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

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.

Lessons learned through the 20-year development of a national fatal drowning database in Australia

BACKGROUND

Co-ordinated, evidence-based policy and programmatic efforts are needed to respond to complex drowning prevention problems. Comprehensive, current, and robust data are vital for agenda setting, burden and risk factor identification, intervention design and evaluation, as well as setting policy. We aim to record methods used in, and identify impacts of, the development of a national fatal drowning database (NFDD) in Australia, including lessons learned across research, policy, and practice.

METHODS

We employ a case study method using process mapping and document review to explore the evolution, drivers and impacts of the NFDD. We analyse methodological approaches including those relating to data definitions, drowning case collection, and management, as well as tracking the various outputs of the NFDD. We describe a development timeline that presents impact of drowning prevention policy, and research agendas on database development, and research investments more specifically.

RESULTS

Our study identified that the collected variables grew 20-fold from 2002 to 2022, reaching 259 variables, and 5,692 unique cases of fatal drowning. The NFDD employs data triangulation methodology, combining keyword and targeted searches of coronial files, media report monitoring, and organisational data provision. Database development is influenced by the Australia Water Safety Strategy, policymaker and practitioner-initiated research agendas, and identification of knowledge gaps. We identified numerous outputs spanning publications, media, intervention development, and legislative submissions.

CONCLUSION

A comprehensive and robust NFDD informed by policymaker and practitioner input can enhance surveillance, policy, and intervention development for drowning prevention. Employing mixed data collection and validation methods can supplement weaknesses in official data sources. There is a need for the NFDD to continue to evolve in its application while maintaining rigorous case identification and data quality assurance processes. Despite significant investment, the outputs and influence on drowning prevention practice in Australia has been extremely valuable and contributed to sizeable reductions in Australia's fatal drowning rate.

Disadvantaged by More Than Distance: A Systematic Literature Review of Injury in Rural Australia

Rural populations experience injury-related mortality and morbidity rates 1.5 times greater than metropolitan residents. Motivated by a call for stronger epidemiological evidence around rural injuries to inform prevention, a systematic review of peer-reviewed literature published between January 2010 and March 2021 was undertaken to explore the epidemiology of rural injury and associated risk factors in Australia. A subsequent aim was to explore definitions of rurality used in injury prevention studies. There were 151 papers included in the review, utilizing 23 unique definitions to describe rurality. People living in rural areas were more likely to be injured, for injuries to be more severe, and for injuries to have greater resulting morbidity than people in metropolitan areas. The increase in severity reflects the mechanism of rural injury, with rural injury events more likely to involve a higher energy exchange. Risk-taking behavior and alcohol consumption were significant risk factors for rural injury, along with rural cluster demographics such as age, sex, high socio-economic disadvantage, and health-related comorbidities. As injury in rural populations is multifactorial and nonhomogeneous, a wide variety of evidence-based strategies are needed. This requires funding, political leadership for policy formation and development, and implementation of evidence-based prevention interventions.

Pre-Existing Medical Conditions: A Systematic Literature Review of a Silent Contributor to Adult Drowning

Medical conditions can increase drowning risk. No prior study has systematically reviewed the published evidence globally regarding medical conditions and drowning risk for adults. MEDLINE (Ovid), PubMed, EMBASE, Scopus, PsycINFO (ProQuest) and SPORTDiscus databases were searched for original research published between 1 January 2005 and 31 October 2021 that reported adult (≥15 years) fatal or non-fatal drowning of all intents and pre-existing medical conditions. Conditions were grouped into the relevant International Classifications of Diseases (ICD) codes. Eighty-three studies were included (85.5% high-income countries; 38.6% East Asia and Pacific region; 75.9% evidence level III-3). Diseases of the nervous system (n = 32 studies; 38.6%), mental and behavioural conditions (n = 31; 37.3%) and diseases of the circulatory system (n = 25; 30.1%) were the most common categories of conditions. Epilepsy was found to increase the relative risk of drowning by 3.8 to 82 times, with suggested preventive approaches regarding supervised bathing or showering. Drowning is a common suicide method for those with schizophrenia, psychotic disorders and dementia. Review findings indicate people with pre-existing medical conditions drown, yet relatively few studies have documented the risk. There is a need for further population-level research to more accurately quantify drowning risk for pre-existing medical conditions in adults, as well as implementing and evaluating population-level attributable risk and prevention strategies.

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.

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.

Spain's suicide statistics: do we believe them?

PURPOSE

There is a widespread belief that suicides around the world are under-counted. A substantial proportion of suicides may have been inappropriately registered as accidental or of undetermined cause or intent. There is reason to explore to what extent low suicide rates in some nations could be partly attributable to under-counting.

METHODS

Mortality statistics of most countries are available on-line. Numbers of suicide deaths in Spain, and in England and Wales (E & W), in male and female 5-year age groups, in each year between 2014 and 2018, were documented, along with deaths coded to ICD-10 accident or 'undetermined death' categories. Crude mortality rates were calculated using official population figures. Single year suicide, undetermined death, and non-transport accidental death rates of 12 other nations were calculated.

RESULTS

Spain's crude suicide rate per 100,000 remains low (7.89) compared to other nations; its event of undetermined intent (EUI) death rate was 0.09 (contrasting with E & W's 1.74). Its accidental poisoning rate is much lower than that of E & W. The study showed much higher rates of ill-defined/unknown cause deaths in late life in Spain (both genders) than in E & W, and age-associated increases in accidental drowning rates parallel with increased suicide by drowning.

CONCLUSIONS

Reportedly low suicide rates in Spain could be partly attributable to increased rates of 'hidden suicide' (accidental drowning, male accidental poisoning, and possibly ill-defined/unknown cause deaths, but not EUIs). It would be appropriate (and not just in Spain) to increase numbers of verbal and/or forensic autopsies in questionable 'undetermined' cases.

Description and prediction of outcome of drowning patients in New South Wales, Australia: protocol for a data linkage study

INTRODUCTION

Despite being a preventable cause of death, drowning is a global public health threat. Australia records an average of 288 unintentional drowning deaths per year; an estimated annual economic burden of $1.24 billion AUD ($2017). On average, a further 712 hospitalisations occur due to non-fatal drowning annually. The Australian state of New South Wales (NSW) is the most populous and accounts for 34% of the average fatal drowning burden. This study aims to explore the demographics and outcome of patients who are admitted to hospitals for drowning in NSW and also investigates prediction of patients' outcome based on accessible data.

METHODS AND ANALYSIS

This protocol describes a retrospective, cross-sectional data linkage study across secondary data sources for any person (adult or paediatric) who was transferred by NSW Ambulance services and/or admitted to a NSW hospital for fatal or non-fatal drowning between 1/1/2010 and 31/12/2019. The NSW Admitted Patient Data Collection will provide data on admitted patients' characteristics and provided care in NSW hospitals. In order to map patients' pathways of care, data will be linked with NSW Ambulance Data Collection and the NSW Emergency Department Data Collection. Finally patient's mortality will be assessed via linkage with NSW Mortality data, which is made up of the NSW Register of Births, Deaths and Marriages and a Cause of Death Unit Record File. Regression analyses will be used to identify predicting values of independent variables with study outcomes.

ETHICS AND DISSEMINATION

This study has been approved by the NSW Population & Health Services Research Ethics Committee. Results will be disseminated through peer-reviewed publications, mass media releases and at academic conferences. The study will provide outcome data for drowning patients across NSW and study results will provide data to deliver evidence-informed recommendations for improving patient care, including updating relevant guidelines.

Forensic Applications of Microbiomics: A Review

The rise of microbiomics and metagenomics has been driven by advances in genomic sequencing technology, improved microbial sampling methods, and fast-evolving approaches in bioinformatics. Humans are a host to diverse microbial communities in and on their bodies, which continuously interact with and alter the surrounding environments. Since information relating to these interactions can be extracted by analyzing human and environmental microbial profiles, they have the potential to be relevant to forensics. In this review, we analyzed over 100 papers describing forensic microbiome applications with emphasis on geolocation, personal identification, trace evidence, manner and cause of death, and inference of the postmortem interval (PMI). We found that although the field is in its infancy, utilizing microbiome and metagenome signatures has the potential to enhance the forensic toolkit. However, many of the studies suffer from limited sample sizes and model accuracies, and unrealistic environmental settings, leaving the full potential of microbiomics to forensics unexplored. It is unlikely that the information that can currently be elucidated from microbiomics can be used by law enforcement. Nonetheless, the research to overcome these challenges is ongoing, and it is foreseeable that microbiome-based evidence could contribute to forensic investigations in the future.

Next steps for drowning prevention in rural and remote Australia: A systematic review of the literature

OBJECTIVE

To examine unintentional drowning by remoteness in Australia.

DESIGN

A systematic review of both peer-reviewed and grey literature published between January 1990 and December 2019 (inclusive).

METHOD

Using Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, MEDLINE (Ovid), PubMed, EMBASE, Scopus, PsycINFO (ProQuest), SPORTDiscus and Google Scholar were searched for studies exploring fatal and non-fatal unintentional drowning by remoteness. Epidemiological data, common factors and prevention strategies were extracted and mapped to Australian standard geographical classifications (major cities, inner regional, outer regional, remote and very remote). Level of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation and prevention strategies aligned to the hierarchy of control.

RESULT

Thirty-two studies satisfied inclusion criteria (66% reporting epidemiology; 59% risk factors; and 44% prevention strategies). All (100%) included studies were assessed very low against Grading of Recommendations Assessment, Development and Evaluation. Findings indicate rural populations (ie, excluding major cities) have higher rates of drowning positively correlated with increasing remoteness. Common factors included age (child), natural water bodies, undertaking boating and watercraft activities and alcohol consumption. While a range of prevention strategies has been proposed, only one study outlined a rural drowning prevention strategy which had been implemented and evaluated. Strategies were generally low on the hierarchy of control.

CONCLUSION

Rural populations are proportionately overrepresented in drowning statistics. Proposed prevention strategies have unknown efficacy. Greater research into rural drowning of Australians is needed especially exploring behavioural motivations, program delivery, cost-effectiveness and evaluation. Development and use of a standard definition for remoteness are recommended. Rural populations use water extensively; therefore, there is an urgent need to keep them safe.

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.

Epidemiology, Risk Factors and Measures for Preventing Drowning in Africa: A Systematic Review

Background and Objectives: Drowning is a leading cause of unintentional injury related mortality worldwide, and accounts for roughly 320,000 deaths yearly. Over 90% of these deaths occur in low- and middle-income countries with inadequate prevention measures. The highest rates of drowning are observed in Africa. The aim of this review is to describe the epidemiology of drowning and identify the risk factors and strategies for prevention of drowning in Africa. Materials and Methods: A review of multiple databases (MEDLINE, CINAHL, PsycINFO, Scopus and Emcare) was conducted from inception of the databases to the 1st of April 2019 to identify studies investigating drowning in Africa. The preferred reporting items for systematic review and meta-analysis (PRISMA) was utilised. Results: Forty-two articles from 15 countries were included. Twelve articles explored drowning, while in 30 articles, drowning was reported as part of a wider study. The data sources were coronial, central registry, hospital record, sea rescue and self-generated data. Measures used to describe drowning were proportions and rates. There was a huge variation in the proportion and incidence rate of drowning reported by the studies included in the review. The potential risk factors for drowning included young age, male gender, ethnicity, alcohol, access to bodies of water, age and carrying capacity of the boat, weather and summer season. No study evaluated prevention strategies, however, strategies proposed were education, increased supervision and community awareness. Conclusions: There is a need to address the high rate of drowning in Africa. Good epidemiological studies across all African countries are needed to describe the patterns of drowning and understand risk factors. Further research is needed to investigate the risk factors and to evaluate prevention strategies.

Vulnerability to fatal drowning among the population in Southern Bangladesh: findings from a cross-sectional household survey

OBJECTIVES

This study aimed to determine the fatal drowning burden and associated risk factors in Southern Bangladesh.

SETTINGS

The survey was conducted in 39 subdistricts of all 6 districts of the Barisal division, Southern Bangladesh.

PARTICIPANTS

All residents (for a minimum 6 months prior to survey) of the Barisal division, Southern Bangladesh.

INTERVENTION/METHODS

A cross-sectional, divisionally representative household survey was conducted in all six districts of the Barisal division between September 2016 and February 2017, covering a population of 386 016. Data were collected by face-to-face interview with adult respondents using handheld electronic tablets. International Classification of Diseases (ICD)-v. 10 (ICD-10) Chapter XX: External causes of morbidity and mortality codes for drowning, W65-W74, X36-X39, V90, V92, X71 or X92, were used as the operational definition of a drowning event.

RESULTS

The overall fatal drowning rate in Barisal was 37.9/100 000 population per year (95% CI 31.8 to 43.9). The highest fatal drowning rate was observed among children aged 1-4 years (262.2/100 000/year). Mortality rates among males (48.2/100 000/year) exceeded that for females (27.9/100 000/year). A higher rate of fatal drowning was found in rural (38.9/100 000/year) compared with urban areas (29.3/100 000/year). The results of the multivariable logistic regression identified that the factors significantly associated with fatal drowning were being male (OR 1.7, 95% CI 1.2 to 2.3), aged 1-4 years (OR 3.0, 95% CI 1.4 to 6.4) and residing in a household with four or more children (four or more children OR 1.8, 95% CI 1.1 to 2.9; and five or more children OR 2.1, 95% CI 1.2 to 3.7).

CONCLUSION

Drowning is a public health problem, especially for children, in the Barisal division of Southern Bangladesh. Male gender, children 1-4 years of age and residing in a household with four or more children were associated with increased risk of fatal drowning events. The Barisal division demands urgent interventions targeted at high-risk groups identified in the survey.