Spectrum and Possible Appropriate Technology for Specific Protection against Cutthroat Kite String “Manja” Injury : Annals of Indian Academy of Otorhinolaryngology Head and Neck Surgery

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Spectrum and Possible Appropriate Technology for Specific Protection against Cutthroat Kite String “Manja” Injury

Tank, Nitishkumar D; Palkhade, Rajendra1; Dhatrak, Sarang Vilas; Chavhan, Snehal Prakash

Author Information

Health Science Division, ICMR-National Institute of Occupational Health, Ahmedabad, Gujarat, India

1Biological Science Division, ICMR-National Institute of Occupational Health, Ahmedabad, Gujarat, India

Address for correspondence: Dr. Snehal Prakash Chavhan, Health Science Division, ICMR-National Institute of Occupational Health, Meghani Nagar, Ahmedabad - 380 016, Gujarat, India. E-mail: [email protected]

Received December 14, 2022

Received in revised form February 23, 2023

Accepted March 09, 2023

This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 4.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Annals of Indian Academy of Otorhinolaryngology Head and Neck Surgery 6(2):p 31-34, Jul–Dec 2022. | DOI: 10.4103/aiao.aiao_13_22
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Abstract

INTRODUCTION

Like past, this year also the auspicious occasion of Makar Sankranti (Uttarayan) got stigmatized due to news items on incidences of deaths and cutthroat injuries to bike riders reported in print media. Such news made us think to know how much is the burden of such accidents? What kind of injuries are caused by kite string ‘manja’, and whether such incidents can be prevented and sanctity of this pious festival can be maintained?!! To get the answers we conducted a literature search on the medical databases such as PubMed, Semantic Scholar, and Google Scholar and reviewed full-text articles. We also searched on Google for news reports in digital print media on injuries during kite-flying season. This narrative review not only focuses on different types of injuries sustained due to kite string during kite-flying season but also tries to draw attention on deadly cutthroat kite string injuries. Further, we did not limit ourselves to delineating the problem but we have tried to find out possible solution by emphasizing on protective role of inverted “U” shaped aluminum bar/guard adopted by Gujarati community in Uttarayan (Makar Sankranti) which can act as preventive strategy against cutthroat kite string injuries and help prevent biker’s deaths.

METHODS OF LITERATURE SEARCH

In search of articles on kite string injuries and its preventive strategies, we began by conducting an online search on PubMed, Semantic Scholar, and Google Scholar databases. Boolean search using keywords such as “Kite String and Injury, Manja and Injury, Bike riders and Cutthroat injuries” were done. We also looked into news reports published during the period of Makar- Sankranti on digital print media regarding kite string injuries using Google search engine. Other research articles were discovered manually from the citations. Eligible studies included only full-text articles based on observational and analytical design, case series, and case reports which were available without subscription charges and downloadable in PDF format. There were studies which were concurrently present in all three databases but we opted for that database which gave us the subscription free access which avoided the overlap of studies to certain extent and we could review total number of articles 30 (9 PubMed, 1 Semantic Scholar, 9 Google Scholar, and 11 news reports) [Figure 1].

F1-1
Figure 1:
Methodology of literature search

STATUS OF KITE FLYING

Kites are thought to be invented in China and then spread across different parts of the world.[1] Kite is now global sport, especially in South East Asia.[2] A fact that many International Kite Festivals are organized in different times of year all over the world which depicts it all round popularity.[2,3] Kites are cultural part of India. In festival of Makar Sankranti/Uttarayan, falling in mid of January every year, whole India rejoices the kite-flying activity. In some parts like Hyderabad in Telangana, kite flying starts a month before Makar Sankranti. Kite flying is a mode of celebration on some other festivals also such as Republic Day, Independence Day, Raksha Bandhan, and Janmashtami. Every year Indian state of Gujarat celebrates a globally popular International Kite Festival for 3 days just before Uttarayan in cities such as Ahmedabad, Vadodara, and Surat.[3] “Kite fight” is a common scene in these festive days in which a kite flyer tries to win or cut the kite of another person. Over the years, competitiveness in kite fighting has made people use dangerous methods to make their thread strong and sturdy. In the past, kite strings were usually made up of cotton. Later, elastic strings and nylon strings got introduced in market and now a day’s kite flyers are applying hazardous materials such as metallic powder, glass powder, and chemicals on cotton string for purpose of kite fighting which is called as “Manja.” Introduction of Chinese manja which is made of nylon has made situation even worse. Such deadly strings have turned a docile act of joyful kite flying into a dangerous affair and now it has become reason for severe injuries, disabilities, and deaths each year.[4]

TYPES OF INJURIES CAUSED BY MANJA

Hand injuries

In case series from Aligarh, India, 11 patients reported kite-related hand injuries in 2 years, total number of injured digits were 14, total number of injured tendons were 26, and 1 patient had nerve injury.[5] A study done in Jaipur, India, also reported that in a single month of January, 187 cases of kite-related injuries were encountered, out of which 28% of kite-related injuries involved upper extremities.[6]

Ocular injuries

A result of prospective cohort analysis of ocular injuries in 6 years (2014–2019) due to kite string during the season of Makar Sankranti conducted at a tertiary eye care center in Jaipur, India, showed that out of 68 patients with kite-related ocular injury there were 73.52% cases of globe injury and 26.47% cases of adnexal tissue injury. Among globe injury patients, open globe injury was 52.93% and closed globe injury was 16.17%. The major ocular injuries seen in descending order were globe rupture (29.4%), isolated lid tear (26.5%), and lid tear along with corneal tear in (13. 2%) patients.[7]

Neck/cervical injuries

A study done in Jaipur, India, reported that out of total 359 trauma cases presented to the accident and emergency department in kite-flying season of 2018, 52.08%, i.e.,187 patients were of direct trauma from kite strings and among them head and neck (59%) was the most frequently affected region. They divided patients into two groups Group A – kite flyers and Group B of passively injured persons. In Group B trauma cases, commonly injured area was head-and-neck region, i.e.(65%).[6] A prospective analysis of 104 patients (outdoor and indoor) with manja injury from January 2011 to January 2015 was carried out at Civil Hospital, Ahmedabad, where authors found majority of the injuries occurred while driving or in pedestrians with the neck being the most commonly affected body part.[8] A rare complication of kite string injury has been reported from the United Kingdom in which patient developed pseudoaneurysm of facial artery consequent to blunt arterial trauma by string of a wondering kite.[9]

Cutthroat injuries have also been published previously as case series[10] and case reports from India.[11,12] A rare case of subcutaneous facial emphysema has also been reported from Nagpur, Maharashtra, where cutthroat injury by “Manja” was implicated as responsible factor.[13] A complicated case of cutthroat injury from manja was also reported from Bangladesh.[14] In study done in brazil where kite flying also cultural activity out of 13 patients/victims (12 men and 1 woman) of kite string injuries, 11 victims were bike riders, 1 victim bicycle rider, and 1 was riding a horse. This study clearly emphasizes on an increased risk of cutthroat injuries, particularly to bike riders.[15] A study conducted in Basant festival which equivalent to Makar Sankranti in Pakistan showed that kite flying was responsible for 139, i.e. 7.09% of all admissions in hospitals in kite-flying season. Out of these reported cases, 12 (8.6%) had head trauma and 15 (10.8%) had sustained cutthroat neck injuries because of chemical-coated manja.[16] Besides these published literatures many news reports in digital media showcase deadly nature of manja.[17-20]

Leg injuries

A study done on 30 cases of manja cut injury presenting to a tertiary care center at Nagpur in years 2017, 2018, and 2019 showed that the neck, face, legs, and hands are the typically most affected sites as most of the patients are traveling on a speedy two-wheelers.[21]

All of the above evidence suggests potentially hazardous nature of kite string injury and its special risk to motorcyclists, cyclists, and pedestrians.[22] Innocent people may become a victim of kite string injury owing to kite string coming in their vicinity without attracting their attention.[23] For bike riders, the speed of vehicle becomes an attributable factor which dictates the expanse as well as depth of injury and resultant severity of trauma to the neck. High driving speed leads to more grievous injury to soft tissues of the neck and face by the slitting action of manja. In response to risk involved in kite flying, the Egypt government has tried to curb this menace by banning kite flying.[24] Honorable National Green Tribunal of India also has taken up steps in this regards and has banned Chinese manja considering its injurious nature by order dated July 11, 2017,[25] but off late reports are emerging that glass-coated manja also has same hazardous effects as that of Chinese manja.[26] Acting on this issue Honorable Gujarat high court has also imposed ban on glass-coated manja.[27] Despite of ban, both types of manja are still available in market and reports of injuries keep coming up every now and then in news media.[28] This situation highlights the fact that in India it is impossible to ban kite flying and the use of manja because it is a part of Indian culture. Considering grave nature of injuries linked to manja, Gujarat home department has asked for records related to slitting of throats by kite threads from districts across the state, such data will not only unearth the hidden burden of cutthroat injuries by manja but also will lead to affirmative action by states for prevention of manja injuries.[29]

PREVENTIVE/MITIGATION MEASURES

When we tried to find out a preventive strategies against kite string injuries, we came to know that the existing literature is mainly coming from hospital settings where main focus is on secondary prevention strategy of early diagnosis and prompt treatment, i.e. surgical management.[9,14] Some articles did report strategies for primary prevention such as health promotion, where authors have talked about awareness generation about deadly nature of manja, safe place of kite flying away from roadside, legislative approach by banning kites, etc.[10,16]

Talking about specific protection only one article had given a cursory remark about role of protective devices on bikes.[8] However, we would like to highlight on innovative strategy of Guajarati community which has invented a “Make in India” cost-effective measure to reduce cutthroat manja injury. This strategy is installation an inverted “U” or “V” shaped aluminum bar on bike handles [Figure 2]. This is a lightweight bar/guard which fits perfectly on bike handle and it is fastened by screws [Figure 3]. Its placement does not affect the vision of rider. This guard has two bends, one at level of mirror of bike which decreases the gap between bar and rider and second bend at top which allows manja to pass over rider’s head, thereby preventing a contact of manja with bike rider’s neck. The guard costs only around 50–60 rs. which makes it an economical measure, which can be adopted by everyone. This kind of bar/guard is voluntarily installed in state of Gujarat during season of Uttarayan. Considering the nationwide problem of cutthroat injuries due to manja we would like to advocate that adoption of this kind of measure should be made mandatory during kite-flying season for bike riders in other states of India as well where kite flying is performed. People should be encouraged to install these guards at least 15 days before and after the festival of Makar Sankranti because it is reported that people start kite flying well before actual season and cases of cutthroat injuries start showing up advance in time of kite-flying season.[30]

F2-1
Figure 2:
The protective guard on bike
F3-1
Figure 3:
Positioning of protective guard on bike

Although responsible citizens of Gujarat set an excellent example by voluntarily installing this kind of bars/guards during Uttarayan, the situation still remains bilk because its adoption is meager which is suggested by news of cutthroat injuries from Gujrat during festive season. Situation in other states is even worse as this kind of protective practice is not seen at all, such circumstances warrant an urgent promotion of such bars/guards in other states such as Maharashtra, Rajasthan, West Bengal, Telangana, Odisha, and Andhra Pradesh where kite flying is cultural activity. The only limitation with this bar/guard is that the pillion rider may not get same amount of protection as that front rider but for front riders who bear the major brunt of cutthroat injuries, its benefits are immense.

CONCLUSION

Sporadic and seasonal reporting of kite string injuries makes estimation of its burden a difficult task such situation creates a need for record-keeping exercise of all cases of kite string injuries by state governments to come up with preventive strategy. Frequent media reports and case reports of deadly cutthroat injuries make us realize that this is a significant public health issue. Despite knowing the danger of manja, people are reluctant to quit its use, which warrants a measure more effective than awareness creation for preventing such injuries. In such scenario “Made in India” low cost appropriate technology of inverted “U” or “V” shaped aluminum bar/guard can make huge difference by averting preventable cutthroat kite string injuries and can act as a boon for bike riders who ride bike during kite-flying season.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

REFERENCES

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      Keywords:

      Cutthroat injury; kite string injury; manja injury; specific protection

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