Drowning--United States, 2005-2009.
Death certificate data for 2005-2009 were obtained from the National Vital Statistics System. * Fatal unintentional drowning was defined as any death for which the underlying cause recorded on death certificates was one of the following international Classification of Diseases, 10th Revision codes: W65--W74, V90, or V92. By international standards, boating-related drowning (V90 and V92) is classified as transportation-related death. ([dagger]) Boating-related deaths are presented in this report as a subcategory to allow for international comparison, although most boating in the United States is not for transportation.
Data on nonfatal drowning were gathered from NEISSAIP, which is operated by the U.S. Consumer Product Safety Commission. NEISS-AIP collects data annually on approximately 500,000 initial visits for all types of injuries treated in U.S. EDs. ([section]) Data are drawn from a nationally representative subsample of 66 hospitals out of 100 NEISS hospitals selected as a stratified probability sample of hospitals in the United States and its territories; the hospitals have a minimum of six beds and a 24-hour ED.
Nonfatal cases included those classified as having a precipitating or immediate cause of "drowning/near-drowning," a diagnosis of "submersion," or the mention of "drown" or "submersion" in the comment field. To collect and classify nonfatal cases in a manner similar to deaths, case narratives were reviewed and intentional and motor vehicle crash--related drownings were excluded. Persons who were dead on arrival or who died in the ED also were excluded. Each case was assigned a sample weight on the basis of the inverse probability of selection; these weights were summed to provide national estimates. National estimates were based on 605 patients treated for nonfatal drowning at NEISS-AIP hospital EDs during 2005-2009. Confidence intervals were calculated using statistical software to account for the complex sample design. Because of the small sample size, percentages of nonfatal injuries for location by age group were based on unweighted data and thus are not nationally representative.
Drowning was examined by age group, sex, race/ethnicity, location, disposition (e.g., treated and released, hospitalized or transferred), day of week, and month of year when possible. Persons identified as Hispanic might be of any race. Persons identified as white, black, or other race all were non-Hispanic. Rates were calculated using U.S. Census bridged-race intercensal population estimates. ([paragraph]) Significant differences (p<0.05) between rates were determined using a t-test for nonfatal drowning rates and a z-test for death rates.
During 2005-2009, overall, an average of 3,880 persons died from unintentional drowning (including boating incidents) annually in the United States (1.29 deaths per 100,000 population) (Table). Rates were highest among children aged [less than or equal to] 4 years (2.55), and the death rate for males (2.07) was nearly four times that for females (0.54). The death rate for blacks (1.40) was significantly higher than the overall death rate (1.29), and the death rate for Hispanics was significantly lower (1.19). Racial/ethnic disparity in drowning death rates was greatest among children aged 5-14 years (blacks, 1.34; Hispanics, 0.46; and whites, 0.48). Approximately half (51.1 %) of fatal drownings occurred in natural bodies of water. From 2005 to 2009, death rates declined significantly from 1.34 per 100,000 to 1.25 (p=0.002).
During 2005-2009, an estimated 5,789 persons on average were treated annually in U.S. EDs for nonfatal drowning (Table). Children aged [less than or equal to] 4 years accounted for 52.8% of the ED visits, and children aged 5-14 years accounted for 17.5%. Males accounted for 60.2% of nonfatal drowning patients, and 50.2% of the ED patients required hospitalization or transfer for further care. In addition, of nonfatal drowning injuries among those aged [greater than or equal to] 15 years, 21.8% were associated with alcohol use.
Nonfatal (45.5%) and fatal (37.1%) incidents occurred most commonly on weekends and during June--August, 57.5% and 46.7%, respectively. Among children aged [less than or equal to] 4 years, 50.1% of fatal incidents and 64.6% of nonfatal incidents occurred in swimming pools (Figure). Drownings in natural water settings increased with increasing age group. Incidents in bathtubs accounted for approximately 10% of both fatal and nonfatal drownings and were most common among children aged [less than or equal to] 4 years.
Orapin C. Laosee, PhD, Association of Southeast Asian Nations institute for Health Development, Mahidol Univ, Nakhonpathom, Thailand. Julie Gilchrist, MD, Rose A. Rudd, MSPH, Div of Unintentional injury Prevention, National Center for injury Prevention and Control, CDC. Corresponding contributor: Julie Gilchrist, firstname.lastname@example.org, 770-488-1178.
In the United States, children aged 1-4 years continue to have the highest drowning death rates, and those rates are higher than the rates for all other causes of death in that age group except congenital anomalies (3). Other groups at greater risk for drowning include males, who account for approximately 80% of fatal drowning victims, and blacks, whose drowning death rate is 9% higher than that of the overall population (and, among those aged 5-14 years, 116% higher than the overall population) (4,5). Males might be at greater risk because they are more likely to overestimate their swimming ability, choose higher risk activities, or more commonly use alcohol (6). Blacks might be at greater risk because they often lack survival swimming skills (7,8).
Age, race/ethnicity, sex, and socioeconomic factors have been associated with lack of swimming ability among urban children (7). Swimming skills have been promoted as a means to reduce drowning risk, although concerns have been raised that initiating swimming lessons in young children might increase their risk for drowning (9). Teaching basic survival skills (e.g., ability to right oneself after falling into water, proceed a short distance, and float or tread water) to children aged >4 years in Bangladesh significantly reduced drowning rates (10). Furthermore, formal swimming lessons have been shown to reduce the risk for fatal drowning among children aged 1-4 years in the United States and China and might also reduce risk among older age groups (9). Other effective interventions include bystander cardiopulmonary resuscitation, four-sided pool fencing that separates the pool from the house and yard, and use of lifejackets (1,9).
Death certificates and ED records lack critical pieces of information, such as details on the victim's activities and swimming ability, the body of water, weather conditions, health conditions, use of life jackets, type and functionality of fences or barriers, supervision type and quality (e.g., impaired), presence of lifeguards, and whether cardiopulmonary resuscitation was performed by a bystander. These data are needed to better understand drowning incidents, design interventions, and track their effectiveness. Among children aged <18 years, these data could be obtained by full implementation and analysis of data from the National Child Death Review Case Reporting System. ** This system, managed by the National Center for Child Death Review in Okemos, Michigan, could provide data compiled by state and local teams to more completely describe drowning circumstances. Currently, 40 states voluntarily submit data to the system, and a public use data set is available to researchers through application to the center.
The findings in this report are subject to at least three limitations. First, whereas fatalities occurring in EDs were excluded from the nonfatal data presented, NEISS-AIP does not provide information on outcomes after hospitalization; therefore, data for fatal and nonfatal drownings might not be mutually exclusive. Second, some unintentional drownings might have been classified as undetermined and some homicides or suicides as unintentional. Finally, the extent of exposure to recreational water settings might vary by age, sex, season, level of swimming skill, or other factors; however, these data were not available. As a result, rates are population-based and do not account for exposure.
Parents and caregivers of children, and participants in and supervisors of activities in or near water, should be aware of drowning hazards, use appropriate prevention strategies, and be prepared with life-saving skills in the event of emergencies. Additional information regarding drowning risk factors and prevention strategies is available at http://www.cdc.gov/ homeandrecreationalsafety/water-safety/index.html and at http://www.cdc.gov/safechild.
What is already known on this topic?
Drowning is recognized worldwide as a leading cause of unintentional injury death that disproportionately affects children.
What is added by this report?
In the United States, an average of 3,880 persons died from unintentional drowning each year during 2005-2009, and an estimated 5,789 received emergency department care for nonfatal drowning. Children aged [less than or equal to] 4 years had the highest rates of both fatal and nonfatal drowning, and the death rate for males was approximately four times the rate for females. Among children aged [less than or equal to] 4 years, 50.1% of fatal incidents occurred in swimming pools.
What are the implications for public health practice?
Because swimming pools (often at their own home) remain high risk locations for children aged [less than or equal to] 4 years and research shows that early formal swimming lessons reduce risk among children aged 1-4 years, public health and medical professionals should encourage and support swimming lessons as a life-saving skill along with other proven interventions. This skill also might reduce the risk for drowning among older age groups and in other settings.
(1.) Peden M, Oyegbite K, Ozanne-Smith J, et al, eds. World report on child injury prevention. Geneva, Switzerland: World Health Organization; 2008. Available at http://www.who.int/violence_injury_prevention/child/ injury/world_report/report/en/index.html. Accessed May 10, 2012.
(2.) CDC. Vital signs: unintentional injury deaths among persons aged 0-19 years--United States, 2000-2009. MMWR 2012;61:270-6.
(3.) CDC. Web-Based Injury Statistics Query and Reporting System (WISQARS). Atlanta, GA: US Department of Health and Human Services, CDC; 2012. Available at http://www.cdc.gov/injury/wisqars/ index.html.
(4.) CDC. Nonfatal and fatal drownings in recreational water settings--United States, 2001-2002. MMWR 2004;53:447-52.
(5.) Nasrullah M, Muazzam S. Drowning mortality in the United States, 1999-2006. J Community Health 2011:36;69-75.
(6.) Howland J, Hingson R, Mangione TW, Bell N, Bak S. Why are most drowning victims men? Sex differences in aquatic skills and behaviors. Am J Public Health 1996;86:93-6.
(7.) Irwin CC, Irwin R L, Ryan T D, Drayer J. Urban minority youth swimming (in)ability in the United States and associated demographic characteristics: toward a drowning prevention plan. Inj Prev 2011;15:234-9.
(8.) Gilchrist J, Sacks JJ, Branche CM. Self-reported swimming ability in US adults, 1994. Public Health Rep 2000;115:110-1.
(9.) Weiss J. Technical report: prevention of drowning. Pediatrics 2010; 126:e253-62.
(10.) Rahman A, Rahman F, Hossain J, Talab A, Scarr J, Linnan M. Survival swimming--effectiveness of SwimSafe in preventing drowning in mid and late childhood. Presented at the World Conference on Drowning Prevention, Danang, Vietnam, May 11, 2011.
* Additional information available at http://www.cdc.gov/nchs/deaths.htm.
([dagger]) Additional information available at http://www.cdc.gov/nchs/injury/injury_ tools.htm.
** Additional information available at http://www.childdeathreview.org/ reporting.htm.
TABLE. Annual number, percentage, and rate* of nonfatal and fatal unintentional drownings, ([dagger]) by selected characteristics-- National Vital Statistics System and National Electronic Injury Surveillance System--All Injury Program, United States, 2005-2009 Nonfatal Characteristic Estimated (%) Rate (95% CI) no. Age (yrs) 0-4 3,057 (52.8) 15.21 (6.86-23.56) 5-14 1,012 (17.5) 2.49 (1.62-3.36) [greater than or equal to] 15 1,718 (29.7) 0.71 (0.38-1.05) Unknown 2 (0.03) -- -- Sex Male 3,486 (60.2) 2.35 (1.24-3.47) Female 2,301 (39.7) 1.50 (0.87-2.13) Unknown 2 (0.03) -- -- Race/Ethnicity ([section]) White -- -- -- -- Black -- -- -- -- Other race -- -- -- -- Hispanic -- -- -- -- Unknown -- -- -- -- Location of drowning ([paragraph]) Bathtub 534 (9.2) -- -- Swimming pool 3,341 (57.7) -- -- Private pool ** 1,616 (27.9) -- -- Public pool 956 (16.5) -- -- Unspecified pool 769 (13.3) -- -- Natural water 1,460 (25.2) -- -- Fresh water 525 (9.1) -- -- Ocean ** 412 (7.1) -- -- Boating/Water transport ** 400 (1.2) -- -- Unspecifed natural water ** 123 (7.8) -- -- Other/ Unspecified ** 454 (7.8) -- -- Disposition Treated and released 2,540 (43.9) 0.84 (0.46-1.23) Hospitalized/ Transferred 2,908 (50.2) 0.97 (0.40-1.53) Other/Unknown 340 (5.9) 0.11 (0.05-0.18) Overall 5,789 (100.0) 1.92 (1.07-2.78) Fatal Characteristic No. (%) Rate Age (yrs) 0-4 513 (13.2) 2.55 5-14 252 (6.5) 0.62 [greater than or equal to] 15 3,107 (80.1) 1.29 Unknown 9 (0.2) -- Sex Male 3,057 (78.8) 2.07 Female 823 (21.2) 0.54 Unknown -- -- -- Race/Ethnicity ([section]) White 2,561 (66.0) 1.28 Black 566 (14.6) 1.40 Other race 209 (5.4) 1.21 Hispanic 524 (13.5) 1.19 Unknown 20 (0.5) -- Location of drowning ([paragraph]) Bathtub 403 (10.4) -- Swimming pool 683 (17.6) -- Private pool ** -- -- -- Public pool -- -- -- Unspecified pool -- -- -- Natural water 1,982 (51.1) -- Fresh water -- -- -- Ocean ** -- -- -- Boating/Water transport ** 347 (8.9) -- Unspecified natural water ** 1,635 (42.1) -- Other/ Unspecified ** 813 (21.0) -- Disposition Treated and released -- -- -- Hospitalized/ Transferred -- -- -- Other/Unknown -- -- -- Overall 3,880 (100.0) 1.29 ([dagger]) Abbreviation: CI = Confidence interval. * Per 100,000 population. ([dagger]) Includes drowning deaths associated with boating incidents, a type of transportation injury death. The overall death rate excluding boating-related drowning was 1.17 per 100,000 population. ([section]) Persons identified as Hispanic might be of any race. Persons identified as white, black, or other race are all non-Hispanic. Nonfatal rates are not presented for racial/ ethnic groups because race/ethnicity was unknown for a substantial percentage of persons with nonfatal injuries. ([paragraph]) Location of drowning by specific pool and natural water type is unavailable for mortality data. Rates are not presented for location because the denominator for each is the entire population. ** Nonfatal estimates might be unstable because the coefficient of variation is >30%, unweighted count <20, or 5-year weighted estimate <1,200.