Drowning deaths in Sweden with emphasis on the presence of alcohol and drugs - a retrospective study, 1992-2009

Without a trace: Long-term missing women and girls and 'no-body' femicides from the Republic of Ireland

Missing persons are a major part of everyday policing. However, some missing person cases can be highly emotive and challenging such as missing women and girls. Women who go missing have a greater risk of coming to harm. This study focused on 38 long-term missing women and girls from the Irish Republic from 1971 to 2023 of which 12 cases are now classified as homicides, and the whereabouts of the bodies remain unknown. The majority of cases are in Leinster with 25. Eight missing persons are under 18 years, and 22 are between the ages of 18 and 45 years. Domestic violence was a feature in five cases, involvement in a fight prior to disappearance in seven cases, and inconsistencies in statements by intimate partners and close family members regarding the victim's mental health were noted in seven cases. In nine cases, the personal belongings of the victim remained in the home. In seven cases, there was suggestive evidence that the victim entered water. These factors were seen in both the missing and classified homicide cases. The suicide narrative is heavily implied in many of these cases. A woman's mental health and stage of life such as pregnancy, childbirth and menopause can be exploited and used as an advantage to a potential killer. It is therefore paramount that missing women who are considered to have taken their own lives should be thoroughly investigated, with a special focus on cases where evidence suggests drowning and jumping from a height.

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.

Unintentional drowning fatalities in Sweden between 2002 and 2021

BACKGROUND

Despite declining over the past three decades, unintentional drownings still account for an estimated 236 000 annual deaths worldwide. Susceptibility persists amongst demographic groups and is influenced by sex, age, and socio-economic status, emphasizing the need for targeted interventions. Due to rapidly evolving population dynamics, particularly within Europe, there is a further responsibility to understand the impact of ethnicity on the risks of drowning to guide prevention.

METHODS

We conducted a national population-based retrospective study using data from the Swedish National Board of Forensic Medicine and Statistics Sweden for the years 2002 to 2021. The analysis includes variables such as age, sex, presence of alcohol and narcotics as well as activity undertaken at the time of drowning and type of water body. Furthermore, we considered ethnicity to identify subpopulations at greater risks.

RESULTS

Results revealed a plateau in unintentional drowning rates in Sweden since 2012, despite an overall decrease from 2002 to 2021. Findings confirm the trend that males are overrepresented within drowning statistics across all age groups, and that individuals aged > 50 constitute over half of all unintentional drownings. Men aged between 40-69 years boating, and individuals of non-Swedish origin, particularly those < 20 years of age, face a notably greater risk of drowning, underscoring the need for subpopulation-targeted prevention strategies.

CONCLUSION

The ten-year plateau in unintentional drowning signals the need for an official national prevention strategy with annual evaluations. Suggestions also include improved parental supervision of children, further avoidance of alcohol while swimming and boating, as well as targeted swimming lessons and water competency training for individuals of non-Swedish origin.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

ISSUES

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

APPROACH

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

KEY FINDINGS

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

IMPLICATIONS

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

CONCLUSION

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

The burden of attempted hanging and drowning presenting to hospitals in Ireland between 2007 and 2019: a national registry-based study

PURPOSE

To measure the impact of hospital-treated self-harm by hanging and drowning in Ireland in 2007-2019 and identify risk factors for these methods of self-harm.

METHOD

Data on all self-harm presentations to Irish hospitals between 2007 and 2019 were obtained from the National Self-Harm Registry Ireland, a national self-harm surveillance system. Multinomial regression was used to explore factors associated with attempted hanging and drowning.

RESULTS

The age-standardised incidence rate of attempted hanging and drowning increased by 126% and 45%, respectively, between 2007 and 2019. The incidence of both methods was highest among young people aged 15-24 years. The odds of presenting to hospital for attempted hanging were highest in males (aOR 2.85, 95% CI 2.72-3.00), people experiencing homelessness (aOR 1.32, 95% CI 1.16-1.49) and individuals living in the capital, Dublin (aOR 1.23, 95% CI 1.17-1.29). The odds of presenting for attempted drowning were highest in males (aOR 1.68, 95% CI 1.58-1.78) and people experiencing homelessness (aOR 2.69, 95% CI 2.41-2.99).

CONCLUSION

The incidence of hospital-treated self-harm by hanging and drowning is increasing in Ireland and is highest among adolescents and young adults. Males and people experiencing homelessness may be at highest risk and warrant targeted preventive interventions.

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).

Drug Safety and Suicidality Risk of Chronic Pain Medications

Chronic pain is one of the main leading causes of disability in the world at present. A variety in the symptomatology, intensity and duration of this phenomenon has led to an ever-increasing demand of pharmacological treatment and relief. This demand for medication, ranging from well-known groups, such as antidepressants and benzodiazepines, to more novel drugs, was followed by a rise in safety concerns of such treatment options. The validity, frequency, and diversity of such concerns are discussed in this paper, as well as their possible effect on future prescription practices. A specific caution is provided towards the psychological safety and toll of these medications, regarding suicidality and suicidal ideation. Most significantly, this paper highlights the importance of pharmacovigilance and underscores the necessity of surveillance programs when considering chronic pain medication.

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.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Risk of suicide attempt and suicide associated with benzodiazepine: A nationwide case crossover study

BACKGROUND

Previous studies that found an association between benzodiazepines and suicidal behaviours were confounded by indication bias.

AIMS

To limit this bias, a case crossover study (CCO) was conducted to estimate the risk of suicide attempt and suicide associated with benzodiazepines.

METHOD

Patients ≥16 years, with hospitalised suicide attempt or suicide between 2013 and 2016, and at least one benzodiazepine dispensing within the 120 days before their act were selected in the nationwide French reimbursement healthcare system databases (SNDS). For each patient, frequency of benzodiazepine dispensing was compared between a risk period (days -30 to -1 before the event) and two matched reference periods (days -120 to -91, and -90 to -61).

RESULTS

A total of 111,550 individuals who attempted suicide and 12,312 suicide victims were included, of who, respectively, 77,474 and 7958 had recent psychiatric history. Benzodiazepine dispensing appeared higher in the 30-day risk period than in reference ones. The comparison yielded adjusted odds ratios of 1.74 for hospitalised suicide attempt (95% confidence interval 1.69-1.78) and 1.45 for suicide (1.34-1.57) in individuals with recent psychiatric history, and of 2.77 (2.69-2.86) and 1.80 (1.65-1.97) for individuals without.

CONCLUSION

This nationwide study supports an association between recent benzodiazepine use and both suicide attempt and suicide. These results strengthen the need for screening for suicidal risk carefully before initiation and during treatment when prescribing benzodiazepines.

REGISTRATION NO

EUPAS48070 (http://www.ENCEPP.eu).

Alcohol-related mortality in 15–24-year-olds in Denmark (2010–2019): a nationwide exploratory study of circumstances and socioeconomic predictors

Background

Adolescents and young adults aged 15-24 years are disproportionately affected by unnatural deaths, including accidents, suicide and interpersonal violence for which alcohol is a leading risk factor. We aimed to explore the extent of and circumstances surrounding alcohol-related deaths in young people aged 15-24 years and whether socioeconomic background and ethnicity differ in those who died due to alcohol-related causes as compared to the background population.

Methods

All deaths of 15-24-year-olds occurring in Denmark from 2010 to 2019 were investigated. We manually reviewed death certificates containing information on circumstances, results from autopsies and blood tests, and statements from witnesses. Relevant information published in the media (most often newspaper articles) was included. Our main outcome measures were alcohol-related death and manner of death (accidents (transport accidents, drownings, falls, poisonings), suicide and violence). Further, we designed a population-based case-control study including 10 age- and sex-matched controls per case to test whether there was a socioeconomic gradient in alcohol-related deaths. We used parents' educational level and employment status to define socioeconomic position. Immigration status was used to assess ethnicity.

Findings

Over the 10-year period, 1783 deaths occurred among 15-24-year-olds. Of those, 1067 (60%) were due to unnatural causes, corresponding to a mortality rate of 14.8 (95% confidence interval: 13.9-15.7) per 100,000. Twelve percent of unnatural deaths (n = 125) were alcohol related, corresponding to a rate of 1.7 (1.4-2.0) per 100,000, and were higher in males (2.9 [2.3-3.4]) than in females (0.6 [0.3-0.8]); thus, males accounted for 105 (84%) of alcohol-related deaths. The majority of alcohol-related deaths occurred on Fridays, Saturdays and Sundays (n = 77, 62%). Accidents accounted for 82% (n = 102) of alcohol-related deaths, followed by suicide (n = 19, 15%) and interpersonal violence (n = 4, 3%). Of all fatal accidents, 102 of 636 (16%) were alcohol related. Of all deaths caused by drownings and falls, 14 of 26 (54%) and 10 of 25 (40%), respectively, were alcohol related. Alcohol-related drownings most often occurred while the deceased was alone, whereas alcohol-related falls most often occurred in relation to parties, involving falls from a window or balcony. Those who died from alcohol-related causes more often had parents with a short education or who were unemployed, as compared to the general population. For example, odds ratios were 3.9 (2.2-7.0) and 1.8 (1.2-2.9) for having parents with short and medium as compared to long educations. The odds ratio for being of Danish origin was 4.0 (1.7-9.5) compared to being first- or second-generation immigrants.

Interpretation

In 15-24-year-olds, alcohol-related deaths accounted for a substantial proportion of all unnatural deaths. There was substantial socioeconomic inequality in alcohol-related deaths, as has repeatedly been shown for chronic alcohol-related mortality in older adults.

Funding

Trygfonden.

An overview of suicides related to motor vehicles

Although vehicles may be used in a wide variety of suicides, this has not been a focus in the forensic literature. Thus, an analysis of coronial autopsy reports at Forensic Science SA, Adelaide, South Australia over a 16-year period from January 2005 to December 2020 was undertaken to provide an overview of cases in which it was considered that a vehicle had been integral to the successful completion of a suicide. De-identified details were collected from all cases in which a vehicle had facilitated or been used as a method of suicide. A number of different types of vehicle-related suicide methods were identified, including cases where vehicles had been used as secure places for suicide or where the vehicle had been used to cause significant blunt force trauma or to enter a lethal environment such as water. Specific examples were taken from the following categories: (1) inhalation of gas, (2) drug toxicity, (3) hanging or ligature strangulation, (4) self-immolation, (5) drowning, (6) vehicle collision, (7) driving off a cliff, (8) jumping or lying in front of a vehicle and (9) the use of more than one method (i.e. complex). This report is not intended to provide an epidemiological analysis of car-related suicides. Instead, the details of selected cases have been used to illustrate the spectrum of methods that may be used in vehicle-assisted suicides.

Critical care drowning admissions in Southwest England 2009-2020, a retrospective study

Aim

In the United Kingdom (UK), 600 deaths per annum are attributable to drowning. Despite this there is scarce critical care data on drowning patients globally. We describe drowning cases admitted to critical care units with a focus on functional outcomes.

Materials and Methods

Medical records for critical care admissions following a drowning event were retrospectively reviewed across six hospitals in Southwest England for cases presenting in the period between 2009 and 2020. Data was collected according to the Utstein international consensus guidelines on drowning.

Results

Forty-nine patients were included, 36 males and 13 females, including seven children. Median submersion duration was 2.5 min 20 cases were in cardiac arrest when rescued. At discharge 22 patients had preserved functional status, 10 patients had a reduced functional status. 17 patients died in hospital.

Conclusion

Admission to critical care following drowning is uncommon and associated with high rates of mortality and poor functional outcomes. We find that 31% of those who survived a drowning event subsequently required an increased level of assistance with their activities of daily living.

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.

Contribution of Drugs to Drowning in Scotland from 1996 to 2020

OBJECTIVE

Psychoactive substance use (including alcohol) can affect risk perception, leading to accidents and deaths. There is little detailed or up-to-date information on the role of drugs in drownings in the United Kingdom (UK). This Scottish case-study aimed to fill this knowledge gap.

METHODS

Anonymised data for individual drug-poisoning-related drowning registered from 1996 to 2020 were provided by the National Records of Scotland. Statistical analyses were performed for socio-demographics, ICD coding, cause of death, and substances implicated.

RESULTS

It has been reported that death registrations increased from 7 in 2017 to over 20 during 2019-20. These deaths (n=160) accounted for <1% of all drug-related poisoning deaths; this proportion rose to record levels (c.1.5%) during 2019-20. Most deaths (69%) involved males. The mean age was 39.8 (range 16-81, SD 15.0) years. The main drug classes implicated were: opiates/opioids (41%), benzodiazepines (31%), stimulants (19%), and antidepressants (14%). Moreover, 57% of benzodiazepines were 'designer' drugs.

CONCLUSION

Scottish drownings associated with drug consumption are increasing rapidly. It has been observed that central nervous system depressant drugs (e.g., opioids, benzodiazepines, alcohol) are often involved in drowning. 'Designer' benzodiazepines are a principal factor in increasing Scottish drug-related poisoning deaths; they may be partially responsible for increasing numbers of related drownings. Evidence-based strategies to further reduce the number of preventable drownings should include reference to the dangers of drugs.

Analysis of drowning fatalities in the Vistula River in years 2011-2020 in the Lesser Poland Voivodeship

Aim

The aim of the present study is to analyze drowning fatalities in the Vistula River from 2011 to 2020 in the Lesser Poland Voivodeship.

Material and methods

The material for the study consisted of autopsy protocols provided by the Department of Forensic Medicine in Cracow. Demographic data, results of post-mortem examinations and results of basic toxicological tests - levels of ethyl alcohol in the blood and urine of decedents were analyzed. The extracted data were subjected to statistical analysis using TIBCO Statistica® 13.3.0 software. χ2 and one-way ANOVA tests of independence (p < 0.05) were performed.

Results

79 cases were analyzed. The mean age was 44.2 years (SD = 16.81). The majority of the study group was male (73.1%). 57.9% of men were under the influence of alcohol (>0.5 per mille) at the time of drowning, compared to 23.8% of women (p = 0.008). Most bodies were found between the Kosciuszko and Dąbie barrages (57.0%). Spring and summer were the most common seasons for drownings (59.5%). 35.4% of victims suffered from psychiatric illnesses. Emphysema aquosum was more frequent in bodies that were not in an advanced state of putrefaction (p = 0.000). 23.1% of victims had head injuries, 14.1% - upper limb injuries, while 11.5% had lower limb injuries.

Conclusions

Inebriated men are more likely to be victims of drowning, which may be due to a greater tendency toward reckless behavior and irresponsible consumption of alcoholic beverages. Most drownings occur in the city center, which points to suicide as the cause of incident. The occurrence of external injuries is the result of jumping from a great height or the effect of carrying the corpse downstream.

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

INTRODUCTION

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

METHOD

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

RESULTS

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

PRACTICAL APPLICATIONS

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

Nonfatal drowning-related hospitalizations and associated healthcare expenditure in India: An analysis of nationally representative survey data

BACKGROUND

Drowning is a global public health challenge, with significant burden in low- and middle-income countries. There are few studies exploring nonfatal drowning, including the economic and social impacts. This study aimed to quantify unintentional drowning-related hospitalization in India and associated healthcare expenditure.

METHOD

Unit level data on unintentional drowning-related hospitalization were obtained from the 75th rounds of the National Sample Survey of Indian households conducted in 2018. The outcome variables were indices of health care cost such as out of pocket expenditure (OOPE), health care burden (HCB), catastrophic health expenditure (CHE), impoverishment, and hardship financing. Descriptive statistics and multivariate analysis were conducted after adjusting for inflation using the pharmaceutical price index for December 2020. The association of socio-demographic characteristics with the outcome variable was reported as relative risk with 95% CI and expenditure reported in Indian Rupees (INR) and United States dollars (USD).

RESULTS

174 respondents reported drowning-related hospitalization (a crude rate of 15.91-31.34 hospitalizations per 100,000 population). Proportionately, more males (63.4%), persons aged 21-50 years (44.9%) and rural dwelling respondents (69.9%) were hospitalized. Drowning-related hospitalization costs on average INR25,421 ($345.11USD) per person per drowning incident. Costs were higher among older respondents, females, urban respondents, and longer lengths of hospital stays. About 14.4% of respondents reported hardship financing as a result of treatment costs and 9.0% of households reported pushed below the poverty line when reporting drowning-related hospitalization.

CONCLUSIONS

Drowning can be an economically catastrophic injury, especially for those already impacted by poverty. Drowning is a significant public health problem in India. Investment in drowning prevention program will reduce hospitalization and economic burden.

PRACTICAL APPLICATIONS

This study provides support for investment in drowning prevention in India, including a need to ensure drowning prevention interventions address the determinants of health across the lifespan.

Fatal drowning statistics from the Netherlands - an example of an aggregated demographic profile

Introduction

Incompleteness of fatal drowning statistics is a familiar problem impeding public health measures. Part of the problem may be that only data on accidental drowning are used and not the full potential of accessible data.

Methods

This study combines cause-of-death certificates and public prosecutor’s court documents between 1998 and 2017 to obtain an aggregated profile. Data are also used as a basis for a trend analysis.

Results

The dataset includes 5571 drowned persons (1.69 per 100,000). The highest risk group are persons above the age of 50. Demographic differences are observed between suicide by drowning, accidental drowning, and drowning due to transportation (0.72, 0.64, 0.28 per 100.000) and between native Dutch, and Dutch with western and non-western background (1.46, 1.43, 1.76 per 100.000). Non-residents account for another 12.2%. When comparing the periods 1998–2007 with 2008–2017, the Standard Mortality declines for suicide drowning and accidental drowning among persons with a native Dutch and non-western background. Single regression analysis confirms a decrease of drowning over the full period, breakpoint analysis shows an increase in the incidence of the total number of drowning, suicide by drowning and accidental drowning starting in 2007, 2008 resp. 2012.

Discussion

Compared to the formal number of fatal accidental drowning in the Netherlands (n = 1718; incidence 0.52 per 100,000), the study identifies 350% more drowning. Differences in demographic data and the recent increase needs to be explored for public health interventions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12620-3.

Influence of a Survival Swimming Training Programme on Water Safety Knowledge, Attitudes and Skills: A Randomized Controlled Trial among Young Adults in Sri Lanka

Drowning among young adults is high in Sri Lanka. Water safety education is a recommended strategy for drowning prevention but is often overlooked for young adults. This study aimed to evaluate the effectiveness of an adapted educational intervention, "Swim for Safety" on improving water safety knowledge, attitudes and survival swimming skills among undergraduates (19-28 years) in Sri Lanka. This study employed a parallel-group, two-arm randomized controlled trial design. The intervention group (n = 78) received a face-to-face, 12-lesson education programme, and the control group (n = 78) received a brochure and weekly mobile phone messages for six consecutive weeks. Baseline, post-intervention and three-month follow-up knowledge, attitudes and skills were evaluated. Knowledge and attitudes were assessed using a self-administered questionnaire and skills were evaluated following a skills assessment protocol. In total 116 participants, 60 intervention group and 56 control group, completed the study. At baseline there were no differences between groups in median scores of water safety knowledge, attitudes and survival swimming skills. The intervention group demonstrated statistically significant increases in median water safety knowledge, attitudes and survival swimming skill scores compared with the control group, following the intervention and maintained at three-month follow-up (p < 0.05). The adapted Swim for Safety programme significantly improved water safety knowledge, attitudes, and survival swimming skills among young adults in Sri Lanka. Therefore, it is recommended that the SfS programme be implemented widely to prevent drowning in young adults.

Clinical spectrum and risk factors for mortality among seawater and freshwater critically ill drowning patients: a French multicenter study

Background

Drowning is a global threat and one of the leading causes of injury around the world. The impact of drowning conditions including water salinity on patients’ prognosis remains poorly explored in Intensive Care Units (ICUs) patients.

Methods

We conducted a retrospective multicenter study on patients admitted to 14 ICUs in the west of France from January 2013 to January 2020. We first compared demographic and clinical characteristics at admission as well as clinical courses of these patients according to the salinity of drowning water. Then, we aimed to identify variables associated with 28-day survival using a Cox proportional hazard model.

Results

Of the 270 consecutive included patients, drowning occurred in seawater in 199 patients (73.7%) and in freshwater in 71 patients (26.3%). Day-28 mortality was observed in 55 patients (20.4%). Freshwater was independently associated with 28-day mortality (Adjusted Hazard Ratio (aHR) 1.84 [95% Confidence Interval (CI) 1.03–3.29], p = 0.04). A higher proportion of freshwater patients presented psychiatric comorbidities (47.9 vs. 19.1%; p < 0.0001) and the etiology of drowning appeared more frequently to be a suicide attempt in this population (25.7 vs. 4.2%; p < 0.0001). The other factors independently associated with 28-day mortality were the occurrence of a drowning-related cardiac arrest (aHR 11.5 [95% CI 2.51–52.43], p = 0.0017), duration of cardiopulmonary resuscitation (aHR 1.05 [95% CI 1.03–1.07], p < 0.0001) and SOFA score at day 1 (aHR 1.2 [95% CI 1.11–1.3], p < 0.0001).

Conclusions

In this large multicenter cohort, freshwater drowning patients had a poorer prognosis than saltwater drowning patients. Reasons for such discrepancies include differences in underlying psychiatric comorbidity, drowning circumstances and severities. Patients with initial cardiac arrest secondary to drowning remain with a very poor prognosis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-021-03792-2.

Suicide along the Australian coast: Exploring the epidemiology and risk factors

Suicide is an increasing global concern with multiple risk factors, yet location-based understanding is limited. In Australia, surf lifesavers (SLS) and lifeguards patrol the coast, performing rescues and assisting injured people, including people who suicide. This study is a descriptive epidemiological analysis of Australian coastal suicide deaths. The results will be used to inform training and support surf lifesaving personnel and suicide prevention organisations. This is a population-based cross-sectional study of suicide deaths at Australian coastal locations (between 1 January 2005 and 31 December 2019). Data were sourced from the National Coronial Information System and SLS Australia's Incident Report Database. Analyses explored decedent, incident, and risk factors by sex and method. Across the study period, there were 666 coastal suicide deaths (71.0% male, 43.4% jumping from high places [X80]). Males were more likely to suicide by other means (hanging, self-poisoning, firearm discharge; n = 145, 83.8%), compared to females who were more likely to suicide by drowning ([X71]; n = 77, 37.7%). In one third (n = 225, 38.3%) toxicology was a contributing factor. The risk of coastal suicides was 10.3 times higher during the seven-days prior to their birthday (p<0.001). Evidence of mental ill health was reported in 61.4% (n = 409) of cases and evidence of suicidal behaviour was reported for 37.4% of decedents (n = 249), more prevalent in females. SLS responded in 10.7% (n = 71) of coastal suicides (most jumps from high places; n = 36, 50.7%). Coastal suicides differ to national trends suggesting that location-based differences should be considered during development of preventative and protective measures, especially at a community level. Accessibility, availability, perceived lethality and symbolic qualities are proposed to influence suicide location decisions. These results will guide support and education strategies for surf lifesaving personnel, contributes to established, ongoing suicide surveillance efforts (including hot-spot identification) and add to the limited literature exploring place-based suicide.

Incidence and characteristics of drowning in Sweden during a 15-year period

AIM

Drowning is a global health problem and deeper knowledge about the extent and causes is of utmost importance for implementing preventative actions. The aim of this study was to describe the incidence and characteristics of drowning in Sweden over time, including both non-fatal and fatal cases.

METHODS

All cases identified as drowning (ICD-10 coding) at a national level in Sweden between 2003-2017 were collected. Three sources of data from the Swedish National Board of Health and Welfare were extracted via the Cause of Death Register and the National Patient Register.

RESULTS

Over 15 years, a total of 6609 cases occurred, resulting in an annual incidence of 4.66 per 100 000. The median age was 49 years (IQR 23-67) and 67% were males. Non-fatal drownings represented 51% (n = 3363), with an overall non-fatal to fatal ratio of 1:1, this being 8:1 for children (0-17 years of age). Non-fatal cases were more often female (36% vs. 30%; p < 0.001), younger 30 (IQR 10-56) vs. 60 (IQR: 45-72) (p < 0.001) and of unintentional nature (81% vs. 55%; p < 0.001). The overall incidence decreased over time from 5.6 to 4.1 per 100 000 (p < 0.001). The highest rate of 30-day survival was found in females 0-17 years (94%, 95% CI 91.1-95.5) and the lowest in males >66 years (28.7%, 95% CI 26.2-31.2). Although the incidence in children 0-4 years increased from 7.4 to 8.1 per 100 000 (p < 0.001), they demonstrated the highest non-fatal to fatal ratio (13:1).

CONCLUSION

Drowning is declining but remains a consistent and underestimated public-health problem. Non-fatal drowning cases represent about half of the burden and characteristics differ from fatal drowning cases, being younger, more often female and of unintentional nature.

Increased winter drownings in ice-covered regions with warmer winters

Winter activities on ice are culturally important for many countries, yet they constitute a high safety risk depending upon the stability of the ice. Because consistently cold periods are required to form stable and thick ice, warmer winters could degrade ice conditions and increase the likelihood of falling through the ice. This study provides the first large-scale assessment of winter drowning from 10 Northern Hemisphere countries. We documented over 4000 winter drowning events. Winter drownings increased exponentially in regions with warmer winters when air temperatures neared 0°C. The largest number of drownings occurred when winter air temperatures were between -5°C and 0°C, when ice is less stable, and also in regions where indigenous traditions and livelihood require extended time on ice. Rates of drowning were greatest late in the winter season when ice stability declines. Children and adults up to the age of 39 were at the highest risk of winter drownings. Beyond temperature, differences in cultures, regulations, and human behaviours can be important additional risk factors. Our findings indicate the potential for increased human mortality with warmer winter air temperatures. Incorporating drowning prevention plans would improve adaptation strategies to a changing climate.

Characteristics of drowning deaths in an inner city river

A study was undertaken of all drowning deaths that occurred over a 30-year period from 1988 to 2017 in the urban section of the River Torrens, Adelaide, South Australia, an augmented waterway that runs through the central business district. Autopsy records from Forensic Science South Australia (FSSA) were reviewed. There were 34 drownings (0-5 cases/yr) with 28 males and 6 females (M;F = 4.6:1), with an age range for males of 18-76yrs (mean 42.0; SD 18.0) and for females of 20-84yrs (mean 69.3; SD 24.5). There were 15 (44%) accidents, 11 (32%) suicides, 1 (3%) homicide and 7 (21%) undetermined. Of the 22 cases during or after 1994 with complete toxicology reports, 10 (45%) had a blood alcohol concentration (BAC) of greater than 0.05% (g/100 mL) with an illicit substance detected in 4 (18%) cases: (MDMA (3,4-methylenedioxymethamphetamine), methylamphetamine and THC (delta-9-tetrahydrocannabinol) acid). The presence of various therapeutic drugs was also detected in 10 cases (45%) including temazepam, fluoxetine, diazepam, olanzapine, amitriptyline, carbamazepine, codeine, citalopram and valproate. Although the numbers of cases were not high, the urban portion of the River Torrens had a much higher number of drowning events per kilometre compared to other inland waterways in South Australia such as the Murray River. This is most likely due to the vulnerability that exists for intoxicated individuals in the city from falls into the water and to the availability of the river as a means of suicide to members of the adjacent urban population.

Association between anxiolytic/hypnotic drugs and suicidal thoughts or behaviors in a population-based cohort of students

AIMS

To investigate the association between the use of anxiolytic/hypnotic drugs and suicidal thoughts and/or behavior (STB) in students.

METHODS

12,112 participants who completed the baseline questionnaire in the i-Share cohort between April 2013 and March 2017 were included. STB were defined at inclusion as suicidal thoughts over the previous year and/or a lifetime suicide attempt. The use of prescribed anxiolytic/hypnotic drugs over the previous 3 months was measured at baseline and follow-up time points (in 2,919 students). Psychiatric disorders were assessed through validated scales. Multivariate logistic regression models were run using disease risk score.

RESULTS

At inclusion, 25.2% of students had STB and 10.3% used anxiolytics/hypnotics. STB at baseline were associated with a more frequent use of anxiolytics/hypnotics in the previous 3 months, after adjustment for covariates including anxiety, depression, sleep, impulsivity, and substance use. The use of anxiolytics/hypnotics at baseline was not associated with the occurrence, persistence or remission of STB one year later. STB at baseline were associated with a new anxiolytic/hypnotic treatment one year later.

CONCLUSIONS

Anxiolytic/hypnotic drug use was associated with STB in students independently of many risk factors of suicide and most psychiatric disorders that require such treatment, which raises drug safety concerns.

Risk factors for fatal drowning in a Greek region: a retrospective case-control study

BACKGROUND

Fatal drowning is one of the leading causes of unintentional injury mortality worldwide and a persistent public health concern in Greece. While several pathologic and sociodemographic contributing factors have been previously identified, these have not been extensively investigated in conjunction with the effects of psychoactive substances.

METHODS

A retrospective case-control study of drowning deaths was conducted in the Greek regions of Northern Greece and Thessaly during a 10-year period. A regression model was constructed examining differences in detected substances, autopsy findings and sociodemographic characteristics between 240 victims of unintentional fatal submersion and 480 victims of other causes of sudden or violent death.

RESULTS

The majority of victims were males (69.4%) and foreign nationality was associated with increased odds of drowning. Cardiomegaly and coronary bypass grafts were significantly more likely to have been recorded among drowning victims, while the frequency of other circulatory system disorders was also elevated. Several of these findings were potential arrhythmogenic substrates which could adversely interact with the diving reflex. Selective serotonin reuptake inhibitors (SSRIs) were the most commonly detected pharmacological group (9.0%), and along with tramadol, there was an increased likelihood of exposure to them. These drugs have been previously associated with QT prolongation and other adverse effects which may contribute to fatal outcomes in a seawater environment. In contrast, there was a decreased risk of exposure to dependence-inducing drugs and paracetamol.

CONCLUSIONS

Male sex, older age, foreign nationality and cardiovascular disease predisposed individuals to an elevated risk of fatal submersion. SSRI antidepressants and tramadol may contribute to this outcome.

Fatal intentional drowning in Australia: A systematic literature review of rates and risk factors

INTRODUCTION

Unintentional drowning deaths are only part of the drowning profile, with little attention being paid to intentional drowning in Australia. Strategies for the prevention of intentional drowning deaths are likely to be different from unintentional. Quality documentation, analysis and dissemination of intentional deaths data is crucial for developing appropriate strategies for prevention.

OBJECTIVE

To conduct a systematic literature review to investigate the mortality rates and risk factors of intentional drowning deaths in Australia.

METHODS

A systematic search guided by PRISMA was performed using Ovid MEDLINE, CINAHL, PsycINFO (ProQuest), Scopus, Google Scholar, and BioMed Central databases to locate relevant original research articles published between 2007 and 2018.

RESULTS

Ten papers reporting the mortality rates and risk factors of intentional drowning deaths in Australia published between 2007 and 2018, with study periods of the included articles spanning from 1907 to 2012, were reviewed. Most studies investigated suicidal drowning deaths in Australia, none reported homicidal drowning deaths. The downward trend of fatal suicide drowning was identified in Australia. The annual rate of intentional drowning between 1994 and 2012 can be inferred from eight studies, ranging from 0.06 to 0.21 for nation-wide mortality rates. The highest annual state-wide mortality rate was identified in the state of Queensland, ranging from 0.02 to 0.11 per 100,000 individuals. Of four studies examining the risk factors of fatal intentional drowning in Australia, being of older age groups, being female, and the presence of substance use were identified as important factors for suicidal drowning deaths. The national-scale proportion of suicide drowning in Australia, ranging from 2% to 3% of all intentional self-harm deaths, was also identified.

CONCLUSION

Limited publications reporting the mortality rates and risk factors of intentional drowning deaths in Australia were identified. Being of older age groups and being female were recognised as factors for suicide drowning deaths, and psychoactive substances were widely identified amongst cases. Future research on improving death reporting systems and the legal framework for medico-legal death investigation, along with the investigation of the risk factors of intentional drowning, are required to inform the planning, implementation, and evaluation of prevention interventions for intentional drowning deaths in Australia.

Self-reported injury in Australian young adults: demographic and lifestyle predictors

OBJECTIVES

Injury is the major cause of mortality and morbidity among adolescents and young adults. This study examined the use of injury self-reports and various causes of injury among adolescents.

METHODS

A cohort recruited in 2002 as a representative sample of students from the State of Victoria in south-east Australia was followed and resurveyed in young adulthood in 2010 (mean age 21.0) and 2012 (mean age 23.1) with 75% of the target sample retained (N=2,154, 55.8% female).

RESULTS

Prior injuries were reported by 55.5% in 2010 and 54.6% in 2012, leaving 18% with continuing disability. Reported causes of injury in 2012 were sports (55.1%) and alcohol use (9.7%). Logistic regression revealed that injury in 2012 was predicted by rural school attendance in 2002 (Adjusted Odds Ratio [OR] 1.4 CI 1.1-1.7) and in 2010 by male gender (OR 2.2, CI 1.8-2.6), reported self-harm (OR 1.6 CI 1.1-2.2), and unemployment (OR 0.7, CI 0.5-1.0).

CONCLUSIONS

Self-reported injury among young adults is reliably reported, and suggests the need to further examine gender, rural communities and self-harm, and indicates modifiable contributors to injury. Implications for public health: Modifiable contributors to injury prevention are revealed as work environment, sports participation and alcohol use.

Male depressive traits in relation to violent suicides or suicide attempts: A systematic review

BACKGROUND

Male sex is a consistently reported risk factor for violent suicide. It has been suggested that this association may be driven by so-called male depression - as operationalized by the Gotland Male Depression Scale (GMDS). The aim of this systematic review was to investigate if males dying by or attempting suicide with violent methods, display symptoms compatible with male depression.

METHODS

This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A systematic search of PubMed, Embase and PsycINFO was performed using search terms covering: male sex, violent suicide/suicide attempt, and symptoms of male depression from the GMDS. Subsequently, a qualitative synthesis of studies meeting predefined inclusion criteria was carried out.

RESULTS

A total of 28 studies reporting on 91,933 violent suicides and 113 violent suicide attempts were included in the qualitative synthesis. The suicide/suicide attempt methods reported in these studies were predominantly shooting, hanging or drowning. The only two symptoms from the GMDS that was reported in relation to violent suicides/suicide attempts was overconsumption of alcohol or drugs and suicide attempts in the biological family. No studies had systematically assessed suicide victims or attempters for symptoms of male depression.

LIMITATIONS

Publication-, selection-, and information biases may have affected this review.

CONCLUSIONS

Symptoms of male depression are rarely reported in relation to violent suicides/suicide attempts. The most likely explanation for this finding is that there has been little focus on this potential association. Future studies should address this void.

Boating-related drowning in Australia: Epidemiology, risk factors and the regulatory environment

OBJECTIVE

Recreational boating is a popular pastime in many high income countries, and is a leading activity prior to drowning. This study reports on unintentional fatal drowning associated with boating-related incidents in Australia.

METHODS

A total population, retrospective, cross sectional design examined all boating-related unintentional drowning deaths between July 1, 2005 and June 30, 2015. Variables examined included age, sex, location of drowning incident, vessel type, activity, presence of alcohol/drugs, and lifejacket wear. Relative risk (with a 95% confidence interval) was calculated using fatal drowning rates per 100,000 population and rates per 100,000 registered vessels. Chi square analysis and non-parametric tests for significance were applied. Statistical significance was deemed p < .05.

RESULTS

A total of 415 people drowned while boating during the study period, 91.8% male and 35.7% aged between 25 and 44 years. Men were 10 times more likely to drown when boating than females (RR = 10.64 CI:7.55-14.97). Over one-quarter (28.7%) of incidents involved alcohol, in 30.6% drugs were identified (31.3% were illegal) and 90.4% were not wearing a lifejacket. Children were more at risk of drowning on a houseboat than adults (RR = 7.13; CI:1.61-31.61). Females were more likely to drown than males when using a personal watercraft (RR = 10.53; CI:2.75-40.33).

CONCLUSION

Boaters may be taking unnecessary risks by disregarding safety regulations, such as not wearing lifejackets and substance use (such as alcohol and illegal drugs). Boating in remote locations presents a high risk of drowning. While safety regulations are in place, enforcement and behavior change remain challenges. Practical application: Findings support recommendations for increased enforcement of alcohol-related regulations and introducing drug-testing for boaters. Consistency of boating safety regulations, especially around lifejacket wear, is recommended to influence behavior change. The effectiveness of current lifejacket regulations need to be critically evaluated in the context of increasing wear rates for adults and children.

Unnatural Death among Treatment Seeking Substance Users in Singapore: A Retrospective Study

Substance use carries a higher risk of unnatural death. A retrospective analysis of 42 treatment seekers between 2011-2015 was conducted through medical record review to understand the profile and circumstances leading to premature deaths. Ninety percent of the subjects were males. The mean age at death was 44.9 (SD ± 13.1). Opioids (52.4%), benzodiazepines (45.2%) and alcohol (35.7%) were the main substances used by the group. Suicide was the most common cause of death (n = 27, 64.3%) followed by accidents (n = 15; 35.7%). Among the suicide cases, alcohol was the main substance used (33.3%) followed by opioids (25.9%). A total of 58.5% (n = 24) deaths occurred within a year of their last visit while 41.5% (n = 17) were dead more than a year after their last visit. Of the total cases (n = 41), 63% had a history of mental illness with depressive disorder (53.8%) being the most common. History of suicide attempts were reported in 34.1% (n = 14) of cases and 50% of the subjects (n = 21) had a history of suicidal ideation. Drug related offences were reported in 57.1% of the subjects, of which 60% (n = 18) committed suicide. The findings support the need for appropriate treatment resources to reduce the untimely deaths among substance users.

Differences in the epidemiology of out-of-hospital and in-hospital trauma deaths

BACKGROUND

Trauma is a leading cause of mortality. Holistic views of trauma systems consider injury as a public health problem that requires efforts in primary, secondary and tertiary prevention. However, the performance of trauma systems is commonly judged on the in-hospital mortality rate. Such a focus misses opportunities to consider all deaths within a population, to understand differences in in-hospital and out-of-hospital trauma deaths and to inform population-level injury prevention efforts. The aim of this study was to provide an epidemiological overview of out-of-hospital and in-hospital trauma deaths in a geographically-defined area over a 10-year period.

METHODS

We performed a population-based review of out-of-hospital and in-hospital trauma deaths over the period of 01 July 2006 to 30 June 2016 in Victoria, Australia, using data from the National Coronial Information System and the Victorian State Trauma Registry. Temporal trends in population-based incidence rates were evaluated.

RESULTS

Over the study period, there were 11,246 trauma deaths, of which 71% were out-of-hospital deaths. Out-of-hospital trauma deaths commonly resulted from intentional self-harm events (50%) and transport events (35%), while in-hospital trauma deaths commonly resulted from low falls (≤1 metre) (50%). The incidence of overall trauma deaths did not change over the study period (incidence rate ratio 0.998; 95%CI: 0.991, 1.004; P = 0.56).

CONCLUSIONS

Out-of-hospital deaths accounted for most trauma deaths. Given the notable differences between out-of-hospital and in-hospital trauma deaths, monitoring of all trauma deaths is necessary to inform injury prevention activities and to reduce trauma mortality. The absence of a change in the incidence of both out-of-hospital and in-hospital trauma deaths demonstrates the need for enhanced activities across all aspects of injury prevention.

Violent deaths among elderly in Attica, Greece: A 5-year survey (2011-2015)

According to World Health Organization (WHO) estimations, approximately 6 million people lose their lives yearly due to some kind of injury, while one-third of these incidents are due to violent acts. Violent deaths include accidents (road traffic accidents, drownings, falls, heat effects etc), suicides as well as homicides. Elderly people seem to be at greater risk due to their special characteristics as a vulnerable social group. The aim of this study was to investigate violent deaths (accidents, suicides and homicides) among elderly people in Attica, Greece, during the period 2011-2015 by examining manner of death with respect to demographic data (gender and age) and toxicological examination results. A total of 546 violent deaths among people over 65 years old were included in this study. Autopsy findings along with toxicological examination results were collected from the archives of the Department of Forensic Medicine and Toxicology of the National and Kapodistrian University of Athens. The findings of the study showed that most of the victims were male (63.74%). The overwhelming majority of violent deaths (425 cases) were accidents, 92 cases suicides, and the remaining 29 cases homicides. Drowning was the leading cause of all accidental deaths, followed by road traffic accidents. Hangings prevailed among violent suicide methods and asphyxiation presented as a predominant homicide method.

Sudden Unexpected Death and the Mammalian Dive Response: Catastrophic Failure of a Complex Tightly Coupled System

In tightly coupled complex systems, when two or more factors or events interact in unanticipated ways, catastrophic failures of high-risk technical systems happen rarely, but quickly. Safety features are commonly built into complex systems to avoid disasters but are often part of the problem. The human body may be considered as a complex tightly coupled system at risk of rare catastrophic failure (sudden unexpected death, SUD) when certain factors or events interact. The mammalian dive response (MDR) is a built-in safety feature of the body that normally conserves oxygen during acute hypoxia. Activation of the MDR is the final pathway to sudden cardiac (SCD) in some cases of sudden infant death syndrome (SIDS), sudden unexpected death in epilepsy (SUDEP), and sudden cardiac death in water (SCDIW, fatal drowning). There is no single cause in any of these death scenarios, but an array of, unanticipated, often unknown, factors or events that activate or interact with the mammalian dive reflex. In any particular case, the relevant risk factors or events might include a combination of genetic, developmental, metabolic, disease, environmental, or operational influences. Determination of a single cause in any of these death scenarios is unlikely. The common thread among these seemingly different death scenarios is activation of the mammalian dive response. The human body is a complex tightly coupled system at risk of rare catastrophic failure when that "safety feature" is activated.

Pattern of intentional drowning mortality: a total population retrospective cohort study in Australia, 2006-2014

BACKGROUND

While a downward trend in unintentional drowning deaths in Australia has been observed, little is known about intentional drowning mortality. Limited information on intentional drowning death impedes the planning, implementation, and evaluation of prevention strategies. This study aims to describe rates of intentional fatal drowning in Australia and compare these to other categories of drowning.

METHODS

Data were sourced from the Australian Bureau of Statistics (ABS) over a 9-year period (2006-2014). Rates and trends of intentional drowning were compared with unintentional, water-transport related and undetermined intent drowning. Rates of intentional drowning deaths across gender, age groups, states/territories, remoteness of residence and First Peoples of Australia were calculated. Relative risk (RR) (95% confidence interval [CI]) was calculated, and chi-square tests of independence were performed (p < 0.05).

RESULTS

The crude mortality rate for intentional drowning deaths in Australia over the study period was 0.23/100000, lower than unintentional drowning (0.89/100000). Males were 1.6 (CI: 1.4-2.0) times more likely than females to intentionally drown, however females made up a significantly larger proportion of intentional drowning deaths (38.2%) compared to unintentional deaths (22.4%) (χ2 = 47.3; df = 1; p < 0.05). A significant linear association between age group and intentional drowning was observed (χ2 = 131.3; p < 0.05), with individuals aged 75 years and over 32.6 times more likely to intentionally drown. Non-Indigenous peoples were 4.1 times more likely to intentionally drown in comparison to First Peoples of Australia. Residents of Inner Regional, Outer Regional, and Major Cities were 4.2 times (CI: 0.6-30.0), 4.1 times (CI: 0.6-29.9), and 4.0 times (CI: 0.6-28.6) more likely to intentionally drown, respectively, compared with residents of Very Remote areas.

CONCLUSIONS

This study adds to the limited evidence currently available about intentional drowning rates and trends in Australia. Being male, of older age groups, non-Indigenous, residing in Inner and Outer Regional areas, and Major Cities were risk factors for intentional drowning deaths. Improving data collection systems and furthering understanding of the risk factors of intentional drowning, as well as the development, implementation, and evaluation of prevention programmes, are required to reduce the risk of intentional drowning death in Australia.

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

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

Benzodiazepine use risk: Understanding patient specific risk perceptions and medication beliefs

BACKGROUND

Benzodiazepines are widely prescribed psychotropic medications. These medications have the potential to cause alertness impairing effects and their prolonged use is associated with serious adverse effects. Despite the listed adverse health outcomes and provision of warnings, many benzodiazepine users tend to ignore the safety information and use them inappropriately.

OBJECTIVE

To elicit the risk perceptions of benzodiazepine users and explore the association of risk perceptions with their socio-demographic factors or medication use profiles (e.g. past withdrawal attempt, length of use and future willingness to try behavioural alternatives).

METHODS

Point of purchase surveys were conducted with patients who were supplied benzodiazepines from selected pharmacies across New South Wales (NSW), Australia. Survey items included questions about patient's demographic characteristics, their past attempt for withdrawing benzodiazepines and their future intention to consider alternative behavioural therapies. The validated Beliefs about Medications Questionnaire (BMQ-specific) and a customised scale assessing risk perception were included in the survey. Data obtained from the surveys were entered into the IBM SPSS package (Version 22.0) and subjected to descriptive, correlational and regression analyses.

RESULTS

Seventy-five patients (67% female, a mean age of 54.3) obtaining benzodiazepines from 12 pharmacies were recruited for the survey. Participant's beliefs regarding potential side effects of benzodiazepines and their level of education were significantly associated with their risk perception scores. While the overall risk perception scores did not influence patient's previous attempts to withdraw benzodiazepines, the risk perception score about immediate effects of benzodiazepines (within 3-4 h of consumption) was a predictor of preference for behavioural therapies. Eighty-three percent (n = 62) of the participants believed that pharmacists can play a key role in improving risk perceptions of consumers around benzodiazepine use.

CONCLUSIONS

Individual patient characteristics and their beliefs about medications significantly influence their perception of risk about benzodiazepine use. The findings of this study suggest that pharmacist support can be utilized in effective risk communication, promoting the safe use of benzodiazepines and in facilitating the uptake of relevant behavioural interventions as alternatives to benzodiazepines.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Epidemiology of alcohol-related unintentional drowning: is post-mortem ethanol production a real challenge?

BACKGROUND

Post-mortem (PM) ethanol production may hamper the interpretation of blood alcohol concentration (BAC) in victims of drowning. Different exclusion criteria (e.g. cases with low BAC or with protracted interval between death and toxicological analysis) have been proposed with no factual figures to reduce the potential bias due to PM ethanol production when examining the prevalence rates for alcohol-related drowning. The aim of this study is to verify the extent to which PM alcohol production may affect the accuracy of studies on drowning and alcohol.

FINDINGS

Unintentional fatal drowning cases (n = 967) for which a full medico-legal autopsy and toxicological analysis was performed, in Finland, from 2000 to 2013, and relevant variables (demographic data of the victims, month of incident, PM submersion time, blood alcohol concentration, urine alcohol concentration (UAC), vitreous humour alcohol concentration (VAC) were available. Overall, out of 967 unintentional drownings, 623 (64.4%) were positive for alcohol (BAC > 0 mg/dL), 595 (61.5%) had a BAC ≥ 50 mg/dL, and 567 (58.6%) a BAC ≥ 100 mg/dL. Simultaneous measurements, in each victim, of BAC, UAC, and VAC revealed PM ethanol production in only 4 victims (BAC: 25 mg/dL - 48 mg/dL). These false positive cases represented 0.4% of drownings with BAC > 0 mg/dL and 14.3% of drownings with BAC > 0 mg/dL and < 50 mg/dL.

CONCLUSIONS

The present study suggests that PM ethanol production has a limited impact on research addressing the prevalence rate for alcohol-related drowning and that the use of too rigorous exclusion criteria, such as those previously recommended, may led to a significant underestimation of actual alcohol-positive drowning cases.

A Retrospective, Cross-Sectional Cohort Study Examining the Risk of Unintentional Fatal Drowning during Public Holidays in Australia

Australia’s celebration of its public holidays often involves aquatic recreation, frequently mixed with consumption of alcohol, both of which are risk factors for drowning. This study examines how the demographics and circumstances of public holiday drownings compare to the average day drownings. A total population survey (1 July 2002 to 30 June 2017) of unintentional fatal drownings in Australia were extracted from the Royal Life Saving National Fatal Drowning Database. Date of drowning and state/territory of residence were used to determine if the drowning occurred on a public holiday in the person’s place of residence. 4175 persons drowned during the study period. There was a statistically significant difference between the incidence of fatal drowning on public holidays and the other days, with fatal drowning 1.73 times more likely to occur on public holidays (CI: 1.57–1.89). The increased risk of drowning on public holidays should inform the timing and the content of drowning prevention campaigns and strategies.

Exploring visitation at rivers to understand drowning risk

INTRODUCTION

Globally, rivers are a common drowning location. In Australia, rivers are the leading location for fatal drowning. Limited information exists on exposure and impact on river drowning risk.

METHODS

Australian unintentional fatal river drowning data (sourced from coronial records) and nationally representative survey data on river visitation were used to estimate river drowning risk based on exposure for adults (18 years and older). Differences in river drowning rates per 100 000 (population and exposed population) were examined by sex, age group, activity prior to drowning, alcohol presence and watercraft usage.

RESULTS

Between 1 January 2014 and 31 December 2016, 151 people drowned in Australian rivers; 86% male and 40% aged 18-34 years. Of survey respondents, 73% had visited a river within the last 12 months. After adjusting for exposure: males were 7.6 times more likely to drown at rivers; female drowning rate increased by 50% (0.06-0.09 per 100 000); males aged 75+ years and females aged 55-74 years were at highest risk of river drowning; and swimming and recreating pose a high risk to both males and females. After adjusting for exposure, males were more likely to drown with alcohol present (RR=8.5; 95% CI 2.6 to 27.4) and in a watercraft-related incident (RR=25.5; 95% CI 3.5 to 186.9).

CONCLUSIONS

Calculating exposure for river drowning is challenging due to diverse usage, time spent and number of visits. While males were more likely to drown, the differences between males and females narrow after adjusting for exposure. This is an important factor to consider when designing and implementing drowning prevention strategies to effectively target those at risk.

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

ISSUES

Drowning is a global public health issue, and there is a strong association between alcohol and risk of drowning. No previous systematic review known to date has identified factors associated with alcohol use and engagement in aquatic activities resulting in injury or drowning (fatal and non-fatal).

APPROACH

Literature published from inception until 31 January 2017 was reviewed. Included articles were divided into three categories: (i) prevalence and/or risk factors for alcohol-related fatal and non-fatal drowning and aquatic injury, (ii) understanding alcohol use and aquatic activities, and (iii) prevention strategies. Methodological quality of studies was assessed using National Health and Medical Research Council (NHMRC) Level of Evidence and risk of bias was assessed using the Newcastle-Ottawa Quality Assessment Scales.

KEY FINDINGS

In total, 74 studies were included (57 on prevalence and/or risk factors, 15 on understanding alcohol use, and two on prevention strategies). Prevalence rates for alcohol involvement in fatal and non-fatal drowning varied greatly. Males, boating, not wearing lifejackets, and swimming alone (at night, and at locations without lifeguards) were risk factors for alcohol-related drowning. No specific age groups were consistently identified as being at risk. Study quality was consistently low, and risk of bias was consistently high across studies. Only two studies evaluated prevention strategies.

IMPLICATIONS

There is a need for higher quality studies and behavioural basic and applied research to better understand and change this risky behaviour.

CONCLUSION

On average, 49.46% and 34.87% of fatal and non-fatal drownings, respectively, involved alcohol, with large variations among studies observed.

Suicides by drowning in Greece: Findings from a 10-year sample (2006-2015)

We studied a sample of suicide victims from Greece's main port of Piraeus area (population: approx. 700,000 individuals) and investigated all suicides for the 10-year period 2006-2015, collecting data from the victims' forensic records at the Piraeus Department of Forensic Medicine. Sixty-nine (15.9%) out of 435 suicides were due to drowning, 51 (73.9%) males and 18 (26.1%) females. Drowning was the third most common suicide method with most in the sea (92.8%), fewer in wells (7.2%). Median age: males 52.2 years (standard deviation (SD): 20.3, range: 27-89) and females 58.8 years (SD: 15.2, range: 32-84). Psychiatric medications: antidepressants (6 cases, 8.9%), benzodiazepines (6 cases, 8.9%) and antipsychotics (1 case, 1.5%). Other substances: alcohol (14 cases, 20.9%), cocaine (1 case, 1.5%) and opioids (1 case, 1.5%). No seasonal effect was observed for suicides by drowning. Greece, being a country with an embracing coastline, could provide a field of study for suicide by drowning.