An estimated 7 million people die of burn injuries every year in India, making it the largest group of injuries after road accidents. 80% of those who suffer burn injuries are women and children. Almost 1-1.5 lakh people get crippled and need multiple surgeries and prolonged rehabilitation every year.

According to The Lancet, in 2019 over 23,000 fire-related deaths were estimated in India which is about 20% of the global mortality burden. Additionally, 1.5 million DALYs (disability-adjusted life-years) were attributed to burns. The burden of burns among women (aged 15–49 years) in India is three times higher than that among men. Factors like unsafe cooking and kitchen practices, suicides, homicides associated with domestic violence, dowry-related conflict and acid throwing cases make women more vulnerable to burns. Burn cases also come from industrial workers and corporates.
 
For patients with burns, donated skin functions like band aid for a short time, reducing pain and decreasing the risk of infection and potentially save their lives. For patients with large burn wounds, early burn closure becomes critical as the infected burn can lead to systemic sepsis and is also the major cause of death in such patients in India. Gradually grafted skin wears off and new skin grows out.
 
Even though the skin is the largest human organ, awareness on skin donation is very low in India. Despite the fact that India contributes to a huge global burden of burn related deaths and survival of burns patients critically depends on availability of skin, India has acute shortage of skin for such patients. On the other hand, burn prevention is one of the major public health programs around the world.
 
In India, one of the oldest burns units, at KEM Hospital, became operational in 1981 and India’s first Skin Bank was set up at Sion Hospital in 2000. Though India now has around 67 burn centres and more than half in private sector their geographical distribution and service availability is uneven.

“Lakhs of people need skin but only hundreds donate. Our biggest challenge is to be in constant touch with the relatives so they don’t change their mind for donation because either they are scared, emotional or there is lack of awareness,” says Jaishree Damani, a volunteer with Sunday Friends, a voluntary organisation.

Since 2002, Sunday Friends (http://sundayfriends.in/) has been working on creating awareness on skin donation. The family of a deceased  person wanting to donate skin contacts its volunteers who then connect them with doctors at Municipal Sion Hospital, Masina Hospital (charitable) at Byculla or National Burns Centre(NBC), a private facility at Airoli in Navi Mumbai, depending on closest proximity. The hospital will then require a death certificate, cause of death, age of the deceased person, if there is any skin related problem. A doctor, a trained technician and two ward boys are then sent to the donors place for skin extraction which takes an hour to extract, complete the dressing and hand over the body to their family. No blood group matching is required in skin grafting.

“There is acute shortage of skin and we don’t have the amount of skin required. We have monthly skin requirement of 100-150 patients but only have 20-25 skins in our bank. Only the first layer of skin is extracted. We need to remove myths on skin donation and create more awareness through media and social media so that more and more people are willing to donate skin,” says Charudutt Vaidya, skin bank coordinator at Masina Hospital.

In Sion Hospital too, which gets 700 patients on an average, there is not enough skin in Bank
With only one-eighth thickness of the skin extracted in a surgical procedure through an instrument called Dermatome or an instrument that is in the shape of a big razor (used in public facility). There is no blood loss and no internal organs are exposed during extraction. No blood or age group match is required for skin donation and skin donation has to be done within 6-8 hours of a donor’s death.

As skin is stretchable; taller the donor, the more skin can be extracted. Skin is generally grafted from legs, back and abdomen. Anyone over 18 years who does not have Hepatitis B, skin disease, AIDS, HIV and preferably no diabetes at the time can donate skin. On the death of brain-dead people, their full body can be donated. Skin harvesting is done by plastic surgeons and same skin can be used by specialists like surgeons and general/orthopedic surgeons.

Extracted skin is taken to the laboratory in a chemical-filled bottle and it is further chemically treated 19 times over. If serology and microbiology reports are satisfactory the grafts can be preserved in minus 70-80 degree C in a special storage freezer up to five years. Skin is grafted on patients in layers depending on the gravity of infection. Grafted skin wears out in three weeks, by when the original skin grows out.
 
In India, donation and transplantation of human organs and tissues is governed by the Transplantation of Human Organs and Tissues Act (THOTA) 1994 and amended in 2011, as well as the Transplantation of Human Organs and Tissues Rules, 2014. Skin donation cannot be done by patients of HIV, Hepatitis B or C, STDs (sexually transmitted diseases), Septicemia, skin cancers or skin diseases.

At a Skin Bank, skins grafts are available at nominal rates and are of excellent quality and processed according to all international standards. Charges are taken only for the procedure in a government facility while costs are higher in a private hospital.

A Skin Bank organisation is complex and requires continuous updating. Record-keeping in a skin bank has fixed protocols. After consent for skin donation of deceased, the relatives have to sign a consent form and give the death certificate after which manual coding is done. The record book mentions the name of patient, weight, residence, next of kin, the number of grafts taken and given to whom, the patient’s response to grafting, if the doctor was satisfied with the quality of skin, time of collection, etc, among other things and has to be precisely recorded. Skin bank operators have to be trained with periodic checks for responsibility.
 
“As there is a cost for running a skin bank which includes cleaning, processing and preservation of skin as per the protocol to be followed, sending the team for collection, sampling of skin to rule out Covid positivity, having disposable blades among other things, only if the bank has enough skin it can function,” says Dr Suhas Abhyankar, professor and head, dept of plastic surgery, DY Patil School of Medicine, Nerul, Navi Mumbai, and consultant Masina Hospital Skin Bank and Research Centre.
‘At Sunday Friends we are taught to create awareness in a single person before every meal for our good Karma. Every call we complete gives us the feeling of doing our Karma and a sense of accomplishment,” says Damini.

Another volunteer at Sunday Friends for the last 21 years, who does not wish to be quoted, says, “Government must create awareness on skin donation. A small country like the Netherlands has made skin donation compulsory after death. We dispose of bodies. Instead, our society needs to get sensitised for skin donation so lives of burns patients can be saved. Two eyes can give sight to two people and skin donation can give life to minimum one person.

“Majority of burns patients are poor and related to dowry cases and for that reason we work with general hospitals like Sion and Masina. At least 500 cases we see are of dowry deaths. Along with NBC, free camps are held for free treatment of burns patients. Poor people don’t know guidelines. For those from the below poverty line we guide them about how to avail benefit of government policies and schemes like Rajiv Gandhi Jeevandayee Arogya Yojana etc, through their ID cards like Aadhaar card, pan card or ration card and also help bridge their deficit funds through our trust. We have seen that 80%-85% burns patients benefit with skin donation,” says the volunteer.

Volunteers at Sunday Friends have been provided with an office at Sion Hospital and they work 24x7.  Calls for skin donation are generally received from 7 pm onwards till early morning. They keep themselves updated on new developments on donation and organise awareness seminars with help of doctors to motivate and convince people for donation. Sunday Friends has helped provide tools and equipment required for skin extraction for doctors and technicians.

“Masina Hospital gets 3-6 new burns cases every week but the hospital has skin shortage and there is no skin in the bank. On an average 4-8 skin donations are received in a month. More burns cases are received from Diwali onwards till February-March with higher numbers of suicides, dowry and accident cases. During monsoons the number of cases is low. With 19 Burns Beds, 70% to 80% are occupied on an average. Often patients come with 80%-90% burns,” says Dr Abhyankar. He adds that the skin bank at Masina was set up in 2017 and received sufficient amount of skin till 2019 but the numbers went down drastically during the pandemic as the skin of Covid positive patients cannot be donated.