International Journal of Occupational Safety and

Ergonomics

ISSN: 1080-3548 (Print) 2376-9130 (Online) Journal homepage: https://www.tandfonline.com/loi/tose20

Chemical mismanagement and skin burns among

hospitalized and outpatient door (OPD) patients

Dr. Salman Majeed PhD, Dr. Mati Ur Rahman PhD, Dr. Hammad Majeed PhD,
Sami Ur Rahman Mphil, Asif Hayat Mphil & Dr. Sandra D. Smith PhD

To cite this article: Dr. Salman Majeed PhD, Dr. Mati Ur Rahman PhD, Dr. Hammad
Majeed PhD, Sami Ur Rahman Mphil, Asif Hayat Mphil & Dr. Sandra D. Smith PhD
(2019): Chemical mismanagement and skin burns among hospitalized and outpatient
door (OPD) patients, International Journal of Occupational Safety and Ergonomics, DOI:
10.1080/10803548.2019.1638142

To link to this article: https://doi.org/10.1080/10803548.2019.1638142

Accepted author version posted online: 28

Jun 2019.

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Publisher: Taylor & Francis & Central Institute for Labour Protection – National Research Institute (CIOP-
PIB)

Journal: International Journal of Occupational Safety and Ergonomics

DOI: 10.1080/10803548.2019.1638142

Chemical mismanagement and skin burns among hospitalized and outpatient door (OPD)
patients

Authors and affiliations

1) Dr. Salman Majeed

First name: Salman
Last name: Majeed
Academic degree: PhD
Affiliation 1: College of Management, Shenzhen University, Shenzhen, Guangdong, 518060, China.
Email: Salmanphd@hotmail.com
2) Dr. Mati Ur Rahman
First name: Mati
Last name: Ur Rahman
Academic degree: PhD
Affiliation: College of Chemistry, Fuzhou University, Fuzhou, Fujian, 350002, China.
3) Dr. Hammad Majeed
First name: Hammad
Last name: Majeed
Academic degree: PhD
Affiliation: Department of Chemistry, University of Agriculture, Faisalabad, Punjab, 38000, Pakistan
4) Sami Ur Rahman
First name: Sami
Last name: Ur Rahman
Academic degree: Mphil
Affiliation: Urban Policy Unit Planning and Development Department, Government of Khyber
Pakhtunkhwa (UPU, P&DD GoKP) Civil secretariat, Peshawar, Khyber Pakhtunkhwa, 25120, Pakistan.
5) Asif Hayat
First name: Asif
Last name: Hayat
Academic degree: Mphil
Affiliation: College of Chemistry, Fuzhou University, Fuzhou, Fujian, 350002, China.
6) Dr. Sandra D. Smith
First name: Sandra
Middle Initial: D.
Last name: Smith
Academic degree: PhD
Affiliation: Graduate School of Management, University of Auckland Business School, University of
Auckland, Auckland City 1010, Auckland, New Zealand

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 Chemical mismanagement and skin burns among hospitalized and outpatient door (OPD)
patients

Abstract

Purpose

This paper attempts to elucidate the nature of chemicals causing major and minor skin burns, and their associated
characterization across the different industries, using Fujian provincial hospitals’ admission and outpatient door
(OPD) records.

Materials and methods

Data were collected from the provincial hospitals of Fujian through the questionnaire, sent via email, from June 1,
2017, to November 30, 2017. The collected responses were statistically analyzed in SPSS 19 through the
interquartile range, median, Mann-Whitney U test, and Fisher’s exact test at two-tailed significance level.

Results and conclusions

The results of 306 collected responses reveal that the majority of skin burn cases are due to lack of technical
education and professional training among the workers handling chemicals. This study suggests that management’s
effective supervision and governmental regulations may help to prevent chemical skin burns at work, and can further
be controlled by hiring professional workers alongside providing training to them in chemical handling as well as
using protective equipment and developing appropriate management policies to improve victim’s wellbeing and
quality of life. Findings will help the workers, doctors, hospitals, industries, government, and other stakeholders to
understand and control chemical hazards at-site to minimize the risks of chemical skin burn incidents.

Keywords: Chemical burns; skin burns; burns prevention; Occupational health and safety; management, wellbeing,
quality of life.

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1. Introduction

Burn injuries have adverse impacts on the victim’s body and soul, in all age cohorts, which may further
lead to his/her poor health and wellbeing [1]. Incidents of chemical burns are growing enormously with a large
number of reported occupational injuries, i.e., 1.4-8.5 % of all burn causalities [2]. Most of the reported burn cases
in many countries are often linked to occupational injuries [2, 3]. Although the chemical industry is the backbone of
a country, reported cases of chemical burn are steadily increasing in this industry. Many non-chemical industries
also report skin burns due to chemicals. It is noted that serious health complications may be developed after
chemical burns, such as eyes’ burn due to chemicals may result in partial or full visual function failure [4], or
ingestion of alkali, acid, or caustic agents may lead to complexities in esophagus and lungs [5]. All such kinds of
chemical burns and their associated serious outcomes may further lead to an individual’s death [4, 5]. Fewer studies
also report skin burns due to different acids and other chemicals which may be one of the leading causes of life-
threatening hypocalcemia [6, 7].
Chemical skin burn accidents have been reported by many epidemiologic studies across the world [3, 8, 9].
These incidents vary with geographies, population, and infrastructure of the industries [10]. Many reasons for burn
incidents are noted in the existing studies, e.g., causative agents, which are commonly involved in the oft-quoted
skin burn injuries, i.e., acids and alkalis. Scholars note that hydrochloric acid, sulfuric acid, potassium hydroxide,
and sodium hydroxide are some of the agents which may cause skin burns immediately. Some solvents may also be
the reasons for skin burns, such as white phosphorus [11]. These types of acids, alkalis, and solvents are widely used
in the chemical processing industry, the manufacturing industry, and in the non-chemical industries. Acids, alkalis,
and solvents are also used in restaurants and tourism sites for cleaning and washing purposes. After the reported
accidents of fire and scalding injuries in China, chemical burns are frequently documented as the leading cause of
occupational and other injuries [8]. When such accidents happen, initial treatment protocols at hospital are to
remove victims’ rings or jewelry (if wearing) alongside removing those pieces of cloths which have been covered by
chemical or have been burned [12]. It is advised to cover patients with blankets, dry sheets, or burnshield to prevent
hypothermia, controlled-cooling of wound and dressing the burn-wound as first-aid treatment in hospital emergency
[12, 13].
Since chemical skin burns adversely impact victim’s quality of life, medical tourism is gradually becoming
popular due to individuals’ aspirations to travel offshore for a different quality of life treatments [14, 15, 16]. From
this perspective, plastic and reconstructive (PRS) surgeries could be offered to burn victims, at affordable cost,
across the globe to meet their expectations of improved health, wellbeing, and quality of life if such treatments are
not domestically available to them. Although PRS treatments have made possible to treat skin burns by various
techniques, such as skin graft, skin flaps, etc., it still involves time, costs, pain, and risk of side effects[17, 18].
Since chemical skin burns are associated with critical health complexities, the incidence and
characterization of chemicals may help to prevent chemical hazards and their ultimate negative impacts on the
victims’ quality of life. Hence, the incidence and characterization of chemicals are given important priorities. Some
scholars document patients’ demographics and the properties of causative agents from the perspectives of major
chemical skin burns accidents and present the statistics of those patients admitted in hospitals or treated in burn

3
centers [19]. However, minor chemical skin burns accidents, which need outpatient door (OPD) services, have yet to
be analyzed. Chemical skin burns cases in hospital OPD are meaningful to consider in an attempt to present the
broader and real picture of chemical hazards, which previous studies are lacking in their breadth and depth. Basic
themes of management functions, i.e., planning, organizing, staffing, and controlling, are widely discussed in the
management literature [20]. These themes are often discussed as support to policy-making and risk aversion in

working settings [21]. However, these management functions are not yet discussed from the perspective of
managing the risks of chemical burns at-site. The planning of improved prevention measures during chemical
handling procedures, implemented by trained professionals, may help to minimize the risks of chemical skin burns.
Appropriate policymaking, regulations, and safety procedures in handling hazardous chemicals are suggested to
control the overall mechanism of chemical threats to individuals’ health and wellbeing, and for its effective
management.

To address mentioned chemical threats to skin burns and to introduce appropriate managerial practices in
the industries, an observational study is conducted in China on the cases of chemical skin burns by taking into
account the standardized data from the Fujian provincial hospitals. This study clarifies the incidences of chemical
skin burns, which are reported in Fujian province, in an attempt to solidify the conceptualization and management of
chemical burn accidents and their characterization across the industries in different contexts. Some existing
suggestions from previous studies are followed in collecting the data and devising strategies to control chemical skin
burns. The main objective of this work is to investigate the associated reasons of chemical skin burns in working
settings, in both admitted and OPD patients of the hospitals, and fuel the discussion on strategy development to
improve industrial preventive measures to minimize the risk of chemical hazards.

2. Methodology

The standardized data were considered by conducting an observational study in Fujian province for a
definite period of time. The study research team developed a questionnaire (Appendix A) in order to collect data
from the case records of the victims of chemical skin burns accidents who visited hospitals’ OPD units or got
inpatient stay in the hospitals. The presented questionnaires incorporated questions on the demographic information
of the patients, cause of chemical skin burns accident, causative chemical substance which burned/damaged the skin
of patients, accident location, the availability and management of on-site first-aid facility for the chemically burned
individual’s injury, availability of protective equipment, and the victims’ intentions for further cosmetic/PRS
surgeries. The developed questionnaire was further solidified for its content and purpose with the help of eight
persons, i.e., two professionals of the chemical processing industry, one professor of chemistry, one instructor of
chemistry, one physician specialized in burn treatment, one surgeon specialized in plastics and reconstructive
surgery, and two patients who suffered from chemical skin burns in the past, to clarify the study objective and
understanding. The questionnaire was originally developed in the English language, which was later translated into
the Chinese language with the help of blind translation-back translation method for its accuracy [22]. The translated
version of the questionnaire was also proofread by a native Chinese speaker, who was proficient in the English
language, for the clear understanding and translation of the English-versioned questionnaire. In order to measure the

4
content validity of the questionnaire, a pre-test was conducted by sending the questionnaire to five hospitals located
in the Fuzhou city. The Cronbach’s α value of the pre-test, i.e., α = 0.78, was found acceptable to proceed further for
this study. The developed questionnaire was little adjusted after the pre-test results on the basis of participants’
recommendations to meet the objectives of the study in a better way.

This study was conducted in the six-month period between June 1, 2017, and November 30, 2017. The
developed questionnaire was sent via email to twenty-four hospitals of the Fujian province, however, only thirteen
hospitals’ burn units participated in this study. A total of 328 responses were received back via email, within the
mentioned time period, on the basis of patients’ records that visited hospitals’ OPDs for minor skin burn incidents or
were hospitalized for major skin burns incidents. Written informed consent of the patients was also supplied along
with the hospitals’ provided responses. Burn units’ personnels gathered relevant information and filled the
questionnaires by reviewing patients’ case reports and interviewing the patients. Among 328 completed and returned
questionnaires, only 22 questionnaires were incomplete and not considered for the final data set. The small number
of incomplete questionnaires shows the completeness of the research frame and the effective management of the
research portfolio. Incomplete questionnaires were excluded from the final data set to ensure the reliability and
validity of results and analysis. Hence, a total of 306 responses were retained for final data analysis. The collected
responses were further divided into group 1 and group 2 on the basis of hospital admission and OPD treatments
respectively.

2.1 Ethics

The present study’s protocol was reviewed and authenticated by the institutional review board of Union
Hospital Fuzhou (UHF) (UHF 2017-03-014), which actively participated in conducting the present research work as
well.

2.2 Statistical Analysis

Due to abnormal distribution of data, results were summarized as an inter-quartile range (Q1, Q3) and
median. Mann-Whitney U test was applied in order to measure the differences between hospitalized and OPD
groups. Count, percentage, and cumulative percentage were performed for other categorical variables. Fisher’s exact
test was applied for measuring the association of categorical variables within patients’ groups. A two-tailed
significance level of p < 0.05 was considered for all the statistical measurements. SPSS 19 was used for performing
statistical analysis of the data. Additionally, distributions of industries and causative agents by the skin were
examined.

3. Results

3.1 Demographic profile of the patients

Table 1 shows the demographic profile of patients that met with chemical skin burn incidents. The results
show that 167 patients (54.58 %) were males, while 139 patients (45.42 %) were females. The patients’ age ranged
from 15 to 80 years (37; 30, 44) with an average age of 37 years. By analyzing the chemically burned patients’ age
distribution, it was found that patients from 31 to 40 years of age (33.66%) were mostly the victims of chemical skin

5
burns as compared to others, followed by those patients within the range from 41 to 50 years (22.22%) and 51 to 60
years (14.05%) of age. Further, it was found that 123 patients (40.20%) had completed up to elementary school
education, 114 (37.25%) had completed up to high school study level, 43 (14.06%) had completed up to graduate
study level, and 26 (8.50%) had completed up to postgraduate study level.

Table 1 results further espouse that 41 patients (13.40%) worked for government-owned organizations, 24
(7.84%) were workers of foreign-owned organizations, 178 (58.17%) were employees of the private local-owned
organizations, and 63 (20.59%) were engaged in working for other miscellaneous organizations. Since the workers
of private local-owned organizations were the majority of the victims of the chemical skin burns, this trend was also
observed in the hospitalized and OPD patients, i.e., 116 (64.80%) and 62 (48.82%) respectively. While foreign-
owned organizations were least-reported in the chemically skin-burned incidents in terms of both hospitalized and
OPD patients. Moreover, the majority of the victims of chemical skin burns were daily wagers (139; 45.43%),
followed by contractual work status holders (109; 35.62%) and those having permanent work status (58; 18.95%).
This trend was also observed in hospitalized and OPD patients. By analyzing the demographic details of the
patients’ two groups (as presented in Table 1), it was found that the patients’ hospitalized and OPD groups were
significantly different at p < 0.05 confidence level in association of gender (p = 0.002), highest education (p =
0.036), organization type (p = 0.001), and work status (p = 0.024). However, the difference in the distribution of age
groups between the two groups was not significant (p > 0.05).

Table 1: Patients’ demographic profiles

Variables All cases Group 1 (Hospitalized) a Group 2 (OPD)b p-value
n % CP n % CP n % CP
Gender
Male 167 54.58 54.58 101 56.42 56.42 66 51.97 51.97 0.002*
Female 139 45.42 100 78 43.58 100 61 48.03 100
Total 306 100 179 100 100 100
Age groups (Years) c
37 (30, 44) 37 (30, 44) 38 (30, 45) 0.817
15 – 20 9 2.94 2.94 6 3.35 3.35 3 2.36 2.36
21 - 30 36 11.76 14.70 16 8.94 12.29 20 15.75 18.11
31 - 40 103 33.66 48.36 64 35.75 48.04 39 30.71 448.82
41 - 50 68 22.22 70.58 49 27.37 75.41 19 14.96 63.78
51 - 60 43 14.05 84.63 25 13.97 89.38 18 14.17 77.95
61. - 70 31 10.13 94.76 12 6.70 96.09 19 14.96 92.91
71 - 80 16 5.24 100 7 3.91 100 9 7.09 100
Total 306 100 179 100 127 100
Highest education 0.036*
Elementary school 123 40.20 40.20 93 51.96 51.96 30 23.62 23.62
High school 114 37.25 77.45 76 42.46 94.42 38 29.92 53.54
Graduate 43 14.05 91.50 6 3.35 97.77 37 29.13 82.67
Post graduate 26 8.50 100 4 2.23 100 22 17.33 100
Total 306 100 179 100 127

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Organization type < 0.001*
Government ownerships 41 13.40 13.40 24 13.41 13.41 17 13.39 13.39
Foreign ownerships 24 7.84 21.24 11 6.15 19.56 13 10.24 23.63
Private local ownerships 178 58.17 78.41 116 64.80 84.36 62 48.82 72.45
Others 63 20.59 100 28 15.64 100 35 27.55 100
Total 306 100 179 100 127 100
Work status 0.024*
Permanent 58 18.95 18.95 31 17.32 17.32 27 21.26 21.26
Contract 109 35.62 54.57 62 34.64 51.96 47 37.00 58.26
Daily wages 139 45.43 100 86 48.04 100 53 41.74 100
Total 306 100 179 100 127 100
aGroup 1-patients who were victims of major chemical skin burns and hospitalized.
bGroup 2-patients who were victims of minor chemical skin burns and treated in OPD (not hospitalized)
cAge as median (IQR) and compared by Mann-Whitney U test; Fisher’s exact test applied for categorical variables (%)

*Significant differences between groups (at p < 0.05), n = number of patient records, CP = Cumulative percentage
3.2 Data of chemical skin burns by industry

Hospital records provided data on eighteen industries in Fujian province where patients met with chemical
skin burns. Most of the skin burns’ cases were reported from the manufacturing of chemicals or chemical products’
industries (44; 14.38%), followed by the chemical processing industry (34; 11.11%), the textile industry (31;
10.13%), and the iron and steel products’ manufacturing industry (29; 9.48%). Apart from these processing and
manufacturing industries, cases of chemical skin burns were also reported from the services industries, e.g., building
cleaning and waste management services (15; 4.90%), and the tourism and hospitality industry (14; 4.58%), which
were further accompanied by the food and beverages manufacturing industry’s cases (16; 5.23%). The details are
summarized in Table 2.

Table 2: Chemical skin burns across industries according to hospitals records (from June 2017 to November 2017)
Industry n % CP

Chemical processing industry 34 11.11 11.11

Manufacturing of chemicals or chemical products 44 14.38 25.49
Agriculture 11 3.59 29.08
Cement manufacturing industry 7 2.29 31.37
Food and beverages industry 16 5.23 36.60
Iron and steel product manufacturing industry 29 9.48 46.08
Fabric dying industry 22 7.19 53.27

Textile industry 31 10.13 63.40

Machinery and equipment manufacturing industry 16 5.23 68.63
Rubber products manufacturing industry 12 3.92 72.55
Leather processing industry 18 5.88 78.43
Leather products, footwear, and jewelry business 6 1.96 80.39
Tourism and hospitality industry 14 4.58 84.97
Transportation industry 9 2.94 87.91

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Gas, electricity, and air conditioning equipment 4 1.31 89.22
Repair and maintenance of motor vehicles and motorcycles 7 2.29 91.51
Building cleaning and waste management 15 4.90 96.41
Pest control services and cleaning services 11 3.59 100
Total 306 100

n = number of patient records, CP = Cumulative percentage

3.3 Chemical skin burns: Incidents and characterization

3.3.1 Cause of incident

Table 3 data show that the chemical mishandling is mentioned as one of the most frequently reported
causes of chemical skin burns (168; 54.90%), followed by an inappropriate working place (77; 25.16%), e.g.,
slippery floor, broken floor tiles, old machinery and chemical equipment with leakage, etc., with other reported
causes (61; 19.94%), e.g., robbery, street fight, attempted suicide, etc.

Table 3 Incidents and characterization of chemical skin burns

Variable All Group 1 (Hospitalized)b Group 2 (OPD)b p-value

n % CP n % CP n % CP

Chemical skin burns- cause <0.001*

Mishandling of chemicals 168 54.90 54.90 117 65.36 65.36 51 40.17 40.17

Inappropriate working place 77 25.16 80.06 38 21.23 86.59 39 30.71 70.88

Others 61 19.94 100 24 13.41 100 37 29.12 100

Total 306 100 179 100 127 100

Location of skin burns 0.027*

Production 127 41.51 41.51 89 49.72 49.72 38 29.92 29.92

Laboratory 83 27.12 68.63 42 23.46 73.18 41 32.28 62.20

Cleaning industrial unit 37 12.09 80.72 19 10.61 83.79 18 14.17 76.37

Domestic 18 5.88 86.60 12 6.71 90.50 6 4.72 81.09

Others 41 13.40 100 17 9.50 100 24 18.91 100

Total 306 100 179 100 127 100

On-site first aid 0.015*

Available 69 22.55 22.55 24 13.40 13.40 45 35.43 35.43

Not available 193 63.07 85.62 136 75.98 89.38 57 44.88 80.31

Others 44 14.38 100 19 10.62 100 25 19.69 100

Total 306 100 179 100 127 100

Protective equipments <0.001*

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Sufficiently available 51 16.67 16.67 19 10.61 10.61 32 25.20 25.20

Not sufficiently available 118 38.56 55.23 82 45.81 56.42 36 28.35 53.55

Total 306 100 179 100 127 100

Training status <0.001*

Pre-job training 60 19.61 19.61 27 15.08 15.08 33 25.98 25.98

On job training 52 16.99 36.60 24 13.41 28.49 28 22.05 48.03

No training 194 63.40 100 128 71.51 100 66 51.97 100

Total 306 100 179 100 127 100

Burned surface area (%) 5 (1, 6, 9) 3 (1, 8) 6 (4, 11) 0.002*

Intentions for cosmetic/reconstructive 0.068

surgery

Yes 67 21.90 21.90 43 24.02 24.02 24 18.90 18.90

No 239 78.10 100 136 75.98 100 103 81.10 100

Total 306 100 179 100 127 100

aBurned surface area is presented as median (IQR) and compared by Mann-Whitney U test; Fisher’s exact test applied for categorical variables (%)
bGroup 1-patients who were victims of major or minor chemical skin burns and hospitalized. Group 2-patients who were victims of minor chemical skin
burns and treated in hospital OPD (outpatient door).
.*Significant differences between groups (at p < 0.05), N = number of patient records, CP = Cumulative percentage
3.3.2 Location of incident

Most of the chemical skin burns (127; 41.51%) were reported from the production units of the industries;
83 (27.12%) incidents happened in the laboratories; 37 (12.09%) incidents happened while cleaning the industrial
units, 18 (5.88%) incidents happened domestically and 41 (13.40%) incidents happened in the other locations.

3.3.3 Causative chemical agents

Table 4 shows that acids are the frequently reported cause of chemical skin burns (178; 58.15%). More
precisely, sulfuric acid was the most common causative agent of chemical skin burns (48; 15.67%).
Solvents/detergents (81; 26.76%) were also the reasons for chemical skin burns after the acids, followed by alkalis
(47; 15.36%). Out of 179 chemical skin burns victims, who got hospital inpatient stay, results showed that majority
of the patients were burned due to acids (127; 70.94 %), followed by the solvents/detergents (28; 15.65%) and
alkalis (24; 13.41%). However, solvents/detergents (53; 41.74%) were the common cause of skin burns among
patients who were treated in hospital OPDs, followed by acids (51; 40.15%) and alkalis (23; 18.11%). These details
are presented in Figure 1 and 2.

3.3.4 Availability of on-site first-aid treatment

Table 3 shows that 193 patients (63.07%) didn’t report the availability of first-aid treatment where skin
burns occurred due to chemicals, while 69 patients (22.25%) mentioned the availability of on-site first-aid treatment,
e.g., water irrigation of the wound, application of neutralizing agents on the wound, and emergency medicine.

9
Moreover, 44 patients (14.38%) mentioned other first-aid alternatives, e.g., transferring to the nearby medical
facility soon after when the skin burn incident occurred, etc.

3.3.5 Protective equipment

Only 51 victims (16.67%) out of 306 patients of the chemical skin burns cases reported the sufficient
availability of protective equipment and tools in order to deal with the chemical hazards where skin burn incidents
occurred, such as face masks, eye covers, coats, hand gloves, and emergency showers, while 118 patients (38.56%)
mentioned that protective equipments and tools were not sufficiently available. The majority of the chemically
burned victims, 137 patients (44.77%), reported the non-availability of such protective equipments and tools where
skin burns occurred.

3.3.6 Training status

Table 3 results show that 194 (63.40%) of chemically skin-burned patients did not have any kind of
training level to deal with chemical hazards. Only 60 (19.61%) out of 306 patients had prior training, while 52
(16.99%) chemical skin burn victims mentioned their on-job training status where chemical hazards occurred.

3.3.7 Intentions for cosmetic/reconstructive surgery

Out of 306 chemically burned patients, only 67 patients (21.90%) showed their intentions to undergo
cosmetic/reconstructive surgical treatment. However, the majority of chemically burned patients, 239 (78.10%),
didn’t prefer to further undergo cosmetic/reconstructive surgeries in order to cure their chemically burned skin.
Apart from these results, an increasing trend was observed for the cosmetic/reconstructive surgical treatment in
hospitalized patients (43; 24.02%) as compared to OPD patients (24; 18.90%).

Table 4 Causative agents of major and minor skin burns

Causative agents of skin burns All Group 1 (Hospitalized)b Group 2 (OPD)b

n % CP n % CP n % CP

Acids
Sulfuric acid (H2SO4) 48 15.67 15.67 41 22.91 22.91 7 5.51 5.51
Hydrofluoric acid (HF) 33 10.78 26.45 27 15.08 37.99 6 4.72 10.23

Phosphoric acid (H3PO4) 16 5.23 31.68 12 6.70 44.69 4 3.15 13.38

Hydrochloric acid (HCl) 24 7.84 39.52 16 8.94 53.63 8 6.30 19.68

Nitric acid (HNO3) 9 2.94 42.46 4 2.23 55.86 5 3.94 23.62

Acetic Acid (CH3COOH) 7 2.29 44.75 4 2.23 58.09 3 2.36 25.98

Bromic Acid (HBrO3) 4 1.31 46.06 1 0.56 58.65 3 2.36 28.34

Boric Acid (BH3O3) 11 3.59 49.65 7 3.91 62.56 4 3.15 31.49

Yellow phosphorous 22 7.19 56.84 14 7.82 70.38 8 6.30 37.79

Gold testing solution 4 1.31 58.15 1 0.56 70.94 3 2.36 40.15

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Alkalis
Calcium hydroxide(Ca(OH)2 11 3.59 61.74 7 3.91 74.85 4 3.15 43.30

Sodium hydroxide (NaOH) 14 4.58 66.32 8 4.47 79.32 6 4.72 48.02

Potassium hydroxide (KOH) 22 7.19 73.51 9 5.03 84.35 13 10.24 58.26

Solvents/ detergents

Phenol (C6H6O) 19 6.21 79.72 7 3.91 88.26 12 9.45 67.71

Chloroform (CHCl3) 4 1.32 81.04 1 0.56 88.82 3 2.36 70.07

Liquid ammonia (NH3) 11 3.59 84.63 3 1.68 90.50 8 6.30 76.37

3-Methylphenol(C7H8O) 3 0.99 85.62 1 0.56 91.06 2 1.57 77.94

Cleaning agent (unspecified) 37 12.09 97.71 14 7.82 98.88 23 18.11 96.05

Detergent (unspecified) 5 1.63 99.34 1 0.56 99.44 4 3.16 99.21

Ethylene (C2H4) 2 0.66 100 1 0.56 100 1 0.79 100

Total 306 100 179 100 127 100

aGroup 1-patients who were victims of major or minor chemical skin burns and hospitalized. Group 2-patients who were victims of minor chemical skin
burns and treated in OPD (not hospitalized).
n = number of patient records, CP = Cumulative percentage

Table 3 shows incidents and characterization of chemical burns of the skin and their analysis through a
comparison between hospitalized patients (placed in group 1) and non-hospitalized, i.e., OPD, patients (placed in
group 2). The mentioned results show that hospitalized and OPD groups were significantly different in chemical
skin-burn causes, protective equipment and tools, and training status (p < 0.001). In group 2, the majority of the
chemical skin burns victims protected themselves; as compared to the group 1 patients, with the protective
equipment, and possessed some kind of training as well. Further, the location of the incident and non-availability of
the first-aid treatment were the significant reasons, 0.027 and 0.015 respectively, for the majority of the chemical
skin burned and hospitalized patients. The total skin burned surface area of the hospitalized patients was also higher
(0.002) than OPD patients. Both of the patients’ groups were not significantly different (0.068 at p < 0.05) in terms
of their intentions for cosmetic/PRS treatments.

4. Discussion

Many strategies are developed to minimize the risks of chemical hazards at work; however, proper working
arrangements and provision of first-aid facilities alongside systematic managerial support are also helpful in
avoiding chemical skin burns incidents [23, 24]. Recently, the expansion of production capacities in corporations at
both government and local levels in parallel to foreign-owned organizations has increased demand for chemicals.
Consequently, the consumption of chemicals has been increased in almost every kind of industry. This
unprecedented growth in the consumption of chemicals has impacted young organizations, such as sole
proprietorships and private enterprises. However, the rise in chemical consumption in all kinds of government,
private, local, and foreign-owned ownerships has not proportionally improved workers’ education and training
standards for their safety. From this perspective and on the basis of the findings of this study, skin burns accidents

11
due to chemical mismanagement are found increasing throughout China, more precisely in Fujian Province.
Findings show that lack of information on chemical hazards, mishandling of chemicals, and the non-availability of
proper protective equipment and tools caused frequent chemical skin-burns. Private-local owned organizations had a
greater part of the chemical skin burn incidents than foreign and government ownership. The reasons for the
exceptionally large number of chemical skin burns in private-local organizations might be due to the management’s
improper investment in training and education programs to generate awareness among their workers about the
chemical burns. This discussion is also supported by Table 1 which shows that with the increase in education level, a
decreasing trend was observed among the hospitalized patients for major/minor skin burns due to chemicals.
However, this trend was found in a mixed tone among patients with minor skin-burn injuries and in hospitals’ OPD
units. Findings of this study support the notion that planning for the higher level of education, specialized courses,
and training may help to organize the working environment of private-local owned organizations to control/lower
chemical skin burns accidents, and generate awareness of properly managing chemicals at the site. Since complete
prevention is hard to meet, but effective managerial measures could be sought from the findings of this study and
could be implemented by local-private organizations to minimize the risks of chemical skin burn accidents. By
following the footprints of foreign-owned organizations, private-local owned organizations and government
stakeholders may develop long term strategic plans to help workers by providing them relevant training and
enhancing their capabilities of dealing with hazardous chemicals. Nation-wide strategic partnerships could be
developed with foreign companies to provide advanced chemical management training to private-local organizations
and those government organizations which are lacking behind in learning advanced methods of working in
hazardous chemical sites to ensure the overall safety of workers. Private-local organizations must be supported to
learn the latest management techniques from advanced countries or foreign-owned organizations, operating in
China, for overall safety, workers’ protection, and avoid chemical mismanagement.

Fujian provincial government recently supported the development of small and medium enterprises (SMEs)
throughout the province, which fueled the establishment of many SMEs that deal with the chemicals or chemical
processing for other industries. These developing SMEs might not be following the standardized safety precautions
while managing the operations of their chemicals. This might also be one of the reasons for the majority of skin-
burn incidents in Fujian province. Since this study was conducted in Fujian province, which is a new market to
report chemical skin burns hazards, findings show an increasing trend of chemical skin burns accidents in China

[25]. These findings are roadmaps for all the industries, which are consuming chemicals in any capacity in any

geographic location, to focus more on workers’ safety and improve their chemical management standards.

The present study shows that 54.58% of the chemically burned victims were males, and 45.42 were
females. Thus, the higher percentage of chemically skin-burned males than females shows that the results of this
study are in line with the research conducted by Hardwiche et al. [19]. Moreover, the majority of the chemically
skin-burned victims were daily wagers. The training and awareness level of these workers might be lower than the
permanent and contractual employees. These daily wagers might not be familiar with the appropriate handling of
chemicals, use of protective equipment, safety precautions and other general operational proficiencies. Hence, the

12
appropriate hiring of the workers, who have gone through some kind of training levels to handle the chemical
substances, may help to bring down chemical burns’ incident rate. The results of the present study suggest that
education, training, hiring of the competent staff, generating awareness by sharing information about the chemical
hazards, and sophisticated management’s supervision may help to control the skin burns due to chemicals in the
working environment.

Apart from the industries which are involved in the chemical business directly, chemical skin burns were
also reported from the non-chemical industries, such as, the transportation industry, the tourism industry, and the
hospitality industry. The potential causes of chemical hazards in such industries might be due to the lack of
awareness among the employees about the nature of the chemical substance. Acids, solvents/detergents, and alkalis
were commonly reported as the causes of chemical skin burns in Fujian province. Overall, acids were the most
frequent cause of skin burns. Additionally, this frequent trend was also observed among hospitalized patients, while
OPD patients reported skin burns mostly due to solvents/detergents. Since the present study results reported that
acids (58.15%) were the leading cause of chemical skin-burns followed by solvents/detergents (26.49%), these
results partially support the work of Xie et al. [8], where the authors discussed that acid (61.01 %) and alkali
(32.36%) were the leading causes of chemical burns in Guangdong province of China.

The various acids, cleaning agents, and detergents may cause chemical burns when their high-grade
solutions are used, e.g., hydrochloric acid and bleach. In cleaning agents, low-grade sulfuric acid is used which may
still be the cause of severe skin burns. Acids were reported as the cause of both major and minor skin-burns (as
mentioned in Table 4), however, solvents/detergents and most of the reported alkalis were the causes of minor skin
burns. Such chemicals may lead to fatal consequences, e.g., chemical poisoning and victim’s death [26]. These
results are consistent with the studies conducted by Xie et al. [8] and Ye et al. [25] where authors mentioned acids,
followed by alkalis, as leading causes of chemical skin burns. Additionally, inflammation could be experienced
which may damage the skin when chemicals get in contact with the human body [27]. Some alternative methods of
burn treatments are also noted by different scholars to treat burn wounds, such as aloe vera, honey, and bee pollen
are noted helpful to facilitate granulation of burn wound due to their anti-inflammatory, antiviral, antimicrobial,
antifungal, and immunostimulating properties [28, 29, 30].

Zorba et al. [31] also discussed that chemicals burned 13% of the cleaning workers in the industries when
they got in contact with the cleaning chemicals. Hence, the lack of proper chemical understanding in the non-
chemical industries may generate severe chemical hazards. Since the present study results reported a high
percentage of skin-burns due to unspecified cleaning agent (37; 45.68% ) in solvents/detergents category (81 cases),
these results provide support for the study conducted in Saudi Arabia where authors mentioned cleaning agents as
the most common cause of chemical burns [32].

Various first-aid treatments are mentioned for the acid burned victims, such as immediate washing of the
wound, and application of calcium on the burned skin area [26, 33]. Washing the chemically burned skin with
excessive water act as a cooling agent and, hence, serves as an effective first-aid treatment as well. If the cause of

13
burn wound is highly concentrated sulfuric acid, an exothermic reaction may be started during initial irrigation with
water. This can be minimized with a copious amount of water [34].

Certain chemicals may need some topical applications, e.g., phenols, before irrigation of the chemically
burned skin wound [35]. Therefore, the nature of causative agents should be identified before giving first-aid
treatment. It involves management responsibility to arrange and provide first-aid facilities on-site as well as provide
appropriate training to workers and others who are handling chemicals and where chemical skin burns may occur.
Although findings (Table 3) show that on-site first-aid facilities helped chemically skin-burned patients and reduced
the risk of major skin-burns resulting in lower hospitalization stay, the management of the organization still needs to
improve the provision of first-aid facilities and its training to the workers in order to properly manage the risk of
chemical burns. Administrative measures could be adopted to provide safety data sheets (SDS) to workers to
communicate the nature of the hazardous substance and precautionary measures. Management may adopt global
harmonized system (GHS) product labeling guidelines, such as, product identifier, manufacturer’s contact
information, hazard pictogram, i.e., toxicity, carcinogenicity, and irritants, signal words, e.g., danger, warning, etc.,
hazard statement, e.g., harmful if swallowed or having direct contact with body, etc., and precautionary measures
[36] to help workers and others for the safe handling of chemicals and avoid accidents of chemical skin burns. Some
of the chemical burn cases have been shown in figure 3 which were captured after getting permission from the
patients. These patients got burn wounds due to mishandling of chemicals and hurt their obvious body parts, such as
face, legs, and hands. Moreover, management should generate awareness among the workers about the
precautionary measures to be adopted while handling chemicals, e.g., wearing rubber gloves, coats, shoes, face
mask, and wearing other protective gear. Ye et al. [25] note that protective equipment and tools for head, neck, and
extremities may help to minimize the accidents of chemical skin burns. This phenomenon demands proper planning
and policymaking in order to control the potential hazards of the chemical burns. The majority of the chemically
skin-burned patients aged 31-60 years old (69.33%) as presented in Table 1. It could be due to the reason that
patients of this age group might actively be involved in work-related activities, and these results are consistent with
the results of Xie et al. [8] and Li et al.[37]. Hence, these facts should be considered while selecting and providing
training to the employees/workers.

Burn injuries often involve prolonged hospitalization. However, burn victims may pass through serious
body disfigurement which may bring severe emotional stress for burn victims alongside negatively impacting their
health and wellbeing [38, 39]. PRS may be an effective approach to bring burn victims’ quality of life. Findings
show that the majority of the skin burned patients didn’t show their intentions for cosmetic/reconstructive surgery. It
is noted that reconstructive surgeries are complicated and may be prolonged until victims’ expectations are met or
there is nothing more left to offer [38]. Findings show that the preference for cosmetic/reconstructive surgical
treatment was higher among the hospitalized patients, who had major skin burns, as compared to the OPD patients
who reported minor skin burns. Since the majority of the skin burned patients were daily wagers with a probability
of their poor financial resources, some of the possible reasons for not preferring cosmetic/reconstructive surgical
treatment could be the availability and costs of treatment. Nevertheless, workers or others who are having a direct
encounter with chemicals and meet with their burn accidents must be prepared for reconstructive surgeries, in case

14
needed, alongside providing training to prevent burn accidents. This will be helpful to motivate burn victims with
brighter prospects of life after reconstructive surgeries and mentally prepare them to undergo PRS and prolonged
hospitalization because a depressed or unmotivated patient will not think or go after cosmetic/reconstructive
surgeries due to psychological trauma [38]. The government may support chemically skin-burned victims with the
affordable cosmetic, plastic, and reconstructive surgery opportunities, in tandem with other rehabilitation options, so
that the chemically skin-burned victims may again become a productive part of the society. Governments may
benefit from the unprecedented growth of medical tourism which increasingly involves cosmetic surgeries at
affordable costs across the globe [14, 16]. It will help to bring overall improvement in the quality of life of skin burn
victims by spending time on therapeutic places.

A proper understanding of chemical, health, and wellness systems alongside their planning, policymaking,
and management is needed to steer the overall mechanism of a healthy business environment. The government needs
to undertake a proactive inspection of working units to control the potential chemical hazards and provide all the
possible first-aid and recovery treatment in a timely manner.

This study has certain limitations. First, this study was conducted in Fujian province. The causes of
chemical skin burns may be different in other geographies. Although the reported skin burns cases are documented
in many industries across the Fujian province, there could be still many other kinds of industries where chemical
skin burns might have occurred and not reported, which needs to be counted. This study solely focused on the
chemical burns of the skin; however, chemical burns of the eye, internal organs or other parts of the body were not
under the scope of this study. The future studies may be conducted in other regions with efforts to incorporate the
other industries’ data. Despite chemical burns of the skin, chemical burns of the other parts of the body can also be
studied in the light of the findings of the present study. Although the present study is the first research attempt in
order to study chemical burns of the skin in both hospitalized and non-hospitalized groups, it might be possible that
many chemically burned victims who didn’t visit any Fujian provincial hospital are likely to happen and, hence, not
reported in this study.

5. Conclusion

Incidents of chemical skin burns can be controlled/minimized through improvement in the managerial
supervision, appropriate policy-making, hiring of professional workers, workers’ safety education, training
programs, appropriate handling of the chemicals with protective equipment, and governmental regulations. All these
measures may help to create awareness among the workers about the chemical burns of the skin. The role of
government is also important in supporting the chemically burned victims, to bring improvement in their quality of
life by providing all the available treatment options, such as, cosmetic/reconstructive surgery, which is not
economical and common in its general understanding. This study provides important data and discussion for the
workers, doctors, hospitals, industries, and others to understand the potential hazards of chemicals and manage them
to prevent chemical skin burns and help to improve workers’ wellbeing.

15
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Fig 1 Causative agents of skin burns in Group 1 (Hospitalized)

Fig 2 Causative agents of skin burns in Group 2 (OPD)

Fig 3a Picture of chemically burned patient-leg 1

Fig 3b Picture of chemically burned patient-leg 2

Fig 3c Picture of chemically burned patient-face

Fig 3d Picture of chemically burned patient-hand

Appendix A

Questionnaire form

Title of the research project

Chemical mismanagement and skin burns among hospitalized and outpatient door (OPD) patients.

Section A

Patient’s Background information

Name ______________________________

Contact/Email________________________
Nationality Chinese

Profile

Please tick () the appropriate option:

Gender: Treatment registry unit

(1) Male (2) Female Inpatient Outpatient door

Age groups: (OPD)

(1) 15-20 Years old (2) 21-30 years old

(3) 31-40 years old (4) 41-50 years old

(5) 51-60 years old (6) 61-70 years old

(7) 71-80 years old

Education:

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(1) Elementary school (2) High school

(3) Graduate (4) Post graduate

Nature of working organization:

(1) Government owned set-up (2) Foreign owned set-up

(3) Private-local owned set-up (4) others

If others, please mention details

Nature of employment
(1) Permanent (2) Contractual

(3) Daily wages

Please mention the nature of industry’s business where accident happened:

(1) Chemical industry (2) others

If others, please mention the details:

Please mention the nature of chemical which caused skin burns:

(1) Acids (2) Alkalis

(3) Solvents/detergents (4) others

Please briefly write the name of the chemical substance (if known):

If others, please mention the details

Which of the following reasons caused chemical skin burns?

(1) Mishandling of chemicals (2) Inappropriate working place

(3) Others

If others, please mention the details:

At which of the following locations chemical skin burns accident happened?

(1) Production (2) Laboratory

(3) Industrial cleaning unit (4) Home

(5) Others

If others, please mention the details:

Were first-aid facilities available on-site where skin burns accident happened?
(1) Yes (2) No

(3) Others

If others, please mention the details:

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Were protective equipments sufficiently available on-site where skin burns accident happened?

(1) Yes (2) No

(3) Others

If others, please mention the details:

Please mention if any training had before handling chemical substance.

(1) Pre-job training (2) On-job training

(3) No training at all.

If others, please mention the details:

Please mention the details of total burn surface area (TBSA).

(1) First degree burn (2) Second degree burn

(3) Third degree burn

Additional details (if any)

Are there any future intentions to avail cosmetic/reconstructive surgical treatments?

1) Yes (2) No

(3) Others
If others, please mention the details:

Corresponding researcher’s details:

Name:

Email:

Mob:

Institute:

Study Ethics approved by: Union Hospital Fuzhou (UHF 2017-03-014)

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