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

Drowning prevention strategies for migrant adults in Australia: a qualitative multiple case study

Drowning is a global public health issue, with minority populations, including migrants, experiencing significant disparities in drowning. The World Health Organization recommends learning to swim as a strategy to reduce drowning. In Australia, migrants are identified as a priority population for drowning prevention, accounting for approximately one-third of all drowning deaths.This study aimed to identify swimming and water safety programs aimed at adult migrant populations in Australia and to explore how these programs are meeting the needs of migrant adults.Using a qualitative multiple case study methodology a desktop review was conducted of 30 publicly accessible swimming and water safety programs across Australia aimed at migrant communities. From this review, six programs were purposively selected for in-depth analysis. Interviews and focus groups with 63 participants (program, managers, swim teachers and program participants), were conducted, guided by the Health Belief Model and Theory of Planned Behaviour. Data was thematically analysed using a deductive approach.Four overlapping key themes with 14 sub-themes were identified: (1) Motivations for establishing programs for migrant adults, (2) Perceived barriers to participation, (3) Addressing cultural and socio-economic determinants of health and (4) Factors and challenges to program success. Findings revealed that drowning among migrant communities was the catalyst for establishing programs, and that staff consciously design these swim programs to make programs accessible and relevant to migrants. This includes offering single-gender programs, providing culturally appropriate swimwear, having bilingual teachers, low or no cost participation fees and ensuring training pathways to employment in the aquatic industry.Swimming and water safety programs that acknowledge and respond to migrants' needs and characteristics offer multiple benefits beyond drowning prevention, including improved physical, social and mental health, and positive settlement experiences. These programs highlight the importance of acquiring water safety awareness, knowledge and skills, and how this can influence generational attitudes and behaviour towards drowning risk and water engagement. Drowning is a complex public health issue, with collaboration among multisectoral stakeholders required to create an impact and reduce inequities, especially for vulnerable populations such as migrant adults.

Analysis of the clinical features of 980 accidental pediatric injuries in the PICU

Objective

This study aimed to investigate the causes and clinical characteristics of 980 cases of accidental pediatric injuries admitted to the pediatric intensive care unit (PICU) to provide clinical evidence to support the prevention and reduction of severe accidental pediatric injuries.

Methods

A total of 980 patients with accidental pediatric injuries admitted to the pediatric intensive care unit (PICU) of Hunan Children's Hospital from 2017 to 2023 were included in this study.

Results

Between 2017 and 2023, 980 patients with accidental pediatric injuries were admitted to the PICU, comprising 588 boys and 392 girls (boy-to-girl ratio: 1.5:1). During the study period, a total of 16,151 children were admitted to the PICU, of whom 980 were admitted due to accidental injuries and 15,171 due to non-accidental injuries. There were no statistically significant differences in sex distribution between the accidental and non-accidental injury groups. Accidental pediatric injuries were most common among infants, toddlers, and preschool children, with the number of PICU admissions decreasing with increasing age. Across all years, infants and preschool children were the most affected. Traffic accidents and falls showed an increasing trend over time, whereas poisoning and drowning showed a decreasing trend. Differences in the composition of causes by year were statistically significant. The overall mortality rate among children with accidental injuries was 4.39%. The mortality rates by cause were as follows: traffic accidents (4.2%), falls (3.2%), foreign objects (7.1%), carbon monoxide poisoning (0.0%), food poisoning (9.7%), drug poisoning (1.0%), other types of poisoning (4.2%), burns and corrosive injuries (0.0%), drowning (13.0%), suffocation syndrome (23.1%), and other causes (4.3%). Prognostic differences between causes were statistically significant.

Conclusion

Accidental pediatric injuries predominantly occur in boys, with infants and preschool children being the most affected. These injuries are more common in summer, with drug poisoning, traffic accidents, and falls being the main causes. Among the common causes, traffic accidents and falls showed an increasing trend, whereas poisoning and drowning showed a decreasing trend. Suffocation syndrome, drowning, and food poisoning were associated with high mortality rates.

The Safety of Social Media Instigated Visitation to National Parks in New South Wales, Australia: Insights From a Population Representative Sample

ISSUE ADDRESSED

The integration of social media, smartphone technology and the widespread sharing of images has reshaped tourism, sparking new trends such as selfie-tourism and social media-driven travel. National parks, offering scenic and pristine landscapes, have become prime destinations for these pursuits. The popularity of platforms like Instagram and Facebook, combined with the influence of travel-focused social media personalities, has inspired a wave of visitors seeking "selfie-worthy" locations. However, this shift in visitation motives has raised environmental and safety concerns: visitors venture off-trail, engage in risky photography practices and disrupt natural habitats, increasing the risk of injury and fatalities in hazardous coastal and cliff areas. National parks face growing challenges, with social media's allure prompting a variety of visitors who may lack awareness of responsible tourism practices. This trend imposes costs on park management, emergency services and local ecosystems, necessitating new strategies to balance tourism promotion with ecological protection and public safety.

METHODS

This cross-sectional survey involved New South Wales (NSW) residents aged 18+ who had previously visited a coastal national park in NSW. Conducted online from 18 to 25 August 2023, the survey recruited a demographically representative sample through Dynata, an established survey panel provider. Demographic data included age, gender, education, country of birth, years in Australia, main language spoken at home and language proficiency. The survey examined park visitation behaviours and safety perceptions, with specific questions assessing social media's influence on visitation motivations.

RESULTS

A total of 1009 NSW residents completed the survey, with 51.5% identifying as female and 75.4% born in Australia. Social media influenced 32% of respondents to visit coastal national parks, with Instagram being the most popular platform, followed by Facebook and TikTok. Younger age groups (18-34) were significantly more likely to visit parks because of social media compared to older adults (55+; χ2 = 252.07, p < 0.05), though no significant difference was found by gender. Social media platform preferences differed by age, with younger respondents favouring Instagram and TikTok and older respondents favouring Facebook (χ2 = 316.18; p < 0.001). Of those who visited due to social media, 65% took photos and 36% engaged in risky photography (e.g., cliff edges), though no significant age difference was found for risky photo behaviour. Although 56.8% considered park infrastructure safe for social media photos, 43.1% did not, with respondents suggesting improvements in barriers, signage and individual responsibility.

CONCLUSIONS

The study findings underscore the need for a stronger focus on visitor safety related to photography in NSW national parks, with acknowledgement of visitation instigated by social media. Risky behaviours associated with photography are prevalent and pose significant safety challenges. Public health initiatives should prioritise educational campaigns and safety infrastructure improvements that address risky photography behaviours, independent of social media influences. SO WHAT?: Park management should highlight personal responsibility and consider educational campaigns about the potential dangers of photography in these settings. Nevertheless, social media companies have a role to play in controlling dangerous content that is published on their platforms which is leading to risky behaviours in the real world.

Global burden of drowning and risk factors across 204 countries from 1990 to 2021

Drowning is a major global public health issue with marked variations in incidence, mortality, and disability-adjusted life years (DALYs) across regions, age groups, and sexes. Although previous studies have examined global trends in drowning, few have comprehensively analyzed regional and national disparities while addressing potential reporting biases and confounding factors. Data from the Global Burden of Disease (GBD) Study 2021, focusing on drowning-related incidence, death rates, and DALYs, and examined trends from 1990 to 2021 across various regions and countries. The study used age-standardized rates to assess trends and risk factors associated with drowning. In 2021, there were 856.1 thousand drowning cases globally, leading to 274.2 thousand deaths and 15.7 million DALYs. Age-standardized rates showed significant reductions since 1990: incidence decreased by 51.5% to 11.1, deaths by 60.9% to 3.6, and DALYs by 67.3% to 211.9. Solomon Islands, Belarus, and Ukraine had the highest incidence rates, while Nauru, Central African Republic, and Marshall Islands reported the highest death and DALYs rates. DALYs rates were highest in children aged 0-5 years and declined with age. A negative correlation was observed between SDI and DALYs rates. Key risk factors included occupational injuries (13.2%), high temperature (4.6%), and alcohol use (1.7%), while low temperature had a negative contribution (-10.6%). Despite reductions, drowning remains a major public health issue, especially in low-SDI countries. Targeted interventions addressing Occupational injuries, High temperature and Alcohol use are essential to further reduce drowning-related morbidity and mortality.

Shaping global strategy, mobilising for local action: reflections from the World Conference on Drowning Prevention 2023

Drowning is a significant cause of preventable mortality and morbidity and has been described as a serious, preventable and neglected public health challenge. Amid building momentum for drowning prevention, most notably with recent United Nations and World Health Assembly Declarations, researchers, policymakers and practitioners convened at the World Conference on Drowning Prevention (WCDP) 2023 under the conference theme of 'shaping a global strategy - mobilizing for local action'. In this special feature, we reflect on the outcomes of the WCDP 2023. Throughout the work presented by more than 750 research, policy and technical experts from over 50 countries, five overarching themes emerged: (1) advancing further contextualisation and interventions, especially in Africa; (2) integrating drowning prevention into climate and disaster agendas; (3) addressing the threats and opportunities in migration; (4) positioning drowning prevention as an issue of social justice; and (5) expanding focus on implementation research. WCDP 2023 delegates co-designed a conference call to action comprising of 16 statements designed to further strengthen global efforts on drowning prevention between now and the WCDP 2025. These actions aim to encourage increased collaboration, create new knowledge, address inequities, amplify voices of those most affected and continue shared commitments to eliminate drowning.

National estimates of mortality of unintentional drowning in China from 1990 to 2021 and its predicted level in the next decade: results from the global burden of disease study 2021

Background

It is reported that burden of unintentional drowning deaths is high in low- and middle-income countries. In recent decades, China has achieved remarkable economic growth and substantial advancements in infrastructure development; however, the understanding of the unintentional drowning burden in China has lagged behind. This article aims to provide an in-depth understanding of the current unintentional drowning situation in China.

Methods

Unintentional drowning from GBD 2021 was estimated for cause-specific mortality and, age, sex, and temporal trends from 1990 to 2021. In addition, we used decomposition analysis to quantify the drivers of changes in unintentional drowning from 1990 to 2021 and we also predicted the mortality of unintentional drowning in the next 10 years based on APC model.

Results

In 2021, the deaths attributable to unintentional drowning in China were 57554.02 (95% UI: 47463.15~69111.96), corresponding to age-standardized mortality rate (ASMR) of 4.12 (95% UI: 3.39 ~ 4.96) per 100,000 population. The mortality rate was relatively high among children aged 0-10 years and individuals aged 60 years and above and the highest number of deaths were recorded in the age groups of <5 years (3753.78, 95% UI: 2834.88 ~ 4903.46), 5-9 years (4938.93, 95% UI: 4207.74 ~ 5751.58), and 10-14 years (4197.10, 95% UI: 3581.12 ~ 4819.72). The mortality of unintentional drowning was higher for males than females across all age groups. A decline in unintentional drowning mortality rates was observed from 1990 to 2021, with an average annual percentage change (AAPC) of -4.19%. Epidemiological changes were the primary contributors to the observed decline in unintentional drowning deaths (decreased by 124985.81). The ASMR of unintentional drowning would continue to decrease slowly at the national level and that the decreasing trends would be stable in the future.

Conclusion

From 1990 to 2021, the mortality rate of unintentional drowning in China showed a downward trend. Males, children under 10 years old, and older adult people aged 65 and above were identified as high-risk factors for drowning. The research findings emphasize the importance of continuing to strengthen data collection systems, identifying risk factors, and developing drowning prevention strategies tailored to China's national conditions.

Burden of unintentional drowning in China from 1990 to 2019 and exposure to water: findings from the Global Burden of Disease 2019 study

BACKGROUND

Drowning is an important contributor to the burden of deaths in China. Exposure to open water is a risk factor for drowning, but few studies quantify its impact on drowning. The purpose of this study was to provide an up-to-date analysis of unintentional drowning in China, including impact of exposure to open water.

METHODS

Chinese provincial data from the Global Burden of Disease Study 2019 were used to describe the burden of unintentional drowning in 33 provinces and changes from 1990 to 2019. Provincial outdoor open water resource data were used to explore the relationship between outdoor open water resources and drowning burden using K-median clustering analysis.

RESULTS

Between 1990 and 2019, the unintentional drowning incidence, mortality and disability adjusted life years (DALY) rates declined by 31.2%, 68.6% and 74.9%, respectively, with differences by age, sex and province. In 2019, the DALY rate for drowning was relatively higher in children under 20 year, the elderly over 80 years than other age groups and was relatively higher in men. There was no statistical difference in overall incidence rate by sex. Provincial differences in unintentional drowning burden show a positive relationship with the availability and size of outdoor open water.

CONCLUSIONS

As expected availability of water increases drowning risk. There is a need to address drowning environmental risk especially among children and the elderly. Localised water safety plans which consider drowning burden and environmental risk factors are needed in China to ensure a sustained decline of unintentional drowning.

Criteria for early discharge of drowning patients from the emergency department

OBJECTIVE

Clinical factors previously shown to independently predict safe discharge were applied at ED presentation to determine whether we could identify a group of drowning patients who do not require treatment and are thus safe for rapid discharge.

METHOD

We conducted a retrospective study of drowning presentations to EDs of the Sunshine Coast Hospital and Health Service in Queensland, Australia between 1 January 2015 and 31 December 2022. Rapid discharge criteria (RDC) were defined as a normal spontaneous respiratory rate (adjusted for age), a normal peripheral blood saturation (≥94%) on room air, an Alert measurement on the Alert, Voice, Pain, Unresponsive scale, clear chest auscultation and the absence of any requirement for oxygen or other ventilatory assistance from Emergency Medical Services. Primary outcome was the requirement for treatment (oxygen, ventilation or airway intervention).

RESULTS

Five hundred and seventy-seven drowning presentations were included. Two hundred and fifty-five (44.2%) patients met RDC at ED presentation. Patients meeting RDC were more likely to be younger (median 9 years, IQR 3-21 vs 20 years, IQR 4-44, P < 0.016) than those with not meeting RDC. Eight patients meeting RDC had received bystander CPR. There were no deaths in the RDC group (0/255 (0%) vs 17/322 (5.3%), P < 0.016). No patient meeting RDC required treatment (0/255 (0%) vs 145/322 (45.0%), P < 0.016).

CONCLUSIONS

Drowning patients who meet rapid discharge criteria at ED presentation will not require treatment for their drowning and may be considered for discharge from the ED without further investigation or mandatory period of observation.

The Danish Drowning Cohort: Utstein-style data from fatal and non-fatal drowning incidents in Denmark

BACKGROUND

Effective interventions to reduce drowning incidents require accurate and reliable data for scientific analysis. However, the lack of high-quality evidence and the variability in drowning terminology, definitions, and outcomes present significant challenges in assessing studies to inform drowning guidelines. Many drowning reports use inappropriate classifications for drowning incidents, which significantly contributes to the underreporting of drowning. In particular, non-fatal drowning incidents are underreported because many countries do not routinely collect this data.

THE DANISH DROWNING COHORT

The Danish Drowning Cohort was established in 2016 to facilitate research to improve preventative, rescue, and treatment interventions to reduce the incidence, mortality, and morbidity of drowning. The Danish Drowning Cohort contains nationwide data on all fatal and non-fatal drowning incidents treated by the Danish Emergency Medical Services. Data are extracted from the Danish prehospital electronic medical record using a text-search algorithm (Danish Drowning Formula) and a manual validation process. The WHO definition of drowning, supported by the clarification statement for non-fatal drowning, is used as the case definition to identify drowning. All drowning patients are included, including unwitnessed incidents, non-conveyed patients, patients declared dead prehospital, or patients with obvious clinical signs of irreversible death. This method allows syndromic surveillance and monitors a nationwide cohort of fatal and non-fatal drowning incidents in near-real time to inform future prevention strategies. The Danish Drowning Cohort complies with the Utstein style for drowning reporting guidelines. The 30-day mortality is obtained through the Civil Personal Register to differentiate between fatal and non-fatal drowning incidents. In addition to prehospital data, new data linkages with other Danish registries via the patient's civil registration number will enable the examination of various additional factors associated with drowning risk.

CONCLUSION

The Danish Drowning Cohort contains nationwide prehospital data on all fatal and non-fatal drowning incidents treated by the Danish Emergency Medical Service. It is a basis for all research on drowning in Denmark and may improve preventative, rescue, and treatment interventions to reduce the incidence, mortality, and morbidity of drowning.

Application of Refill, Recoil, Rebound (3R) as a Novel Chest Compression Technique in Cardiopulmonary Resuscitation; Report of Two Cases

Cardiopulmonary resuscitation (CPR) remains controversial with dismal outcomes for cardiac arrest (CA) victims. Inadequate organ perfusion and frequent CPR-related trauma most likely occur due to inappropriate adaptation to hemostatic conditions, electrophysiology, cardiotorsal anatomy, and thoracic biomechanics. Alternatively, we propose a new technique compromising chest compressions through the 5th intercostal space while placing the victim in the left lateral decubitus position with wrapped abdomen and raised legs, allowing to: bypass the sternal barrier, refill the heart, and then recoil-rebound the chest (3R /CPR), within the axis of the cylindrical ribcage. Our goal is to evaluate the technique following its necessary application on two drowning victims. It seems that, 3R/CPR adapts the pathophysiological conditions of CA victims promoting a less traumatic return of spontaneous circulation (ROSC), making it worthy of further investigation and study.

Gaps in the evidence for interventions in global drowning research

BACKGROUND

Since 2014, drowning has received increased political attention. Translating this political commitment to saving lives needs policy-supported evidence-informed interventions. An evidence gap map (EGM) was developed, which aims to facilitate the strategic prioritisation of future research and efficient commissioning of interventions.

METHODS

Available evidence was sought by searching four electronic databases using drowning key terms from 2005 to 2023. Peer-reviewed studies, which measured the outcome of a drowning prevention intervention, were included in the EGM. Classification of interventions was guided by the WHO's recommendations for drowning prevention interventions and strategies. Intervention outcomes were classified into health, social, economic, policy and other supporting outcomes.

RESULTS

49 intervention studies were identified. Of these, 25 studies were conducted in high-income countries (HICs), 19 in low- and middle-income countries (LMICs), 3 in both HICs and LMICs and 2 were not country specific. Interventions, which used community education, were the most common (n=29, 27%), followed by teaching school-age children swimming and water safety skills (n=13, 12%) and others combined (n=66, 61%). Majority of interventions focused on process outcomes such as knowledge acquisition (n=42, 39%) in comparison with objective outcomes such as incidence of drowning mortality (n=21, 19%). No studies reported on interventions that manage flood risks.

CONCLUSIONS

Knowledge gaps of effective drowning prevention interventions were identified using an EGM, emphasising the need for methodological advancements reporting on outcomes measures, implementation research and targeted research among high-risk populations in LMICs.

A Cross-Sectional Survey of Unintentional Injuries Among 15-24-Year-Old Vocational School Youth From Pakistan Between 2021-2022

There is a lack of recent data on the incidence of unintentional injuries and occupational injuries from Pakistan, among youth 15 to 24 years of age. This survey was conducted among vocational school youth in Peshawar, Pakistan (2021-22). Parental consent and assent were obtained for students <18 years of age. After obtaining consent, students were given a hard copy of the self-administered, World Health Organization community survey guide for injuries and violence questionnaire in a classroom session. Incidence Rate Ratios (IRR) were reported for unintentional and occupational injuries There were 547 youth of which [356 (54%)] were males. Majority [535 (97%)] of the students had received formal education before vocational training, while fathers had higher formal education [437(80%)], compared to mothers [326 (60%)]. The median family income of these vocational students was 30 000 Pakistani rupee (PKR) per month. Vocational youth mostly lived in crowded family settings with 239 participants (44%) living with ≥8 family members in the household. In terms of risk behaviors, there was minimal use of tobacco [532 (97.3%)] and minimal alcohol [9 (2%)]. Non-use of helmets was found in [273 (50%)], which was similar to seat belt non-use in [307 (56%)] of participants. Eight percent of students carried a gun for personal protection. Males had 3.24 times higher rates of road traffic injuries, 1.28 times higher rates of occupational injuries, and 1.63 times higher rates of unintentional injuries overall compared to their female counterparts. The 15 to 19 age group had significantly lower incidence of burns and falls compared to the 20 to 24 age group. Factors that increased the risk of unintentional injuries UIT were tobacco use adjusted IRR = 1.25 (95% CI: 1.05-2.69, P = .049), not using a seat belt adjusted IRR = 1.3 (95% CI: 1.14-1.69, P < .001), lack of formal education prior to vocational training in the youth, adjusted IRR of 4.6 (95% CI: 1.12-18.91, P = .034), lack of father's education adjusted IRR = 4.71 (95% CI: 2.12-10.49, P < .001), lower family income (≤35 000 PKR) adjusted IRR = 2.04 ( 95% CI: 1.04-4.02, P = .039), larger household size (≥8 members), with an adjusted IRR of 3.59 (95% CI: 3.11-5.07, P < .001). In contrast, age ≤19 years showed a higher unadjusted risk (IRR = 2.05, 95% CI: 1-4.2, P = .049), but this association was not significant after adjustment (adjusted IRR = 1.61, 95% CI: 0.8-3.27, P = .184). Marital status and mother's education were not significantly associated with UIT. This study on vocational youth in Pakistan highlights the critical need for targeted interventions. We recommend prioritizing stricter enforcement of traffic laws, implementing public awareness campaigns specifically for vocational youth, and providing subsidized safety equipment, such as helmets. Furthermore, integrating comprehensive road safety and health education into vocational training curricula is crucial. By addressing these critical areas, significant reduction in injury rates and improved safety and well-being of this vulnerable population may be realized.

Effectiveness of interventions to prevent drowning among children under age 20 years: a global scoping review

Background

Drowning is a leading cause of death among young children. The United Nations Resolution on global drowning prevention (2021) and World Health Assembly Resolution in 2023 have drawn attention to the issue. This scoping review synthesizes the current evidence on the effectiveness of child drowning prevention interventions since the 2008 World Report on Child Injury Prevention and implications for their implementation.

Methods

Quantitative studies published between 2008 and 2023 focusing on interventions targeting unintentional injuries, including drowning, among children and adolescents under age 20 years were searched on Cochrane Database of Systematic Reviews, Epistemonikos, PubMed, and Embase. Relevant data on interventions were extracted using a pre-defined template on Microsoft Excel. This scoping review focuses on the interventions addressing drowning.

Results

Overall, 12 studies fulfilled the inclusion criteria. Evidence generated between 2008 and 2023 support the effectiveness of introducing barriers around water bodies, immediate resuscitation and first-responder training, and use of personal floatation devices (PFDs). Basic swimming and water safety skills training for children ages 6 years and older, and enacting and enforcing regulations on pool fencing and PFD use were found to be promising based on new evidence published since 2008. This scoping review also found evidence on new interventions studied since 2008, such as close adult supervision, inspections of safety standards of pools, and the use of door barriers and playpens, all of which demand further research to ensure context-specific implementation in LMICs.

Conclusion

While there is evidence to support both existing and new interventions, most of the available interventions are still classified as promising and emerging, underlining the need for further evaluation of those interventions in diverse settings (including low and middle- income) through effectiveness studies and implementation research. In addition, it is important to highlight the nexus between drowning prevention and the Sustainable Development Goals to advocate multisectoral and interdisciplinary collaboration, to influence the broader child health agenda.

Impact of lifeguard oxygen therapy on the resuscitation of drowning victims: Results from an Utstein Style for Drowning Study

INTRODUCTION

No published evidence was identified regarding the use of oxygen in the treatment of drowning in two recent systematic reviews. The aim of our study was to investigate the impact of on scene, pre-Emergency Medical Services (EMS) oxygen therapy by lifeguards in the resuscitation of drowning victims.

METHOD

We conducted a retrospective case match analysis of drowning patients presenting to the EDs of Sunshine Coast Hospital and Health Service. Patients were matched for age, sex and severity of drowning injury. The primary outcome was in-hospital mortality. Secondary outcomes included positive pressure ventilation (PPV) by EMS and the ED, as well as admission to the Intensive Care Unit.

RESULTS

There were 108 patients in each group. Median (IQR) age was 22 (15-43) in the oxygen group and 23 (15-44) years in the non-oxygen group. There were 45 females in the oxygen group and 41 females in the non-oxygen group. Sixteen patients had suffered cardiac arrest and three patients respiratory arrest in each group. There were five deaths in each group. Initial oxygen saturation on arrival of EMS was identical in both groups 89.2% (±19.9) in the oxygen group versus 89.3% (±21.1) (P = 0.294) in the non-oxygen group. The oxygen group required PPV more frequently with EMS (19 vs 11, P < 0.01) and in the ED (19 vs 15, P < 0.01).

CONCLUSION

On scene treatment with oxygen by lifeguards did not improve oxygenation or outcomes in drowning patients.

Global, regional, and national drowning trends from 1990 to 2021: Results from the 2021 Global Burden of Disease Study

BACKGROUND

Drowning is a preventable public health concern that burdens emergency care systems globally. This study comprehensively evaluated fatal drowning patterns across population, time, and geography from 1990 to 2021 to inform effective prevention strategies.

METHODS

Using the 2021 Global Burden of Disease Study framework and standardized estimation methods, the study analyzed global and regional drowning burden in terms of mortality, incidence, and disability-adjusted life-years (DALYs), based on population registry data and drowning-related epidemiological covariates.

RESULTS

Global drowning incidents decreased by 33.67% from 1990 to 2021. The drowning incidence rate and mortality rate declined from 24.20 and 9.68 per 100,000 in 1990 to 10.85 and 3.48 per 100,000 in 2021, respectively. Years of life lost and DALYs rates due to drowning also decreased significantly, from 715.80 and 718.69 per 100,000 in 1990 to 197.64 and 198.92 per 100,000 in 2021. Regionally, East Asia had the highest drowning mortality (27.15% of global deaths), while the high-income Asia Pacific region experienced the highest incidence rate (21.38 per 100,000). South Asia had the greatest number of drowning deaths (75,639). Tropical Latin America showed the largest incidence decline, while high-income Asia Pacific exhibited increasing trends. Drowning disproportionately affected children under 5 and the elderly in most regions.

CONCLUSIONS

While global drowning rates have declined, progress varies across regions. To improve prevention, focus should target low-income/middle-income countries and vulnerable populations like children and the elderly. Increased investment in safety education and rescue resources is vital to address their disproportionate risks.

Joint effects of heat-humidity compound events on drowning mortality in Southern China

BACKGROUND

Several previous studies have examined the association of ambient temperature with drowning. However, no study has investigated the effects of heat-humidity compound events on drowning mortality.

METHODS

The drowning mortality data and meteorological data during the five hottest months (May to September) were collected from 46 cities in Southern China (2013-2018 in Guangdong, Hunan and Zhejiang provinces). Distributed lag non-linear model was first conducted to examine the association between heat-humidity compound events and drowning mortality at city level. Then, meta-analysis was employed to pool the city-specific exposure-response associations. Finally, we analysed the additive interaction of heat and humidity on drowning mortality.

RESULTS

Compared with wet-non-hot days, dry-hot days had greater effects (excess rate (ER)=32.34%, 95% CI: 24.64 to 40.50) on drowning mortality than wet-hot days (ER=14.38%, 95%CI: 6.80 to 22.50). During dry-hot days, males (ER=42.40%, 95% CI: 31.92 to 53.72), adolescents aged 0-14 years (ER=45.00%, 95% CI: 21.98 to 72.35) and urban city (ER=36.91%, 95% CI: 23.87 to 51.32) showed higher drowning mortality risk than their counterparts. For wet-hot days, males, adolescents and urban city had higher ERs than their counterparts. Attributable fraction (AF) of drowning attributed to dry-hot days was 23.83% (95% CI: 21.67 to 26.99) which was significantly higher than that for wet-hot days (11.32%, 95% CI: 9.64 to 13.48%). We also observed that high temperature and low humidity had an additive interaction on drowning mortality.

CONCLUSION

We found that dry-hot days had greater drowning mortality risk and burden than wet-hot days, and high temperature and low humidity might have synergy on drowning mortality.

Deaths related to drowning in Antalya, an important tourism center in the Mediterranean region: A 10-year retrospective study

Objectives: Drowning is one of the most common causes of accidental deaths in all age groups. This study aims to compare the sociodemographic data, scene of incident findings, clinical characteristics, and autopsy findings of Turkish and foreign victims of drowning in Antalya, one of the most popular global holiday destinations. Study Design: This study is the most extensive case series of drowning in Turkey. Methods: A retrospective examination was made of 7775 autopsies, of which 692 (8.9%) were identified as drowning cases. Results: Almost half of the cases were elderly males of foreign nationality, with a chronic disease and high alcohol consumption, who were found wearing swimming clothes and had died accidentally, mostly in the sea or swimming pools. The majority of Turkish victims were male children and adolescents, found wearing normal daily clothes, who died from a fall or while performing high-risk activities, such as jumping from height. Most of these cases died at the scene of the incident due to an accident or suicide. Conclusions: Such incidences of deaths in Antalya could be reduced with the implementation of precautions, with adjustments made according to the increased risks and, particularly, the mobility of the older age group. Significantly, chronic disease is an important risk factor in cases of drowning.

The epidemiology and outcomes of hospitalized drowning in Thai children: a national data analysis 2015-2019

BACKGROUND

Drowning remains a common cause of death among children. However, the epidemiology and impact of drowning in Thailand was underexplored. This study aimed to analyze the epidemiology and clinical outcomes of pediatric drowning in Thailand and to determine the factors associated with the need for intubation and mortality.

METHODS

Data derived from the Thai healthcare delivery system for the period between 2015 and 2019 were used to examine the monthly admissions, mortality rates, length of hospital stay, and the number of patients who received endotracheal intubation. Multivariate logistic regression analysis was employed to identify the risk factors associated with the need for intubation and mortality.

RESULTS

Of the 4,911, 58.8% were under six years old, 63.5% were male, and 31.2% were from the Northeastern region. The majority drowned during April, which is the summer season in Thailand. Among these patients, 28.8% required intubation, with the highest proportion found in the 6-<12 years age group (35.9%). The independent risk factors for intubation were metabolic acidosis (adjusted odd ratio [aOR] 9.74; 95% confidence interval [CI] 7.14-13.29; p < 0.001) and pulmonary edema (aOR 5.82; 95%CI 3.92-8.65; p < 0.001). The overall mortality rate due to drowning was 12.6%. Factors significantly associated with mortality included in-hospital cardiac arrest (aOR 4.43; 95%CI 2.78-7.06; p < 0.001), and the presence of drowning-related complications, particularly renal failure (aOR 7.13; 95%CI 3.93-12.94; p < 0.001).

CONCLUSION

Drowning admissions and mortality were highest among male children under six years old, occurring mainly during the summer season. Significant factors associated with intubation requirement included metabolic acidosis and pulmonary edema. The mortality was significantly associated with in-hospital cardiac arrest and drowning-related complications, particularly renal failure.

TRIAL REGISTRATION

This is an observational study, does not include any intervention, and has therefore not been registered.

Burden of unintentional drowning in Indonesia: insights from the Global Burden of Disease Study 2019

INTRODUCTION

A high burden of unintentional fatal drowning has been reported in low- and middle-income countries. However, little is known about unintentional drowning in Indonesia.

METHODS

This population-based retrospective cohort study analysed unintentional drowning data for Indonesia sourced from The Global Burden of Disease Study 2019. Estimates of trends, mortality rates, incidence rates, years lived with disability (YLDs) and disability adjusted life years were generated.

RESULTS

A decline in unintentional drowning mortality rates was observed, with an average annual mortality rate of 2.58/100 000. Males were 1.81 (95% CI 1.79 to 1.84) times more likely than females to unintentionally drown. Average annual mortality rates were highest among the under-5 age group (9.67/100 000) and 70 and over (5.71/100 000 for males; 5.14/100 000 for females). Distributions of drowning deaths vary depending on region, with mortality rates higher in Papua, Kalimantan, Sulawesi, Maluku, Sumatra and Nusa Tenggara regions.

DISCUSSION

While a decline in drowning mortality rates in Indonesia was identified between 2005 and 2019, mortality rates for unintentional drowning remained high among children under 5 years, the elderly population and those residing in Papua, Kalimantan, Sulawesi, Maluku, Sumatra and Nusa Tenggara, warranting further focused attention.

CONCLUSION

A downward trend in the rate of unintentional drowning deaths in Indonesia is observed from 2005 onwards, with risk variation based on age, gender and region. The findings highlight the importance of addressing drowning as a cause of premature mortality and health system burden in Indonesia, including through enhancing drowning data collection systems and identifying drowning risk factors.

Child drowning in Indonesia: insights from parental and community perspectives and practices

Child drowning is a significant public health issue in Indonesia, however, there is insufficient understanding of the issue and its associated risk factors within communities. This qualitative study aimed to explore parental and community perceptions and practices related to child drowning in Indonesian communities, and the perceived causes and risk factors. Seven focus group discussions (n = 62) were conducted with parents of children aged under-5 years and village community leaders in seven villages across all districts of Lombok Island, West Nusa Tenggara Province of Indonesia. Participants were recruited using purposive and snowball sampling. The thematic analysis, guided by Braun and Clarke's framework, used both deductive approaches, utilizing the Health Belief Model's constructs and inductive approaches. Most participants were unaware of the susceptibility of their children and others in their community to drowning and of the potential severe outcomes of drowning such as injury, disability and death. Participants generally associated drowning with beaches or open seas. Unprotected wells, tubs and buckets were identified as notable risk factors for child drowning in and around the home, shaped by some experience of child drowning incidents in the community. Supervision was identified as protective factor, however, mothers were often unavailable to supervise children, and supervision responsibility was often delegated to other family and community members. This study highlights the urgent need to enhance public awareness regarding children's susceptibility to drowning. Further exploration of local contexts and social determinants of drowning in Indonesian communities is crucial for ensuring effective water safety and drowning prevention strategies.

Challenges to young children's swimming lesson participation in New South Wales, Australia

BACKGROUND

Child swimming lessons are a key intervention for drowning prevention; however, participation has been severely affected by COVID-19 restrictions and cost-of-living challenges. To encourage re-engagement, the New South Wales government began providing A$100 swimming lesson vouchers. Parent/carers of eligible preschool-aged children were asked to complete a survey during voucher creation. This study aimed to examine pre-existing challenges to lesson participation among families who had not participated in the preceding 12 months.

METHODS

Cross-sectional data from parent/carer surveys completed between December 2021 and June 2022 were analysed. Binary logistic models analysed associations between sociodemographic factors and answered affirmatively to one or more challenges to participation from a predefined list.

RESULTS

Of 221 218 vouchers created, 79 553 parent/carers (36%) indicated that their child had not participated in swimming lessons in the last 12 months and responded to the question about participation challenges. Parent/carers of children with disabilities or residing in low socioeconomic areas had higher odds of indicating cost was a challenge while regional/remote families had over five times higher odds of indicating swim school availability difficulties. Families speaking a non-English language at home had over 2.5 times higher odds of thinking that their child was too young for swimming lessons, higher odds of thinking swimming lessons were not important and higher odds of indicating that COVID-19 had challenged participation.

CONCLUSION

These findings highlight how different population groups experience challenges to participation in swimming lessons. Alleviating costs and increasing lesson availability is important.

Drowning prevention challenges and opportunities: An exploratory study of perspectives of delegates from ASEAN nations

The South East Asian region has the world's second highest fatal drowning burden. This study reports analysis of survey data from representatives from nations within the Association of South East Asian Nations regarding current efforts, challenges and future opportunities for drowning prevention. Twenty-two responses were received from respondents from all ASEAN nations excepting Cambodia and Myanmar. Drowning prevention initiatives varied across ASEAN nations, with most efforts focused on public education and raising awareness, including the provision of drowning data to the media. The lack of comprehensive, national level data collection was identified as a challenge, necessitating strengthened data collection capacity. Governmental involvement spanned one to six different ministries, highlighting the multi-sectoral nature of drowning prevention. However, a lead ministry could be identified in only two countries. Despite the challenges identified, there remain many opportunities to strengthen drowning prevention across ASEAN nations, addressing a significant regional public health threat.

Climate change: A pointer to increased small-scale fisher drowning deaths

Drowning is an overlooked public health concern and drowning risk is dependent on environmental risk factors. The preponderance of drowning deaths occurs in low- and middle-income countries. Small-scale fishers face high occupational risk of drowning. Climate change increases the frequency and intensity of storms, thereby exacerbating fishers' risks and creating a need to examine the contribution of storms to fisher drowning deaths for the development of mitigation strategies. We examined this relationship between weather and fisher drowning deaths in Lake Victoria, which is Africa's largest lake, a site of high fishing pressure, and where climate change is predicted to increase thunderstorms. We conducted a verbal autopsy with people knowledgeable about recent fatal fisher drowning incidents to collect information about the deceased fishers and circumstances surrounding the incidents across 43 landing sites in the Kenyan shore of Lake Victoria. Semi-structured interviews with stakeholders also elucidated community perspectives on drowning risks. Fatal drownings were often attributed to bad weather (41.8%). Other risk factors, such as non-use of life jacket and navigation equipment, co-occurred with bad weather at high rates (69.5% and 67.8%, respectively) to jointly contribute to fatal drowning incidents. Such co-occurrence of risk factors indicates that actions across multiple risk factors can help mitigate the issue. Stakeholder analysis revealed a range of opportunities for improved communication of risks and action to mitigate risks across boat operators and manufacturers, as well as multiple levels of management. Across global small-scale fisheries, limited use of safety equipment and intensive fishing pressure may coincide with increases in extreme weather events, necessitating action to address current and mitigate future drowning risks to small-scale fishers.

Drowning and Nonfatal Drowning in Children and Adolescents: A Subsequent Retrospective Data Analysis

Fatal and nonfatal drowning are among the leading causes of death and lifelong severe neurological impairment among children and adolescents. This study aimed to complement research from Leipzig 1994-2008 to seek trends within risk factors, treatments, and outcomes throughout the last decade. We retrospectively investigated data of 47 inpatients aged 0-18 admitted to Leipzig University Department of Pediatrics who matched ICD-10 code T75.1 from 2008 to 2020 and compared them to a preceding study at the same institution. We also examined the prognostic value of parameters regarding the patients' outcomes. There were three median incidents per annum. The median age was 2.75 years; 76% of incidents happened in males. An accumulation was seen during the summer months and weekends. Most drowning incidents occurred in private ponds or pools (48.9%). Thirty-nine children were discharged without resulting morbidity, four showed neurological impairment, and three died. Risk factors concerning age, sex, and incident characteristics were confirmed. Special supervision needs still apply to 1-3-year-old male children or children with pre-existing health conditions around private pools and ponds. Hospitalization duration shortened, and morbidity and lethality decreased since the previous study. There was structural improvement in primary care and medical documentation. Parameters suggesting good outcomes include a submersion time < 5 min, GCS > 3 points, spontaneous movement upon admission, remaining pupillary light response, the absence of cardiovascular arrest, body temperature ≥ 32 °C, pH > 7, blood glucose < 15 mmol/L, lactate < 14 mmol/L, base excess ≥ -15 mmol/L, and the absence of ARDS. Clear legislation can contribute to improved private home water safety. Further studies should include a broad in- and outpatient spectrum and standardized incident documentation presupposing Utstein-style reporting. Regular reinvestigation of consistent geographical regions facilitates process evaluations of drowning epidemiology and therapy evolution.

The burden, risk factors and prevention strategies for drowning in Türkiye: a systematic literature review

INTRODUCTION

Drowning is a public health problem in Türkiye, as in the rest of the world. This study aims to systematically review the literature on drowning in Türkiye with a focus on data sources, epidemiology, risk factors and prevention strategies.

METHODS

Literature searches were conducted using PubMed, SPORTSDiscus, Scopus, Web of Science, Turk MEDLINE, Google Scholar and Google Akademik (Turkish language). Studies (limited to original research written in English and Turkish) reporting drowning (unintentional and intentional; fatal and non-fatal) of residents and tourists in Türkiye were independently dual screened at the title and abstract and full text stages. Study quality was assessed using JBI checklists and evidence level assessed based on study design.

RESULTS

From a total of 917 studies, 49 met the inclusion criteria. Most (51%) focused on unintentional fatal drowning. Included studies were most commonly analytical cross-sectional studies (n = 23) and case series (n = 20) meaning the evidence level was low or very low for 48 (98%) studies. Fifteen studies examined drowning at the national level, while sub-national studies (n = 30) focused on urban areas across three provinces: Antalya (n = 6), Istanbul (n = 6), Izmir (n = 4). There was little consensus on risk factors beyond male drowning risk, and no data reported on implemented or evaluated drowning prevention interventions.

DISCUSSION

There is a need for more national-level studies to identify the causes of drowning and to guide intervention implementation and evaluation to inform policy makers and donors. Currently official data is limited in its detail, providing age and gender data only, hampering efforts to identify, and thus address, causal factors for drowning.

PRACTICAL APPLICATIONS

There is currently very little evidence to inform investment in effective drowning prevention interventions in Türkiye. To improve this, data collection systems on drowning in Türkiye need to be strengthened via the development a national drowning registry.

TRIAL REGISTRATION

#CRD42022382615.

The effect of the 'Swim Reaper' program on water safety awareness, drowning mortality and morbidity among males aged 15-34 years in Aotearoa, New Zealand

BACKGROUND AND OBJECTIVE

To increase water safety awareness among young males New Zealand introduced the Swim Reaper program in 2016. The program ran annually over summer and in 2018/19 an evaluation was conducted. The objective of this study was to evaluate the impact of the 2018/19 Swim Reaper social media-based campaign on self-reported water safety awareness and identify changes in fatal and nonfatal drowning rates for New Zealand resident males aged 15-34 years before and after the 2016 Swim Reaper program.

METHODS

Online surveys pre (December-2018) and post (February-March-2019) Swim Reaper campaign were used to estimate water safety awareness post-campaign relative to pre-campaign using negative binomial regression adjusted for potential confounders. Interrupted time series (ITS) analysis, adjusted for seasonality, explored changes in drowning mortality, hospital admissions and Accident Compensation Corporation (ACC) claims pre and post program introduction (2016).

RESULTS

A total of 518 males responded (50.6% post-campaign). There were significant improvements (post vs. pre-campaign) in self-reported water safety awareness. ITS analysis showed a reduction in drowning related hospital admissions post relative to pre-program (RR = 0.47; [95%CI: 0.24-0.90]; p = 0.02).

DISCUSSION

Young males are an at-risk cohort for drowning and creating behavior change among this group can be challenging. Using a unique, humor-based approach the Swim Reaper program appears to be having some impact on self-reported water safety behaviors, as well as unintentional drowning-related hospitalization rates. Further evaluation, more clearly linked to campaign themes, is required to ascertain direct impact of the program.

CONCLUSION

The novelty and reach of the campaign within the context of a prevailing downward trend in drownings may provide support for social media-based programs targeting this hard-to-reach demographic.

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.

Epidemiology of unintentional injuries among 15-24-year-old vocational school youth from Peshawar Pakistan: A cross-sectional survey

Background

The burden of unintentional injuries among youth (15-24 years) is high. There is paucity of data on unintentional injuries in youth working in Vocational Training Institutes.

Objective

To determine the incidence, characteristics, and risk factors of unintentional injuries among youth.

Methods

Design:: A retrospective cross-sectional survey was conducted among select vocational school youth in Peshawar, Pakistan between February 2022 to October 2022.Participants:: A total of 547 study participants participated in the survey, 356 were males while 191 were females. Data were collected on using the World Health Organization community survey guide for injuries and violence. Multilevel Negative Binomial Regression model was used to report incidence rate ratios of all unitentional injuries.

Results

A total of 503 injuries were reported by the youth, with road traffic injuries being the most common (n=197, 39%), followed by burns (n=89, 18%), falls (n=79, 16%) and poisonings (n=15, 3%), drownings (n=23, 7.1%). Occupational injuries reported during vocational training were (n=95, 18%). Males had a higher incidence rates of RTI 3.24[2.35-5.3], falls 1.30 [0.74-2.27], poisonings 2.14 [0.57-7.58] and drownings 2.46(0.84-7.21), while females had a higher incidence rate of burns 2.19 [1.785-3.46].Lack of education 4.6 [1.12 -18.91] (p=0.034), smoking 1.25 [1.05 -2.69] (p=0.049), lack of fathers education 4.71 [2.12 -10.49] (p=<0.001), carrying a gun 6.59 [2.54 -17.11] (p=<0.001), crowded families 3.59 [3.11 -5.07] (p=<0.001), lower family income 2.04 [1.04 -4.02](p=0.039*), lack of helmet use 4.54 [2.12 -9.76] (p=<0.001) and lack of seat belt use 1.3 [1.14 -1.69] (p= <0.001) were significant risk factors for unintentional injuries in youth.

Conclusion Added value of the study

This study is one of the first research studies conducted in vocational school youth in Pakistan. It provides the recent rate of unintentional injuries among the youth of Pakistan. High occupational injuries among vocational school youth were reported which needs further research.

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.

Enhancing Water Safety: Exploring Recent Technological Approaches for Drowning Detection

Drowning poses a significant threat, resulting in unexpected injuries and fatalities. To promote water sports activities, it is crucial to develop surveillance systems that enhance safety around pools and waterways. This paper presents an overview of recent advancements in drowning detection, with a specific focus on image processing and sensor-based methods. Furthermore, the potential of artificial intelligence (AI), machine learning algorithms (MLAs), and robotics technology in this field is explored. The review examines the technological challenges, benefits, and drawbacks associated with these approaches. The findings reveal that image processing and sensor-based technologies are the most effective approaches for drowning detection systems. However, the image-processing approach requires substantial resources and sophisticated MLAs, making it costly and complex to implement. Conversely, sensor-based approaches offer practical, cost-effective, and widely applicable solutions for drowning detection. These approaches involve data transmission from the swimmer's condition to the processing unit through sensing technology, utilising both wired and wireless communication channels. This paper explores the recent developments in drowning detection systems while considering costs, complexity, and practicality in selecting and implementing such systems. The assessment of various technological approaches contributes to ongoing efforts aimed at improving water safety and reducing the risks associated with drowning incidents.

Using ERIC to Assess Implementation Science in Drowning Prevention Interventions in High-Income Countries: A Systematic Review

This systematic review identifies and describes the use of the Expert Recommendation for Implementing Change (ERIC) concepts and strategies using public health approaches to drowning prevention interventions as a case study. International calls for action have identified the need to better understand the implementation of drowning prevention interventions so that intervention design and implementation is improved. In high-income countries (HICs), interventions are sophisticated but still little is known or written about their implementation. The review was registered on PROSPERO (number CRD42022347789) and followed the PRISMA guidelines. Eight databases were searched. Articles were assessed using the Public Health Ontario Meta-tool for quality appraisal of public health evidence. Forty-nine articles were included. Where ERIC strategies were reported, the focus was on evaluative and iterative strategies, developing partnerships and engaging the target group. The review identified few articles that discussed intervention development and implementation sufficiently for strategies to be replicated. Findings will inform further research into the use and measurement of implementation strategies by practitioners and researchers undertaking work in drowning prevention in HICs and supports a call to action for better documentation of implementation in public health interventions.

Development and validation of an intervention package to improve lifejacket wear for drowning prevention among occupational boaters on Lake Albert, Uganda

BACKGROUND

Occupational drowning is a growing public health concern globally. The human cost of fishing is highest in sub-Saharan Africa. Although lifejackets prevent drowning, the majority of boaters in Uganda do not wear them. We developed and validated a peer-to-peer training manual to improve lifejacket wear among occupational boaters on Lake Albert, Uganda.

METHODS

The intervention was developed in three stages. In stage one, we conducted baseline studies to explore and identify aspects of practices that need to change. In stage two, we held a stakeholder workshop to identify relevant interventions following the intervention functions of the behaviour change wheel (BCW). In stage three, we developed the content and identified its implementation strategies. We validated the intervention package using the Content Validity Index for each item (I-CVI) and scale (S-CVI/Ave).

RESULTS

Seven interventions were identified and proposed by stakeholders. Training and sensitisation by peers were unanimously preferred. The lowest I-CVI for the content was 86%, with an S-CVI/Ave of 98%. This indicates that the intervention package was highly relevant to the target community.

CONCLUSION

The stakeholder workshop enabled a participatory approach to identify the most appropriate intervention. All the proposed interventions fell under one of the intervention functions of the BCW. The intervention should be evaluated for its effectiveness in improving lifejacket wear among occupational boaters.

Danish Drowning Formula for identification of out-of-hospital cardiac arrest from drowning

BACKGROUND

Accurate, reliable, and sufficient data is required to reduce the burden of drowning by targeting preventive measures and improving treatment. Today's drowning statistics are informed by various methods sometimes based on data sources with questionable reliability. These methods are likely responsible for a systematic and significant underreporting of drowning. This study's aim was to assess the 30-day survival of patients with out-of-hospital cardiac arrest (OHCA) identified in the Danish Cardiac Arrest Registry (DCAR) after applying the Danish Drowning Formula.

METHODS

This nationwide, cohort, registry-based study with 30-day follow-up used the Danish Drowning Formula to identify drowning-related OHCA with a resuscitation attempt from the DCAR from January 1st, 2016, through December 31st, 2021. The Danish Drowning Formula is a text-search algorithm constructed for this study based on trigger-words identified from the prehospital medical records of validated drowning cases. The primary outcome was 30-day survival from OHCA. Data were analyzed using multiple logistic regression.

RESULTS

Drowning-related OHCA occurred in 374 (1%) patients registered in the DCAR compared to 29,882 patients with OHCA from other causes. Drowning-related OHCA more frequently occurred at a public location (87% vs 25%, p < 0.001) and were more frequently witnessed by bystanders (80% vs 55%, p < 0.001). Both 30-day and 1-year survival for patients with drowning-related OHCA were significantly higher compared to OHCA from other causes (33% vs 14% and 32% vs 13%, respectively, p < 0.001). The adjusted odds ratio for 30-day survival for drowning-related OHCA and other causes of OHCA was 2.3 [1.7-3.2], p < 0.001. Increased 30-day survival was observed for drowning-related OHCA occurring at swimming pools compared to public location OHCA from other causes with an OR of 11.6 [6.0-22.6], p < 0.001.

CONCLUSIONS

This study found higher 30-day survival among drowning-related OHCA compared to OHCA from other causes. This study proposed that a text-search algorithm (Danish Drowning Formula) could explore unstructured text fields to identify drowning persons. This method may present a low-resource solution to inform the drowning statistics in the future.

REGISTRATION

This study was registered at ClinicalTrials.gov before analyses (NCT05323097).

Burden of fatal drowning in California, 2005-2019

OBJECTIVE

To characterise risk factors for fatal drowning in California, USA to inform priorities for prevention, policy and research.

METHODS

This retrospective population-based epidemiological review of death certificate data evaluated fatal drowning events in California from 2005 to 2019. Unintentional, intentional, and undetermined drowning deaths and rates were described by person (age, sex, race) and context-based variables (region and body of water).

RESULTS

California's fatal drowning rate was 1.48 per 100 000 population (n=9237). Highest total fatal drowning rates occurred in the lower population density northern regions, among older adults (75-84 years: 2.54 per 100 000 population; 85+: 3.47 per 100 000 population) and non-Hispanic American Indian or Alaska Native persons (2.84 per 100 000 population). Male drowning deaths occurred at 2.7 times the rate of females; drowning deaths occurred mainly in swimming pools (27%), rivers/canals (22.4%) and coastal waters (20.2%). The intentional fatal drowning rate increased 89% during the study period.

CONCLUSIONS

California's overall fatal drowning rate was similar to the rest of the USA but differed among subpopulations. These divergences from national data, along with regional differences in drowning population and context-related characteristics, underscore the need for state and regional level analyses to inform drowning prevention policy, programmes and research.

Fatal drowning in Indonesia: understanding knowledge gaps through a scoping review

Little is known about unintentional drowning deaths in Indonesia, the world's fourth most populous and largest archipelagic country. This study aimed to describe the epidemiology and risk factors of unintentional drowning in Indonesia and explore existing health promotion and drowning prevention approaches in Indonesia within a socio-ecological health promotion framework. A scoping review, guided by PRISMA-ScR, was conducted to locate peer-reviewed studies and government reports/policy documents published until May 2023, in English or Indonesian language, using MEDLINE (Ovid), CINAHL, Informit, PsycINFO (ProQuest), Scopus, SafetyLit, BioMed Central and Google Scholar, Indonesian journal databases (Sinta, Garuda) and government agencies websites around the terms: drown, swim, flood, hurricane, cyclone, disaster, water rescue and maritime/boat safety. This review identified 32 papers. However, a paucity of information on unintentional drowning rates, risk factors and prevention in Indonesia was noted. The unavailability of a coordinated national drowning data collection system in Indonesia, from which national and subnational subcategory data can be collected, underlines the possibility of under-representation of drowning mortality. The association between various exposures and drowning incidents has not been fully investigated. An over-reliance on individual-focused, behaviour-based, preventive measures was observed. These findings highlight the need for improving drowning surveillance to ensure the availability and reliability of drowning data; and strengthening research to understand the risk factors for drowning and delivery of drowning prevention programs. Further policy development and research focusing on health promotion approaches that reflect a socio-ecological approach to drowning prevention in Indonesia is imperative.

The Combined Effects of Short-Term Exposure to Multiple Meteorological Factors on Unintentional Drowning Mortality: Large Case-Crossover Study

BACKGROUND

Drowning is a serious public health problem worldwide. Previous epidemiological studies on the association between meteorological factors and drowning mainly focused on individual weather factors, and the combined effect of mixed exposure to multiple meteorological factors on drowning is unclear.

OBJECTIVE

We aimed to investigate the combined effects of multiple meteorological factors on unintentional drowning mortality in China and to identify the important meteorological factors contributing to drowning mortality.

METHODS

Unintentional drowning death data (based on International Classification of Diseases, 10th Edition, codes W65-74) from January 1, 2013, to December 31, 2018, were collected from the Disease Surveillance Points System for Guangdong, Hunan, Zhejiang, Yunnan, and Jilin Provinces, China. Daily meteorological data, including daily mean temperature, relative humidity, sunlight duration, and rainfall in the same period were obtained from the Chinese Academy of Meteorological Science Data Center. We constructed a time-stratified case-crossover design and applied a generalized additive model to examine the effect of individual weather factors on drowning mortality, and then used quantile g-computation to estimate the joint effect of the mixed exposure to meteorological factors.

RESULTS

A total of 46,179 drowning deaths were reported in the 5 provinces in China from 2013 to 2018. In an effect analysis of individual exposure, we observed a positive effect for sunlight duration, a negative effect for relative humidity, and U-shaped associations for temperature and rainfall with drowning mortality. In a joint effect analysis of the above 4 meteorological factors, a 2.99% (95% CI 0.26%-5.80%) increase in drowning mortality was observed per quartile rise in exposure mixture. For the total population, sunlight duration was the most important weather factor for drowning mortality, with a 93.1% positive contribution to the overall effects, while rainfall was mainly a negative factor for drowning deaths (90.5%) and temperature and relative humidity contributed 6.9% and -9.5% to the overall effects, respectively.

CONCLUSIONS

This study found that mixed exposure to temperature, relative humidity, sunlight duration, and rainfall was positively associated with drowning mortality and that sunlight duration, rather than temperature, may be the most important meteorological factor for drowning mortality. These findings imply that it is necessary to incorporate sunshine hours and temperature into early warning systems for drowning prevention in the future.

Epidemiology, clinical aspects, and management of pediatric drowning

Drowning is the third leading cause of injury death in the pediatric population worldwide, with incidence peaking among those aged 1-4 years and again in adolescence.The purpose of this commentary is to review the basic pathophysiology of drowninginjury and factors that affect the outcome, such as submersion and hypothermia. We also discuss principles of prehospital and in-hospital management, comprising resuscitation and stabilization, administration of oxygen and intravenous liquids, and central reheating.Even though the mortality rate has decreased in recent years, further investments and safety measures are needed to prevent child drowning deaths.

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.

The application of the Haddon matrix in identifying drowning prevention solutions in the north of Iran

The application of the Haddon matrix in identifying drowning prevention solutions in the north of Iran is necessary. We dealt with drownings on three levels of prevention including before, during, and after the injury in northern Iran (Guilan province). This study aimed to investigate the use of Haddon's matrix in preventing three-level drowning cases before, during, and after the accident in the north of Iran. This qualitative study consisted of 9 focus groups with a sample size of 78 people including 48 nursing staff, 21 emergency medicine specialists, and 30 people from non-medical personnel (local community leaders, executive officials of relevant organizations, lifeguards, staff working in health centers, and families of victims). All group discussions were recorded and the questions were based on the focus group table. According to Haddon's table of results, the major risk group was the young and adolescent boys and more in the area of neglect in culture-building and education. In this study, the role of factors was investigated separately and the necessary solutions were presented that can be used as a scientific and practical basis to achieve the main goal of drowning prevention. These strategies require cross-sectoral collaboration, which seems to be a strong interaction with a greater focus on major risk groups to address deficiencies and prevent the recurrence of potential accidents. The study aimed to investigate the use of Haddon's matrix in the prevention of three-level drowning cases before the event, during the event, and after the event in northern Iran.

Effects of Exposure to Formal Aquatic Activities on Babies Younger Than 36 Months: A Systematic Review

This systematic review investigated the possible effects of exposing infants to formal activities in aquatic environments. A literature search of eight databases was concluded on 12 December 2022. Studies were eligible if they: (i) focused on 0-36 months of age infants, (ii) addressed the exposure of infants to formal aquatic activities, and (iii) compared the 'same condition of aquatic exposure with the control' or 'before and after exposure'. The PRISMA protocol was used. Articles considered for inclusion (n = 18) were clustered in the health, development, and physiological outcome domains. The results show that research is focused on indoor activities, mainly in baby swimming programs and baby aquatic therapy interventions. Swimming and aquatic therapy practices are generally safe for babies' health, and there are benefits to preterm and newborns exposed to aquatic therapy once the physiological parameters are maintained in normal and safe patterns. A positive effect is also suggested in general gross and fine motor skills, visual motion perception, cognitive flexibility, and response selection accuracy for infants who participated in aquatic programs. Further investigation with high-quality experimental designs is required to establish the effect of exposure of infants to formal aquatic activities (Systematic Review Registration: CRD42021248054).

Change in global burden of unintentional drowning from 1990 to 2019 and its association with social determinants of health: findings from the Global Burden of Disease Study 2019

OBJECTIVE

To systematically analyse global, regional and national burden change of unintentional drowning from 1990 to 2019, and to further quantify the contribution of social determinants of health (SDH) on the change.

DESIGN

Data from the Global Burden of Disease Study 2019 were used in this study.

SETTING AND PARTICIPANTS

Individuals of all ages and genders from 204 countries and territories.

MAIN OUTCOME MEASURES

The main outcomes were the age-standardised rates (ASRs) of mortality and disability-adjusted life-years (DALYs) of unintentional drowning. The percentage change in the ASRs were used to estimate the joint effect of SDH on trends in global burden of drowning.

RESULTS

We observed that the global burden of unintentional drowning declined markedly from 1990 to 2019, with age-standardised mortality rate and DALYs rate decreasing by 61.5% and 68.2%, respectively. Women, children, middle Socio-Demographic Index (SDI) countries, South-East Asia and Western Pacific region had higher reduction. At national level, greater reductions were observed in Armenia and Republic of Korea, but significant increases in Cabo Verde and Vanuatu. We found that every one percentile increase in six SDHs (Gross Domestic Product (GDP) per person, SDI, educational attainment, health spending, health workers and urbanisation) was associated with a decrease of 0.15% and 0.16% in drowning age-standardised mortality rate and DALYs rate globally, respectively. Health spending and GDP per capita were the main contributors to the reduction of drowning globally.

CONCLUSIONS

The global burden of unintentional drowning significantly declined in the past three decades, and the improvement of SDHs such as GDP per capita and health spending mainly contributed to the decrease. Our findings indicate that improvement of SDHs is critical for drowning prevention and control.

Effect of integrated intervention to prevent child drowning in rural areas of Guangdong, China: a cluster randomized controlled trial

BACKGROUND

Drowning is the leading cause of death for children under the age of 15 years in Guangdong Province, China. This serious public health issue also exists in low- and middle-income countries (LMICs), which have few value-integrated intervention programs. The current study presents an integrated intervention project that aims to explore an effective pattern of prevention for child drowning in rural areas and feasibility to perform in other LMICs.

METHODS

We conducted a cluster randomized controlled trial by comparing the incidence of non-fatal drowning among children in two groups in rural areas of southern China. We recruited the participants in two phases and reached a total of 10 687 students from 23 schools at two towns in Guangdong Province, China. At the first and second phases, 8966 and 1721 students were recruited, respectively.

RESULTS

The final evaluation questionnaires were collected after 18 months of integrated intervention, where we obtained 9791 data from Grades 3-9. The incidence of non-fatal drowning between the intervention and control groups after intervention did not differ significantly from the baseline according to the total number of students, male students, female students and Grades 6-9 [0.81; 95% confidence interval (CI): [0.66, 1.00]; p = 0.05, 1.17; 95% CI: [0.90, 1.51]; p = 0.25, 1.40; 95% CI: [0.97, 2.02]; p = 0.07 and 0.97; 95% CI: [0.70, 1.34]; p = 0.86], except for Grades 3-5 (1.36; 95% CI: [1.02, 1.82]; p = 0.037). The study observed a significantly positive benefit of awareness and risk behaviours of non-fatal drowning between the intervention and control groups (0.27, 95% CI: [0.21, 0.33]; p = 0.00, -0.16; 95% CI: [-0.24, -0.08]; p = 0.00).

CONCLUSIONS

The integrated intervention exerted a significant impact on the prevention and management of child non-fatal drowning, especially in rural areas.

Mortality trends and the impact of exposure on Australian coastal drowning deaths, 2004-2021

OBJECTIVE

The aim of this study is to characterise Australian coastal drowning trends and evaluate impact of exposure on drowning risk.

METHODS

Descriptive epidemiological analysis of unintentional fatal drowning occurring July 2004-June 2021 at Australian coastal sites (beaches, rock platforms, bays, harbours, offshore locations etc.). Total population, exposed-person and exposed-person-time rates per 100,000 population were calculated by age, sex, socio-economic status, remoteness category and pre-submersion activity. Annual trends were assessed using joinpoint regression. Exposure-based rates used estimates from Surf Life Saving Australia's National Coastal Safety Survey.

RESULTS

The cumulative unintentional coastal fatal drowning rate was 0.43 per 100,000 Australian residents (95%CI: 0.41-0.45) and did not change throughout the study period (p=0.289). The exposed-person rate was 0.67 per 100,000 coastal visitors (95%CI: 0.62-0.72), and there were 0.55 coastal drowning deaths per 10 million coastal visitor hours (95%CI: 0.51-0.59). Men, older people and residents of lower socio-economic and remote areas had higher drowning rates; rock fishing and scuba diving had the highest activity exposure-based rates.

CONCLUSIONS

Education- and policy-based coastal safety interventions should focus on identified risk factors to reduce annual coastal drowning rates.

IMPLICATIONS FOR PUBLIC HEALTH

Exposure-based risk measurements are important for developing and prioritising interventions; assessments based on counts or total population measures alone may misinform prevention efforts.

Addressing gaps in our understanding of the drowning patient: a protocol for the retrospective development of an Utstein style database and multicentre collaboration

INTRODUCTION

This retrospective observational study aims to create a comprehensive database of the circumstances of drowning (including care provided and outcomes of care) to report against the Utstein style for drowning (USFD) for patients presenting to the emergency department (ED). Four areas will be examined: a feasibility study of the USFD; a comparison of classification and prognostication systems; examination of indications and efficacy of different ventilation strategies; and differences in the circumstances, severity, treatment and outcomes of drowning by sex and gender.

METHODS AND ANALYSIS

This protocol outlines retrospective data collection for all patients presenting to EDs of the Sunshine Coast Hospital and Health Service in Queensland, Australia with the presenting problem or discharge diagnosis of drowning or immersion between 2015 and 2022. Patients computerised health records (emergency medical service record, pathology, radiology results, medical and nursing notes for ED, inpatient units and intensive care units) will be used to extract data for entry into an USFD database. Descriptive (eg, median, IQR) and inferential statistical analyses (eg, analysis of variance) will be used to answer the separate research questions. Development of an International Drowning Registry using the USFD dataset and the Research Electronic Data Capture (REDCap) web application is discussed.

ETHICS AND DISSEMINATION

This study has been approved by Metro North Human Research and Ethics Committee (Project No: 49754) and James Cook University Human Research Ethics Committee (H8014). It has been endorsed by national drowning prevention organisations Royal Life Saving Society Australia (RLSSA) and Surf Life Saving Australia (SLSA). Study findings will provide data to better inform clinical management of drowning patients and provide an evidence base on sex and gender differences in drowning. Results will be disseminated through peer review publications, conference presentations and media releases. Results will also be disseminated through RLSSA and SLSA membership of the Australian and New Zealand Resuscitation Council and the Australian Water Safety Council.

Context of boat drowning in Ghana: a mixed qualitative research study

BACKGROUND

Drowning is a significant public health challenge globally. In Africa and Ghana, drowning has remained a silent epidemic among poor communities. Limited evidence has challenged advances in drowning knowledge and prevention. While drowning deaths are often widely circulated in the newspapers, drowning data are not systematically organised to constitute a body of evidence sufficient for scientific exploration. Although drowning was frequent, they were poorly understood. We explore the context of drowning from multiple perspectives from the Volta-basin where the largest man-made lake in the world has become a hotspot for drowning.

METHOD

This study adopts a sequential-mix-qualitative study comprising content analysis of newspaper reports on drowning, structured-observations and in-depth interviews with boaters and fisherfolk. We first explored, the content of newspapers over a 10-year period. This information provided the context of drowning. We followed up with extensive observation of activities on the lake by a team of five. Photovoice qualitative interviews were conducted with 22 boaters, fishers and community members. Thematic content analysis was applied to both the newspaper reports and the in-depth interviews.

RESULTS

Drowning was attributed to both proximate and distal causes. Distal causes were the reasons for movement, while proximate causes were the immediate cause of the drowning. Travelling to farm, market, hospital, church, sell were important distal causes of drowning. Proximate determinants included strong winds, tree stumps, overcrowding, no-adherence to safety procedures, spiritual reasons and high tides. Four types of boat accidents were observed: boat-capsizing, boat-sinking, boat-splitting and boat-catching-fire. Ideas converged and diverged in comparing the newspaper content analysis to the photovoice interviews.

Cervical spine immobilisation is only required in drowning patients at high risk of axial loading of the spine

OBJECTIVES

Wave forced impacts are known to result in cervical spine injuries (CSI) and approximately 20% of drownings in Australia occur at the beach. The most common mechanism of injury in studies examining the frequency of CSI in drowning patients is shallow water diving. The aim of the present study was to determine what proportion of CSIs occurring in bodies of water experienced a concomitant drowning injury in a location where wave forced impacts are likely to be an additional risk factor.

METHODS

Electronic medical records at the Sunshine Coast Hospital and Health Service EDs, Queensland Ambulance Service case records and Surf Life Saving Queensland data between 1 January 2015 and 21 April 2021 were manually linked. Outcomes recorded included victim demographics, scene information, hospital course and patient disposition.

RESULTS

Ninety-one of 574 (15.9%) CSIs occurred in a body of water with risk of drowning. However, only 4 (4.3%) had a simultaneous drowning injury, representing 0.8% (4/483) of drowning presentations. Ten (10.9%) patients reported loss of consciousness, including the four with drowning. The principal mechanism of CSI was a wave forced impact (71/91, 78%). Most injuries occurred at the beach (79/91, 86.8%). Delayed presentation was common (28/91, 31%). A history of axial loading was 100% sensitive when indicating imaging.

CONCLUSIONS

The combination of CSI and drowning is uncommon. Cervical spine precautions are only required in drowning patients with signs or a history, or at high risk of, axial loading of the spine. This paper supports the move away from routine cervical spine precautions even in a high-risk population.

A Review of Interventions for Drowning Prevention Among Adults

Adult drowning is a complex and multifactorial public health challenge requiring community, national and global efforts to mitigate impacts. This study updates the evidence base for public health interventions that address adult fatal and non-fatal drowning. A systematic review was undertaken of the peer-reviewed literature for English-language primary studies published between 2011 and 2021describing a drowning intervention with adults. Twenty-two studies were included. Most studies (n = 16) were conducted in high-income countries. Yearly trends in drowning prevention intervention publications were analysed with 2015 (n = 6) the peak publishing year. Over half of the study designs were pre-post (n = 15). Intervention duration ranged from 4 hours to 11 years. Ten studies described either behaviour change theory or formative evaluation to inform design. Thirteen studies targeted interventions at a population level, seven at a group level and two at individual level. Studies identified a range of prevention strategies, categorised as behavioural (n = 9) (e.g., swimming lessons), socio-ecological (n = 8) (e.g., mandatory personal flotation devices) and mixed (n = 5) (e.g., awareness campaign and barriers to prevent access to water). A range of outcomes were described including changes in awareness, water safety knowledge, attitudes, water safety behaviours and skills, environmental, policy and regulation changes and drowning rates. Findings indicate a small but important increase in the evaluation and publication of effective interventions to prevent adult drowning. The complexity of the issues surrounding drowning requires multi-strategy and context -specific adult focused prevention interventions. Contemporary evidence that identifies effective interventions that contribute to prevention efforts is an essential first step in addressing the challenge.

Atmospheric circulation and mortality by unintentional drowning in Spain: from 1999 to 2018

AIMS

Drowning deaths are a leading cause of unintentional deaths worldwide. Few studies have analysed the role of meteorology in drowning, and with inconclusive results. The aim of this work is to analyse the temporal and geographical distribution of deaths by accidental drowning and submersion in Spain over 20 years, and to assess the relationship between accidental drowning and main atmospheric circulation patterns.

METHODS

An ecological study was performed, in which drowning and submersion mortality data from 1999 to 2018, considering demographic variables, were analysed. To study the association with atmospheric circulation we used an ERA5 reanalysis product over the whole European continent and the Climatic Research Unit Time Series (CRU TS) data set.

RESULTS

The annual average rate of deaths by accidental drownings was 11.86 deaths per million of habitants in Spain. The incidence in males was four times higher than in females, and when comparing age groups, the rate in the eldest group was the highest. Unintentional drowning deaths were not equally distributed around the country; the provinces with the highest registered standardized drowning death rates were touristic waterfront provinces either in Eastern Spain or in one of the archipelagos. There was a significant relationship between accidental drowning and meteorological variables during summer months, and drowning deaths were spatially correlated with sea-level pressure over the Mediterranean basin.

CONCLUSION

Although the mortality rate registered a statistically significant decreasing tendency over the studied period, our results must be taken into consideration to improve the prevention strategies in the country since most of these deaths are avoidable.

The epidemiology, risk factors and impact of exposure on unintentional surfer and bodyboarder deaths

Surfing and bodyboarding (SAB) are popular activities, but not without risk. Limited SAB mortality and exposure risk explorations exist, so this cross-sectional study explores epidemiology and risk factors for SAB deaths (1 July, 2004-30 June,2020) in Australia: including decedent and incident profiles, causes of death, differences between fatalities during SAB and other coastal activities; and the impact of exposure on SAB mortality risk. Fatality data were sourced from the National Coronial Information System, incident and media reports. Tide-state data, population data and participation data were sourced from relevant authorities. Analyses included chi-square testing and simple logistic regression with odds ratios. There were 155 SAB deaths (80.6% surfing; 96.1% male; 36.8% aged 55+years; 0.04/100,000 residents; 0.63/100,000 surfers). Drowning was the most common cause of death (58.1%; n = 90), but higher in bodyboarding, with bodyboarders 4.62 times more likely to drown than surfers (95%CI: 1.66-12.82; p = 0.003). Almost half (44.5%; n = 69; χ22 = 9.802; p = 0.007) were with friends/family, and the largest proportion occurred during a rising tide (41.3%; n = 64; χ23 = 180.627; p<0.001) followed by a low tide (36.8%;n = 57). Australians surf 45.7 times each year, for 1.88 hours each visit equalling 86.1 'exposed' hours. With exposure-time considered, exposure-adjusted surfer mortality rate (0.06/1 million hours) is lower than other in-water activities (0.11/1 million hours). Younger surfers (14-34 years) surfed more yet had the lowest mortality rate (114.5 hours/year; 0.02/1 million hours). Older surfers (55+ years) had a lower SAB mortality rate (0.052) than the all-cause crude mortality rate of their average population counterparts (1.36). Cardiac conditions were identified in 32.9% (n = 69) of SAB deaths. SAB are relatively safe, with lower exposure mortality rates than other activities. Prevention should target older surfers, inland residents, and identification of surfers with risk factors for cardiac events.