Brazil Covid-19: Change of hospitalizations and deaths due to burn injury?

Dear Editor,

The Covid-19 pandemic caused collapses across the globe in a short period of time, arriving in Brazil on February 27, 2020 [1]. Globally, the number of confirmed cases is 28,637,952 and 4,282,164 of these cases are located in Brazil [2].

The World Health Organization (WHO) in this period implemented measures of isolation, social distancing and, later, severe methods such as lockdown [3]. These measures may predispose individuals to spend more time in the domestic environment and, consequently, leading to a greater exposure to sanitizer products, which contain ethanol, isopropyl alcohols, hydrogen peroxides in various concentrations [4]. Those liquid substances are toxic and flammable that can lead to burn injuries [5].

In this exposure scenario, this study aimed to evaluate the number of hospitalizations and the number of deaths caused by burns during the pandemic period of COVID-19 in Brazil. The dataset of deaths and admissions by burn injuries was extracted from the Hospital Information System (SIH) public database of the Unified Health System (SUS) of Brazil. This data was accessed through the TABNET tool, freely available in the SUS Department of Informatics (DATASUS) website and filtered with the option “General, by admission location, from 2008 on”. A subset of the data was then selected for the period 2016–2020 and months March – July. Population data was gathered in the Brazilian Institute of Geography and Statistics (IBGE) database and hospitalization rate was reported per a 1000 population.

Descriptive analysis was performed for the number of burn injury admissions across the five Brazilian regions. After properly checking the assumption of normality using the Shapiro-Wilk test, comparisons between the mean of the total number of deaths and admissions for the period 2016–2019 and 2020 were performed with a t-test at a 95% confidence level. All analysis was performed with the software GraphPad Prism 7.0.

Hospitalization rate due to burns per 1000 inhabitants in all Brazilian regions studied (North, Northeast, Southeast, South and Midwest) from 2016 to 2020 did not show clear patterns of changes. However, the data revealed evidence of higher rates in the South and Midwest regions (Fig. 1 ). In addition, we found no difference between the mean number of burn injury hospitalization in the period 2016–2019 and 2020 (p = 0.8453) (Fig. 2 ). Interestingly, there was a significant difference in mortality (number of deaths) by burns in 2020 compared to the previous years (p = 0.0285) (Fig. 3 ).

Fig. 1

Burn Injury Hospitalization Rate per 1000 Population from 2016 to 2020 across Brazilian regions.

Fig. 2

Comparison of the mean number of injury hospitalizations from 2016 to 2019 and 2020. Bars represent the standard error of the mean (SEM).

Fig. 3

Comparison of the mortality by burn injury from 2016 to 2019 and 2020. Bars represent the standard error of the mean (SEM).

In the United Kingdom, a 50% decrease in the number of hospitalizations caused by burns was found [6]. In Turkey, on the other hand, there was a 60% increase in the number of pediatric hospitalizations due to burns, during the period of the COVID-19 pandemic [7]. In the United States, a significant increase in the proportion of burns in the 21-year-old age group related to domestic fires during the pandemic was found, when comparing the months March-April 2020 to the same period in the previous year, 2019 [8].

Regarding the number of hospitalizations due to burns, our data do not show any difference between the mean number in all Brazilian regions studied. In Morocco (Mohammed Vth Teaching Armed Forces Hospital), there was a decrease of 50% during the period from March to June 2020, when compared to the same period in the previous year [9]. In the United Kingdom at a regional burn center during the period from March to May 2020, a total of 16 patients were hospitalized, when compared to the previous year (2019) where 32 patients were hospitalized [10]. The results of our study show similarities between periods compared to other countries, which also identified a decrease in hospitalizations.

In the North, Northeast and Southeast Brazilian regions, the data do not show clear patterns of change in the rate of hospitalization due to burns between the years 2016–2020. However, higher rates were evidenced in the South and Midwest in all years regardless of the pandemic by COVID-19. A hypothesis to explain the predominance of higher numbers of hospitalization related to burns in the South and Midwest regions would be the influence of several factors (socioeconomic, climate and vegetation), especially the climatic changes that affect these regions, occurring mainly in May [11]. This change does not happen only in Brazil, but also in Australia [12]. All these factors may have contributed to the increase in the number of injuries caused by burns in these regions, however there is still little information that can corroborate with this data.

The data showed an increase in the number of burn deaths in Brazil during the periods studied. In the United States, in an emergency department, only one burn death (residential fire) was registered during the pandemic [8]. Once again, due to the scarcity of published material, no plausible scientific evidence was found on the increase in the number of burn deaths in the pandemic period.

In conclusion, Brazil is in a plight situation when compared to other countries regarding the elevated number of burn deaths during the pandemic period of COVID-19 in 2020. Although no difference was found in the number of hospitalizations due to burns in the period studied and in the different Brazilian regions, it is clear that the South and Midwest regions require greater attention due to the higher rate of hospitalization related to burns.

Declarations of interest

The authors declare that they have no conflict of interest.