Alcohol use, aquatic injury, and unintentional drowning: A systematic literature review

Drowning incidents precipitated by unusual causes (DIPUCs): A narrative review of their diagnoses, evaluation and management

Drowning is a cause of significant morbidity and mortality worldwide. In most circumstances, the proximate cause is attributable to human factors, such as inexperience, fatigue, intoxication, or hazardous water conditions. The phenomenon of drowning incidents precipitated by unusual circumstances (DIPUCs) - either fatal or nonfatal - involving otherwise healthy individuals under generally safe conditions has not been comprehensively addressed in the medical and drowning literature to date. In this review, we discuss etiologies of DIPUCs, diagnostic clues, suggested workup, suggested postmortem testing, and implications for surviving patients and families. Identifying the cause of a drowning incident can be extremely challenging for the initially treating physician, relying perforce on historical context, environmental clues, physical exam, medical history, eyewitness accounts or video recordings. If no clear explanation for a drowning incident emerges despite a thorough investigation, clinicians should consider some of the less common diagnoses we describe in this paper, and, when appropriate, refer for an autopsy with postmortem molecular genetic testing. While time-consuming, these efforts can prove life-saving for some non-fatal drowning victims and the families of all victims of DIPUCs.

The prevalence of alcohol-related deaths in autopsies performed in Lithuania between 2017 and 2020: a cross-sectional study

BACKGROUND

Consumption of alcohol is a risk factor for non-communicable and infectious diseases, mental health problems, and can lead injuries and violence. The aim of this study was to evaluate the prevalence of alcohol-involved deaths among decedents who died of external causes and underwent autopsy in Lithuania.

METHODS

Study includes age persons of any age (from 0 to 110 years) who died and were autopsied in Lithuania from 1 January 2017 to 31 December 2020. Data were obtained from the Lithuanian State Register of Deaths and Their Causes.

RESULTS

Among external causes of death, the presence of alcohol was detected in 55.0% of cases. Male decedents had a significantly higher number of positive BAC level recorded, at 46.6%, compared with female decedents (32.1%; P < 0.001). The highest incidence of deaths where the alcohol was detected in the deceased's blood was found when the decedent was listed as being in the victims of assault group (71.5%, 95% CI 65.4-77.2). However, the highest median BAC score was found for those in the accidents group (59.7%, 95% CI: 58.2-61.2, BAC 2.42 ‰, IQR 1.86).

CONCLUSIONS

The findings of this study suggest that alcohol use may be a contributing factor in a wide range of fatal incidents, including accidents, injuries, and cases of violent intent. Inequalities between males and females were identified, with a higher proportion of males with alcohol detected in blood at the time of death.

Child drowning mortality in Israel: Trends and measures for prevention

INTRODUCTION

In this study, we use the media-based database of Beterem-Safe Kids Israel, to provide a 15-year review of unintentional fatal childhood drowning in Israel, between 2008 and 2022.

METHOD

It total, we identified 257 cases of child mortality due to drowning during this period.

RESULTS

Our results demonstrate a gradual rise in childhood mortality due to drowning, from 72 cases in 2008-2012, to 85 cases in 2013-2017, and to 100 cases in 2018-2022. Especially worth noting is the increase in childhood drowning in domestic swimming pools. We point to a link between low socioeconomic status and cases of drowning, showing that the risk of drowning extends beyond a mere matter of caregiver inattention. We recommend a series of regulatory and legislative steps to reduce fatal childhood drowning, including fencing built around domestic swimming pools, extending lifeguard activity hours, adding declared beaches, forming programs of safe behavior in water environments for adolescents, and establishing swimming lessons during the 2nd grade, for all populations. We further recommend that a special focus will be put in municipalities situated at the bottom of the socioeconomic index.

Young people's alcohol use in and around water: A scoping review of the literature

ISSUES

The surrounding social and commercial context, including alcohol advertising, heavily influences alcohol consumption. Alcohol use is a major risk factor for both fatal and non-fatal drowning, particularly for young people.

APPROACH

We conducted a scoping review to explore the peer-reviewed literature on the use of alcohol by young people (aged 15-34 years) in the context of aquatic environments. Five electronic academic databases were searched for English-language studies conducted in high-income countries and published in the last 15 years (since 2008). The MetaQAT framework was used to assess methodological quality of included studies.

KEY FINDINGS

The review included a total of 24 studies, including those addressing the prevalence of and/or risk factors for alcohol use in aquatic environments among young people (n = 13); the epidemiology of alcohol-related unintentional drowning in young people (n = 9); and interventions to reduce alcohol-related harm around water (n = 3). Findings suggest that young people commonly consume alcohol around water, particularly young men. We found multiple influences on this behaviour, including the perception of risk, location of aquatic activity and presence of others, particularly peers.

IMPLICATIONS

Understanding the literature addressing alcohol use around water among young people will assist in identifying and setting priorities for drowning prevention, including the need to mitigate the effects of alcohol advertising which promotes drinking in and around water.

CONCLUSION

There is a clear imperative to address the use of alcohol by young people in aquatic environments. These findings have key implications for public health policy, advocacy and practice.

Mixed-methods community assessment of drowning and water safety knowledge and behaviours on Lake Victoria

BACKGROUND

Drowning is a major cause of death in Uganda, especially among young adults with water-based occupations and livelihoods. Information about drowning and other water-related deaths and injuries is limited. To address this gap in knowledge, study partners assessed knowledge, attitudes and beliefs about drowning and drowning prevention interventions in the Mayuge district of eastern Uganda.

METHODS

This study consisted of a mixed-methods, cross-sectional community health assessment. Research was conducted in 10 landing sites of 6 subcounties within Mayuge district bordering Lake Victoria and focused on 505 head-of-household interviews, 15 key informant interviews, 10 landing site observations and 3 focus group discussions with 10 young adults each.

RESULTS

While landing site observations revealed high lake use, households reported limited community drowning prevention knowledge and revealed risky behaviours and attitudes towards water safety. Less than one-third (30.9%) of participants reported that at least one family member can swim. 64.2% of all respondents reported no existing safety measures (eg, signage, fences) around the lake and 95.8% reported no aquatic emergency response system in their community. The majority of households (85.7%) had experienced a drowning incident in their area. Key informants and focus group participants were eager for community-based interventions and offered solutions that reflected international drowning prevention recommendations.

CONCLUSIONS

The results reveal gaps in services, access and knowledge and highlight a need for water safety services and interventions in lakeside communities in Uganda and throughout the Lake Victoria Basin.

Association between air temperature and unintentional drowning risk in the United Kingdom 2012-2019: A nationwide case-crossover study

OBJECTIVE

Drowning is a leading cause of death. The World Health Organization (WHO) and United Nations (UN) emphasise the need for population-level data-driven approaches to examine risk factors to improve water safety policies. Weather conditions, have the potential to influence drowning risk behaviours as people are more likely to spend time around water and/or undertake risky activities in aquatic spaces as a behavioural thermoregulatory response (e.g., seeking coolth).

METHODS

A case-crossover approach assessed associations between changes in daily maximum air temperature (data from the nearest weather station to each drowning event) and unintentional drowning risk using anonymous data from the validated UK Water Incident Database 2012-2019 (1945 unintentional deaths, 82% male). Control days were selected using a unidirectional time-stratified approach, whereby seven and 14 days before the hazard day were used as the controls.

RESULTS

Mean maximum air temperature on case and control days was 15.36 °C and 14.80 °C, respectively. A 1 °C increase in air temperature was associated with a 7.2% increase in unintentional drowning risk. This relationship existed for males only. Drowning risk was elevated on days where air temperature reached 15-19.9 °C (Odds Ratio; OR: 1.75), 20-24.9 °C (OR: 1.87), and ≥ 25 °C (OR: 4.67), compared with days <10 °C. The greatest elevations in risk appeared to be amongst males and when alcohol intoxication was suspected. Precipitation showed no significant association with unintentional drowning risk.

CONCLUSIONS

Identifying such relationships highlights the value of considering weather conditions when evaluating environmental risk factors for drowning, and may inform water safety policy and allocating resources to prevention and rescue.

Examining the relationship between heatwaves and fatal drowning: a case study from Queensland, Australia

BACKGROUND

Globally, drowning is a leading cause of injury-related harm, which is heavily impacted by environmental conditions. In Australia, fatal unintentional drowning peaks in summer, yet the impact of prolonged periods of hot weather (heatwave) on fatal drowning has not previously been explored.

METHODS

Using a case-crossover approach, we examined the difference in drowning risk between heatwave and non-heatwave days for the Australian state of Queensland from 2010 to 2019. Heatwave data, measured by the excess heat factor, were acquired from the Bureau of Meteorology. Incidence rate ratios (IRRs) were calculated by sex, age of drowning decedent, category of drowning incident (International Classification of Diseases-10 codes) and heatwave severity. Excess drowning mortality during heatwaves was also calculated.

RESULTS

Analyses reveal increased fatal drowning risk during heatwave for males (IRR 1.22, 95% CI 0.92 to 1.61), people aged 65+ years (IRR 1.36, 95% CI 0.83 to 2.24), unintentional drowning (IRR 1.28, 95% CI 0.98 to 1.69) and during severe heatwaves (IRR 1.26, 95% CI0.88 to 1.82). There were 13 excess drowning deaths due to heatwave over the study period.

DISCUSSION

The findings confirm an increased risk of fatal drowning during heatwaves. With increased likelihood and severity of heatwaves, this information should be used to inform drowning prevention, in particular the timing of public awareness campaigns and patrolling of supervised aquatic locations.

CONCLUSIONS

Water safety and patrolling organisations, as well as first responders, need to prepare for more drowning deaths during heatwave conditions. In addition, drowning prevention education ahead of heatwaves is needed for recreational swimmers, and older people, particularly those with comorbidities which may be further exacerbated by a heatwave.

Feasibility study of the Utstein Style For Drowning to aid data collection on the resuscitation of drowning victims

Aim

The revised Utstein Style For Drowning (USFD) was published in 2015. Core data were considered feasible to be reported in most health systems worldwide. We aimed to determine the suitability of the USFD as a template for reporting data from drowning research.

Method

Clinical records of 437 consecutive drowning presentations to the Sunshine Coast Hospital and Health Service Emergency Departments (ED) between 1/1/2015 and 31/12/2021 were examined for data availability to complete the USFD. The proportions of patients with each variable documented is reported. Time taken to record core and supplementary variables was recorded for 120 consecutive patients with severity of drowning Grade 1 or higher.

Results

There were 437 patients, including 227 (51.9%) aged less than 16 years. There were 253 (57.9%) males and 184 (42.1%) females. Sixty-one patients (13.9%) received cardiopulmonary resuscitation (CPR). There were nine (2.1%) deaths after presentation to the ED. Median time for data entry was 17 minutes for core variables and 6 min for supplementary. This increased to 29 + 6 minutes for patients in cardiac arrest. Sixteen (32.7%) of 49 core variables and four (13.3%) of 30 supplementary variables were documented 100% of the time. One (2.0%) core and seven (23.3%) supplementary variables were never documented. Duration of submersion was documented in 100 (22.9%) patients.

Conclusion

USFD is time consuming to complete. Data availability to enable completion of the USFD varies widely, even in a resource rich health system. These results should be considered in future revisions of the USFD.

Selfie-Related Incidents: Narrative Review and Media Content Analysis

BACKGROUND

Selfie-related injury has become a public health concern amid the near ubiquitous use of smartphones and social media apps. Of particular concern are selfie-related deaths at aquatic locations; areas often frequented because of their photogenic allure. Unfortunately, such places exhibit hazards inherent with their environment.

OBJECTIVE

This study aimed to ascertain current evidence regarding selfie-related injuries and recommended risk treatment measures in the academic literature as well as how selfie-related injuries and deaths were being reported by the media, allowing us to identify key challenges facing land managers and public health practitioners in mitigating selfie-related injuries and deaths.

METHODS

Between October and December 2022, we performed a narrative review of peer-reviewed literature published since January 2011. Literature was screened to identify causal factors implicated in selfie-related deaths and injuries, as well as risk treatments recommended. Furthermore, we used an environmental scan methodology to search for media reports of selfie-related injuries and deaths at aquatic locations in Australia and the United States. Individual cases of selfie-related aquatic injuries and deaths sourced from news reports were analyzed to assess epidemiological characteristics, and a thematic content analysis was conducted to identify key themes of news reporting on selfie-related deaths and injuries.

RESULTS

In total, 5 peer-reviewed studies were included. Four studies identified falls from height as the most common injury mechanism in selfie incidents. Drowning was the second most common cause of death. Recommended risk treatments were limited but included the adoption of "no selfie zones," physical barriers, signage, and provision of information on dangerous locations to social media users. In total, 12 cases were identified from media reports (4 injuries and 8 fatalities; 7 in Australia and 5 in the United States). The mean age of the reported victims was 22.1 (SD 6.93) years with victims more likely to be female tourists. Content analysis revealed 3 key themes from media reports: "blame," "warning," and "prevention and education." Few media reports (n=8) provided safety recommendations.

CONCLUSIONS

The selfie-related incident phenomenon should be viewed as a public health problem that requires a public health risk communication response. To date, little attention has been paid to averting selfie-related incidents through behavior change methodologies or direct messaging to users, including through social media apps. Although previous research has recommended "no selfie zones," barriers, and signage as ways to prevent selfie incidents, our results suggest this may not be enough, and it may be prudent to also engage in direct safety messaging to social media users. Media reporting of selfie incidents should focus on preventive messaging rather than blame or warning.

Identifying strategic priorities for advancing global drowning prevention: a Delphi method

INTRODUCTION

The burden of drowning is gaining prominence on the global agenda. Two United Nations system resolutions in 3 years reflect rising political support, but priorities remain undefined, and the issue lacks a global strategy. We aimed to identify strategic priorities for advancing global drowning prevention using a modified Delphi method.

METHODS

An advisory group was formed, and participants recruited with diverse expertise and backgrounds. We used document review, and data extracted from global health partnerships to identify strategic domains and draft priorities for global drowning prevention. Participants rated the priorities in two Delphi rounds, guided by relevance, feasibility and impact on equity, and where consensus was ≥70% of participants rating the priority as critical.

RESULTS

We recruited 134 participants from research (40.2%), policy (26.9%), technical (25.4%) and community (7.5%) backgrounds, with 38.1% representing low- and middle-income countries. We drafted 75 priorities. Following two Delphi rounds, 50 priorities were selected across the seven domains of research and further contextualisation, best practice guidance, capacity building, engagement with other health and sustainable development agendas, high-level political advocacy, multisectoral action and strengthening inclusive global governance. Participants scored priorities based on relevance (43.2%), feasibility (29.4%) and impact on equity (27.4%).

CONCLUSION

Our study identifies global priorities for drowning prevention and provides evidence for advocacy of drowning prevention in all pertinent policies, and in all relevant agendas. The priorities can be applied by funders to guide investment, by researchers to frame study questions, by policymakers to contrast views of expert groups and by national coalitions to anchor national drowning prevention plans. We identify agendas including disaster risk reduction, sustainable development, child and adolescent health, and climate resilience, where drowning prevention might offer co-benefits. Finally, our findings offer a strategic blueprint as the field looks to accelerate action, and develop a global strategy for drowning prevention.

Sociodemographic inequalities in mortality from drowning in the Baltic countries and Finland in 2000-2015: a register-based study

BACKGROUND

Drowning is an important public health problem. Some evidence suggests that the risk of drowning is not distributed evenly across the general population. However, there has been comparatively little research on inequalities in drowning mortality. To address this deficit, this study examined trends and sociodemographic inequalities in mortality from unintentional drowning in the Baltic countries and Finland in 2000-2015.

METHODS

Data for Estonia, Latvia and Lithuania came from longitudinal mortality follow-up studies of population censuses in 2000/2001 and 2011, while corresponding data for Finland were obtained from the longitudinal register-based population data file of Statistics Finland. Deaths from drowning (ICD-10 codes W65-W74) were obtained from national mortality registries. Information was also obtained on socioeconomic status (educational level) and urban-rural residence. Age-standardised mortality rates (ASMRs) per 100 000 person years and mortality rate ratios were calculated for adults aged 30-74 years old. Poisson regression analysis was performed to assess the independent effects of sex, urban-rural residence and education on drowning mortality.

RESULTS

Drowning ASMRs were significantly higher in the Baltic countries than in Finland but declined by nearly 30% in all countries across the study period. There were large inequalities by sex, urban-rural residence and educational level in all countries during 2000-2015. Men, rural residents and low educated individuals had substantially higher drowning ASMRs compared to their counterparts. Absolute and relative inequalities were significantly larger in the Baltic countries than in Finland. Absolute inequalities in drowning mortality declined in all countries across the study period except between urban and rural residents in Finland. Changes in relative inequalities were more variable during 2000-2015.

CONCLUSION

Despite a sharp reduction in deaths from drowning in the Baltic countries and Finland in 2000-2015, drowning mortality was still high in these countries at the end of the study period with a substantially larger risk of death seen among men, rural residents and low educated individuals. A concerted effort to prevent drowning mortality among those most at risk may reduce drownings considerably in the general population.

Public holiday and long weekend mortality risk in Australia: A behaviour and usage risk analysis for coastal drowning and other fatalities

OBJECTIVE

This article aims to determine the impact of public holidays and long weekends on the risk of drowning and non-drowning deaths on the Australian coast.

METHODS

A retrospective case-control study using relative risk ratios and Z-scores to compare all unintentional fatalities on the Australian coast between 2004 and 2021 to a longitudinal representative survey sample of the Australian public and their coastal usage.

RESULTS

Overall, the coastal mortality risk increased by 2.03 times for public holidays (95%CI = 1.77-2.33, p<0.0001) and 2.14 times by long weekends (95%CI = 1.85-2.48, p<0.0001). Children <16 years had the highest increased risk of death on public holidays (RR = 3.53, 95%CI = 1.98-6.31, p = 0.0005) and long weekends (RR = 2.90, 95%CI = 1.43-5.89, p = 0.011), while residents who were born overseas had a higher risk of death compared to those born in Australia. For public holidays, the greatest increase in risk was for swimming/wading and bystander rescues, while for long weekends, it was for scuba diving and snorkelling.

CONCLUSIONS

Public holidays and long weekends increase the risk of both drowning and non-drowning deaths on the Australian coast, which differed by demographics and activities.

IMPLICATIONS FOR PUBLIC HEALTH

These results highlight periods of risk when targeted coastal safety messaging to high-risk demographics (particularly children and overseas-born residents), and provision of surf lifesaving resources can be increased.

The characteristics of drowning among different types of international visitors to Australia and how this contributes to their drowning risk

OBJECTIVE

Australia is a popular destination for international visitors. This study reviews international visitor drowning deaths in Australia and analyses drowning by visitor type.

METHODS

A total population retrospective study exploring drowning deaths of international visitors was conducted between 2008 and 2018. Data were extracted from the Royal Life Saving National Fatal Drowning Database and categorised into four subgroups: overseas tourists, international students, working holiday makers and work-related visitors. Descriptive statistics, non-parametric tests and relative risk (RR) were calculated.

RESULTS

In total, 201 international visitors drowned in Australia, 7% of all drowning deaths; a crude drowning rate of 0.27/100,000 visitors versus 0.95/100,000 for residents (RR=0.19 [95% CI: 0.16-0.22]). Most deaths were males (79%) and people aged 18-34 years (50%). Visitors frequently drowned at beaches (33%), and when swimming (41%). Thirty-five percent recorded a pre-existing medical condition. Overseas tourists on holiday were the most likely to drown compared to other subgroups.

CONCLUSION

International visitors represent a small but increasing proportion of people drowning in Australia. The circumstances of which visitors drown vary by travel purpose, age, country of origin, location of drowning and activity.

IMPLICATIONS FOR PUBLIC HEALTH

International visitors have unique safety needs, requiring tailored prevention based on the purpose of travel and country of origin.

Drinking and swimming around waterways: The role of alcohol, sensation-seeking, peer influence and risk in young people

The role of individual and sociocultural factors contributing to drowning risk for young adults is complex and poorly understood. This study examined the relationship between behaviour in and around waterways and: 1) alcohol consumption; 2) resistance to peer influence; 3) sensation-seeking; 4) perception of risk among people aged 15–24 in Western Australia. A cross-sectional online survey was conducted at three time-points with a convenience sample. Predictor variables included: Alcohol Use Disorder Identification Test Consumption (AUDIT_C); Resistance to Peer Influence; Brief Sensation Seeking scale; Benthin’s Perception of risk. Pearson chi-squared tests determined the association between demographic and predictor variables. Logistic regression explored influence of potential predictor variables on behaviour in and around water. The final sample (n = 730) participants, consisted of females (n = 537, 74.5%), metropolitan dwelling (n = 616, 84.4%), and attended university (n = 410, 56.9%). Significant associations were found for those who swum after drinking alcohol compared with those that had not by age, gender, education. For every 1-unit increase in AUDIT-C participants were 60% more likely to swim after drinking (OR 95% CI 1.60 1.44–1.78). Participants who considered an adverse event serious were 15% less likely to have swum after drinking alcohol (OR 0.85 95% CI 0.73–0.99). The complex relationship between social participation in activities in and around waterways, higher drowning rates, propensity for risk, and the meaning young adults attach to risk locations and practices present unique challenges for drowning prevention research. Findings should be used to improve the awareness and education components of future youth water safety strategies in high-income settings.

The role of alcohol and drug intoxication in fatal drowning and other deaths that occur on the Australian coast

INTRODUCTION

Alcohol and drug (illicit or prescription) intoxication impairs motor skills, coordination, decision making abilities, hazard perception, and is known to increase the risk of death in coastal environments. Prior coastal safety research has focused largely on the impact of alcohol on drowning, with less research on the influence of drugs and leaving a significant number of other non-drowning fatalities largely excluded, despite being preventable with mitigation of injuries or medical factors.

METHOD

This retrospective cross-sectional study explored the impact of alcohol and drugs on unintentional Australian drowning deaths and other coastal fatalities over a 16-year period to identify higher-risk populations and coastal activity groups for which alcohol/drug use is increased.

RESULTS

It was found that alcohol, benzodiazepines/sedatives, and amphetamine usage was prevalent in coastal deaths. Of the 2,884 coastal deaths, 80.6% of decedents had known toxicological data. Alcohol and/or drug intoxication contributed to 23% of coastal drowning deaths and 19% of fatalities. For drowning and other fatalities combined, 8.7% were due to alcohol, 8.7% due to drugs, and 4.1% due to both alcohol and drugs. Australian-born decedents were more likely to involve alcohol (RR = 1.7, 95%CI = 1.26-2.3, p &lt; 0.001), drugs (RR = 2.62, 95%CI = 1.85-3.7, p &lt; 0.001), or both alcohol and drugs (RR = 4.43, 95%CI = 2.51-7.82, p &lt; 0.001) with an increased risk identified in Indigenous Australian populations (RR = 2.17, 95%CI = 1.12-4.24, p = 0.04). The impact of alcohol and drug intoxication varied by activity, with Personal Watercraft users more likely to die due to alcohol intoxication (RR = 2.67, 95%CI = 1.23-5.78, p = 0.035), while scuba divers (RR = 0, p &lt; 0.001), snorkelers (RR = 0.14, 95%CI = 0.036-0.57, p &lt; 0.001), and rock fishers (RR = 0.46, 95%CI = 0.22-0.96, p = 0.03) were less likely. Recreational jumping and fall-related coastal deaths were more likely to involve alcohol and alcohol/drugs combined.

PRACTICAL APPLICATIONS

This study identifies factors to further investigate or target with prevention strategies to decrease the holistic burden of mortality due to alcohol and/or drug usage on the Australian coast.

The link between medical conditions and fatal drownings in Canada: a 10-year cross-sectional analysis

BACKGROUND

Drowning accounts for hundreds of preventable deaths in Canada every year, but the impact of preexisting medical conditions on the likelihood of death from drowning is not known. We aimed to describe the prevalence of pre-existing medical conditions among people who fatally drowned in Canada and evaluate the risk of fatal drowning among people with common pre-existing medical conditions.

METHODS

We reviewed all Canadian unintentional fatal drownings (2007-2016) in the Drowning Prevention Research Centre Canada's database. For each fatal drowning we established whether the person had pre-existing medical conditions and whether those conditions contributed to the drowning. We calculated relative risk (RR) of fatal drowning stratified by age and sex for each pre-existing medical condition using data from the Canadian Chronic Disease Surveillance System.

RESULTS

During 2007-2016, 4288 people fatally drowned unintentially in Canada, of whom one-third had a pre-existing medical condition. A pre-existing medical condition contributed to drowning in 43.6% (n = 616) of cases. Fatal drowning occurred more frequently in people with ischemic heart disease (RR 2.7, 95% confidence interval [CI] 2.5-3.0) and seizure disorders (RR 6.3, 95% CI 5.4-7.3) but less frequently in people with respiratory disease (RR 0.12, 95% CI 0.10-0.15). Females aged 20-34 years with a seizure disorder had a 23 times greater risk than their age- and sex-matched cohort (RR 23, 95% CI 14-39). In general, fatal drowning occurred more often while people were bathing (RR 5.9, 95% CI 4.8-7.0) or alone (RR 1.99, 95% CI 1.32-2.97) and less often in males (RR 0.92, 95% CI 0.88-0.95) or in those who had used alcohol (RR 0.72, 95% CI 0.65-0.80), among those with pre-existing medical conditions.

INTERPRETATION

The risk of fatal drowning is increased in the presence of some preexisting medical conditions. Tailored interventions aimed at preventing drowning based on pre-existing medical conditions and age are needed. Initial prevention strategies should focus on seizure disorders and bathtub drownings.

A Smart Multi-Sensor Device to Detect Distress in Swimmers

Drowning is considered amongst the top 10 causes of unintentional death, according to the World Health Organization (WHO). Therefore, anti-drowning systems that can save lives by preventing and detecting drowning are much needed. This paper proposes a robust and waterproof sensor-based device to detect distress in swimmers at varying depths and different types of water environments. The proposed device comprises four main components, including heart rate, blood oxygen level, movement, and depth sensors. Although these sensors were designed to work together to boost the system’s capability as an anti-drowning device, each could operate independently. The sensors were able to determine the heart rate to an accuracy of 1 beat per minute (BPM), 1% SpO2, the acceleration with adjustable sensitivities of ±2 g, ±4 g, ±8 g, and ±16 g, and the depth up to 12.8 m. The data obtained from the sensors were sent to a microcontroller that compared the input data to adjustable threshold values to detect dangerous situations. Being in hazardous situations for more than a specific time activated the alarming system. Based on the comparison made in the program and measuring the time of submersion, a message indicating drowning or safe was sent to a lifeguard to continuously monitor the swimmer’ condition via Wi-Fi to an IP address reachable by a mobile phone or laptop. It is also possible to continuously monitor the sensor outputs on the device’s display or the connected mobile phone or laptop. The threshold values could be adjusted based on biometric parameters such as swimming conditions (swimming pool, beach, depth, etc.) and swimmers health and conditions. The functionality of the proposed device was thoroughly tested over a wide range of parameters and under different conditions, both in air and underwater. It was demonstrated that the device could detect a range of potentially hazardous aquatic situations. This work will pave the way for developing an effective drowning sensing system that could save tens of thousands of lives across the globe every year.

The water incident database (WAID) 2012 to 2019: a systematic evaluation of the documenting of UK drownings

Background

Death by drowning is a leading cause of accidental death in the United Kingdom (UK) and worldwide. The World Health Organization (WHO) states that effective documentation of drowning is required to describe drowning frequency and to underpin effective drowning prevention intervention, thus improving the quality of data describing drowning frequency represents a key initiative. The water incident database (WAID) has been used to document UK fatal and non-fatal water-based incidents since 2009. WAID has not undergone a systematic evaluation of its data or data collection procedures to establish if the database meets the WHO requirements. The present study investigated the characteristics of UK fatal drowning incidents and audited current WAID data capture procedures.

Methods

Data for the fatal drowning cases recorded between 2012 and 2019 were reviewed. Descriptive data were generated 1) to describe fatal drownings in the UK’s WAID in this period; 2) a sub-set of drownings were audited i) for completeness of data entry and, based on source documents, ii) for quality of data entry; 3) these processes were used to make recommendations for onward revisions to WAID.

Results

A total of 5051 fatalities were recorded between 2012 and 2019. Drowning was most frequent amongst males aged 35 to 60 years (n = 1346), whilst suspected accidents and suicides accounted for 44 and 35% of fatalities. Suicide by drowning was at a peak in the most recent year of data analysed (i.e., 2019; 279 cases) highlighting an urgent need for targeted intervention. Audit part 2i) indicated that 16% of all fields were incomplete, thus indicating potential redundancy, duplication, or the need for onward review. Audit part 2ii) indicated high levels of agreement (80 ± 12%) between audited cases and the ‘true’ WAID entries.

Conclusions

This study confirms WAID as a rigorous, transparent and effective means of documenting UK drownings thereby meeting WHO requirements for data quality; yet future improvements are recommended. Such findings allow researchers and policy makers to use WAID to further investigate UK drowning with a view to improving public safety measures and drowning prevention interventions. Observations alongside several expert recommendations have informed a revised version of WAID.

Alcohol and the Risk of Injury

Globally, almost four and a half million people died from injury in 2019. Alcohol's contribution to injury-related premature loss of life, disability and ill-health is pervasive, touching individuals, families and societies throughout the world. We conducted a review of research evidence for alcohol's causal role in injury by focusing on previously published systematic reviews, meta-analyses and where indicated, key studies. The review summarises evidence for pharmacological and physiological effects that support postulated causal pathways, highlights findings and knowledge gaps relevant to specific forms of injury (i.e., violence, suicide and self-harm, road injury, falls, burns, workplace injuries) and lays out options for evidence-based prevention.

Public Response on Social Media to a Social Marketing Campaign for Influencing Attitudes towards Boating Safety

The purpose of this research paper is to assess the response on Facebook to a social marketing campaign for recreational boating safety. The campaign ran for the 2018 and 2019 boating seasons in British Columbia, Canada. Messages related to boating safety were delivered in multi-media formats, including ten Facebook posts. All public comments on the campaign Facebook page in response to the ads were included in the analysis. Comments were reviewed for tone and subject; those that related directly to the campaign or boating safety-related topics, such as alcohol use or enforcement, were labeled positive, negative or neutral in tone. Metrics such as likes and shares were also noted. The overall engagement rate (defined as engagements over people reached) was 4.1%. The posts were liked >7000 times and received 901 shares. A total of 219 comments were analysed. Almost half of the comments were positive (n = 106, 48.4%). Fifty comments were off-topic (22.8%), 45 were neutral (20.5%) and 18 were negative (8.2%). The majority of comments were positive, indicating that the campaign performed as planned and was generally well received by the people for whom it was intended. Comments illuminated prevailing attitudes towards risks, injuries and safety practices related to recreational boating. Positive comments valued safety as an aspect of having a pleasant experience, rather than a barrier. Negative comments were about perceiving reduced fun of boating, rather than objecting to the campaign itself. As a component of a multi-media social marketing strategy, Facebook can be a source of instant feedback from the campaign audience.

Another gender data gap: female drowning in Aotearoa, New Zealand

INTRODUCTION

A gender gap is present in drowning research and prevention interventions, resulting in an inequitable focus on males. This study aimed to address the gender data gap, exploring female drowning in Aotearoa, New Zealand.

METHODS

National data on female fatal and non-fatal drowning requiring hospitalisation between 2003 and 2019 were sourced from DrownBase, Water Safety New Zealand's drowning database. Univariate and χ² analyses were conducted for fatal and hospitalisation data. Crude rates were calculated and used to explore temporal trends and RR by age groups and ethnicity for fatal and non-fatal drowning. Ratios for drowning-related hospitalisations and Accident Compensation Corporation (ACC) claims to drowning deaths were also calculated.

RESULTS

From 2003 to 2019, a total of 1087 female drowning fatalities and non-fatal (76.0%) drowning incidents requiring hospitalisation occurred. Linear trends indicate hospitalisations increased (y=0.0766x+1.4271; R²=0.4438), while fatal drowning decreased (y=-0.0101x+0.7671; R²=0.1011). The highest fatal (1.60) and non-fatal (8.22) drowning rates were seen among children aged 0-4 years. For every one female drowning fatality, there are 3.46 hospital admissions and 675.55 ACC claims.

DISCUSSION

Female drowning represents a significant burden on the health system and the community in New Zealand. Further investment in interventions targeting females about their own risky behaviours around water (not only children in their care) is suggested, including interventions focused on hazardous conditions and alcohol consumption.

CONCLUSION

For decades, the focus of drowning prevention among adolescents and adults has been on males. However, efforts must be broadened to prevent any further increase in drowning-related incidents among females in Aotearoa, New Zealand.

"They don't think it will ever happen to them": Exploring factors affecting participation in alcohol-influenced aquatic activity among young Australian adults

ISSUE ADDRESSED

Young adults are over-represented in alcohol-related drownings in high-income countries; however, little research has investigated their behaviours and decision-making to inform prevention efforts.

METHODS

Semi-structured interviews were conducted with 23 young Australian adults (aged 18-24 years). Questions, informed by previous research, inquired about behavioural practices in aquatic contexts and influences on involvement in alcohol-influenced aquatic activity. Interviews were transcribed verbatim. Thematic and interpretative phenomenological analysis followed.

RESULTS

Two main themes: personal and contextual awareness, and the impact of other people affected perceptions and involvement in alcohol-influenced aquatic activity. Perceived control of situations and self-confidence affected how these influences impacted individuals' involvement. Participants acknowledged some young adults likely overestimate their aquatic abilities. This awareness was not discussed in relation to their own capabilities.

CONCLUSION

Drowning prevention efforts should inform young adults of the dangers of combining alcohol and aquatic activities, and make risks appear more immediate and applicable. Consideration should be given to measuring both perceived and actual aquatic abilities within various aquatic environments, to determine whether self-reported perceived competence is an accurate proxy measure for actual aquatic ability. The influence of alcohol should also be highlighted. Steps are required for a positive shift in Australian norms of alcohol use in aquatic settings and the social and cultural attitudes towards this. SO WHAT?: This study provides new insight into young adults' perceptions and involvement in alcohol-influenced aquatic activity. It enhances the evidence base for drowning prevention and health promotion practitioners and should inform more focused campaigns to prevent alcohol-related drownings among young Australian adults.

Health and Economic Burden of Injurious Falls Into Irrigation Canals in Japan: A Retrospective Cohort Study

BACKGROUND

Falls into small water bodies can cause drowning and trauma. Such falls, especially into irrigation canals, and the subsequent trauma are common in Japan. However, few studies have investigated their characteristics, costs, and prognosis.

OBJECTIVE

Our aim was to clarify the characteristics, prognosis, and economic burden of trauma due to falls into irrigation canals in Kurashiki City, Japan.

METHODS

This 4-year, single-center, retrospective cohort study was conducted at a Japanese tertiary care hospital between January 1, 2013 and December 31, 2016. We enrolled patients who had fallen into irrigation canals constructed more than 300 years ago, and transported to our hospital by ambulance. The study outcomes included the characteristics, prognosis, and health care costs of such trauma.

RESULTS

We enrolled 266 patients with a median age of 66 years (range 19-64 years). Most patients fell into irrigation canals while walking (49.3%), riding a bicycle (35.0%), or driving or riding in a car (7.1%). Extremities were the most frequently affected body parts, and the head and chest were less frequently affected. Four patients (1.5%) died in the emergency department (ED), and 121 (45.5%) were hospitalized (109 in our hospital and 12 transferred to other hospitals). The total costs of ED and hospital stays were 777,625 US dollars (266 patients) and 712,059 US dollars (109 patients hospitalized in our hospital), respectively.

CONCLUSIONS

Trauma due to falls into irrigation canals can be severe and even fatal, and the related costs are high. Our study highlights the importance of implementing appropriate measures to prevent falls into irrigation canals and of promoting awareness among citizens.

Association Between Socioeconomic and Demographic Characteristics and Non-fatal Alcohol-Related Injury in Maringá, Brazil

Background: Previous research has corroborated a high burden of alcohol-related injury in Brazil and the presence of socioeconomic disparities among the injured. Yet, individual-level data is scarce. To fill this gap, we examined the association between demographic and socioeconomic characteristics with non-fatal alcohol-related injury in Maringá, Brazil.

Methods: We used household survey data collected during a 2015 cross-sectional study. We conducted univariate and multivariate analyses to evaluate associations of demographic (age, gender, race) and socioeconomic characteristics (employment, education, income) with non-fatal alcohol-related injury.

Results: Of the 995 participants who reported injuries, 62 (6.26%) were alcohol-related. Fifty-three (85%) alcohol-related injuries were reported by males. Multivariate analysis indicated being male (OR = 5.98 95% CI = 3.02, 13.28), 15–29 years of age (OR = 3.62 95% CI = 1.72, 7.71), and identifying as Black (OR = 2.38 95% CI = 1.09, 4.95) were all significantly associated with increased likelihood of reporting an alcohol-related injury, whereas unemployment was significantly associated with decreased likelihood of reporting an alcohol-related injury (OR = 0.41 95% CI = 0.18, 0.88).

Conclusion: Our findings suggest that in Maringá, being male, between the ages of 15 and 29, employed, or identifying as Black were characteristics associated with a higher risk for non-fatal alcohol-related injury. Individual level data, such as ours, should be considered in combination with area-level and country-level data when developing evidence-based public-health policies.

The burden of unintentional drowning: global, regional and national estimates of mortality from the Global Burden of Disease 2017 Study

Background

Drowning is a leading cause of injury-related mortality globally. Unintentional drowning (International Classification of Diseases (ICD) 10 codes W65-74 and ICD9 E910) is one of the 30 mutually exclusive and collectively exhaustive causes of injury-related mortality in the Global Burden of Disease (GBD) study. This study’s objective is to describe unintentional drowning using GBD estimates from 1990 to 2017.

Methods

Unintentional drowning from GBD 2017 was estimated for cause-specific mortality and years of life lost (YLLs), age, sex, country, region, Socio-demographic Index (SDI) quintile, and trends from 1990 to 2017. GBD 2017 used standard GBD methods for estimating mortality from drowning.

Results

Globally, unintentional drowning mortality decreased by 44.5% between 1990 and 2017, from 531 956 (uncertainty interval (UI): 484 107 to 572 854) to 295 210 (284 493 to 306 187) deaths. Global age-standardised mortality rates decreased 57.4%, from 9.3 (8.5 to 10.0) in 1990 to 4.0 (3.8 to 4.1) per 100 000 per annum in 2017. Unintentional drowning-associated mortality was generally higher in children, males and in low-SDI to middle-SDI countries. China, India, Pakistan and Bangladesh accounted for 51.2% of all drowning deaths in 2017. Oceania was the region with the highest rate of age-standardised YLLs in 2017, with 45 434 (40 850 to 50 539) YLLs per 100 000 across both sexes.

Conclusions

There has been a decline in global drowning rates. This study shows that the decline was not consistent across countries. The results reinforce the need for continued and improved policy, prevention and research efforts, with a focus on low- and middle-income countries.

Protocol for developing a mental imagery intervention: a randomised controlled trial testing a novel implementation imagery e-health intervention to change driver behaviour during floods

INTRODUCTION

Drowning due to driving into floodwater accounts for a significant proportion of all deaths by drowning. Despite awareness campaigns such as 'If it's flooded, forget it', people continue to drive into floodwater. This causes loss of life, risk to rescuers and damage to vehicles. The aim of this study was to develop and evaluate an online e-health intervention to promote safe driving behaviour during flood events.

METHODS AND ANALYSIS

The study will use a 2×3 randomised controlled trial in which participants are randomised into one of two conditions: (1) education about the risks of driving into floodwater or (2) education about the risks of driving into floodwater plus a theory-based behaviour change intervention using planning and imagery exercises. The effect of the intervention on the primary outcome, intention to drive through floodwater and the secondary outcomes will be assessed using a series of mixed-model analysis of covariances.

ETHICS AND DISSEMINATION

The study has been approved by the Griffith University Human Research Ethics Committee. Participants will review a study information sheet and provide informed consent prior to commencing participation. Results will be disseminated through peer-reviewed publications, industry reports, media releases and at academic conferences. Deidentified data will be made publicly available following publication of the results.

TRIAL REGISTRATION NUMBER

ACTRN12618001212246.

The Influence of Alcohol and Drugs on Drowning among Victims of Senior Years

Unintentional fatal drowning among older people is an issue as lifespans lengthen and older people embrace active retirement. While pre-existing medical conditions are a known risk factor for drowning among this age group, less is known about the role of alcohol and drugs. This 15-year (1 July 2002 to 30 June 2017) Australian study used coronial data to investigate the impact on older people (aged 65 years and older) of the obtundent effects of prescribed drugs which had been ingested by those with a positive blood alcohol concentration (BAC). Of the closed coronial cases with toxicological information (N = 471), one quarter (24.6%; N = 116) had consumed alcohol prior to drowning (one in seven BAC ≥ 0.05%), of which a third also had obtundent drugs present (33.6%; N = 39). Rivers/creeks/streams and swimming pools were the locations with the highest number of drowning deaths. Bathtubs (36.8%) and rivers/creeks/streams (17.9%) recorded the highest proportion of cases with victims having a BAC ≥ 0.05%. Bathtubs (13.2%), lakes (7.0%), and rivers/creeks/streams (6.8%) recorded the highest proportion of drowning cases with obtundent drug involvement. Obtundent drug involvement was significantly more likely for activities where the person who drowned was alone (i.e., unknown activity) (X2 = 6.8; p = 0.009). Common obtundent drugs included Diazepam, Tempazepam, and Codeine. Advocacy to prevent drowning in older people is a complex challenge, due to the myriad of locations where drowning occurs, the consumption of alcohol, and polypharmacy required for treating illness and maintaining good health.

Breathalysing and surveying river users in Australia to understand alcohol consumption and attitudes toward drowning risk

BACKGROUND

Little is known about people's river usage, a leading drowning location. This study examines alcohol consumption patterns of river users and their attitudes to drowning risk.

METHODS

A convenience sample of adult (18+ years) river users were surveyed at four river locations. The survey covered eight domains: demographics; river attendance frequency; frequency of engaging in water activities; drinking patterns; alcohol and water safety knowledge; alcohol and water safety attitudes; alcohol consumption; and Blood Alcohol Concentration (BAC). For BAC, participants were asked to record time since their last alcoholic drink and were then breathalysed to record an estimate of their BAC. BAC was examined by BAC reading (negative, positive, ≥0.050%). Hazardous lifetime drinking levels were calculated and their impact on drowning risk evaluated. Univariate and chi square analysis (95% confidence interval) was conducted.

RESULTS

Six hundred eighty four people participated (51.6% female; 49.0% aged 18-34 years). Sixteen percent (15.9%) had a positive BAC (Mean + BAC = 0.068%; SD ± 0.08; Range = 0.001-0.334%), with 7.2% ≥0.050% (Mean BAC ≥0.050% =0.132%; SD ± 0.06). Those significantly more likely to record a BAC ≥0.050% at the river were: aged 18-34 years, resided in inner regional and low socio-economic areas, visited the river in the afternoon, with friends, on days with higher maximum air temperatures, frequent river users (11+ times in the last 30 days) and those who spend longer in the water (301+ minutes). River users who recorded a BAC ≥0.050% were more likely to self-report engaging in risky activities (i.e. diving into water of unknown depth and jumping into the river from height). River users on Australia day (a national public holiday) were significantly more likely to drink heavily (Mean BAC ≥0.05% = 0.175%; SD ± 0.09).

CONCLUSIONS

Despite males accounting for 85% of alcohol-related river drowning deaths, similar numbers of males and females were consuming alcohol at the river. This study has addressed a gap in knowledge by identifying river usage and alcohol consumption patterns among those at increased drowning risk. Implications for prevention include delivering alcohol-related river drowning prevention strategies to both males and females; at peak times including during hot weather, afternoons, public holidays and to river users who swim.

The Flood-Related Behaviour of River Users in Australia

INTRODUCTION

Flooding is a common natural disaster affecting 77.8 million people and claiming the lives of 4,731 people globally in 2016. During times of flood, drowning is a leading cause of death. Flooding is a known risk factor for river drowning in Australia. With little known about river usage in Australia, this study aimed to examine the links between person demographics and self-reported participation in two flood-related behaviours, driving through floodwaters and swimming in a flooded river.

METHODS

A self-reported questionnaire was administered to adult river users at four high-risk river drowning locations; Alligator Creek, Townsville, Queensland; Murrumbidgee River, Wagga Wagga, New South Wales; Murray River, Albury, New South Wales; and Hawkesbury River, Windsor, New South Wales. Univariate and chi square analysis was undertaken with a 95% confidence interval (p<0.05). All river users surveyed, were also breathalysed to record an estimate of their blood alcohol content (BAC) on their expired breath. Results: 688 river users responded to the questionnaire; 676 (98.3%) answered the driving question and 674 (98.0%) answered the swimming in floodwaters questions. Of the respondents, 35.7% stated they had driven through floodwater and 18.7% had swum in a flooded river. Males were more likely (p<0.001) to report having undertaken both activities. Australian-born respondents were more likely to report having driven through floodwaters (p=0.006). Those aged 18-24 years old and those residing in outer regional areas were more likely (p<0.001) to have swum in a flooded river. Those who self-reported participating in both driving through floodwaters (p=0.001) and swimming in a flooded river (p<0.001) were significantly more likely to record contributory levels of alcohol (i.e. a BAC ≥0.05%) when breathalysed at the river.

DISCUSSION

Ensuring the safe movement of people during floods is difficult, particularly for those living in regional Australia, due in part to long distances travelled and reduced investment in infrastructure such as bridges. With males and females equally exposed, more effective prevention strategies must target both sexes and may include improved education on when it is safe to drive through (low depth, still water, stable road base) and when it is not (e.g. deep water, moving water and unstable road base). This study identified one in five respondents had swum in a flooded river, most commonly young people aged 18-24 years, with participants signficantly more likely to have recorded contributory levels of alcohol when breathalysed. Further research should examine the reasons behind participation in this behaviour, including the role of alcohol.

CONCLUSION

Preventing drowning in floodwaters is an international challenge, made more difficult by people driving through or swimming in floodwaters. Strategies for driving through floodwaters should educate both males and females on when it is safe to drive through floodwaters and when it is not. Further research is required to improve knowledge of the poorly understood behaviour of swimming in flooded rivers.