smaller, that used wood fuel for heat and in which the smoke alarms were located near the cooking areas. Thus photoelectric alarms may be the preferred choice for homes with limited living space, an observation that is relevant as smoke alarm installation programs are advanced in LMIC [215].

The following are recommendations for use of smoke alarms from the National Fire Protection Association (www.nfpa.org/smokealarms):

Ensure that smoke alarms are working by testing monthly, replacing batteries at least yearly, and performing maintenance as instructed by the manufacturer. (Use of lithium batteries assures that the alarm will function for several years. All alarms should be replaced every eight to ten years, because of dust and moisture accumulation, clouding of the receptor and lens of photoelectric devices, and degradation of Ameri- cium-421 in ionization alarms.)

Smoke alarms should be installed on every level of the home, outside each sleeping area, and inside each bedroom.

Smoke alarms should be interconnected so that a fire detected by any of them will trigger the other alarms to sound.

Develop an escape plan so that all occupants know what to do when a smoke alarm sounds.

Use both ionization and photoelectric alarms because their effectiveness varies with how much flame is present in the fire.

Install smoke alarms at a safe distance from nuisance sources, such as kitchen stoves, to minimize the number of nuisance alarms. Under no circumstances should an alarm be disabled because of repeated nuisance alarms – it should be replaced or repositioned.

Residential sprinklers

Prevention of burn injuries and fire deaths, as well as amelioration of fire damages, is effectively and efficiently accomplished through the combined use of smoke detectors and sprinkler systems [53]. Smoke detectors are triggered in the initial moments of the fire event; sprinklers act throughout the event to minimize spread of the fire and in some cases extinguish it. The National Fire Protection Association estimates that the fire death rate in 2003–2006 was

80 % lower in structures protected by sprinklers. In homes with both smoke detectors and sprinklers, the chance of surviving a residential fire is nearly 97 % [93].

However, neither smoke detectors nor sprinklers nor a combination of the two will work effectively to protect certain individuals, such as,

victims who act irrationally, who return to the fire after safely escaping, or who are unable to act to save themselves, such as people who are physically disabled, bedridden or under restraint;

victims whose clothing is on fire and sustain fatal fire injuries from fires too small to activate smoke detectors or sprinklers; and

victims who are unusually vulnerable to fire effects, such as older adults, and those impaired by alcohol or drugs.

Unfortunately, fewer than 2 % of US single-family dwellings are fitted with sprinkler systems [16]. San Clemente, California, was the first US jurisdiction to mandate installation of sprinklers in all new residential structures. The cost of installation of sprinkler systems in new houses is approximately $1 to $2 per square foot; retrofitting sprinklers in existing building is somewhat more expensive, but is comparable to the cost of purchasing and installing new carpeting.

Hot water temperature regulation

Although scald burns are nearly as common as flame burns, particularly in children, across the globe in 2002 only 5.4 % of all burn deaths were attributed to scalds; 93 % of deaths were fire-related [170]. Hot tap water causes nearly one quarter of all pediatric scald burns, and most of these occur in the bathroom. The damage caused by hot tap water burns tends to be more severe than that by other types of scald burns [149]. Experiments on human subjects have shown that partialor full-thickness burns occur only after six hours of exposure if water is 111 F (44 C). Yet if the temperature of the water is increased to 140 °F (60 °C), burns occur within three seconds of exposure [144]. Because water at 120 °F (49 °C) takes 10 minutes to cause significant thermal injury to the skin, hot water heaters are ideally set at this temperature to give people time to escape the damaging effects in time.

Children under the age of five years are at highest risk for hospitalization for burns in HIC among all childhood age groups, and nearly 75 % of these burns are from hot liquid, hot tap water or steam [170]. For instance, 100 % of children admitted from 1994 through 2004 to two burn centers in Finland were the result of hot water scalds [157]. A hospitalbased survey in France during 1991–1992 noted that 17 % of childhood burn injuries were due to scalds [136]. However, a large proportion of scald burns in children are cared for in clinics and emergency rooms without need for hospitalization.

In 1977 in Washington state, 80 % of homes had tap water temperatures greater than 129 °F (54 °C). In 1983a Washington State law was passed, requiring new water heaters to be preset at 120 °F (49 °C). Five years later, 77 % of homes (84 % of homes with postlaw and 70 % of homes with prelaw water heaters) had tap water temperatures of less than 129 °F (54 °C). Mean temperature in 1988 was 122 °F (50 °C) compared with 142 °F (61 °C) in 1977. Few people increased their heater temperature after installation. Compared with the 1970s, numbers of patients admitted for treatment of scald burns, as well as total body surface area burned, mortality, grafting, scarring, and length of hospital stay for scald burns were all reduced. The combination of education and legislation seems thus resulted in a reduction in frequency, morbidity, and mortality of tap water burn injuries in children [72].

In the mid-1980’s in Wisconsin, an educational campaign, which included free thermometers mailed with utility bills, resulted in reduction in the temperature of an estimated 20,000 hot water heaters [111]. A similar study in Dunedin, New Zealand, of a national media campaign combined with educational interventions to households with young children noted a reduction of 50 % in the number of households with hot water heater temperatures over 158 °F (70 °C). However, the majority of households still had temperatures above 131 °F (55 °C) at the end of the intervention [226].

The first state legislation regulating water temperatures was a bill passed in Florida in May, 1980, which mandated preset water heater temperatures to no higher than 125 °F (52 °C). Legislation now exists within the administrative code concerning the regulation of tap water temperature for the Dis-

trict of Columbia and 47 states. In addition, hospitals and related healthcare facilities often have building codes that limit the temperature of hot water supplied to the patients. The majority of states have also adopted a model plumbing code developed by a standards organization, such as the International Code Council (ICC) or International Association of Plumbing and Mechanical Officials (IAPMO), and amend the code to fit their regional needs. These codes not only differ in their individual content, but by their differing editions as well. Different editions of each code can be adopted by different jurisdictions, making plumbing legislation even less uniform across the US. Besides having several different codes to choose from, the application of the code differs from state to state. Some states enforce a state-wide code, while others allow the code to be amended by individual counties. Moreover, different states may apply the code only toward certain buildings. Thus there is no uniform national standard for tap water temperature regulation. Instead, there is a system in the US of state and local jurisdictions adopting a variety of codes and applying them inconsistently across counties and cities. These codes and regulations attempt to reduce scald burns, but because of the lack of uniformity, tap water scalds still remain a serious issue [49].

Building services engineers are directed to store and operate hot water systems at a temperature of 140 °F (60 °C) to prevent outbreaks of Legionnaires’ disease. To prevent scald burns from direct exposure to water at this temperature, mixing valves can be installed in the hot water supply pipe work to provide hot water at safe temperatures for bathing, showering and washing. Thermoscopic or thermostatic mixing valves were developed and first marketed in 1979. Following this, the UK Department of Health and Social Security issued a recommendation that the suitable reduction in water temperature from the heating source (recommended 60 °C) to the tap (recommended 52 °C) should be achieved by a “suitable mixing arrangement” [146]. Electricity Association Technology Ltd. (EATL) investigated the performance of automatic mixing valves in 1992 in the UK. EATL found that although the valves studied all performed equally well at mixing hot and cold water when the supply was constant, there was clear differ-

ences in function amongst the valves when there was loss of cold water supply (as might occur in the household during bathing or showering when another water appliance, such as toilet or washing machine, is turned on) [208].

Lamps and stoves

Although there is slow progress in providing electricity to residences, less than one-quarter of Africans had access to electricity in 2005 [231]. The global use of kerosene in lamps and stoves will no doubt continue for years to come. Unfortunately, many lowincome families use makeshift lamps from wicks placed in discarded beverage or medicine bottles,

and even from burnt-out light bulbs [170]. Burns caused by homemade bottle lamps or commercial wick lamps are common in LMIC [6, 115].

Prevention of lamp burns in LMIC includes three approaches. The first is educational campaigns that promulgate safe behavior with kerosene lamps, including avoiding replenishment of the fuel reservoir while the wick is lit and placing the lamps on stable surfaces. One study in low-income South African communities demonstrated limited but demonstrable success in educating those at highest risk [198]. Another is to use safer oil, such as vegetable oils (e. g. coconut and sesame oils). Unfortunately, these oils are too heavy to rise to the top of the wick, and do not perform well.

The third option is to provide impoverished families with an inexpensive lamp that is designed with safety in mind. Such a lamp is currently being produced and marketed in Sri Lanka. It is short and heavy, so that it does not easily tip over, and has two flat sides that prevent it from rolling if it does tip over. The screw-top lid averts fuel spillage, and the thick glass with which it is made avoids breakage if it falls. It is produced from recycled glass at the low cost of only US$ 0.35 each, and its production provides a boost to the local economy. Its use has been credited with a significant reduction in burn injuries and fires in Sri Lanka [190].

The use of kerosene stoves is even more widespread than homemade lamps, and the magnitude of injury, death and destruction that accompanies them places a tremendous burden on low-income communities. The conceptual framework for prevention of these injuries lends itself to the Haddon Matrix [187]. Table 4 is an inventory of options for interventions in all three time dimensions (pre-event, event, and postevent) including education programs, environmental modifications, and enforcement of existing or creation of new legislation.

Many options outlined in this table appear to be suitable for application in many LMIC. Clearly much could be accomplished by addressing issues of verification of fuel quality, safety of fuel storage and usage, and dispersion of appropriately designed appliances. Compulsory standards covering the performance, safety and homologation requirements for non-pres- sure paraffin fuelled cooking stoves and heaters intended primarily for domestic use were effected by the South African government on January 1, 2007 [84]. These standards were developed after evaluation of nine commonly used stove designs in 2003 showed that not one of the designs met the current national standards. Currently, the SANS 1906:2006 standard for non-pressure stoves and heaters is the only compulsory standard in place. Only one heater has a license to trade under this standard – the Goldair Heater model RD85A (Fig. 5). The new PANDA stove holds a temporary license under this standard. The standard for pressurized kerosene-fuelled appliances (SANS 1243:2007) is currently voluntary and none of the pressure appliances on the market have applied for approval from South Africa Bureau of Standards Commercial against this standard [160].

Fig. 5. The only heater that has a license to trade under the South African standard for non-pressure stoves and heaters is the Goldair Heater model RD85A. It has a three-liter fuel tank, giving it approximately 16 hours of operation. Currently it can be purchased for US $ 84, making it out of the reach of acquisition by most low-income families

Feasibility and cost of implementation of such regulations are often the final barrier to improvements in burn prevention. Enforcement of regulations and codes depends not only upon government commitment but also upon consumer investment in the plan. It is essential that consumers are informed and use their purchasing power to insist that manufacturers, distributors and suppliers of appliances adhere to existing safety standards. Local and regional government health departments should use their influence to support the standards and their enforcement. The public and government should insist on appropriate standards approval before purchasing appliances destined for domestic use regardless of whether the relevant applicable standard is voluntary or compulsory. Such an approach requires intensive educational campaigns both for the community and for relevant government agencies.

Fireworks legislation

Nearly 10,000 people were treated in US emergency rooms in 2007 for fireworks-related injuries. Boys between the ages of five and 15 years have the highest injury rates. Nearly 4,200 children under the age of 15 years were admitted to emergency rooms in the US in 2002 for treatment of fireworks-related injuries [149, 230]. Similarly, the association between boys

and fireworks injuries has been noted in other countries, such as Australia and Greece [1, 224]. Almost 33,000 fires were started by fireworks in 2006 in the US, resulting in six deaths, 70 injuries, and $ 34 million in property damages [92].

The injuries caused by fireworks can be very severe because of heat production (temperatures of ignited devices may exceed 1200 °F) and blast effect. Only approximately 50 % of treated fireworks injuries in the US are burns; approximately one-third are contusions or lacerations, and one-quarter affect the eyes [92, 206]. In Northern Ireland, over half of the patients present with blast injuries to the hand [77]. The use of illegal fireworks accounts for only 8 % of the injuries; most injuries in the US occur while using fireworks approved by Federal regulations. Sparklers and small firecrackers cause 40 % of fireworks injuries. The risk of fire death relative to exposure makes fireworks one of the riskiest consumer products available in the US [92].

Fireworks are associated with national and cultural celebrations throughout the world [12]. On Independence Day in the US each year, more fires are reported than on any other day of the year [92]. As a prelude to the arrival of spring, Persians since at least 1700 BCE have celebrated ChahaˉrshanbeSuˉri on the last Wednesday night of each year. The festivities include participants jumping over bonfires in the streets and setting off fireworks, both hazardous activities. Despite the ubiquity of these practices in Persia and their persistence since ancient times, only 1 % of surveyed families acknowledged having any education on the safe use of fireworks in 2007 in Tehran, Iran; over 98 % of families were ignorant of fireworks safety standards [188].

Fireworks have been regulated in the United Kingdom since 1875, starting with laws covering the manufacture, storage, supply and behavior in the presence of gunpowder. In particular, the last decade has seen the passage of several pieces of fireworks legislation in the UK [68]. The US Consumer Product Safety Commission has regulated consumer fireworks safety since the 1970’s. Current regulations prohibit the sale of the most dangerous types of fireworks, including large reloadable shells, “cherry bombs”, aerial bombs, M-80’s, “silver salutes”, and aerial fireworks containing more than two grains (130 mg) of powder. Other firecrackers and ground

devices are limited to only 50 mg of powder, which is the pyrotechnic composition designed to produce an audible effect (“bang”). Also regulated are the composition of the materials (hazardous materials such as arsenic and mercury are proscribed), the length of time fuses must burn (at least three but no more than nine seconds), and the stability of the bases [220].

Access to all fireworks is banned in the US states of Delaware, Massachusetts, New Jersey, New York and Rhode Island. Arizona allows the exclusive use of novelty fireworks, and only sparklers are permitted in Illinois, Iowa, Maine, Ohio, and Vermont [222]. The impact of legislation on the incidence of fireworksrelated injuries is unclear. Presumably because of proliferation of fireworks legislation, the number of fireworks injuries in the UK dropped from 707 in 2001 to 494 in 2005 [68]. Another opportunity for studying the efficacy of fireworks legislation occurs when restrictions are neutralized. After repeal of a law banning private fireworks in Minnesota, there was an increase in the number of children suffering fireworks-related burns [183]. However, this was not observed after liberalization of fireworks laws in Northern Ireland [77].

Reduction in fireworks-related injuries has been observed elsewhere as a result of focused campaigns. In Denmark, where fireworks are commonly used at New Years’ celebrations, prohibition of the sale of firecrackers coupled with school education programs led to a reduction in the number of children treated for fireworks injuries at two Danish burn centers from 17 in 1991–1992 to only three children in 1993–1994 [200].

Passage and enforcement of legislation in LMIC is often challenging, and education programs may currently be the only option for injury prevention in some cases. In India fireworks injury commonly occur during Diwali (Festival of Lights). The experience at one hospital in Mumbai from 1997 through 2006 was that the prevalence of fireworks injuries was decreasing, due to aggressive education campaigns by government and non-government organizations. Forty-one injuries were treated at the beginning of the study period; only three injuries were treated in 2006 [175].