Nonfatal and fatal drownings in recreational water settings�

Nonfatal and fatal drownings in recreational water settings�United States, 2001-2002
Author: Morbidity and Mortality Weekly Report

Drowning is the seventh leading cause of unintentional injury deaths for all ages and the second leading cause of all injury deaths in children aged 1-14 years (1). Many of these injuries occur in recreational water settings, including pools, spas/hot tubs, and natural water settings (e.g., lakes, rivers, or oceans). To examine the incidence and characteristics of nonfatal and fatal unintentional drownings in recreational water settings, CDC analyzed 2001-2002 data from the National Electronic Injury Surveillance System All Injury Program (NEISS-AIP) and National Vital Statistics System (NVSS) death certificate data from 2001. This report summarizes that analysis, which indicated that, during 2001-2002, an estimated 4,174 persons on average per year were treated in U.S. hospital emergency departments (EDs) for nonfatal unintentional drowning injuries in recreational water settings. Approximately 53% of persons required hospitalization or transfer for more specialized care. During 2001, a total of 3,372 persons suffered fatal unintentional drownings in recreational settings. Nonfatal and fatal injury rates were highest for children aged [less than or equal to] 4 years and for males of all ages. To reduce the number of drownings, environmental protections (e.g., isolation pool-fences and lifeguards) should be adopted; alcohol use should be avoided while swimming, boating, or water skiing or while supervising children; and all participants, caregivers, and supervisors should be knowledgeable regarding water-safety skills and be trained in cardiopulmonary resuscitation (CPR) (Box).

BOX. Strategies for drowning prevention in recreationalwater settings** Make sure an adult is constantly watching children swimming  or playing in or around the water. Do not read, play  cards, talk on the phone, mow the lawn, or engage in any  other distracting activity while supervising children.* Never swim alone or in unsupervised places and always  swim with a buddy. Select swimming sites that have lifeguards  whenever possible.* Avoid drinking alcohol before or during swimming,  boating, or water skiing. Avoid drinking alcohol while  supervising children around water.* Learn to swim. Enroll yourself and your children in  swimming classes. The American Academy of Pediatrics  does not recommend swimming classes as a means  of drowning prevention for children aged <4 years.* Learn cardiopulmonary resuscitation (CPR). Because of  the time it might take for paramedics to arrive, your  CPR skills can make a difference in someone's life.* Do not use air-filled or foam toys, such as "water wings,"  "noodles," or inner-tubes, in place of life jackets (personal  flotation devices). These are toys and are not  designed to keep swimmers safe.* If you have a swimming pool at your home:--Install a four-sided, isolation pool-fence. The fence  should be [greater than or equal to] 4 feet high and should  completely separate the pool from the house and play area of the  yard. Use self-closing and self-latching gates in the  fence with the latches out of children's reach. Consider  additional barriers such as automatic door locks  and door alarms to prevent access by small children  to the yard or pool.--Toys should be removed from the pool immediately  after use. Floats, balls, and other toys might  encourage children to enter the pool on their own  or to lean over the pool and potentially fall in.* Tips for recreation in natural bodies of water:--Know the local weather conditions and forecast  before swimming or boating. Strong winds and  thunderstorms with lightning strikes are dangerous  to swimmers and boaters.--Use U.S. Coast Guard-approved life jackets when  boating, regardless of distance to be traveled, size of  boat, or swimming ability of boaters.--Heed colored beach warning flags.--Watch for dangerous waves and signs of rip currents  (e.g., water that is discolored and unusually  choppy, foamy, or filled with debris). If you are  caught in a rip current, swim parallel to the shore.  Once out of the current, swim toward the shore.* Adapted from SafeUSA. Additional information is available athttp://www.safcusa.org.

NEISS-AIP is operated by the U.S. Consumer Product Safety Commission and collects data about initial visits for all types and causes of injuries treated in U.S. EDs (2). Data are drawn from a nationally representative subsample of 66 hospitals out of 100 NEISS hospitals that were 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. NEISS-AIP provides data on approximately 500,000 injury--and consumer product--related ED cases each year. Death certificate data were obtained from NVSS (3). Rates were calculated by using 2001 and 2002 U.S. Census bridged-race population estimates from the National Center for Health Statistics (1).

Nonfatal cases were identified in the NEISS-AIP data if they had a precipitating or immediate cause of "drowning/near-drowning," a diagnosis of "submersion," or the mention of "drown" or "submersion" in the comment field. Cases were reviewed, and any intentional or nonrecreational drownings (e.g., in bathtub, bucket, toilet, or related to motor-vehicle crash) were excluded. In addition, because deaths are not captured completely by NEISS-AIP, 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 of nonfatal drownings. Estimates were based on weighted data for 206 patients with drowning injuries in recreational water settings treated at NEISS-AIP hospital EDs during 2001-2002. Two years of data were necessary to provide stable rates. Confidence intervals (CIs) were calculated by using a direct variance estimation procedure that accounted for the sample weights and complex sample design. Estimates for the 2 years were annualized by dividing the sample weights by two. Because of the small sample size, percentages of nonfatal injuries by location (Figure) were based on unweighted data for NEISS-AIP cases and, thus, are not nationally representative. Drowning deaths in recreational water settings were defined as those for which the underlying cause recorded on death certificates by a physician or coroner was one of the following International Classification of Diseases, Tenth Revision (ICD-10) codes: W67-W74, V90, or V92. Because NVSS is a complete census of all deaths, it is not subject to sampling error; however, CIs were calculated to account for random error (3). This report uses the terms "nonfatal drowning" and "fatal drowning" to describe the events captured by using these methods.

During 2001-2002, an estimated 4,174 persons on average were treated annually in U.S. EDs for nonfatal unintentional drowning injuries in recreational settings, and 3,372 persons died in 2001 (Table). Children aged [less than or equal to] 4 years accounted for nearly 50% of the ED visits, and children aged 5-14 years an additional 25%. Fatal rates also were highest in children aged [less than or equal to] 4 years. The nonfatal drowning rate for males was nearly twice that for females, and the fatal rate for males was almost five times that for females. These injuries in recreational settings occurred most commonly on weekends (Friday-Sunday), accounting for 56% of nonfatal injuries, and in summer months (June-August), accounting for 56% of nonfatal injuries and 51% of fatalities. For those cases that were known to occur either in a pool or natural water setting, an estimated 75% of nonfatal injuries occurred in pools, whereas 70% of the Fatalities occurred in natural water settings. Nearly 40% of reported nonfatal injuries to children aged [less than or equal to] 4 years occurred in private pools; both nonfatal and fatal injuries in natural water settings increased with age (Figure). Approximately 53% of ED-treated patients required hospitalization or transfer to another hospital for more specialized care.

Editorial Note: Drownings have been a leading cause of injury death in the United States for decades (1). The findings in this report are consistent with previous reports of fatal drownings, indicating that small children are at highest risk, particularly around residential pools (4). in addition, males are at higher risk than females, possibly because of their choices of activities with higher risk and increased use of alcohol (5).

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