Review of Recent Large-Scale Burn Disasters

Worldwide in Comparison to Preparedness Guidelines

Andrea Dai, BS, Gretchen J. Carrougher, MN, RN, Samuel P. Mandell, MD, MPH,
Gary Fudem, MD, FACS, Nicole S. Gibran, MD, FACS, Tam N. Pham, MD, FACS

The US National Bioterrorism Hospital Preparedness Program indicates that each care
facility must have “a plan to care for at least 50 cases per million people for patients
suffering burns or trauma” to receive national funding disaster preparedness. The purpose
of this study is to evaluate whether this directive is commensurate with the severity recent
burn disasters, both nationally and internationally. We conducted a review of medical
journal articles, investigative fire reports, and media news sources for major burn disasters
dating from 1990 to present day. We defined a major burn disaster as any incident with
≥50 burn injuries and/or ≥ 30 burn-related deaths. We compared existing preparedness
guidelines with the magnitude of recent burn disasters using as reference the 2005 U.S.
Health and Human Services directive that each locale must “have a plan to care for at
least 50 cases per million people for patients suffering burns or trauma.” We reported
the number of actual casualties for each incident, and estimated the number of burn
beds theoretically available if the “50 [burn-injury] cases per million people” directive
were to be applied to metropolitan areas outside the United States. Seven hundred fifty-
two burn disaster incidents met our inclusion criteria. The majority of burn disasters
occurred in Asia/Middle East. The incidence of major burn disasters from structural fires
and industrial blasts remains constant in high-income and resource-restricted countries
during this study period. The incidence of terrorist attacks increased 20-fold from 2001
to 2015 compared with 1990 to 2000. Recent incidents demonstrate that if current
preparedness guidelines were to be adopted internationally, local resources including
burn-bed availability would be insufficient to care for the total number of burn casualties.
These findings underscore an urgent need to organize better regional, national, and
international collaboration in burn disaster response. (J Burn Care Res 2017;38:36–44)

Large-scale burn disasters are recognized as diffi-
cult events to manage1 as the number of casualties
quickly exceeds available services in local hospitals.2–4
A scarcity of burn specialists and burn beds exists in
almost every country.2 Uneven geographic distribu-
tion of specialized centers further complicates crisis
management.5,6 Burn centers in low-income coun-
tries are especially under-resourced and inadequately
prepared for a high number of injuries.2,7
From the Department of Surgery, University of Washington Medi-
cine Regional Burn Center, Seattle.
Address correspondence to Tam N. Pham, MD, FACS, Department
of Surgery, UW Burn Center, Harborview Medical Center, 325
Ninth Ave, Box 359796, Seattle, Washington 98104. Email:
tpham94@uw.edu.
Copyright © 2016 by the American Burn Association
1559-047X/2016
DOI: 10.1097/BCR.0000000000000441
36
Copyright © American Burn Association. Unauthorized reproduction of this article is prohibited.
To date, there are few available resources for
disaster planning specifically designed to cope with
large-scale burn casualties. The American Burn Asso-
ciation has estimated that 25 to 30% of injured vic-
tims in most traumatic disasters would require burn
treatment.8 The American Burn Association has
fostered regional and national partnerships between
agencies and burn specialists in the United States.
The International Society for Burn Injuries has writ-
ten a set of “Guidelines for Dealing with Disasters
Involving Large Numbers of Extensive Burns,”
advising each country to define its own disaster plan-
ning system.9 In 2005, the U.S. Health and Human
Services (HHS) National Bioterrorism Hospital Pre-
paredness Program announced that each locale must
have “a plan to care for at least 50 cases per mil-
lion people for patients suffering burns or trauma”
to receive national disaster preparedness funding.10
 Journal of Burn Care & Research
Volume 38, Number 1 Dai et al  37
The American College of Surgeons has adopted
these planning projections in its Disaster Manage-
ment and Emergency Preparedness Program. The
purpose of this study was to evaluate recent global
trends in major burn disasters in terms of frequency,
place of occurrence, and number of casualties and to
determine whether the HHS directive to prepare for
50 cases per million people was commensurate with
the magnitude of recent burn disasters, both nation-
ally and internationally.
METHODS
Search Strategy
We reviewed relevant literature from medical journal
articles, investigative fire reports, and media news
sources for major burn disasters dating from 1990 to
present day. We also queried the “Global Terrorism
Database,” an open-source database using print or
electronic media headed by the University of Mary-
land.11 Other open-source databases and sources of
information included the World Factbook12 from the
Central Intelligence Agency and the International
Institute for Counter Terrorism.13 When possible,
incidents from these databases were cross-checked
with other media sources. All data collection sources
are listed in Table 1.
Definitions
As defined by Masellis et al,14 a burn disaster refers
to the “overall effect of the massive action of a
known thermal agent on individuals, characterized
by high numbers of fatalities and seriously burn-
injured patients with potentially high mortality and
disability.” We defined a “major burn disaster” as
any incident with ≥50 burn injuries and/or ≥30
burn-related deaths for the purpose of this study.
We searched for major disasters that resulted specifi-
cally in burn-related injuries or blast-related injuries
that caused secondary burns. When possible, injuries
were separated such that we only included cutaneous
burns and inhalation injuries in this analysis. If casu-
alty numbers were found to be inconsistent across
multiple data sources, the highest death/injury met-
ric was used.
We categorized each burn disaster by date, place,
fire incident, and burn disaster type. For each cat-
egory, we recorded the number of dead, the number
of injured, and any additional notes or informa-
tion detailing burn-injured casualties. Industrial
burn disasters referred to explosions occurring at
manufacturing plants or factories, and also included
major chemical burn disasters. Public assembly burn
Copyright © American Burn Association. Unauthorized reproduction of this article is prohibited.
disasters included festivals or pilgrimages. Struc-
ture fires included both commercial and residential
enclosed space fires such as nightclubs, theaters,
churches, private homes, hospitals, nursing homes,
or jails. Transportation fires were fires that occurred
onboard planes, ships, trains, and motor vehicles.
Wildfire disasters included bushfire and forest fires.
We defined an act of terrorism as an intentional
explosive or bomb blast attack resulting in high
numbers of civilian casualties. As such, terror-related
activities resulting in burn disasters referred to sui-
cide bombings with attackers wearing explosive
devices or suicide vehicle bombs primarily explosive
in nature. Blast-related terrorist attacks via incendi-
ary devices primarily caused civilian casualties and
were included. Bomb composition in the form of
both vests and vehicles may contain nails, small metal
pieces, such as balls or bolts that are detonated in
dense and confined areas to inflict penetrating, blast,
blunt, and burn injuries.15,16 Burn-injured patients
in blast explosions can typically range from 0.5% of
victims to as high as 30 to 40%.17,18 The proportion
of burn-injured victims from blast attacks depend on
a variety of factors, including open spaced vs closed
spaced attacks, the length of escape time, and the
type of incendiary device used.17 When the number
of burn casualties was not specifically reported after
a blast incident, we assumed a severe-case scenario
in which approximately 30% of the casualties were
burn-injured patients. By adopting a severe-case
scenario, our goal was to inform about the poten-
tial need for burn care resources for each incident.
Terrorist attacks targeting military installations were
excluded unless the incident resulted in the above-
defined number of civilian casualties.
We classified regions of the world primarily by
continent, but also parsed out the Middle East as a
region of current conflict. According to the Central
Intelligence Agency World Factbook,12 the Middle
East includes the following 19 countries: Armenia,
Azerbaijan, Bahrain, Gaza Strip, Georgia, Iran, Iraq,
Israel, Jordan, Kuwait, Lebanon, Oman, Qatar,
Saudi Arabia, Syria, Turkey, United Arab Emirates,
West Bank, and Yemen.
Data Analysis
We recorded and analyzed geographic and injury
distribution using Tableau Desktop Software, Ver-
sion 9.0 (Seattle, WA), a data analysis program that
translates metadata into visually optimal database
queries. In the absence of international guidelines,
we applied the 2005 U.S. HHS National Bioter-
rorism Hospital Preparedness Program protocol10

38  Dai et al January/February 2017
Table 1. Sources of information
Type of Information Source of Information
Medical Journals PubMed Search (1990–2015)
Government reports Online search of reports from
-National Fire Protection Association
-Investigations Reports
www.nfpa.org
Local Ministry of Health Reports
Internet Online media sources from BBC News,
New York Times, The Guardian,
Reuters, CNN, foreign news sources
Global Terrorism Database
http://www.start.umd.edu/gtd/
Central Intelligence Agency
https://www.cia.gov/library/publications/ Excluded: military targets, military casualties
the-world-factbook/
International Institute for Counter
Terrorism
http://www.ict.org.il/
to recent burn disaster casualty trends to estimate
hypothetical burn-bed needs. For each incident, we
calculated the reported number of casualties per mil-
lion persons in that locale by metropolitan popula-
tion size. We applied the directive to prepare for “50
cases per million population for patients sustaining
burns” to estimate the number of burn beds needed
to respond to the specific incident. We interpreted
the wording of “50 cases per million” to refer to
burn-injured patients per million population requir-
ing utilization of emergency resources. We then
compared this estimate to the number of actual casu-
alties for each incident.
RESULTS
Fire Type Trends and Geography
Seven hundred fifty-two incidents met our inclusion
criteria and were reviewed. In order of decreasing
frequency, there were 709 recorded burn disasters
in Asia/Middle East, 42 in Africa, 16 in Europe, 14
in South America, 13 in North America, and 1 in
Australia. There were 69 (9.2%) structure fires, 45
(6%) industrial fires, 28 (3.7%) transportation fires,
5 (0.6%) public assembly fires, and 4 (0.5%) natural
disasters. The remaining 601 (80%) burn disasters
were terrorist attacks.
Structure fires, industrial fires, transportation
fires, and public assembly fires persisted into the 21st
century, as their incidence has remained relatively
Copyright © American Burn Association. Unauthorized reproduction of this article is prohibited.
Journal of Burn Care & Research
Comments/Search Terms
Search terms: “major burn disasters,” “mass burn casualties,” “mass
casualty incident burns,” “civilian mass casualty disasters,”
“mass casualty incident fire,” and “burn disaster preparedness”
Lists of burn disasters categorized by fire incident type utilized in
identifying MCIs
Hospital admissions, number of casualties associated with specific
burn disasters
Search engine “Google” utilized to search for specific incidents
by name and date. Additional incidents mentioned in medical
journal articles and new sources subsequently searched directly
using mentioned media sources
Search Criteria: 1990–2015, explosion/bombing attack type,
suicide-bombers and car bombs included, military targets
resulting in high civilian casualties included
constant during the entire study period (Figure 1).
In Asia (excluding the Middle East), 46 structure
fires during the past 25 years have resulted in 4959
casualties, primarily from 15 structure fire disasters
with 1901 casualties in China. In contrast, Europe
and the United States had only 1432 casualties from
nine structure fires, less than one-third the number
in Asia. Other countries with notable industrial disas-
ters include Malaysia, Thailand, and Bangladesh in
the early 1990s. However, occasional structural fires
continue to occur, most notably the recent 2012
Bangladesh clothing factory fire that resulted in
111 deaths and more than 200 injured. The United
States has had seven major industrial accidents with
a total of 578 casualties during the study period.
Table 2 summarizes the number of casualties by fire
types for all regions of the world.
Major public assembly fire disasters also occurred
primarily in Asia, notably in Taiwan and India. In
June 2015, Taiwan’s colored-powder explosion
resulted in 500 burn victims. Following the explo-
sion, 393 victims were hospitalized (221 in intensive
care), distributed among 46 hospitals in seven cities.19
The 2005 Mandher Devi pilgrimage and two festivals
in 2006 and 2011 in India resulted in 604 casual-
ties. The majority of transportation fires occurred in
Africa, with 2477 casualties from six burn disasters
involving primarily oil tankers and trains.
Following the September 11, 2001 attacks in
New York and Washington DC, acts of terrorism
 Journal of Burn Care & Research
Volume 38, Number 1 Dai et al  39

Figure 1.  Fire type trends. Annual casualties from burn disasters have significantly increased since 2001. The majority is
related to terrorist attacks.

in the form of suicide bombings and car bombs
were the primary contributors to the number of
casualties from burn disasters (Figure 1). The inci-
dence of terrorist attacks increased 20-fold from
2001 to 2015 compared with 1990 to 2000. Of
the 709 major burn disasters recorded in Asia/
Middle East, 606 of those (85%) were terror-
ist attacks. The majority of these terrorist attacks
occurred in the Middle East, namely Iraq, Syria,
Afghanistan, and Pakistan. Iraq accounted for
21,204 (56%) of 38,017 total casualties in the study
period (Table 2). In Africa, three attacks occurred
between 1990 and 2000 compared with 20 attacks
from 2001 to 2015. The highest number of burn
disasters occurred in Nigeria with a total of 9299
casualties. Most of these were the result of suicide
and car bombings (Figures 2 and 3).
Applying “50 Burn-Injured Patients Per
Million” Directive
If the U.S. HHS Preparedness Guidelines10 were to
be adopted internationally, recent incidents dem-
onstrate that local resources would be insufficient.
Table 3 indicates a wide discrepancy between incident
and resources for multiple recent burn disasters. The
directive to prepare for “50 cases per million popu-
lation for patients suffering burns” would have not
has been sufficient for some burn disasters occurring
within the United States. For instance, the greater
metropolitan area of Rhode Island of around 1.1

Copyright © American Burn Association. Unauthorized reproduction of this article is prohibited.

 Journal of Burn Care & Research
40  Dai et al January/February 2017

Table 2. Burn casualties, by fire type and region

North
Fire Type Middle East Asia Africa Europe America* South America Australia

Industrial
 Dead 323 3319 1055 109 61 48
 Injured 100 1922 5000 3609 585 151
Public assembly
 Dead 343 425
 Injured 0 690
Structure fire
 Dead 71 3737 164 205 263 1711
 Injured 300 1963 0 749 215 2135
Terrorist attack
 Dead 11,482 7346 2269 443 2923 114
 Injured 27,988 18,946 8159 3426 7692 456
Transportation
 Dead 1,336 810 1728 494 52 32
 Injured 270 411 688 0 130 0
Wildfire
 Dead 40 52 15 173
 Injured 0 0 500 500

Dead and injured broken down by region vs fire type.

*Includes 2001 NY/DC Terrorist Attack casualties.

million people would have mandated that approxi- those 55 required burn beds would have been 160
mately 55 burn beds be made available to meet the beds short of the 215 casualties that resulted from
required “50 per million” component. However, the Rhode Island Nightclub fire in 2003. In fact,

Figure 2.  Burn disasters geography. Geographic distribution of burn disasters, 1990–2000. Circles, scaled to reflect the
number of casualties recorded in each country, indicate that burn disasters occur in high-, middle-, and low-income countries.

Copyright © American Burn Association. Unauthorized reproduction of this article is prohibited.

 Journal of Burn Care & Research
Volume 38, Number 1 Dai et al  41

Figure 3.  Burn disasters geography. Geographic distribution of burn disasters, 2001–2015. Circles, scaled to reflect the
number of casualties recorded in each country, indicate a growing number of casualties from burn disasters. The regions most
affected are the Middle East and Africa.

many casualties of that structural fire were rapidly
triaged regionally to Massachusetts for stabilization
and definitive care.20
A similar deficiency in medical resources would
have also been apparent in resource-restricted coun-
tries. For instance, the Santa Maria Kiss Nightclub
fire resulted in a total of 768 victims requiring medi-
cal attention.21 In maintaining the 50-bed provision
per 1 million people in Brazil’s southernmost state
among a population of 262,000, Santa Maria would
have been short by 755 beds. In fact, 54 patients
were transported to seven different hospitals in the
neighboring state Porto Alegre, while the remaining
patients requiring hospitalization crowded the emer-
gency departments of five hospitals, the ICUs of 6
hospitals, and all emergency units in Santa Maria.21
This event again illustrated the need to build regional
capacity that includes patient transport options and
interfacility collaboration.
DISCUSSION
Our review of major burn disasters during the past
25 years has three main findings. First, nonterrorism-
related fires continued to occur worldwide. Casualties
from these fire types reached the tens of thousands
during the past decade. Major burn disasters were less
common in certain regions, such as North America
and Europe, presumably because of modern fire-
prevention strategies and building code enforcement.

Table 3. Recent burn disasters: estimated vs actual burn-beds requirements

Population Size Estimated # Burn Beds Per
Year Region (in Millions) Disaster Type Preparedness Guideline* Actual # Casualties

2003 Warwick, RI 1.1 Structure fire 55 215

2013 Rio Grande do Sul, Brazil 0.26 Structure Fire 13 768
2014 Kano, Nigeria 2.8 Terrorism 140 270
2015 Taipei, Taiwan 2.7 Public assembly 135 500
2015 Tianjin, China 11.4 Industrial 575 720

*National Bioterrorism Hospital Preparedness Program.10

Copyright © American Burn Association. Unauthorized reproduction of this article is prohibited.


42  Dai et al January/February 2017
Other regions such as Asia, however, had a high
incidence of fire types throughout the study period.
We postulate that rapid industrialization, weaker
fire-prevention strategies, and fire safety codes may
have contributed to this finding.22,23 On the other
hand, the Rhode Island Nightclub Fire in the United
States (2003)20,24,25 served as a reminder that regula-
tions and fire safety codes were sometimes eschewed
in high-income countries as well. No region in the
world can be considered immune to nonterrorism-
related major fires, as illustrated most recently in the
Kiss Nightclub disaster (Brazil, 2013)26 and the For-
mosa colored-powder explosion (Taiwan, 2015).19
Second, terrorist attacks accounted for the expo-
nential increase in burn-related disasters during the
past 15 years. Although we intentionally excluded
military targets from the study, civilians now account
for more than 80% of those killed and wounded in
modern-day conflicts.27 Terrorist bombings of civil-
ians that result in mass burn casualties often occur
in densely populated areas.28 Specifically, suicide
bombing has proven to be the deadliest form of ter-
rorism,29 resulting in unprecedented levels of casu-
alties worldwide. The injury profile of blast victims
depends on detonation proximity.30 Casualty num-
bers are affected by crowd density at the scene, the
presence of a single or multiple suicide attackers, and
the explosive load power.30 Burns are one of mul-
tiple injury types incurred by victims of blast attacks,
resulting in injury rates as high as 48% of emergency
department and hospitalized patients in confined
space bombings.17 Injuries from improvised explo-
sive devices include flash burns from radiated heat
affecting exposed body parts, contact with heated,
dust-laden air, and burns from secondary structural
fires from incendiary devices.31 Intensely hot flames
from high-explosives reach up to 3000°C, causing
burns of varying severity in relation to victims’ prox-
imity to the detonation.30,32 Patients with extensive
burns (≥30% TBSA) experience a high mortality.33,34
Those who survive the initial blast frequently sustain
burns on exposed body parts, and require extensive
burn care.30,35
Third, our data indicate that large-scale burn
disasters have exceeded, and will likely again exceed
the care capabilities in any locale. Indeed, when we
projected a hypothetical adoption of the U.S. HHS
directive worldwide, recent disasters exceeded the
projected burn-bed capacity of these locales by at
least a factor of two. Furthermore, we recognized
that adequate provision for burn casualty manage-
ment would be largely deficient in many hospital
disaster plans.36 The need for hospitals to have a
minimum level of preparedness links back to the first
Copyright © American Burn Association. Unauthorized reproduction of this article is prohibited.
Journal of Burn Care & Research
steps of disaster management at the initiation of tri-
age and prehospital care. In addition, burn disaster
patients may suffer from other injuries (blast injury,
traumatic injury, and open wounds) in addition to
their comorbid conditions.37 The specific needs of
severely burn-injured patients require time-sensitive
fluid administration, acute hospitalization, and ulti-
mately operative care. Whereas initial stabilization
can be provided by less experienced personnel, oper-
ative burn expertise is often concentrated in referral
centers. Initial management and triage to definitive
care should be incorporated in all burn disaster plans.
The hypothetical application of the U.S. HHS
Preparedness directive focused narrowly on burn
beds, merely a single component of a comprehensive
disaster response that includes medical supplies and
trained burn providers, as well as proficient triage and
transport. The sequelae of burn disasters range from
minor injuries to those who died at the scene, and any
individual seeking medical care. A “surge-capacity” to
accommodate 50 casualties may not correlate to the
actual “capability” to treat 50 burn patients. Count-
ing potentially available hospital beds in a locale can
be misleading. For instance, bed availability depends
on the existing inpatient census, on the number of
patients who require isolation or may be treated by
cohorting on any single day. While nonburn patients
may be transferred out to other facilities to create
more capacity, the human resources at any institu-
tion are fixed. The minimum “surge-capacity” of 50
hospital beds as a benchmark also fails to take into
account the day-to-day ability to provide multidimen-
sional aspects of burn care, such as a sufficient num-
ber of trained personnel, equipment, supplies, and
floor space to accommodate a sudden patient influx
following an incident. The U.S. HHS Preparedness
directive attempted to address this by stating systems
receiving funding must “provide triage treatment and
initial stabilization above the current daily staffed bed
capacity,” but did not address the extensive length
of stay and daily wound care requirements neces-
sary for burn patients. For event-specific planning,
it is incumbent on the event organizers to partner
with public resources in preparing a contingency plan
when organizing large public assemblies. It cannot be
the responsibility of the government to address the
disaster planning needs of specific events. Rather, gov-
ernmental agencies such as the department of health
can function as a partner to mitigate a potential burn
disaster. As such, event planners must be aware of
local and regional burn resources, and work with local
health departments during event planning.
Altogether, our data highlight the importance of
additional regional, national, and international level
 Journal of Burn Care & Research
Volume 38, Number 1 Dai et al  43
collaboration in burn disaster preparedness. Consid-
ering the demands placed on local emergency care
services in a burn disaster, the capability to respond
may simply not be adequate given the prevalence of
terrorist- and nonterrorist-related events globally.
The impact of recent disasters such as the Rhode
Island Nightclub Fire, the Santa Maria Kiss Night-
club Fire, and the Taiwan Formosa Colored-Powder
Explosion was all mitigated through regional col-
laboration. The focus on the availability and track-
ing of burn beds exists because specialized burn-bed
scarcity and limited capability to surge to meet the
demands of an incident are major concerns. In the
event of a major burn disaster, general hospitals and
trauma centers will be called on to provide primary
evaluation, stabilization up to 72 hours, and until
secondary triage to burn centers in the region or in
distant areas is possible. These hospitals will func-
tion as burn surge facilities to provide for a multi-
lateral increase in short-term capabilities across the
region.38 Collaborative burn disaster planning must
develop regional, national systems, or perhaps even
global systems to track daily burn-bed availability
when local facilities are overwhelmed, or be prepared
at all times to take in a minimum number of patients.
Surge capability planning should include a discussion
about memoranda of understanding among facilities
and countries, formation of disaster management
teams that can be deployed on short notice, and
the expansion of telemedicine capabilities for triage,
coordination, and follow-up care.
Study Strength and Limitations
This review has summarized the diverse types of
civilian burn disasters that continue to occur in all
regions of the world, and has also demonstrated the
increasing threat of bombing attacks during the past
15 years. The study has provided an estimate of the
number of burn casualties to inform planning. There
are, however, important limitations to consider. Our
data were collected from media reporting in English,
which may not match with foreign news sources.
As such, our search strategy may have missed some
burn disasters. Accurate and thorough documenta-
tion of injury type and severity was generally poor in
most media sources, and even in published medical
sources.36 Without direct access to medical records
data, distinguishing the injury profiles of victims
within each burn disaster proved difficult. An exten-
sive breakdown of disaster casualty data, specifying
injury type (burn casualties as opposed to trauma
injuries) was not always possible. Similarly, a break-
down of patients sustaining relatively smaller burns
Copyright © American Burn Association. Unauthorized reproduction of this article is prohibited.
(the so-called walking wounded) compared with
patients with large BSA injury, to inhalation injury
only patients, would have been helpful to inform
resource needs and allocation. In addition, some
recorded incidents may have included reporting inac-
curacies, false, or conflicting information, with mul-
tiple causes or no known cause. An important first
measure is to improve the quality of data reporting.
Lack of consistent and accurate data documenting
injury incidence and severity in major burn disasters
have hindered preparedness efforts so far.34 Existing
mass disaster planning manuals from organizations
(including the World Health Organization) highlight
the importance of a surveillance system to routinely
collect data on injuries,39,40 A centralized repository
of high-quality information detailing burn casualty
profiles would improve the design and execution of
preparedness programs.41
In summary, burn mass casualty disasters from
structure fires and industrial fires continued to
occur in high-, middle-, and low-income coun-
tries throughout the study period. Terrorist attacks
increased exponentially during the past 15 years,
highlighting the need for increased burn disaster
preparedness. In the event of a major burn disaster,
local hospitals may quickly become overwhelmed.
If the U.S. HHS Preparedness Guidelines were to
be adopted internationally, recent incidents dem-
onstrate that local resources would be insufficient.
These findings underscore an urgent need to orga-
nize better regional, national, and international col-
laboration in burn disaster response.
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