Management of Wound Healing Vijay K Shukla, Raj Mani, Luc Téot, Satyajit Pradhan
INDEX
×
Chapter Notes

Save Clear


Epidemiological Study of Wounds: An Indian Perspective1

Sanjeev K Gupta,
Vijay K Shukla
 
INTRODUCTION
Wounds have always been a matter of major concern to ectothermic terrestrial animals, who from some sort of instinct or experience learned long ago to keep there wounds moist, warm and clean. In contrast, humans have overridden that instinct and have treated their wounds with an astonishing menu of toxic and irrelevant substances. The worldwide prevalence of wounds is believed to be 1 percent of world population.1 By convention acute wounds are those which are present for duration of less than 6 weeks while chronic wounds are those which are of more than 6 weeks duration. A hospital based study in our centre suggested that leprosy (40%), diabetes (23%), venous disease (11%) and trauma (13%) were among important causes of lower extremity wounds. In this study, 13 percent of wounds were not directly linked to any known cause.2 The reported prevalence of leg ulcers in Europe varies between 0.18 percent and 1 percent and in contrast to the above study is caused mostly by venous disease, arterial disease and diabetes.3-7 The limited epidemiological data that is available regarding lower extremity wounds commonly seen in tropical countries suggests that infectious agents are principally responsible for such wounds. There is a pressing need to study wounds that affect populations in tropical countries as well as the more described chronic wounds due to circulatory insufficiency or diabetes in order to develop community based wound care programmes.8 Hospital based studies are easiest to perform but they have the intrinsic drawback of being skewed because the subjects seeking hospital service do not form a homogenous population. Moreover, hospital based statistics seldom reveal the true population based incidence.
This community based study for epidemiology of wounds has been launched to inform, educate and provoke wound workers so that the pathway to progress is energized for the benefit of those who suffer and those who care.
In our own study, the population was screened in the two communities, one rural and the other semi urban. The total sample size was 6917. There were 104 patients with wounds. The overall prevalence of wounds per thousand populations was 15.03 while that of acute and chronic wounds was 10.55 and 4.48 respectively. Both acute and chronic wounds were commonly seen in the 21–40 years age group. Males were more than twice as likely to develop wounds as compared to females. Wounds were seen more frequently in those engaged in outdoor occupation (Fig. 1.1). Wounds were commonly seen in people having a low literacy status.
The majority of the study subjects with wounds had a low socioeconomic status. Pain as a symptom was present in most of the cases of both acute and chronic wounds though its severity varied. Presence or absence of pain showed a statistically significant correlation with the type of wound, being more in acute wounds. The commonest mode of onset of an acute wound was trauma (98.63%). People who were harbouring a co-morbid medical disease (Table 1.1) like diabetes mellitus, leprosy, and peripheral ischemic disease were more likely to develop a spontaneous onset chronic wound (54.84%). There was a statistically significant association between mode of onset and type of wound.
2
zoom view
Fig. 1.1: Occupation of patients
Table 1.1   Associated disease in cases
Disease
Acute (n=73)
Chronic (n=31)
No.
Percentage
No.
Percentage
Diabetes
1
1.37
6
19.35
Peripheral vascular disease
0
0
1
3.23
Leprosy
0
0
5
16.13
Tuberculosis
1
1.37
2
6.45
Malignancy
0
0
1
3.23
Total
2
2.74
15
48.40
Majority of the patients in the community resorted to home remedies for treatment (acute = 56.68%, chronic = 48.39%). The home remedies most commonly used were in the form of turmeric powder or a paste of onion and lime powder. The commonest therapy offered to patients with acute wounds was in the form of local application of ointments while that for chronic wounds was a combination of local and systemic treatment. Acute (47.94%) as well as chronic (74.21%) wounds were commonly present in lower extremities as compared to other sites of body (Fig. 1.2). Majority of the wounds (acute-97.26%; chronic-83.87%) had a size of less than 5 cm. The edge of most of the acute wounds (78.08%) was sloping while there was great variation in the type of edge of chronic wounds. The floor of chronic wounds in majority of cases revealed unhealthy granulation tissue or necrotic slough. The commonest aetiology for a chronic wound was an uncared acute traumatic wound (51.61%) followed by diabetes (19.35%) and leprosy (16.13%) (Table 1.2).
zoom view
Fig. 1.2: Anatomical location of wounds
Chronic wounds were more likely to develop in individuals who were having an existing co-morbid medical disease like diabetes (19.35%) and leprosy (16.13%) as compared to the general population.
 
DISCUSSION
The present study was undertaken with a view to determine the prevalence of wounds in a community based study in India with an emphasis on chronic wounds and to identify the various etiological factors involved. Globally a number of trials regarding wounds are being conducted but one important question— whether it is necessary to set up community clinics to improve wound care in the community remains unanswered.9 Lack of quantifiable data and apathy has slowed wound research. Quantification of chronic wounds has been difficult. Many such epidemiological studies regarding prevalence of wounds fail to reach statistical significance.10 There is a paucity of data relating to the prevalence and natural history of wounds in the tropical countries. These data can only be obtained by screening a large population for wounds.8
Community based studies conducted in the West have shown a prevalence of wounds of 1.8 per 1000 population.
Table 1.2   Aetiology of chronic wounds
Cause
No. of cases
Percentage
Uncared traumatic
16
51.61
Diabetes
6
19.35
Leprosy
5
16.13
Malignancy
1
3.23
Arterial
1
3.23
Tubercular
2
6.45
Total
31
100
3
Venous diseases account for 81 percent of cases followed by arterial diseases.11-13 Studies conducted in UK have shown that prevalence of chronic wounds was 1.48 per thousand populations. This study suggested that 1 percent of western people have a wound at some time of their life.1
In contrast, our study has shown a prevalence of wounds of 15.03 per thousand populations. Wounds especially the chronic ones are often regarded as disease of the elderly.14 However, in our study a substantial proportion of patients were below the age of 60 years (93.26%). The majority of patients were in the 20 to 40 years age group which might be due to majority of people of this age group being engaged in outdoor occupation which exposes them to the risk of developing a traumatic wound which might further progress to chronic wound. As already shown above, in this study uncared traumatic wounds were the commonest cause for development of chronic wounds. Below the age of 30 years the sex distribution was nearly equal but above 30 years of age males were more commonly affected than females. Trauma was the most frequent etiological factor for wounds in the population below 30 years of age. However, above the age of 30 years, there were associated predisposing chronic diseases in addition to trauma. In the present study, these causes in the order of decreasing frequency were diabetes (19.35%), leprosy (16.13%), tubercular (6.45%), malignancy (3.23%) and arterial diseases (3.23%). This is in contrast to western studies where venous ulcers account for nearly 80 percent of chronic wounds. Furthermore, leprosy is uncommon in the western studies whereas it accounts for 16.13 percent of chronic wounds in our study. Similarly, tuberculosis accounts for 6.45 percent cases of chronic wounds in our study while in series coming out of western countries tuberculosis is extremely rare. Arterial diseases leading to chronic wounds accounted for only 3.23 percent cases of chronic wounds in our study, whereas arterial wounds account for 15–20 percent of cases of chronic wounds in most western series.15-17 This could probably be because of smoking being less common in the population studied.
In our study, amongst the patients with wounds, males (95.20%) outnumbered the females (48.80%). This too is consistent with the fact that males are more often engaged in outdoor occupation, which exposes them to an increased risk of trauma. Even though only 41 percent of families in our study population belonged to a low socio-economic status they accounted for majority of the patients with acute (67.12%) and chronic (83.80%) wounds. Financial constraints prevented these people from seeking medical advice at an early stage. They could not afford even the most relevant investigations, as a result of which precious initial time of wound management was lost allowing the wounds to become chronic. 76.63 percent patients with acute wounds and 90.31 percent patients with chronic wound had a low literacy status. The low literacy status contributed to ignorance on part of patients regarding management of their wounds. This also reflects the lack of penetration of health education in our communities. Despite having access to government health care delivery systems (public sector) and private practitioners, 50.68 percent of patients with acute wounds and 48.39 percent patients with chronic wounds resorted initially to home remedies for treatment of their wounds seeking medical advice only after the wounds failed to heal. In our study, the commonest aetiology for chronic wounds was uncared acute traumatic wounds (51.61%), which is practically unknown in the western world. In the western countries, community based multidisciplinary programmes have been very successful in the management of chronic wounds2 but in our setting we lack even the basic diagnostic and therapeutic facilities at the community level and the patient has to attend a hospital not only for basic investigations but also for something as simple as daily dressings. This contributes to disinclination on part of the patients to seek medical advice at an early stage due to financial and time constraints, as most of the people are working on daily wages and are unable to devote time to seek medical advice. We feel that health education and provision of community based multidisciplinary wound care teams would go a long way in the better management of patients with wounds. However, the actual impact of community based multidisciplinary wound care team in decreasing the burden of chronic wounds in the community needs to be studied further by conducting controlled trials.
 
CONCLUSIONS
We conclude that even though in the community studied the prevalence of chronic wounds is relatively low, the fact that uncared for acute traumatic wounds are the commonest cause for chronic wounds, clearly underlines the need to establish community based wound care teams. These multidisciplinary teams can provide appropriate medical care at the right time and at the right place, thereby minimizing the need to visit hospitals and can save both time and money from the patient's point of view. It is also necessary to ensure availability of adequate diagnostic facilities at the 4community level to diagnose some of the common medical conditions predisposing to the development of chronic wounds (e.g., Diabetes, leprosy etc.). In this study, chronic wound is more common in the illiterate population which indicates that health education of the community needs to be an important component of the services provided by such a multidisciplinary community based wound care team.
REFERENCES
  1. Gottrup F, Holstein P, Jorgensen B, Lohmann M, Karlsmark T. A new concept of multidisciplinary wound healing centre and a national expert function on wound healing. Arch Surg 2001;136:765–71.
  1. Shukla VK, Saraf SK, Kaur P, et al. A clinico-epidemiological profile on non-healing wounds in an Indian hospital. J Wound Care 2000;915:247–50.
  1. Biland L, Wiender LK. Varicose veins and chronic venous insufficiency. Acta Chir Scand 1988;544(Suppl):9–11.
  1. Hannson C, Anderson E, Swanbeck G. Leg ulcer epidemiology in Gothenberg. Acta Chir Scand 1988;544(Suppl):12–6.
  1. Dale JJ, Callarn MJ, Ruckley CV, et al. Chronic ulcers of the leg: A study of prevalence in a Scottish community. Health Bull 1983;41:310–4.
  1. Cornwall JV, Dore CJ, Lewis JD. Leg ulcers: Epidemiology and aetiology. Br J Surg 1986;73:693–6.
  1. Hallbook T. Leg ulcers epidemiology. Acta Chir Scand 1988;544(Suppl):17–20.
  1. Gupta SK, Shukla VK. Leg ulcers in the tropics. Lower Extremity Wounds 2002;1:58–61.
  1. Morrell CJ, Walkers SJ, Dixon S, Collins KA, Brereton LML, Peters J, et al. Cost effectiveness of community leg ulcer clinics: Randomized controlled trial. Br Med J 1998;316:1487–91.
  1. Hunt TK, Harriet Hopf. Quantification and Stratification. Wound research in the future. Lower Extremity Wounds 2002;1:68–71.
  1. Baker SR, Stacey MC, Jopps AG, Hoskin SE, Thompson PJ. Epidemiology of chronic venous ulcers. Br J Surg 1991;78:864–7.
  1. Young JR. Differential diagnosis of leg ulcers. Cardiovasc Clin 1983;13:171–93.
  1. Nelson O, Berquese D, Lindhagen A. Venous and non-venous leg ulcers; Clinical history and appearance in a population study. Br J Surg 1994;81:182–7.
  1. Callam MJ, Harper DR, Dale JJ, et al. Chronic ulcer of the leg: clinical history. BMJ 1987;94:1389–91.
  1. Sarkar PK, Ballantyne S. Management of leg ulcers. Postgrad Med J 2000; 76:674–82.
  1. Philips TJ, Dover JS. Leg ulcers. J Am Acad Dermatol 1991;25:965–87.
  1. Sibbald RG. An approach to leg and foot ulcers: A brief overview. Ostomy Wound Manage 1998;44:28–32.