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| ORIGINAL ARTICLE |
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| Year : 2021 | Volume
: 29
| Issue : 1 | Page : 70-75 |
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Fire-cracker burn injuries during Diwali, a seasonal and preventable epidemic
Kabita Kalita, Swamy Vivek Gurindagunta
Department of Plastic and Reconstructive Surgery, Gauhati Medical College and Hospital, Guwahati, Assam, India
| Date of Submission | 18-Nov-2021 |
| Date of Decision | 02-Jan-2022 |
| Date of Acceptance | 05-Jan-2022 |
| Date of Web Publication | 08-Jun-2022 |
Correspondence Address:
Dr. Swamy Vivek Gurindagunta
House Number 90, Flat B1, Satya Niwas, Lachit Nagar, Opp. Jeet Medicos, Kamrup Metro District, Guwahati - 781 007, Assam
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijb.ijb_29_21
Background: Firecracker injuries are common in India, of which the majority takes place during Diwali. This study analyzes the profile of firecracker injuries in the emergency department (ED) of GMCH, Guwahati.
Materials and Methods: This is a retrospective observational study of all firecracker-related injury patients presenting to our ED 3 days prior and post Diwali from 2016 to 2020. Details of the demographics, cause, and percentage of burns were included. Treatment given for the patients is not mentioned in this study.
Results: We received a total number of 195 patients with burn injuries to the ED from 2016 to 2020, 3 days prior and post Diwali, of which 54.3% (106) cases are firecracker-related burn injuries. 46.2% of the cases were under the age of 19 years. Male (71.7%) predominance was noted. The majority of the injuries involved <20% total body surface area (80.2%). It is noted that the right hand (54%) is most commonly involved followed by the face (17%) and torso (17%). Fountain (38%) is observed to be the most common firecracker causing injuries. In 2020, during the COVID pandemic, there were only two reported cases attending to the ED during the specified period.
Conclusions: This study has expressed the pattern of firecracker injuries in our place during Diwali. An alarmingly high number of young adolescents with significant upper limb injuries were noted. These injuries are prevalent in the productive age groups. Public awareness and education along with an increase in legislative enforcement are needed for the betterment and well-being of the people during the festival season to prevent the catastrophe.
Keywords: Diwali, fire-cracker burn injuries, firecrackers
How to cite this article:
Kalita K, Gurindagunta SV. Fire-cracker burn injuries during Diwali, a seasonal and preventable epidemic. Indian J Burns 2021;29:70-5 |
| Introduction | |  |
Firecrackers worldwide are used as a means of celebration on different occasions. In India, we use fireworks on different occasions as a means of celebration. Firecrackers have a special place in almost every home during the period of Diwali. Firecrackers are not only an integral part of the celebration but also an unfortunate cause of burn injuries. Carelessness and inappropriate production or use of fireworks can lead to these terrible accidents. Burn injury during the period of Diwali is an anticipated and preventable danger in every household using firecrackers. Not only do firework-related injuries cause great harm to the patient but they also place a heavy burden on the family, health-care system, and society. The annual incidence of firecracker-related injuries in India is 7 in every 100,000 population.[1] Studies conducted in Delhi showed an increased incidence of firecracker-related injuries around the days of Diwali, despite targeted legislature being passed for it. A study from North-east India (Guwahati) also found a similar trend during Diwali 910. It has been noted that an alarmingly high number of young adolescents are involved in such incidents, and the upper limbs and face are the most common regions of the body to be involved.[1],[2],[3],[4] An injury to the hand and its underlying structures carry the potential for serious handicap and can interfere with the normal daily activities. Depending on the type and region of injury, firework-related injuries are a public health issue that deserves greater attention. The legal regulations in India regarding the manufacture, sale, and distribution are not restrictive enough to prevent accidental burns. Given the prevalence of firework-related injuries, it is better to re-evaluate the existing safety standards for a safe and burn injury free Diwali. Firecrackers are also used during many other festivals worldwide,[5],[6] making firecracker burn injuries burden a worldwide problem.
Aims and objectives
The aims and objectives of the present study are as follows:
- To observe the characteristics of firecracker burn injury patients (age, sex, place, body area involved, burn depth, and type of firework responsible) attending the emergency department (ED) 3 days before to 3 days after Diwali from 2016 to 2020
- To observe the changing trend in the prevalence of firecracker injuries attending our hospital during this period
- To observe the trend of firecracker injuries in 2020 during the COVID crisis when strict national lockdown was implemented
- To discuss some preventive aspects of the firecracker injuries.
| Materials and Methods | | |
This is a retrospective study of patients attending the ED 3 days before to 3 days after Diwali from 2016 to 2020. The records of patients, during this period, were collected from the medical records department of GMCH, Guwahati after getting approval from the ethical committee.
As this is a retrospective study, no photographs are available and only patients attending the ED are included. The load of firework injuries and characteristics of firework injury patients: age, sex, place, body area involved, burn depth, and type of firework responsible in the specified period are recorded. Treatment done for these patients is not included in the study.
| Results | | |
A total of 195 patients attended the ED 3 days before 3 days to 3 days after Diwali from 2016 to 2020 because of burn injuries, of which 106 (54.3%) patients attended with firework-related injuries. [Table 1] provides the demographic information for this study. Of the total 106 cases, majority of patients 46.2% are under the age of 19 years, 1.9% are above 60 years, and the remaining cases are ranging from 20 to 60 years' age group. The identified cases included 76 males (71.7%) and 30 females (28.3%). Males are most commonly injured as compared to females and the yearly trend is same every year. [Figure 1] shows that in 2016, there were 19 male and 9 female patients that were reported, in 2017 there were 15 male and 5 female patients recorded with a decline of number of females as compared to 2016. However, in 2018, there were again 22 male and 12 female patients, and in 2019, there were 18 male and 4 female patients recorded. | Table 1: Demographics of patients attending emergency 3 days before to 3 days after Diwali from 2016-2020
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 | Figure 1: Year-wise distribution of male and female patients with firecracker burn injuries during Diwali
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In 2020 due to the COVID crisis and national lockdown and strict protocols, there were only two male cases and no female cases recorded.
[Table 1] shows that most of the injured patients belong to the Hindu community (86.8%), a small fraction of patients belong to the Muslim community (13.2%).
[Table 1] shows that 58.5% of the patients are from the same district as that of the hospital but 41.5% were from other districts and states.
[Table 1] shows, of the 106 patients with firecracker burn injuries, only 3.8% of patients had involvement of >70% total body surface area (TBSA) mostly caused by fireworks igniting the clothes of the victim. 2.8% of population had 41%–70% TBSA involvement and 13.2% had 20%–40% TBSA involvement. The majority of patients (80.2%) had <20% TBSA involvement and mostly superficial burns.
[Figure 2] shows that the right hand alone is involved in 24% of cases. The right hand together with the right upper limb, torso, and face involves 15%, 2%, and 7%, respectively. Both upper limbs and hands are involved in 6%. This makes the right hand being involved in a total of 54% of cases. The left upper limb is involved in 5% of cases. Face and torso are involved in 17% of cases each. Lower limbs account for 4%, and the whole body is involved in 3% of cases.
[Figure 3] shows that the firework most commonly involved in burn injuries is the fountain which accounts for 38% of all cases. Pencil cracker ground spinner, garland, rocket, and bomb are 14%, 13%, 12%, 10%, and 8%, respectively. Only 5% of injuries are reported from the candle. | Figure 3: Distribution of patients based on the type of firecracker involved
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| Discussion | | |
Diwali is the major festival for bursting firecrackers. During Diwali, there is mass production and increased availability of firecrackers to a vast majority of the population without any restriction. This increased availability of firecrackers and unsafe practices of bursting them make way for hazardous outcomes of bursting firecrackers, turning the week of Diwali into a burn epidemic. In the Gregorian calendar, the festival generally falls between mid-October and mid-November.[1]
Firecrackers are usually made of cardboard or plastic, with flash powder, cordite, and smokeless powder or back powder as the propellant, match heads, kerosene to lighter fluid, etc.; the entire firecracker must be very tightly packed for it to work best. This make firecrackers a potential weapon if the manufacturing or the practice of bursting crackers is defective.
The epidemiology and pattern of firecracker injuries also differ from place to place. This study was done in a tertiary hospital, Assam, India. To the best of our knowledge, this is the first retrospective analysis done in Assam that focuses on the prevalence of patients with firecrackers injury, the severity of the injury, regions of the body involved, in patients attending the ED 3 days before to 3 days after Diwali.
In this study, majority of the patients were males. This is comparable to the sample group reported in UK,[7] China,[8] Iran,[9] Delhi,[10] and Vellore[11] consisting of 88.2%, 88%, 79%, 84.8%, and 90% males, respectively. This male dominance in frequency and severity of injury may be attributed to increased adventure-seeking behavior among males.
Our age distribution demonstrates children under the age of 19 years as vulnerable population with 46.2%. The children being less experienced with the handling of fireworks, more excited, and less aware of dangers associated with fireworks are potential victims of the firecracker injuries. This trend is supported by the data from other cultures such as other parts of India, and the USA, where children under fourteen formed 40%–50% of the cases.[1],[8] 51.6% were children under 18 years of age in a study from UK6. Two other studies from Delhi show 61.76%[12] and 49.6%.[10]
Our results suggest the most commonly affected body parts are the hands (59%) including only upper limbs and upper limbs with other body parts, of which only right hand 24%, right hand and upper limb 15%, right hand and face 7%, right hand and torso 2%, both upper limbs 6%, left upper limb 5% followed by head and neck (24%) involving only face and face with hands and torso (17%), another study shows 80% of the patients.[6] Various other studies from UK, Iran, Australia, and Saudi Arabia have also demonstrated that hands are most common site 6812.[13] A study from Tamil Nadu 10 shows 79.6% upper limb involvement followed by face 16.9% and torso 9%. Another study from Assam[14] shows 70% right hands, 10% left hands, 5% both hands, 6% facial burns, and 4% trunk. These studies show that there is a very high chance of injuring hands leading to personal and national per capita income loss.
In our study, there is an 80.2% population with <20% TBSA. In a major study conducted in Delhi,[10] majority (90.87%) of them sustained <5% TBSA burns, which is similar to our study. A study from another hospital in Guwahati14 shows most of the cases are between 2% and 6%, a study from Vellore[11] also supports our result. This shows that although there are a lot of patients attending hospitals with firecracker injuries, most of them are superficial and involves only a small body surface area.
The most common firework responsible in our study was fountain 38%, followed by pencil cracker 14%, ground spinner 13%, and garland 13%. Studies done in Delhi[10] and Guwahati[14] show fountain to be the most common cause being 64% and 70%, respectively. Studies from Delhi and Guwahati show bomb 13% and firecrackers 19.1% as the second most common in respective places. This shows that the fountain is the most dangerous and unsafe firework which is being produced in a wide scale during Diwali.
Literature available on firecracker injuries from developed countries (USA) concluded that approximately 10,000 persons annually were affected by firecracker-related injuries.[2],[3] In the UK,[7] the number of firework-related injuries peaks during Halloween and Guy Fawkes Night. In Denmark,[15] there were 4447 patients with firecracker-related injuries during 2 days of New Year over 12 years from 1995 to 2007. Injuries caused by fireworks are a national problem in Greece[16] too.[17] The reported incidence is 7/100,000 children annually, of which 70% are in the age group of 10–14 years. Studies from the USA[2],[3],[4] demonstrated that the states, which are liberal in allowing fireworks for personal use, have seven times greater incidence than the states where more restrictions are imposed. Hence, firework-related injuries have been encountered all over the world.[3],[4],[5],[7],[8],[9],[15],[16],[17] These are the national statistics of different countries. Although most of the cases involve <20% TBSA and are superficial burns, studies have demonstrated that fireworks can result in permanent functional or visual disabilities.[18],[19],[20] Increased public awareness through aggressive campaigning has been shown to reduce the incidence of burns from fireworks around Diwali time in India.[1]
Prevention
As more young male patients are involved, there is a need for awareness programs in schools and colleges targeting this population.
As children under the age of 18 years are more vulnerable, we need to educate children at school and home about the dangers that fireworks pose and their sequelae, and this can be implemented at an earlier school age. There should be strict laws in selling fireworks only to adults above 18 years. Parents/guardians should monitor the children while they are igniting fireworks. Safer Diwali practices should be taught in school and various social and multimedia during Diwali month.
A fire extinguisher if available or a bucket of water/sand should be arranged at the area of firework bursting in case of emergency.
Various studies show that the hands are in the most vulnerable position followed by head and neck, particularly when igniting the firework. Protective measures should be employed such as gloves, eyewear, and face shields. These should be made readily available in firecracker shops and should be advertised and advised in media. Distance ignition techniques should be encouraged.
Anar/flowerpot being the most common firework involved should be marketed with universal safety protocols and should be quality checked to prevent the majority of accidents.
New generations should be taught about the Green Diwali and its benefits.
| Conclusions | | |
Burn injuries due to firecrackers are one of the most prevalent preventable causes of accidental burns throughout the world. Diwali is a festival of great importance in Indian society, not only in families following Hinduism but also most people of all the other religions celebrate this beautiful festival. Diwali is a festival of colorful lights, although firecrackers have no strong historical base, they have become an integral fun part of Diwali. After the government passed multiple laws regarding firecrackers the efficacy of those laws has been very questionable due to the huge population, illiteracy, and lack of awareness of long-term morbidity associated. There has been no actual decrease in the prevalence of firecracker burn injuries in recent years even after an increase in awareness programs and multiple laws governing. Some of the preventive measures can be implemented by the government as completely banning fireworks will create havoc in society. The firecracker burn injuries is a preventive epidemic during Diwali time and that can be proved by looking at the data from 2020 during the nation lockdown, which shows a very steep decrease in firecracker injuries than previous years. Finally, Diwali is a beautiful festival of colorful lights, lets enjoy the lights and try to be away and educate others to be away from the preventable consequences of firework injuries and pollution that ruins our health and surrounding. Together let us try to minimize the injuries from this seasonal preventable epidemic.
Acknowledgment
We acknowledge all the doctors, residents, students, nurses, and other support staff for taking care of these patients during Diwali, staying away from their family and beloved. We acknowledge staff in the records department for their help.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1]
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