average, SDI Ranks, & Geographic Regions: The yearly deaths from 1990 to 2019 is listed as an
age-standardized rate of burn deaths per 100,000 persons controlling for age and gender relative to SDI Rank (A) and Geographic
Region (B). The Global trend line represents the average for all countries. The relative contributions as a percentage of the total
global burden are shown for the SDI Ranks (C) and Geographic Regions (D). See Tables 1 and 2 for the complete list of countries
in each SDI and geographic region. SDI = Socio-Demographic Index; SSA = Sub-Saharan Africa; LAC = Latin America &
Caribbean; MENA = Middle East & North Africa

The country-level data for 2019 death rates in Figure 4 reveals clusters of higher death
rates in the Central Asia (2.5), Southern SSA (4.5), and Eastern Europe (4.6) regions. The countries
with the highest death rates included Belarus (7.4), Papua New Guinea (7.1), Latvia (6.1), Lesotho
(5.9), and Ukraine (5.2). In contrast, Singapore (0.2), Sao Tome and Principe (0.3), Colombia
(0.4), Costa Rica (0.4), and Nicaragua (0.4) had the lowest death rates of all 196 countries.

15

Figure 4: Burn Deaths by Country, 2019

Burn Deaths in 2019 by Country: The choropleth map shows the 2019 burn death rates (deaths per 100,000 people) across all
196 countries included in the study. The color legend shows the relative scale from green (lowest rate) to red (highest rate).

Disability-Adjusted Life Years (DALYs)
DALYs had the greatest overall improvement of the three primary burn metrics over the
29 years with a global reduction of 44%. The Low (-47%), Low-Middle (-48%), and Middle (-
50%) SDI Ranks were all within 3 points of one another around the 50% reduction mark whereas
the High-Middle (-42%) and High (-37%) SDI ranks did not improve as significantly. While the
High SDI countries had the least amount of improvement in DALYs they started at the lowest
DALY rate (123 years per 100,000 people) of all SDIs in 1990 and remained the lowest by the end
of the 29-year period in 2019 at 77 DALYs per 100,000 people. Despite close to a 50% reduction
in DALYs for Low SDI countries, they still accrued at close to double (192%) the rate of people
living in High SDI countries and were 54% above the global average.

16

For geographic regions, MENA had the greatest improvement in DALYs at 57% and in
2019 had the second lowest DALY rate of 87 – only North America was lower at 76. SSA and
LAC had more than 40% rate reductions over the 29 years, but they still had the greatest DALY
rates of 159 and 140 which were 65% and 45% above the global average, respectively. Europe had
the slowest rate of improvement for all regions with a 34% decrease in DALYs.
Looking at the yearly averages and global trendlines in Figure 5.a, the Low- and High-
Middle SDI countries closely followed the global average whereas the Middle and High SDIs
remained below this trendline while the Low SDI cohort was at least 50% above the global average
over the 29 years. Regionally, DALY rates for Europe and MENA were aligned with the global
average, North America was below, and the remainder (LAC, Asia, and SSA) were always above
it (Figure 5.b). Of note, Asia’s DALY rate mirrored that of LAC but had a spike in 2000, the same
time as the death rate spike, with a 75% increase that then returned in 2001 to a similar rate as
1999. This spike also appears to be an artifact of the model.

17

Figure 5: Yearly DALY Rates

Yearly DALYs for Global Average, SDI Ranks, & Geographic Regions: The yearly DALYs from 1990 to 2019 are listed as an
age-standardized rate of years of disability and life-lost due to burns per 100,000 persons controlling for age and gender relative to
SDI Rank (A) and Geographic Region (B). The Global trend line represents the average for all countries. The relative contributions
as a percentage of the total global burden are shown for the SDI Ranks (C) and Geographic Regions (D). See Tables 1 and 2 for
the complete list of countries in each SDI and geographic region. DALYs = Disability-Adjusted Life Years; SDI = Socio-
Demographic Index; SSA = Sub-Saharan Africa; LAC = Latin America & Caribbean; MENA = Middle East & North Africa

Figures 5.c and 5.d show the relative contributions of each SDI Rank and global Region,
respectively. Low (16%; n=1,484,104), Low-Middle (25%; n=2,276,006), and Middle (29%;
n=2,663,230) SDIs accounted for 70% of all DALYs with High SDI (11%; n=1,003,844)
representing slightly more than 10% of the total DALYs burden. Compared to the incidence and
deaths, there is a greater regional disparity for DALYs with Asia (76%; n=4,355,752) and MENA

18

(21%; n=1,188,793) accounting for 96% of all DALYs. Three-quarters occur within Asia alone.
The remaining 3.5% of global DALYs originate from SSA (0.5%; n=31,600), LAC (1%;
n=59,352), Europe (2%; n=126,820), and North America (0.01%; n=726).
Choropleth analysis of DALYs in 2019 showed high DALY rate clusters in Southern SSA
(245), Eastern Europe (221), and Central Asia (204), which mirrored the subregions with the
greatest death rates (Figure 6). At the country-level, Papua New Guinea (545), Haiti (408), Belarus
(322), Lesotho (313), and Azerbaijan (307) had the highest DALY rates, which were similar to the
countries with the worst death rates although Ukraine and Latvia were superseded by Haiti and
Azerbaijan for DALYs. Other than Sao Tome and Principe (28), the other countries with the lowest
DALY rates were different than for death rates and were Taiwan (34), Oman (34), Turkey (35),
and Nepal (36).

19

Figure 6: Burn DALYs by Country, 2019

Burn DALYs in 2019 by Country: The choropleth map shows the 2019 burn DALY rates (years of disability and life-lost due to
burns per 100,000 people) across all 196 countries included in the study. The color legend shows the relative scale from green
(lowest rate) to red (highest rate).

Gender Strata
All three burn metrics were then analyzed relative to gender – male (M) and female (F) –
using age-standardized rates for both SDI Ranks (Figure 7.a, 8.a, and 9.a) and Geographic
Regions (Figure 7.b, 8.b, and 9.b). Globally, burn incidence was similar for males and females
although males in Low SDI countries had 5-10% higher rates of burn injury over the 29 years. The
greatest gender disparities for burn incidence were in the High-Middle and High SDI countries
with males averaging 20% more burns compared to females. In Low and Low-Middle SDI
countries, it was opposite with females being burned at 15-20% higher rates compared to males.
When looking at geographic regions, Asia, LAC, Europe, and North America all had higher burn
rates in males versus females. Male burn incidence was 39%, 20%, 48%, and 28% higher for these
four respective regions compared to the global average. SSA rates were similar between males and

20

females. MENA was the only region where women were burned at higher rates than men with
women suffering burn injury 27% more often than men.

Figure 7: Gender-Stratified Burn Incidence

Gender-Stratified Incidence for Global Average, SDI Ranks, & Geographic Regions: The yearly incidence from 1990 to 2019
is listed as an age-standardized rate of burn cases per 100,000 persons controlling for age and stratified by gender relative to SDI
Rank (A) and Geographic Region (B). The Global trend line represents the average for all countries. See Tables 1 and 2 for the
complete list of countries in each SDI and geographic region. (M) = male; (F) = female; SDI = Socio-Demographic Index; SSA =
Sub-Saharan Africa; LAC = Latin America & Caribbean; MENA = Middle East & North Africa

The gender-stratified death rates for SDI Ranks (Figure 8.a) showed similar rates for Low
and Middle SDI countries whereas males died at higher rates than females in High-Middle (M:F
1.58) and High SDI (M:F 1.35) countries. Notably, for Low-Middle SDI countries women died at
higher rates than men by 32%. These percent differences were consistent throughout most of the
29-year period as shown in Figure 8.a, but the High-Middle SDI countries showed a significant
increase in the male death rate from 1992 to 2010 that then slowly decreased for the remaining
nine years.

21

Figure 8: Gender-Stratified Burn Deaths

Gender-Stratified Deaths for Global Average, SDI Ranks, & Geographic Regions: The yearly deaths from 1990 to 2019 are
listed as an age-standardized rate of burn deaths per 100,000 persons controlling for age and stratified by gender relative to SDI
Rank (A) and Geographic Region (B). The Global trend line represents the average for all countries. See Tables 1 and 2 for the
complete list of countries in each SDI and geographic region. (M) = male; (F) = female; SDI = Socio-Demographic Index; SSA =
Sub-Saharan Africa; LAC = Latin America & Caribbean; MENA = Middle East & North Africa

When looking at Geographic Regions (Figure 8.b), death rates for males were higher than
females across the globe. The difference between death rates for men compared to women – all in
favor of men – were as follows: 65% in Asia , 38% in SSA, 39% in LAC, 11% in MENA, 82% in
Europe, and 29% in North America. From 1992 to 2010, the male death rate from burns
disproportionately increased in Europe to nearly 4 times that of females then the gap narrowed to
a two-fold difference by 2014. In addition, the spike in deaths in Asia previously seen in the
gender-controlled cohort was also seen in both males and females in 2000, which is likely a
modeling artifact.
Low and Middle SDI countries showed similar DALY rates for men and women (Figure
9.a) whereas rates were 43% and 23% higher for men in High-Middle and High SDI areas,
respectively. Low-Middle SDI countries were the only ones with higher DALY rates for women,
with women experiencing 32% more burn DALYs than their male counterparts. Geographically

22

(Figure 9.b), all regions except MENA showed a male bias for DALYs with rate differences of
53% (Asia), 28% (SSA), 19% (LAC), 67% (Europe), and 26% (North America). These percent
differences remained stable throughout the 29-year decline in rates except for Asia which had the
spike in 2000 for both genders and Europe which saw a disproportionate increase for males from
1992 to 2010. These deviations mirrored gender-specific death rates for both Asia and Europe.

Figure 9: Gender-Stratified Burn DALYs

Gender-Stratified DALYs for Global Average, SDI Ranks, & Geographic Regions: The yearly DALYs from 1990 to 2019 are
listed as an age-standardized rate of years of disability and life-lost due to burns per 100,000 persons controlling for age and
stratified by gender relative to SDI Rank (A) and Geographic Region (B). The Global trend line represents the average for all
countries. See Tables 1 and 2 for the complete list of countries in each SDI and geographic region. (M) = male; (F) = female;
DALYs = Disability-Adjusted Life Years; SDI = Socio-Demographic Index; SSA = Sub-Saharan Africa; LAC = Latin America &
Caribbean; MENA = Middle East & North Africa

Age Strata
Figures 10 – 15 provide the age-stratified rates for the SDI Ranks and Geographic Regions.
Figures 10, 12, and 14 show the age-strata relative to SDI Rank. Figures 11, 13, and 15 show the
five age strata with respect to the global regions. For burn incidence in the under 5 years age group,
High SDI countries had more than double the global average while Low and Low-Middle SDIs

23

had rates below the global average (Figure 10). The High-Middle and High SDI regions exhibited
20-30% greater incidence rates for the 15-49, 50-69, and 70+ year old age cohorts at all time points.
For the same age strata, Low, Low-Middle, and Middle SDIs were all below the global average
with this deviation increasing as age increased across the three strata. The 5-14 year age-strata was
most similar across SDI rank.

Figure 10: Age-Stratified Burn Incidence by SDI Rank

Age-Stratified Incidence for Global Average & SDI Ranks: The yearly incidence from 1990 to 2019 is listed as a rate of burn
cases per 100,000 person-years controlling for gender and stratified by age to the following strata: under 5 years (A), 5-14 years
(B), 15-49 years (C), 50-69 years (D), 70+ years (E). The Global trend line represents the average for all countries. See Tables 1
and 2 for the complete list of countries in each SDI Rank. SDI = Socio-Demographic Index; SSA = Sub-Saharan Africa; LAC =
Latin America & Caribbean; MENA = Middle East & North Africa

Figure 11 shows the age-stratified burn incidence by Geographic Region. LAC had
significantly higher burn rates in all age cohorts relative to the global average with the greatest
deviations for children under 5 (400-450%) and 5-14 (200-300%) years. Europe was also well
above the global average for all age strata with those aged 15-49 and 50-69 years having the
greatest relative rates. Asia closely trended with the global average for all age groups except 15-

24

49 years where they averaged 25% above the global trendline and 70+ years where they were 20-
30% below the global average. Like the age-standardized cohort, MENA’s burn incidence was
below average for all age groups, especially for people in the 50-69 and 70+ year strata.

Figure 11: Age-Stratified Burn Incidence by Region

Age-Stratified Incidence for Global Average & Geographic Regions: The yearly incidence from 1990 to 2019 is listed as a rate
of burn cases per 100,000 person-years controlling for gender and stratified by age to the following strata: under 5 years (A), 5-14
years (B), 15-49 years (C), 50-69 years (D), 70+ years (E). The Global trend line represents the average for all countries. See
Tables 1 and 2 for the complete list of countries in each region. SSA = Sub-Saharan Africa; LAC = Latin America & Caribbean;
MENA = Middle East & North Africa

For age-stratified death rates, Figure 12 shows the trends across the five strata relative to
SDI Rank. The Low SDI countries had higher death rates for all age groups when compared to the
global average although those in the 15-49 cohort were closest to the average. The death rate for
those 70 years and older was more than double (2.2) the global average and the other SDI strata
with the High SDI countries being farthest from the Low SDI in this age group. From 1992 to
2010, the Low-Middle and High-Middle SDIs surpassed the Low SDI death rate in the 15-49 age

25

group. The High-Middle SDI countries were also below average and closer to High SDI countries
for all age groups except the middle age ranges (15-49 and 50-69) where a large increase of 33-
52% occurred from 1992 to 2010 before tapering down towards the global average.

Figure 12: Age-Stratified Burn Deaths by SDI Rank

Age-Stratified Deaths for Global Average & SDI Ranks: The yearly deaths from 1990 to 2019 are listed as a rate of burn deaths
per 100,000 persons controlling for gender and stratified by age to the following strata: under 5 years (A), 5-14 years (B), 15-49
years (C), 50-69 years (D), 70+ years (E). The Global trend line represents the average for all countries. See Tables 1 and 2 for
the complete list of countries in each SDI Rank. SDI = Socio-Demographic Index; SSA = Sub-Saharan Africa; LAC = Latin
America & Caribbean; MENA = Middle East & North Africa

Regionally, SSA had increased death rates for all age groups compared to global
counterparts with the greatest differentials seen in those under 5 years (+115%), 50-69 (+235%),
and 70+ (+288%) years (Figure 13). MENA surpassed SSA for death rate in the 5-14 and 15-49
age groups but was close to the global average for those under 5 and above 50 years. North
America’s death rate was below average for all ages, but most noticeably for the age extremes –
those under 5 and over 70 years. Europe was at or below the global average for all ages except

26

those age 50-69 years, which was 10-20% above average. Asia exhibited the spike of death rate in
2000 across all age groups with progressively increasing deviation as age increased across the age
groups.

Figure 13: Age-Stratified Burn Deaths by Region

Age-Stratified Deaths for Global Average & Geographic Regions: The yearly deaths from 1990 to 2019 are listed as a rate of
burn deaths per 100,000 persons controlling for gender and stratified by age to the following strata: under 5 years (A), 5-14 years
(B), 15-49 years (C), 50-69 years (D), 70+ years (E). The Global trend line represents the average for all countries. See Tables 1
and 2 for the complete list of countries in each region. SSA = Sub-Saharan Africa; LAC = Latin America & Caribbean; MENA =
Middle East & North Africa

The DALY rates in those under 5 years were disproportionately higher in the Low SDI
group (+135%) with the Low-Middle SDIs following the global average and the remaining SDIs
below the average (Figure 14). High SDI countries averaged 70-72% below the global trend and
88% below the Low SDI countries. All SDIs were closer to the global average in the 5-14 age
group. The High-Middle and High SDI countries were above average for all ages 15 and greater
whereas the Low to Middle SDI countries were below average for those same ages. The High-

27

Middle and High SDI countries showed greater improvements or reduction in DALY rates over
time for the 50-69 and 70+ age groups compared to the other SDI Ranks during the 29 years.

Figure 14: Age-Stratified Burn DALYs by SDI Rank

Age-Stratified DALYs for Global Average & SDI Ranks: The yearly DALYs from 1990 to 2019 are listed as a rate of years of
disability and life-lost due to burns per 100,000 persons controlling for gender and stratified by age to the following strata: under
5 years (A), 5-14 years (B), 15-49 years (C), 50-69 years (D), 70+ years (E). The Global trend line represents the average for all
countries. See Tables 1 and 2 for the complete list of countries in each SDI Rank. DALYs = Disability-Adjusted Life Years; SDI
= Socio-Demographic Index; SSA = Sub-Saharan Africa; LAC = Latin America & Caribbean; MENA = Middle East & North
Africa

The SSA region had the highest DALY rate for those under 5, approximated the global
average for 5-14 and 15-49 year strata, and was consistently below the global average for the older
age strata (50-69 and 70+ years) (Figure 15). Asia had higher than average DALY rates for the 5-
14 and 15-49 year cohorts whereas they were below average for those 70 years and older. Unlike
deaths, where the 2000 spike was present for all age ranges in Asia, only those under 5 years
experienced a large increase during that time. LAC was also 35-75% above average for all ages 5
years and older with the greatest DALY rate in the 5-14 age group. Europe and North America

28

exhibited similarly elevated DALY rates relative to the LAC region for those 15 years and older.
MENA was the only region consistently below the global average across all age strata with the
most significant differentials seen in the 50-69 (-62%) and 70+ (-78%) cohorts.

Figure 15: Age-Stratified Burn DALYs by Region

Age-Stratified DALYs for Global Average & Geographic Regions: The yearly DALYs from 1990 to 2019 are listed as a rate
of years of disability and life-lost due to burns per 100,000 persons controlling for gender and stratified by age to the following
strata: under 5 years (A), 5-14 years (B), 15-49 years (C), 50-69 years (D), 70+ years (E). The Global trend line represents the
average for all countries. See Tables 1 and 2 for the complete list of countries in each region. DALYs = Disability-Adjusted Life
Years; SSA = Sub-Saharan Africa; LAC = Latin America & Caribbean; MENA = Middle East & North Africa

Mortality Ratio
The final analysis compared burn deaths to incidence for 2019 by calculating the Mortality
Ratio (MR), which provides an approximation of the percentage of people who are burned who
then die due to burn injury – the inverse of burn survival (Figure 16). With respect to SDI Ranks,
increasing SDI Rank translated to progressively lower MRs with High SDI having the lowest MR
of 0.8% in comparison to Low SDI which had the highest MR of 2.8% - a 3.5-fold difference. The

29

largest increase in MRs between adjacent SDIs occurred between the Middle and Low-Middle SDI
countries going from 1.5% to 2.4% – a 60% increase. Otherwise, adjacent SDIs usually varied by
0.3 to 0.4 percentage points (Figure 16.a). For geographic regions, MENA had the highest MR at
3.1%, nearly double the next highest region, SSA (1.6%). LAC (0.4%) had the lowest MR with
Asia (0.8%) and North America (0.9%) also below the global average of 1.5%. MENA’s MR was
7.8 times that of LAC’s and more than double the global average.

Figure 16: Mortality Ratios for SDI Ranks & Geographic Regions, 2019

Mortality Ratio for Global Average, SDI Ranks, & Geographic Regions: The 2019 mortality ratios, which are represented as
the percentage of burn cases that result in death (i.e., yearly deaths/incidence), are shown for SDI Rank (A) and Geographic Region
(B). These mortality ratios are use the age-standardized rates that control for age and gender. The Global mortality ratio represents
the average for all countries. See Tables 1 and 2 for the complete list of countries in each SDI and geographic region. SDI = Socio-
Demographic Index; SSA = Sub-Saharan Africa; LAC = Latin America & Caribbean; MENA = Middle East & North Africa

Discussion
Burn injuries have a significant global impact that should not be ignored.
2–4,19–21
This
devastating form of trauma may cause severe disfigurement, disability, and distress that has
considerable ramifications at the individual, family, community, healthcare, national, and global
level. As a result, it is imperative that clinicians, researchers, policy and advocacy experts, and
other community leaders approach the issues of burn prevention, care, and rehabilitation from both

30

global health and social justice perspectives. Although it is well understood that burn frequency,
severity, and outcomes are closely associated with socioeconomic status, age, and gender; the full
extent of these disparities on national, regional, and global scales has been hard to quantify up until
recently.
10,20–24
With the latest iteration of the Global Burden of Disease database, GBD19, the
capacity of researchers to examine the impact of burns on a larger scale is now possible to a greater
degree of accuracy and reliability.
15–18
As a result, the primary goal of this study was to utilize the
GBD19 to identify specific countries, regions, and sociodemographic factors that contribute to the
global burden of burn injury to more effectively direct the creation of evidence-based
interventions, programs, and policies that overcome barriers to accessing and receiving burn care.
In doing so, we aim to empower providers, leaders, and advocates with contextualized knowledge
that will help them reduce the impact that burns have on burn survivors, their families and
communities, the surrounding healthcare systems, and global surgical capacity.

Global Burns and the Impact of Socio-Demographic Index
Analysis of GBD19’s burn data determined that annually there are more than 8.4 million
burns, 124,000 deaths, and 9.2 million DALYs that occur globally. This significant burn burden
disproportionately affects those living in Low-to-Middle SDI countries, accounting for nearly 70%
of all deaths and DALYs. Compared to High SDI countries, burn-related deaths and DALYs occur
at twice the rate in the general population in lower SDI countries with a four-fold increase in the
likelihood of death or disability after burn injury relative to High SDI regions. Similar disparities
between Low- and Middle-Income (LMIC) and High-Income (HIC) countries have been reported
with numerous studies indicating that 70-90% of burn morbidity and mortality occurs within
LMICs.
4,25,26,26–30
The noticeably worse burn morbidity and mortality in lower SDI countries

31

suggests that burns may be more severe when they occur and health systems are too overburdened
or underequipped to appropriately manage these burn injuries in a timely and effective
manner.
9,22,24,31

In addition, women and children were particularly vulnerable populations with worse death
rates and higher DALYs in the Low and Low-Middle SDI countries compared to the global
average and higher SDI regions. Women living in Low-to-Middle SDI countries were 22% more
likely to be burned and 25% more likely to die from their burns compared to women in High SDI
countries. Higher SDI regions showed an inverse trend with men having higher burn incidence and
death rates than their female counterparts. With respect to age, children under 5 years and elderly
over 70 years of age died nine times more frequently than their High SDI counterparts. Prior
studies have similarly shown that the rate of child deaths due to burn injuries are over seven times
higher in LMICs than in HICs.
21
The GBD19 also estimated 8.3 times more DALYs for those
under 5 years old living in Low SDI countries compared to the global average. The Low SDI
mortality ratio, or percentage of burned individuals who died due to their injuries, was 3.5-fold
higher than the High SDI group (2.8% versus 0.8%) and 87% above the global average for
mortality.
In contrast, the High SDI countries had the lowest death rates across all age strata and the
lowest mortality ratio (0.8%) – nearly 50% below the global average of 1.5%. High SDIs only
accounted for 22% of all global burn cases and 11% of deaths and DALYs. This was the only SDI
where deaths and DALYs contributed a smaller percentage to the global total relative to the overall
number of burn cases in that SDI Rank. Counter to all other observed SDI trends, the burn
incidence rate of the High SDI group was 40% above the global and Low SDI rates implying that
either burns occurred more frequently than in lower SDI countries or that burn injury was recorded

32

more accurately within High SDI countries. It is important to note that, on average, there were 2-
to-4 times more data sources available for High SDI countries than Low SDI countries, which
means that GBD19’s model would be able to better predict the true incidence of burns in High SDI
countries while under-predicting the burn burden for Low SDI countries. This underprediction of
lower SDI burn burden due to a lack of quality data is the most likely explanation given the extent
of prior literature that identifies much higher rates of burn injury in LMICs than HICs.
7,9,10,22
This
influence is likely also present within the death and DALY predictions, so the fact that those two
metrics are worse in lower SDI countries despite underrepresentation emphasizes the significant
disparity that exists due to socioeconomic factors.

The Regional Distribution of Burn Morbidity and Mortality
Evaluating burn metrics according to Region rather than SDI Rank helped elucidate the
geographic distribution of the global burn burden with the understanding that these two factors –
geography and socioeconomics – are closely related to one another. Asia accounted for 55% of all
burns (n= 6,990,550), 47% of deaths (n= 58,601), and 76% of all DALYs (n= 4,355,752) – the
most of any global region. While this is partly due to the relatively large population size compared
to other regions around the world, Asia contributed a significant number of DALYs (76% of the
global total) that is disproportionate to their overall population (60% of world population) and burn
incidence (55% of global burn cases) in comparison to the other regions which tended to have
lower death and DALY contributions compared to their overall number of burn cases. The
literature has identified particular risk factors in this region that likely contribute to this significant
burn morbidity and mortality including higher rates of scald burns in women and children at home,
frequent electrical burns in young adult men from industrial and construction accidents, common

33

use of open flames fueled by kerosene for heating and cooking, and a high rate of mass casualty
burn disasters.
28,32–34
A spike in 2000 within Asia for both deaths and DALYs, particularly in men
aged 15-49 years, may have been due to a series of large-scale burn disasters that created
significant influxes of burn patients on already over-burdened systems leading to greater morbidity
and mortality although exact temporal correlation is not capable with this modeled data.
34–36
It is
also possible this spike is due to some artifact from the model in which the data sources available
for that year resulted in an overprediction by the model.
Central Asia had the greatest impact on all burn metrics within Asia with rates 2 to 4 times
above those seen in East Asia, South and Southeast Asia, and Oceania. Papua New Guinea, part
of Oceania and not Central Asia, was also a significant contributor to burn rates and was in the top
5 of all 196 countries with respect to deaths and DALYs. However, the countries primarily
responsible for Central Asia’s dominance of regional and global burn burden were Azerbaijan,
Mongolia, and Turkmenistan with rates 2.5 to 4.5 times above the global average. Studies from
these countries have shown that children account for 70-80% of all burns, most are scald etiology,
and more than 80% occur in tents or other indoor settings where open flames are used to heat water
and living spaces.
37–40
In Azerbaijan and Iran, there are high rates of self-immolation
41,42
that create
severe and often fatal burn injuries. Work is being done in these countries to address the unique
psychosocial aspects of the prominent burn etiologies in children and women as well as create
targeted burn prevention programs and solutions.
41–44

Sub-Saharan Africa (SSA) had a near-average burn incidence but exhibited the highest
death and DALY rates throughout the 29-year period. Consistent with most other regions, males
had higher death and DALY rates compared to females. In SSA, people died from burns and
experienced significant disability at rates 65-70% above average when compared to global trends

34

with a mortality ratio 50% higher than Asia. People in SSA under 5 and over 50 years of age died
at rates 2 to 3.5 times above their age-matched counterparts from other regions. Southern SSA had
the greatest impact on these rates with Lesotho, Eswatini, and Botswana contributing the most to
this 70-110% increase in burn cases, deaths, and DALYs relative to the global average.
Despite the significant burden of burn injury in these countries and their role in the regional
burden of burn injury, only a single study has investigated burns with respect to any of these
countries. The study looked at community level education regarding burn prevention and first aid
in Botswana compared to Wales, Pakistan, India, and Zambia.
45
They found that LMICs exhibited
greater deficits in knowledge of prevention and first aid with Botswana showing the least burn
prevention knowledge aside from Pakistan. Due to the paucity of country-specific literature in
these low resource-high burden areas, broader SSA studies must be used as surrogates for
understanding these disparities. The increased burn mortality rate seen in the young and elderly
within SSA is corroborated by other studies suggesting that children account for nearly 80% of
burns with a 12-17% mortality rate.
46,47
Some factors in SSA that have been identified as
contributors to this elevated morbidity and mortality include high rates of malnutrition in children,
significant delay in seeking and receiving burn surgery, frequent scald burns from untreated
epilepsy, and social stigma regarding burn injury and seeking care.
46–50

Latin America and the Caribbean (LAC) had the highest incidence of any region, around
250% above the global average, with all age strata following this trend relative to their age-
matched counterparts from other regions. The greatest age disparities were seen in the under 5 and
5-14 year cohorts with rates 3 to 4 times above the average incidence although deaths and DALYs
for these age groups closely mirrored the global trendline. There were notable hotspots in the
Caribbean (Haiti, Cuba, and the Bahamas) and Central America (Guatemala, Honduras, and

35

Nicaragua) with these subregions exhibiting incidence and death rates 2.5 to 3 times above global
averages. Haiti was the most significantly burdened country in the entire LAC region. Studies have
identified substantial challenges in Haiti that contribute to this disproportionate morbidity and
mortality due to pervasive burn infections, delayed access to surgical care, barriers seeking care
due to social stigma, and lack of disaster preparedness following earthquakes and hurricanes
leading to large gaps in access to trauma and rehabilitative services for children.
51–54
Despite the
extensive burn burden in Guatemala, Honduras, and Nicaragua; little has been published on burns
in these areas with a single-center study from Guatemala determining that nearly 70% of all burns
occur in those under 4 years of age and from scald mechanisms.
The Middle East and North Africa (MENA) region accounted for 3% of all burns, but 9%
of deaths and 21% of DALYs. This ratio of deaths and DALYs to cases is the highest of all regions
which indicates that the severity and subsequent disability from burn injuries in MENA are greater
than all other geographic regions. MENA was also the only region where burn incidence was
higher in women than men with 36% greater burden of injury for women. Iran, Iraq, Morocco, and
Yemen accounted for the greatest number of burn deaths and DALYs in the region with rates 40-
80% above average. Studies have identified a complex interplay of factors that contribute to this
sociodemographic and regional distribution of burn injury in MENA including elevated rates of
abuse and self-immolation burns in women, ongoing military conflict with mass burn casualty and
complex blast injuries, used of open fire pit and buried stoves for cooking and heating, and severely
limited burn workforce capacity.
38,42,55–61

Europe and North America had some of the highest burn incidence rates of all regions, but
death and DALY rates were comparatively lower than the global average. In consideration of the
risk factors and prior studies discussed above for the other regions, it is hypothesized that the

36

relatively high prediction for burn incidence is likely due to more extensive access to burn
registries, census and surveillance data, hospital records, and insurance claims that facilitates a
more accurate accounting of the true burn incidence within those regions. Rather than these regions
being over-represented or miscalculated in terms of burn incidence, it is more likely that the other
regions have under-estimated incidence rates due to a lack of sufficient or complete burn data to
input into the GBD model. The existing literature has shown that primary burn metrics – incidence,
deaths, and DALYs – in Europe and North America are consistently lower than those observed in
LMICs and other geographic regions with more than 90% of the global morbidity and mortality
originating in LMICs.
2,4,6,25,26,31
As a result, the observed incidence and DALY rates in these
regions should be considered carefully as it relates to the overall global landscape and relative
contribution to the burn burden.

Prioritizing Global Burn Care Using A Global Surgery Approach
Given the significant global burden of burn morbidity and mortality that was identified
from this GBD19 analysis, it is imperative that a global surgery framework is implemented to
direct geographically- and culturally-relevant solutions to these issues. The specific regions and
countries identified by this analysis which have disproportionately higher burn cases, deaths, and
DALYs may serve as initial targets for evidence-based interventions that address burns at the
individual, community, health system, and national levels. In order to better elucidate the true
burden of burns within these identified hotspots, further studies are warranted within those specific
countries and regions. These investigations should clarify burn provider referral systems and
networks, distribution and capacity of burn units, and regionally-specific burn etiologies to better
design interventions that address deficits within burn prevention, treatment, and rehabilitation.

37

The Three Delays Framework, a global surgery paradigm for considering barriers to
accessing surgical care, may serve as an effective template to consider potential solutions to these
issues.
1
The Three Delays Framework stratifies barriers into those that create issues Seeking,
Reaching, and Receiving care and relate to economic, social, political, geographic, educational,
and medical factors. Delays in Seeking Care arise from barriers that deter individuals from
pursuing burn treatment and include financial & geographic restrictions, cultural beliefs,
insufficient education and poor health literacy, lack of awareness of available services, low
confidence in the healthcare system and the quality of care, and subsequent reliance on traditional
or informal healers to address their burn injuries. For burns, these barriers may be overcome by
implementing locally-driven outreach programs that teach community members about burn
prevention, first aid, and indications for seeking higher levels of care.
12,29,43,62
Furthermore, efforts
must be made to instill confidence in the burn care system through quality improvement measures
and training programs that instill sufficient trust in those seeking care such that they are willing to
pursue treatment when indicated.
Delays in Reaching Care often occur due to physical and financial barriers that impair the
ability of individuals to reach burn providers and centers. In Low SDI regions, burn units are often
scarce and, when present, very far distances from those who are burned. This means that
individuals would need to travel for many hours or days, which requires prohibitively high travel
expenses and may necessitate crossing through dangerous areas of political and social unrest.
Studies show that access to and utilization of facilities can be optimized if these sites are within 2
hours or 100 kilometers of travel, but time and distance are only two components that need to be
considered when determining where burn units need to be constructed.
1
These barriers that prevent
people with burns from reaching treatment centers can be addressed through geospatial mapping

38

of burn networks – providers and facilities – in order to identify populations that would benefit
from more closely located centers as well as interventions to improve travel affordability and
security to these sites of care.
63–65

Delays in Receiving Care primarily have financial and medical etiologies. Financially,
patients may not be able to afford burn care, especially if expensive medications or surgeries are
required, and will therefore never receive the treatments they need. While efforts on the national
level to establish universal health coverage and other systems that ensure access for those unable
to afford care, funding issues and politics at the local, regional, and national levels create
significant hurdles to creating sustainable programs that reduce delays in Receiving Care. As a
result, addressing the medical factors which contribute to this delay are particularly impactful. Paul
Farmer’s “4S” model is valuable for identifying gaps and considering potential solutions. The 4S
model when applied to burn care would state that there are specific Staff (e.g., burn specialists,
nurses, therapists, psychologists, nutritionists, etc.), Stuff (e.g., burn dressings and topical
antimicrobials, surgical equipment, antibiotics, analgesics, etc.), Space (e.g., burn units, operating
rooms, rehabilitation centers, etc.), and Systems (e.g., supply chains, maintenance service lines,
referral networks, etc.) required to provide safe and effective burn care. Training and education
initiatives that expand burn workforce capacity (Staff) have been proposed and used to great effect
in various regions around the world.
12,24–26,31
Additional efforts that optimize burn care by reducing
product waste, implement affordable and sustainable wound care alternatives, and create
innovative solutions to surgical issues will help address Stuff and Space components.
12,66,67
Finally,
implementation of telemedicine and other means of strengthening referral networks will help with
Systems issues.
68
In this way, implementation of the Three Delays Framework and Paul Farmer’s
4S model alongside grassroots advocacy and locally-driven collaboration may facilitate effective

39

and thorough development of solutions to the multifactorial and intersectional barriers that effect
access to burn care across the globe.

Study Limitations
The presented study provides rigorous, data driven estimates of the global burden of burns
based on GBD19’s Disease Model MetaRegression 2.1 (DisMod-MR 2.1) system, a Bayesian
meta-regression tool that was designed by the IHME and University of Washington to ensure
consistency between rates of incidence, deaths, and DALYs for burn injury. Data from the GBD
database represent regional- and country-level estimates from an extensive library of resources;
but it relies on the assumption that the ground truth of the model may be accurately derived from
research papers, surveillance and census data, burn registries, trauma records, health insurance
claims, and other data collection tools to perform the meta-regression and generate estimates for
each metric. Due to the variety of data sources employed, it is important to consider the variability
of the quality and consistency of data used for each country as well as the implications of relying
on somewhat scarce and inconsistent data. Because of this technique, the generated numbers are
not granular enough nor are they etiologically appropriate for use in the analytical determination
of statistical significance. Furthermore, there are no patient-level data which negates the model’s
ability to predict metrics for smaller regions and communities within countries where burn injuries
may be particularly prevalent.
Due to the nature in which data sources are used to model burn metrics, the discrepancy in
the quantity and quality of available data sources between SDI ranks and individual countries
impacts the accuracy of the predictions. Lower SDI countries averaged 300-600 sources for
modeling whereas higher SDI countries, most often in Europe and North America, had more than

40

1,500 sources. Numerous countries in the Low SDI rank had less than 10 data sources, and would
therefore be at the highest risk of modeling error. This sampling bias may have manifested in the
burn incidence phenomenon seen above where higher SDI countries were predicted to have higher
incidence rates than lower SDI countries despite the current body of literature indicating the
opposite – LMICs have significantly higher rates of burn injury.
3,19,20

The database also had limited information on non-flame etiologies like chemical, electrical,
and blast burns. The lack of these data in the model is important because many studies have found
these aforementioned etiologies to be significant contributors to the overall burn burden for lower
income regions and may result in a form of reporting bias that causes underpredictions for burn
frequency and severity in these areas.
19,22,27–30,69
Additionally, DALYs were used as a surrogate
for burn severity, but this simplification may lead to an incomplete understanding of the
relationship between burn size and depth to functional disability and overall burn survival. Despite
these limitations, this study highlights important trends in burn incidence, mortality, and
morbidity. Further studies need to be conducted to validate the trends noted in the database and
better understand regional burn injury patterns, etiology, and outcomes. Given the above
limitations, there is a crucial need for improving upon the WHO’s Global Burn Registry so that it
is more user friendly, time efficient, accessible, validated, and updated in real-time to track burn
epidemiology and outcomes at a more granular and accurate level.
10

41

Conclusions
Trends of burn incidence, morbidity, and mortality highlighted in this study suggest that
burn injuries have been neglected on a global scale and efforts at prevention and care are especially
lacking within LMICs, particularly in Southern sub-Saharan Africa, the Middle East, Central Asia,
Central and Southern America, and the Caribbean. While there has been an overall improvement
in the analyzed burn metrics over the 29 years; women, children, and the elderly continue to suffer
from more severe burns with higher DALY and mortality rates in many regions of the world.
While the Global Burden of Disease database has effectively highlighted the geographic
regions and sociodemographic groups most impacted by burn injuries, further studies are required
to understand these trends and outcomes at the regional, national, and community levels. It is
evident that an intricate interplay of financial constraints, social beliefs and stigmas, political
instability, implicit and explicit biases, healthcare facility deficits, limited medico-surgical
resources, and thinly-stretched providers results in steep barriers to obtaining safe, timely,
effective, and affordable burn care. Collaborative implementation of global health principles
through locally- and regionally-driven programs that are guided by the findings of this study will
help formulate contextualized plans that meaningfully address the intersectional barriers currently
contributing to the disproportionate burden of burn morbidity and mortality around the world.

42

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Asset Metadata

Creator Collier, Zachary Jonathan (author)

Core Title Defining the global burden of burn injuries: a 29 year review of data from 196 countries

School Keck School of Medicine

Degree Master of Science

Degree Program Clinical and Biomedical Investigations

Degree Conferral Date 2022-05

Publication Date 04/20/2022

Defense Date 03/18/2022

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Africa,Asia,Burn,Caribbean,global burden,healthcare disparity,Latin America,low and middle income country,Middle East,OAI-PMH Harvest,thermal injury,Trauma

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Patino-Sutton, Cecilia (committee chair), Gillenwater, Justin (committee member), Magee III, William (committee member)

Creator Email Zachary.Collier@med.usc.edu,Zcollier@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC111037667

Unique identifier UC111037667

Document Type Thesis

Format application/pdf (imt)

Rights Collier, Zachary Jonathan

Type texts

Source 20220421-usctheses-batch-931 (batch), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

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Repository Name University of Southern California Digital Library

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