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Abstract
Objective The COVID-19 pandemic affected burn injury patterns in many countries, but literature on this topic in Canada is limited. The objective of this study is to investigate the changes in the epidemiology of burn injuries in a Canadian population during the COVID-19 pandemic.
Methods Data from the Canadian Institute for Health Information were used to evaluate differences in emergency department visits before and during the COVID-19 pandemic. Logistic regression models estimated the odds of a severe burn occurrence.
Results During the pandemic, there were significant decreases in emergency department visits for burns. Distributions of factors associated with burns showed little to no change. The pandemic period, age, sex, income, month and time of day were significantly associated with severe burns during the study time period.
Conclusions The study found large reductions in the number of emergency department visits during the pandemic, but no evidence of changes in the epidemiology of burns or patterns in the patient populations. Demographic factors associated with severe burns were identified. These factors should be studied to deepen the understanding of the relationship between burn injuries and patient populations.
- Burn
- Epidemiology
- COVID-19
- Cross Sectional Study
Data availability statement
Data may be obtained from a third party and are not publicly available. No data are available.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
There was a lack of Canadian population-based literature on factors associated with health system utilisation for burn injuries during the COVID-19 pandemic. To date, few studies have explored factors associated with severe burn injuries.
WHAT THIS STUDY ADDS
Substantial decreases in the number of burn visits occurred during the pandemic. During the pandemic period, children aged 5–9 years, middle age (40–64) and older adults (65+), people with lower socioeconomic status, the male sex, and the early morning were associated with increased odds of severe burn injuries.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
Our identification of populations who continue to be at risk of severe burns should remain the focus of education and prevention strategies.
Introduction
Since late 2019, the SARS-CoV-2 virus has been the dominant global health issue.1 By the end of 2021, more than 250 million COVID-19 cases and 5 million deaths were recorded due to the SARS-CoV-2 virus.2 Despite the efforts of governments to prevent further spread of the virus, cases continued to increase, leading to substantial human and financial costs around the world. Up to June 2024, the average Canadian cost of a confirmed COVID-19 hospital admission was $25 000, with the total costs of all COVID-19 hospital admissions during that time surpassing $4 billion.3
Rapid transmission of the virus led to strained healthcare systems.4 5 In Canada, various levels of government enacted restrictions such as reduced international travel, endorsements of working from home and restrictions on public services.5–7 Public health guidelines implemented community protection plans such as indoor mask-wearing, frequent hand-washing, avoiding the use of public amenities and quarantine after virus exposure.5 During the lockdowns, public emergency departments (EDs) saw a significant decrease in visits, including an approximate 55% drop in ED visits, following the initiation of lockdowns as reported by the Canadian Institute for Health Information (CIHI).8
Burns and scalds are injuries to human tissue from thermal sources such as liquids, flames and less common sources such as chemicals, radiation and electricity.9 10 These injuries can place a major burden on patients, yet are commonly preventable,9 10 and unintentional,11 especially in paediatric populations.11 12 Moreover, they may cause extreme morbidity, leading to significant decrements in mental and physical health.9 On a global scale, increased risk of burns is associated with lower socioeconomic status (SES),10–13 and being in infanthood, childhood or late adulthood.10 11 However, significant decreases in morbidity and mortality rates have been observed in the 21st century14 15 due to successful health and prevention strategies.13 14 16
While ED visits decreased during the lockdowns,8 the effect of the pandemic on burn injury patterns in the general population is unknown within Canada, despite available information from other countries and populations.17–21 In addition, existing literature does not examine factors associated with the occurrence of severe burn injuries. The effect of the pandemic on burn epidemiology remains unknown within Canada. The objectives of the study are to investigate the epidemiology of burn injury visits to the ED in a Canadian population during the COVID-19 pandemic and determine factors that are associated with ED visits for severe burns. This information may help healthcare systems understand the impact of the pandemic on burn injuries, anticipate the impact of potential lockdowns and better understand factors that are associated with severe burns; providing actionable areas, and populations for public health and injury prevention interventions.
Methods
Study design
We performed a retrospective, population-based secondary analysis of data for the province of Ontario. Data were collected from the National Ambulatory Care Reporting System (NACRS) and the Discharge Abstract Database (DAD), both of which are published by CIHI. The NACRS and DAD databases provide acute care data through ED and hospitalisation reporting. In this study, one visit is counted as one entry in the NACRS, representing an ED visit, or one entry in the DAD, representing a hospitalisation. CIHI data quality processes ensured that patients did not overlap in these two datasets. Information is provided on patient visit characteristics, clinical measures and administrative data related to healthcare system use across Canada.22 23 CIHI uses the International Classification of Diseases codes (ICD-10) to identify diagnoses and the use of health services. CIHI’s data quality mandate24 ensures that data are high quality, unbiased and reliable to aid stakeholders in making informed decisions to improve healthcare services.
Population and setting
The study was based on the population of Ontario and included all individuals who used the publicly funded healthcare system for burn injuries. The province of Ontario is the most populated in Canada, home to a diverse population of 14 million inhabitants.25 Approximately, 90% of the population resides within Ontario’s largest urban areas, including Ottawa, Hamilton and the Toronto region.25 The Ontario healthcare system is operated by the Ministry of Health, and further managed through smaller administrative units, such as the Ontario Health Regions, Public Health Units and municipal or regional governments.26 The provincial government agency, known as Ontario Health, oversees the coordination, modernisation and improvement of the provincial healthcare system.27 Ontario has a publicly funded healthcare system, in which residents’ medical expenses are covered through the Ontario Health Insurance Plan. For non-emergencies and routine health procedures, patients may seek primary care with family-based medical professionals. There are many non-public care centres where patients can receive treatment. Many of these clinics do not share data with CIHI, and therefore are not captured within the NACRS or DAD. For urgent care, residents can access emergency services or visit an ED.28
Burn records were retrieved by CIHI recommended ICD-10 codes T20–T32, (burns to the external body, internal organs and unspecified sites) and L55 (sunburns). The pandemic period considered burn visits reported on or between 1 March 2020 and 31 August 2020. The beginning of the pandemic period was set to March as a provincial state of emergency was declared within Ontario during this month due to the COVID-19 pandemic. The initial pandemic wave was estimated to have ended in August 2020, as the province had reduced restrictions and moved towards a phased re-opening.7 The pre-pandemic period considered burn visits in the parallel dates for 2019. Patients were excluded if their visit occurred outside of the time periods. The study population was representative of the overall Ontario population residing within the province. No demographic variables were used as exclusion criteria.
Patient and public involvement
As the study was a secondary analysis of data, patients were not involved in the research process, and included patient data were anonymised by CIHI.
Measures
Burns may be classified into major and minor based on injury depth and total body surface area.9 Depth refers to skin layers damaged by a burn injury. First-degree burns are superficial which affect only the epidermis. Second-degree burns may be superficial partial-thickness or deep partial-thickness burns. Full-thickness or third-degree burns injure the dermis skin layer, destroying nerves and require surgical treatment.9 To model severe burns, the presence of least one third-degree burn anywhere on their body is denoted as a severe burn event.
Several measures were considered as potential exposure variables. For time period, pre-pandemic refers to March to August 2019. The pandemic period refers to March to August 2020. Age was categorised into the following groups, <1 year, 1 year, 2–4 years, 5–9 years, 10–14 years, 15–19 years, 20–29 years, 30–39 years, 40–49 years, 50–64 years and 65 years and older. Sex was denoted as male or female. Region of living was reported as urban or rural/remote. Income was reported using Statistics Canada standard income quintiles, Q1 (low income), Q2, Q3, Q4 and Q5 (high income). Month of injury corresponds to visit date within the included months (March to August). Time of day was split into four categories. Early morning corresponded to visits between 00:00 and 05:59. Morning corresponded to 06:00 to 11:59. Afternoon were visits between 12:00 and 17:59. Evening/night were visits between 18:00 and 23:59. Ambulance use was reported as used or not used.
Statistical analyses
Descriptive statistics provided an overview of patient injury data for all time periods. Data includes all ED burn visits from the pre-pandemic and pandemic periods.
Logistic regression models were used to determine the odds of a severe burn injury visit. First, a univariate model was built, using only the period variable (pandemic and non-pandemic), including all available data from 2019 and 2020 to explore the potential impact of the pandemic period. Then, a second pooled data model was built, using data from March to August in 2019 and 2020. The model included adjusted exposure variables with their reference groups as follows: period (pre-pandemic), age (20–29 years), sex (female), region (urban), income (Q5), month (March), time of day (afternoon) and ambulance use (not used).
A third model was built using data restricted to the pandemic period (March 2020 to August 2020) and included all previously mentioned variables except period. This set of models allowed for comparisons of factors associated with severe burns across the periods. Results include ORs and 95% CIs. Statistical significance was determined at the 5% (two-sided) significance level. Data were analysed using SAS Version 9.4.29
Results
Year-specific summaries
From March to August 2019, the number of burn injury patient visits was 12 352, which decreased by 23.4% to 9456 in the pandemic period of 2020 (table 1). There were 400 severe burn visits (3.2%) during the pre-pandemic period and 354 (3.7%) during the 2020 pandemic period (table 1). In both years, 20–29 year olds were the most frequently burned, with 2488 (20.1%) visits in 2019 and 1790 (18.9%) in 2020, an approximate 28.1% decrease. Despite slight changes in proportions, the age distributions repeated similar patterns in each year (table 1).
Descriptive summaries of all demographic variables for burn injury patient visits in Ontario (DAD and NACRS), from March 2019 to August 2019 (n=12 352) and from March 2020 to August 2020 (n=9456)
The most frequent visits by sex were males and by region were people in urban areas. In 2019 and 2020, males experienced 6692 (54.2%) and 5291 (55.9%) burn visits, respectively. Urban areas contributed many burns, but decreased from 10 063 (81.5%) to 7747 (81.9%). Health services utilisation was more frequently reported for lower income quintiles. Quintiles 1 and 2 comprised 46.8% (5774 total) of visits in 2019 and 45.8% (4337 total) in 2020. The highest income quintile accounted for 1933 (15.6%) visits in 2019 and 1454 (15.4%) cases in 2020 (table 1).
A monthly trend showed more visits in the summer months of June, July and August and a substantial decrease in visits during the immediate pandemic period in April 2020 (table 1). For daily trends, reported burn visits increased from the early morning to the afternoon, with a slight decrease in the evening/night hours (table 1). From pre-pandemic to the pandemic, there was a slight increase in the proportion of patients that used ambulance services as transportation to an ED visit.
Modelling severe burns using pooled 2019 and 2020 data and pandemic-restricted data
The univariate model found no evidence of a statistically significant association (OR=1.12, 0.99–1.27) between the pandemic period and severe burn ED visits. However, after adjusting for potential confounding effects, the pandemic showed a statistically significant effect (OR=1.18, 1.02–1.36) (table 2). Relative to the 20–29 year old reference category, age cohorts with a significant association of a severe burn ED visit included 5–9 years (OR=1.88, 1.35–2.62), 40–49 years (OR=1.36, 1.08–1.72), 50–64 years (OR=1.51, 1.24–1.84) and 65+ years (OR=2.57, 2.08–3.17). Male patients (OR=1.61, 1.38–1.88) and the lowest income quintile relative to the highest (OR=1.33, 1.14–1.56) had increased odds of experiencing a severe burn ED visit. The regional variable found no evidence of a statistically significant association. March was selected as the reference group to represent the start of the initial pandemic in 2020. In comparison to March, 3 months were significantly associated with severe burns. Specifically, April (OR=1.29, 1.04–1.60) had an increased OR, while June (OR=0.68, 0.55–0.86) and July (OR=0.82, 0.68–0.99) had reduced ORs. Early morning also had a higher OR (OR=1.55, 1.24–1.93) than afternoon (table 2).
Multivariable logistic regression using pooled data from March 2019 to August 2019 and March 2020 to August 2020 to model the ORs of experiencing an ED visit for a severe burn in Ontario (DAD and NACRS) (n=21 808)
Given the significance of the pandemic period in the pooled 2019 and 2020 models (table 2), an additional model was built, using data strictly from the initial wave of COVID-19 from March to August 2020 (table 3). Significant effects of age, sex, income and time of day were similar to the pooled model (table 3).
Multivariable logistic regression for the pandemic period using data from March 2020 to August 2020 to model the ORs of experiencing an ED visit for a severe burn in Ontario (DAD and NACRS) (n=9456)
Discussion
This study highlighted pandemic-related changes in the epidemiology of burn injury patients in the Ontario healthcare system. Overall, there was a decrease of 2896 in the absolute number of ED visits for burns from March 2020 through August 2020 during the pandemic compared with the same months in 2019. Despite the reduction in visits, distributions followed similar patterns in both years for measures such as age, region and income quintile. Severe burn visits decreased by 46 during the pandemic period, but relatively, the proportion of severe burns increased by 15% (3.2% to 3.7%). Moreover, the pooled model showed a significant effect of the pandemic on ED visits due to severe burns (OR=1.18, 1.02–1.36). Previous literature found decreased counts of pandemic-related burn injuries throughout Japan and Europe.17–21 However, other studies in USA30 and Europe31 32 found evidence of increased rates of visits for paediatric patients. Consistent with previous literature, men were more affected by burns than women,33 as males accounted for over 50% of burn visits, and males experienced higher odds of severe burns (OR=1.61, 1.38–1.88), according to the pooled model. Nonetheless, many women experienced additional scalds due to increased time spent on household roles in cooking and cleaning.34
The decrease in pandemic ED visits was expected. School closures, activity cancellations and alternative avenues of care, such as virtual care, likely reduced youth injuries and in-person ED visits.8 Canadians avoided healthcare workers, due to the fear of contracting the virus from these workers, which may have also contributed to decreased ED visits.35 36 Our analysis showed a substantial reduction in ED visits for burn injuries in the first full month of the pandemic in April 2020. Patients may have visited the ED when suffering from more severe burns, which was also noted in Canada.33 In the adjusted pooled model, the pandemic period was associated with severe burn visits compared with the pre-pandemic period. In Europe, the rise in paediatric burn injuries was associated with increased time spent at home, parental teleworking status and burnout.18 37 Although similar conditions arose in Canada, our results did not show an increase in paediatric burns.
To our knowledge, this is the first attempt to model factors associated with severe burn injuries during the pandemic. Both models showed that adults aged 40 years and older had significantly increased odds of severe burns compared with adults who were 20–29 years old. The 5–9 year cohort was the only paediatric cohort with higher odds of severe burn injuries in both models. Increased time at home with parents working, being in the vicinity of heat-related activities and children having thinner skin than adults may lead to the increased risk.18 38 Moreover, adult groups also include the primary working population, who also complete daily responsibilities such as cooking, cleaning, leaving the house for errands and job-related tasks.9 10 39 These activities may increase the odds of experiencing contact burns, scalds or other potential burns, and thus the risk of a severe burn, and a subsequent ED visit. In comparison to females, males had a significant OR for a severe burn ED visit. These findings were consistent across both models and aligned with the previous literature. Males historically have had higher rates or increased risk of being burned,14 16 which may translate into a higher risk for severe burn ED visits. In all models, income Q1 was significantly associated with severe burn ED visits. These findings are consistent with previous literature, as patients of lower SES tend to have reduced access to primary care and use the ED more frequently than individuals of higher SES.40 Future studies could enhance our understanding of the relationship between these two variables.
Strengths
Our population-based approach allowed for a representative and comprehensive understanding of burn injuries in Ontario. The use of a novel approach in modelling severe burns during the pandemic provides unique insight into burn epidemiology. The modelling of severe burns also helps understand the susceptible patient populations that used the ED during this period. These types of burns typically require more resources and intensive medical care, thus understanding what demographic factors are associated may help with resource planning and public health messaging to reduce potential risk in Ontario.
Limitations
Nonetheless, the results of this study should be interpreted with caution. The design was a retrospective analysis of cross-sectional data, thus causal relationships for any variables cannot be ascertained. Further, the majority of the Ontario population is centralised in the South-East portion of the province, specifically Toronto and the surrounding CAs. Study results are thus more relevant for populated areas and may be less generalizable to rural communities.
Another limitation of the study is a potential underreporting of less severe burn injuries. Some literature reported patients were less likely to travel to EDs or medical centres to treat minor burn injuries due to the risk of contracting COVID-19.35 36 Patients with severe and painful burn injuries were thus more likely to present at EDs. However, this information may help medical centres prepare for future events of social restrictions and understand why severe burn injuries are more likely to present at the ED. Finally, multiple testing is an additional limitation in the study as there is an increased risk of achieving a false positive result due to the multiple models and subgroups considered in these analyses.
Conclusion
Overall, we found large decreases in burn ED visits from 2019 to 2020 during the COVID-19 pandemic. However, ED visit patterns did not change drastically, and statistically significant associations were similar across our models. ED visits for severe burns were associated with the pandemic, being a middle-aged (40–64 years) or older adult (65+), being in the 5–9 year paediatric cohort, being among the lowest SES quintile, being of male sex and occurring in the early morning. The complex relationship between exposure and demographic characteristics may help us identify those at risk of burns and the most frequently burned sub-populations. Overall, despite large decreases in patient visits due to burns, the results suggest the epidemiology of burn ED visit patterns did not change during the pandemic. Healthcare system stakeholders and organisers should continue to improve their understanding of which patient groups are susceptible and aim to implement strategies to reduce risks for burn injuries.
Data availability statement
Data may be obtained from a third party and are not publicly available. No data are available.
Ethics statements
Patient consent for publication
Ethics approval
As the study included a secondary analysis of data, human participants and animals did not partake in the study. The study received ethics approval from York University’s Office of Research Ethics (Certificate Number: STU 2022-102).
Acknowledgments
Data for this study were provided by the Canadian Institute for Health Information under the Graduate Student Data Access Program. The findings, opinions and conclusions are those of the authors and do not necessarily reflect the views of their organisation.
References
Footnotes
X @dralisonmac
Contributors AM was the main author of the manuscript, is the submitting and corresponding author and is the guarantor. AM had originally written the manuscript as a thesis as part of his graduate program requirements. The thesis was nominated for the Thesis and Dissertation Prize within the Faculty of Graduate Studies at York University. AM contributed to all stages of the paper, including the conception of the research question, design of the study, drafting of the manuscript and subsequent revisions, approval of a final version for publication and is accountable for the integrity of the work. MR was AM’s direct supervisor in the graduate program and oversaw the writing of the study. MR contributed to all stages of the paper, including the conception of the research question, design of the study, drafting of the manuscript and subsequent revisions, approval of a final version for publication and is accountable for the integrity of the work. AKM was AM’s committee member in the graduate program and provided support during the writing of the manuscript. AKM contributed to all stages of the paper, including the conception of the research question, design of the study, drafting of the manuscript and subsequent revisions, approval of a final version for publication and is accountable for the integrity of the work.
Funding Data for this study were provided by the Canadian Institute for Health Information under the Graduate Student Data Access Program. The findings, opinions and conclusions are those of the authors and do not necessarily reflect the views of either organisation. MR is partially supported by funding from the Canadian Institutes of Health Research and the Public Health Agency of Canada through the Applied Public Health Chairs program.
Competing interests At the time of submission, AM is employed by Ontario Health within the Ontario Ministry of Health. Research reported in this study was not supported by Ontario Health. The opinions, results, views and conclusions reported in this publication are those of the authors and do not necessarily reflect those of Ontario Health. No endorsement by Ontario Health is intended or should be inferred.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.