India Needs More Skin Banks For Burns’ Victims

One of the lesser talked about issues in public health is burn injuries and resulting mortalities. It is only by looking deeper that one realises how grim the situation is globally, and more so in developing countries such as India.

The grim scenario with regards to burns in India can be gauged from the details that have been revealed by both the World Health Organization (WHO) and some leading international medical journals.

According to WHO, “Burns are a global public health problem, accounting for an estimated 180 000 deaths annually. The majority of these occur in low- and middle-income countries and almost two thirds occur in the WHO African and South-East Asia Regions.

“In many high-income countries, burn death rates have been decreasing, and the rate of child deaths from burns is currently over seven times higher in low- and middle-income countries than in high-income countries. Non-fatal burns are a leading cause of morbidity, including prolonged hospitalisation, disfigurement and disability, often with resulting stigma and rejection.

“Burns are among the leading causes of disability-adjusted life-years (DALYs) lost in low- and middle-income countries. In India, over 1 million people are moderately or severely burnt every year.”

In order to provide relief to burn victims, emphasis is now being laid on the establishment of skin banks in public institutions. One such facility, perhaps the first north of Delhi, was inaugurated at the Post Graduate Institute of Medical Education and Research (PGIMER) in Chandigarh recently.

Experts say that apart from direct care costs, indirect costs such as lost wages, prolonged care for deformities and emotional trauma and commitment of family resources, also contribute to the socio-economic impact of burn injuries.

In a paper ‘Burns in India : A call for health policy action’ published in The Lancet in 2021, authors Vikash Ranjan Keshri and Jagnoor Jagnoor pointed out, “The situation in India is particularly worrying. In 2019, more than 23 000 fire-related deaths were estimated in India, which is about 20% of the global mortality burden. Additionally, 1·5 million DALYs were attributed to burns.”

The paper also stated, “The burden of burns among women (aged 15–49 years) in India is three-times higher than that among men. Women have differential exposure to risk, often arising from unsafe cooking and kitchen practices, suicides, and homicides associated with domestic violence and dowry-related conflict. Prevention of burns requires attention to gender-based inequities and upstream social determinants of health.”

A PGIMER spokesperson disclosed that the tertiary care centre for burns at the institute which caters to patients from Punjab, Haryana, Himachal Pradesh, western Uttar Pradesh along with Jammu and Kashmir PGIMER, Chandigarh, receives approximately 500 patients annually.

“Most of these patients have burns on more than 40% of their body surface area, requiring extensive surgeries and often leaving them without enough skin graft donor areas. As a result, healing of burned areas is not possible or is delayed, leading to scarring, contractures and prolonged hospital stay.

During deliberations on ‘Advances in Burn Care and Skin Banking’ experts stated that skin is the largest organ of the human body with crucial protective function, and when lost due to burns must be replaced. This process is called ‘skin grafting’, and uses skin harvested from either the patient’s own body, or donated by deceased individuals.

This skin is used as a temporary burn wound graft, and provides many of the crucial functions of healthy skin like barrier against infection and fluid loss, decrease pain and promote healing of underlying tissues.

Allograft skin is obtained from ‘cadaveric’ (deceased) donors after consent is obtained from the next-of-kin. Tissue donors are carefully screened by reviewing past and present medical records, interviewing medical staff, interviewing the next-of-kin for past medical history and high risk lifestyles. Samples of the donor's blood are also tested for many transmissible diseases including hepatitis and AIDS.

The skin of any deceased person over the age of 18 can be donated within six hours of death, irrespective of gender and blood group, with no upper age limit. The skin is then extracted, harvested and processed, which takes five to six weeks. After this, it can be provided to patients in need.

Unlike kidney and liver, which cannot be stored and need to be transplanted within a few hours of donation, skin can be preserved in 85% glycerol solution and stored between four-eight degrees Celsius for a period of up to five years.

The experts added, “The skin donation process is swift, taking only 30 to 45 minutes. Skin Harvesting is performed by a trained team. Skin is harvested from both the legs, thighs and the back. Only a very thin layer of skin which consists completely of epidermis and part of dermis (0.4 to 0.6 mm thick), is harvested from the deceased.”

There is no bleeding from the site where skin is harvested from, and there is no disfigurement to the body. After the procedure, the donor sites on the body are bandaged appropriately. The donated skin is evaluated, processed, screened at the skin bank, and then used for burn patients, giving them hope and better chances for survival.

It was pointed out that India currently faces a shortage of skin banks, particularly in the North, making the establishment of this facility a crucial milestone.

Keeping in view the magnitude of the problem, a pilot programme on burn care was initiated in the year 2010 by the Ministry of Health & Family Welfare in the name of ‘Pilot Programme for Prevention of Burn Injuries” (PPPBI)’.

The ‘Lancet’ paper quoted above stated, “We call for making burn service free at the point of care across the country. The scope for Pradhan Mantri Jan Arogya Yojana (PMJAY) needs to be expanded to cover all patients with burns and all associated costs. At the same time, there is an urgent need to reform and broaden the scope of the national programme to strengthen burn care in the public sector and to ensure better rehabilitation of burn survivors.

“Social reintegration of burn survivors needs a welfare and justice approach guided by effective policy. In pursuit of universal health care in India, a strong policy statement backed by clear strategies for effective response to burns is urgently needed.”

The authors had pointed out that in the public sector, many burn centres are constrained in terms of infrastructure and human resource capacity and concerns have been raised about the quality of care. Another bottleneck in the public sector is the expenditure for dietary supplements, medicine, transport, and rehabilitation services.