Recommendations for Water Safety and Drowning Prevention for Travelers

Transcription

1 21 REVIEW ARTICLES Recommendations for Water Safety and Drowning Prevention for Travelers Leslie M. Cortés, MHS, * Stephen W. Hargarten, MD, MPH, * and Halim M. Hennes, MD, MS Departments of * Emergency Medicine and Pediatrics, Injury Research Center, Medical College of Wisconsin, Milwaukee, Wisconsin DOI: /j x Drowning is a serious worldwide, mostly preventable injury problem, particularly among international travelers. In 2000, approximately 449,000 people have drowned worldwide, and the exact number of travelers is not precisely known. Although comprehensive infectious disease information has been available to international travelers for many years, advice on injury risk and prevention, more specifically on drowning prevention, has received little attention. The goals of this review were to develop research-based drowning prevention and water-safety recommendations for travelers and to identify research needs for future recommendations. A group of injury-prevention and travelmedicine experts conducted several rounds of voting and ranking of the strength and evidence of drowningprevention recommendations. Each of the thirty-two recommendations created have also been categorized using the Committee to Advise on Tropical Medicine and Travel scale and have been framed in the context of preevent, event, and postevent categories commonly used in injury-control theory and Haddon s Matrix. These recommendations were developed for use by travel-medicine professionals or others who prepare individuals for travel. Several of the identified interventions to prevent drownings lack conclusive scientific evidence of their effectiveness and warrant further studies to better understand their true effectiveness. Furthermore, funding for the studies of intervention effectiveness and the implications of these interventions for international travelers are essential, yet insufficient. According to the World Health Organization, worldwide, an estimated 449,000 people drowned in Approximately 97% of these events occurred in middle- to low-income countries, with mortality rates highest in the regions of Africa and China ( /100,000). 1 Drowning affects children in particular, in all regions of the world; children younger than 5 years had the Corresponding Author: Leslie Maas Cortes, MHS, PMB no. 441, 90 Rio Hondo Avenue, Bayamon, PR 00961, USA. highest drowning mortality rates for both sexes, with the exception of Africa where the rate was higher in children aged 5 to 14 years. 1 In countries where drowning has been studied, rates of drowning vary by gender, age, and location. 2 5 Although some limited data exists on drowning during travel, a clear picture of how international travelers drown is yet to be established. A study investigating the water-related deaths of British children traveling abroad found that 75 children (aged 14 and younger) drowned in the 8-year period of 1996 to Seventy-four percent of these deaths occurred in swimming pools. Most 2006 International Society of Travel Medicine, Journal of Travel Medicine, Volume 13, Issue 1, 2006, 21 34

2 22 Cortés et al. British children drowned in destinations within the European Union (51) and in the United States (10). 6 As a destination, the United States had the highest rate of drowning deaths when exposure was controlled for (3.2 death per million travelers), followed by Spain (2.8 death per million travelers). 6 Interestingly, 4.7% of drowning (non-boat-related) deaths in Australia occurred among international tourists, and the majority of these events occurred in the ocean. 7 In addition, the risk of drowning for foreigners traveling in Denmark was three to four times higher than that for Danes. 8 It is also known that drowning causes approximately 15% (92) of injury deaths among US citizens abroad annually US travelers to Mexico, Central America, Caribbean, Oceania, and Canada have significantly higher proportions of death due to drowning than the proportion of death from drowning experienced by US residents. 13,14 The epidemiology of drowning events in various countries like Australia, United States, Denmark, Finland, Singapore, and others and the specific risk factors associated with drowning events can help travel-medicine professionals better advise their patients to prevent drowning incidents during travel. 4,7,8,15 20 Furthermore, it is well documented that treatment measures in an intensive care unit (ICU) or medical unit have little effect on the outcome for those once admitted because of drowning injuries; for this reason, primary- and secondaryprevention strategies are extremely important. 21 For decades, travel-medicine specialists and government agencies have used comprehensive infectious disease information and promoted immunization against infectious agents to protect international travelers. However, advice on injury precautions in general and water safety and drowning prevention in detail during travel has received little attention. Methods A group of travel-medicine experts and injurycontrol researchers met to discuss the problem of drowning during travel, available data sources, and future research needs. In addition, this group was charged with creating evidence-based recommendations for use by the travel-medicine provider. Participants and Plenary Session The Injury Research Center at the Medical College of Wisconsin and the National Center for Injury Prevention and Control, part of the Centers for Disease Control and Prevention (CDC), cohosted a day and half-long meeting of approximately 60 participants to create evidence-based and expert opinion based injury-prevention recommendations for the international traveler. The Water Safety and Drowning Prevention Participants, an 11-member panel, contained representatives from the following organizations and agencies: World Health Organization, SAFE KIDS Worldwide, US CDC, National Institute of Child Health and Human Development, various academic institutions, Education Development Center, Office of Medical Services at the Department of State, Office of International and Refugee Health at the Department of Health and Human Services, Fogerty International Center, Children s Safety Network, Liberty Center for Safety Research, and the Peace Corps. The plenary sessions of the meeting focused on describing the injury problem among the traveling population. Specific topics addressed were role of advocacy, medical evacuation, safety and student travelers, Peace Corps experience, the international injury problem, data on causes of deaths to US travelers, and the US State Department s approach to development and dissemination of travelers safety information and the role of future of surveillance. This meeting had two specific goals. The first goal was to develop injury-prevention recommendations for use by travel-medicine professionals who advise international travelers. The second goal was to identify research needs and plan for the continual monitoring of the injury problem. Three separate panels were brought together to address three most important injury topics affecting international travelers: drowning, transportation, and violence. Meeting participants received scientific publications on injury during travel and reviews of existing injury-prevention recommendations prior to the 13,22 33 meeting. Recommendation Development Process The Planning Committee created a preliminary set of recommendations by integrating scientific evidence found in the literature and in Internet searches. Figure 1 illustrates the recommendation develop process. Recommendations were then circulated among experts (invitees) to obtain some level of consensus based upon expert opinion. Participants were asked to rank each recommendation according to the level of existing evidence and their expert opinion and were encouraged to contribute additional recommendations or indicate if the recommendation could cause potential harm.

3 Water Safety and International Travel 23 Figure 1 Flow chart of recommendation development process. A set of recommendations remained available for public comment on the Internet at irc for 8 months following the meeting. Meeting participants, members of the injury-control community and travel-medicine community, were invited to comment. Experts in specific topic areas such as boating, scuba, and water-tour operations were also consulted regarding the accurateness and practicality of these recommendations. The Committee to Advise on Tropical Medicine and Travel (CATMAT) scale was used to summarize the strength and quality of the recommendations intended for use by travel-medicine professionals who will be counseling individual travelers. Table 1 describes the CATMAT definitions for levels of strength (A E) and quality of evidence (I III) associated with each recommendation. 33 The recommendations have been further framed in the injury-control context using a modified version of the Haddon s Matrix indicating how the recommendation relates to the three phases of injury event ( Table 2 ). Research has shown that injuries have three phases: the preevent, the event, and the postevent phases. 34 Recommendations associated with the preevent phase are related to primary-prevention or preventing events that might cause injury. Strategies that fall into the event category aim to protect individuals against injury should an injury occur. Those recommendations associated with the postevent phase are focused on minimizing the consequences of an injury after it has occurred through skilled emergency services, medical care, and rehabilitation. Recommendations in all three phases are important to prevent or control injuries from drowning; however, primary and secondary preventions are especially important because it has been well documented that treatment measures administered for drowning-related incidents in an ICU or medical unit have little effect on improving the outcome. Results Twenty-nine drowning-prevention recommendations have been created and labeled using the CATMAT scale of strength and quality of evidence. They have been grouped by topics: general advice, alcohol, advice for travelers with children, and diving and snorkeling. These recommendations have also been labeled as preevent, event, and postevent depending upon how they might prevent or control injury. Some recommendations, eg, alcohol, addressed one or more of the three event phases ( Table 3 ). Other recommendations relate to things one needs to do prior to departure but truly affect the postevent phase of injury, eg, registering your itinerary with your embassy so they can help in case of emergency and purchase of adequate evacuation insurance for your destination. Discussion of the Recommendations Event-Phase Matrix Many of the recommendations affect more than one event phase of the phase-factor matrix ( Table 3 ). 34 If a boat operator does not drink alcohol, research shows that compared to an intoxicated boater, he or she will have an increased ability to make decisions to avoid or to prevent events that may lead to a boating crash or submersion injury (preevent phase), he or she will also posses an increased ability to react should an injury-producing event occur while operating the boat (event phase), and if a boating crash occurs, the boat operator will be better able to recover from a submersion or near-drowning situation without al cohol in his/her body (postevent 7,12,29,48,68,76 84 phase). Other recommendations, such as learning cardiopulmonary resuscitation (CPR) and waterrescue techniques prior to departure, purchasing

4 24 Cortés et al. Table 1 Strength and quality-of-evidence summary Category Definition Categories for the strength of each recommendation A Good evidence to support a recommendation for use B Moderate evidence to support a recommendation for use C Poor evidence to support a recommendation for or against use D Moderate evidence to support a recommendation against use E Good evidence to support a recommendation against use Categories for the quality of evidence on which recommendations are made I Evidence from at least one properly randomized, controlled trial II Evidence from at least one well-designed clinical trial without randomization, from cohort or case - controlled analytic studies, preferably from more than one center, from multiple time series, or dramatic results in uncontrolled experiments III Evidence from opinions of respected authorities on the basis of clinical experience, descriptive studies, or reports of expert committees Adapted from Committee to Advise on Tropical Medicine and Travel (CATMAT), and Macpherson. 33 health insurance for medical evacuation, and notifying your embassy of your whereabouts, are all things travelers can do to make their trip safer prior to departure and prior to the occurrence of an injury event but truly affect the outcome of postevent phase of injury control. They are measures that will help to reduce the effects of a submersion or waterrelated injury after it occurs. Table 2 Injury-control strategies by relationship to event Preevent Recommendations: Preventing Events or Reducing Risks to Reduce the Likelihood of an Injury Events in the preevent category are designed to prevent events or reduce risk factors that might lead to drowning or other types of water-related injury. Many of the recommendations in this category relate to things travelers can do or information travelers can obtain prior to departure or prior to water exposure to better prepare themselves and their families for safe travel. Investigate Exposure to Water, Presence of Pool Fencing, and Lifeguards It is important to investigate potential water exposures at your destination prior to departure. This is especially important for persons traveling with children. In most cases of childhood drowning or neardrownings, the child was out of the supervisor s vision for only a moment and the immersion of the child was silent, with no screams or splashing heard. 62 It is recommended that direct access to water from the hotel or lodging area be prevented by use of a barrier. Climb-resistant fencing at least 4 ft high is one example of an effective barrier. Pools should be surrounded by a 4 ft high climb-resistant fence with a self-closing and self-latching gate. The openings in the fence should be no more than 4 in. wide. Pool fencing is one of the only recommendations that has been proven through scientific research to be effective in the prevention of childhood drownings. 48,49,54,62,85 87 Pool fences are important not only for travelers with children but also for the prevention of drowning of children who may live or play nearby the pool that travelers visit. Rigid pool covers and pool alarms are not suitable replacements for barriers. 87 Preliminary evidence reveals that they are often faulty and tend to be used inconsistently. In addition, it is recommended that travelers choose to stay in hotels that provide lifeguard supervision and that they inquire about the possibility of hiring lifeguards for a large group or party situation. 52 Anecdotal evidence suggests that in large-group party settings, with multiple adults and children swimming and playing around water, children may be at increased risk because oftentimes, no one adult is appointed supervisory responsibilities. Relationship to event Preevent phase (planning phase: pretravel or prewater exposure) Event phase (during travel or during water exposure) Postevent phase (management of injury during or after travel) Adapted from Wilson and colleagues. 34 Purpose of strategy Prevent events that might cause or enable injury or death Prevent injury or death when an event may occur Prevent unnecessary severity when an injury event has occurred Examples of corresponding recommendations Four-sided fencing for pools Coast guard approved personal floatation devices Cardiopulmonary resuscitation

5 Water Safety and International Travel 25 Table 3 Recommendations for water safety during travel Recommendation Preevent, event, Strength and and/or postevent quality of phase evidence References General advice 1. Check travel advisories issued by your government and Preevent B III country-specific travel-health information provided by the World Health Organizations, CDC, or other reliable source 2. Bring PFDs along if you think one will not be available, Preevent, event B III especially for adult nonswimmers and children. PFDs will keep you from sinking but not necessarily from drowning. Select a proper sized and coast guard approved PFD by looking at the label to ensure a safe and a proper fit 3. While aboard a yacht or a cruise ship, identify the location Preevent B III 43 and availability of PFDs for all members in your party, especially elderly and adult nonswimmers and children 4. Learn about animal-related risks and other environmental hazards Preevent in and near the water of your destination. 5. Do NOT assume that hotel, home, or any pool you may encounter Preevent while traveling has been created with adequate depth to prevent injury from a head first entry. A feet-first entry should be the first entry into any body of water. Know the depth of the water and the location of underwater hazards before jumping or diving. 6. Be attentive to signs posting surf and weather conditions and other potential hazards such as presence of animal life. Murky water, Preevent, event B III 15 17, hidden underwater objects, unexpected drop offs, and aquatic plant life are also hazards. Avoid swimming in drainage ditches and arroyos. Big waves and strong tides and currents should be avoided. 7. Drain covers in pools, spas, hot tubs, and whirlpool bathtubs can Preevent, event A III 54 pose an entrapment hazard for hair and holding bodies underwater. Secure drain covers so they cannot be tampered with 8. The World Congress on Drowning recently passed a recommendation that all people learn drowning survival, safety around the water, and swimming skills. Swimming lessons, however, are not appropriate for children under the age of 4 years. The relationship of swimming and survival Preevent, event B III 48, 49, skills and drowning in children requires further study 9. Take a boating course from an approved certifying agency prior to departure to learn about navigation rules; emergency procedures; and effects of wind, water conditions, and weather 10. Operate watercraft only with required training and experience. Have the appropriate number of PFDs on board, an oar, a fire extinguisher (if motorized vessel), a first aid kit, and an oxygen kit (if scuba vessel), and use of automated external defibrillators (AED) is encouraged 11. Choose to stay in lodging that provides lifeguard supervision for designated swimming areas. For large groups and parties, consider hiring a lifeguard. The presence of lifeguards increases favorable outcomes should a submersion occur Preevent, event, postevent Preevent, event, postevent Preevent, postevent D III B III 43 B III 16, 48 50, 52, 53, 62, People should wear PFDs Event B II 43 If they are not swimmers and are around water When water skiing or participating in other towed activities When operating personal watercraft During white water boating activities While sail boarding If they cannot swim, are younger than 13 years, and are on a moving vessel less than 26 ft When on boats 16 ft and over; a wearable PFD is recommended with a minimum of two PFDs on board at all times When water skiing or participating in other towed activities 13. Limit hands, feet, or body from touching reefs, plant, and animal life while in the ocean Event B Continued

6 26 Cortés et al. Table 3 Continued Recommendation 14. Know how to initiate CPR, first aid, and an emergency response should a drowning event occur. Rescue breathing should be initiated immediately along with chest compressions when circulation is absent 15. Register your travel visits with your government embassy or agency that assists citizens overseas 16. Have personal or organizational medical insurance for each traveler that includes medical air evacuation adequate for the travel destination 17 Know how to initiate an emergency response in all countries covered in your travel itinerary 18. Your embassy will assist you with emergency situations or when evacuation may be necessary. If a death occurs, report the incident to your embassy so they can maintain accurate records of travelers affected by water-related incidents and high-risk locations and activities Alcohol 19. If you are planning to drink more than one alcoholic beverage you should avoid swimming, supervising children around the water, or operating or being a passenger in watercrafts. Risk of drowning increases with alcohol and drug consumption in and around the water 20. Avoid riding in a motorized vessel operated by an inexperienced or uncertified driver especially if alcohol or drugs use are suspected Advice for travelers with children 21. Home or hotel swimming pools at your destination should be completely surrounded by a climb-resistant fence (minimum height of 4 ft) with a self-closing, self-latching gate. This protects children you may be traveling with and the children who may live or play nearby 22. Motorized pool covers and pool alarms are not recommended as an additional level of protection when there is not a foursided fence around a pool 23. If you are traveling with young children, try to make certain that your housing/hotel does not permit direct access by your child to a body of water (ocean, lake, river, or pool) in which the child could potentially drown 24. In advance, delegate the responsibility of supervision of children and nonswimmers only to experienced adults who practice touch supervision with their full attention focused on the child, know CPR, how to initiate an emergency response plan and have and will not be consuming alcohol. Do not delegate supervision of children to older children. Even children who are excellent swimmers require supervision when in and around the water 25. Hot tubs and spas should be covered when not in use to protect children from drowning Preevent, event, Strength and and/or postevent quality of phase evidence Postevent A II 36 References Postevent B III 2, 4, 48, 49, 55, 63, Postevent B III Postevent Postevent Preevent, event, postevent B B III A II 7, 29, 48, 68, Preevent, event A II 12, 29, 78, 81, 84 Preevent A II 48, 49, 54, 62, Preevent A III 87 Preevent A III 48, 49, 54, 62, Preevent, event, postevent A II 48, 49, 56, 57, Preevent B III 54 Diving and snorkeling 26. Dive only if you are certified or part of a certification class and Preevent, event B 64, 65 are willing to adhere to diving rules and regulations 27. For travelers intending to dive, a reassessment of physical, Preevent A III 55 mental, and medical fitness is recommended at regular intervals and following an illness or injury 28. Dive or snorkel with a buddy, never alone Event A III 64, Identify divers by using the diver-down flag. Mount it from a vessel or drag it along with a buoy and line Event B 64, 65 CDC = Centers for Disease Control and Prevention; CPR = Cardiopulmonary resuscitation; PFD = personal floatation device.

7 Water Safety and International Travel 27 Pool Safety and Construction Do not assume that any pool or water-recreation area that travelers may encounter has been constructed safely. Building codes governing pool construction vary greatly by country. Oftentimes, especially in resort areas, pools are designed to look beautiful but may not be safe. This is especially true with regard to adequate depth for head-first entry into the water and four-sided pool fencing. The scientific literature offers inconsistent guidelines about safe depths for diving. 46,47 It is important to clearly investigate the swimming area prior to entering the water to avoid injury. Pools may not have been constructed with safe surfaces; for example, pointy jagged rocks may be integrated for design interest but create an unnecessary hazard. Hazards such as unmarked steps, underwater benches, and varying depths may not be clearly marked. Water toys should be put away after use because if left in or around the pool area, they may attract children to the water. Identify the Availability of PDFs or Bring Them with You PDFs may prevent nonswimmers from sinking, but evidence from controlled studies is not available to show that they will prevent drowning. However, despite this, they are believed to be an important means to reducing the risk of drowning. One study indicated that PFDs appear to improve survival and reduce morbidity and mortality from drowning when boating and swimming in natural bodies of water This requires further study. It is recommended that travelers inquire prior to travel about the availability of PFDs at their destination and use them; despite lack of evidence, we believe them to be effective in the prevention of drowning. In addition, rescuers report that people wearing brightcolored PFDs are easier to find. Typically, it is more difficult to locate a PFD that will properly fit a child than an adult, so travelers with children should consider bringing PFDs with them. It is important that PFDs are comfortable, fit properly, and are coast guard approved. 43 The new US Coast Guard approved inflatable life vests are lightweight and more buoyant and tend to be cooler when worn in hot weather. These improvements in design increase the likelihood that they will be worn. Inflatable life vests are not recommended for children, are more expensive, and require maintenance for the CO 2 cartridge that inflates the vest ( boatus.com/boattech/pfd.htm ). If travelers plan to travel on large yachts or cruise ships, they should identify the location and availability of PFDs for all members in their party, especially children, elderly nonswimmers, and others with special needs. It was required by the International Maritime Organization under the International Convention for the Safety of Life at Sea that an abandon ship and fire drill must take place weekly on all passenger ships. Travelers are required by law to participate in these drills while on board. 91 Boating Safety Verifying local laws governing boating in the travel destination prior to departure may be useful for those travelers planning to operate water vessels. It is generally recommended that travelers check to make sure the appropriate number of PFDs, an oar, a fire extinguisher (particularly if it is a motorized vessel), a first aid kit, an oxygen kit (if scuba vessel), and an AED are on board a vessel prior to departure. 43 Travelers should also avoid riding on a motorized water vehicle operated by an inexperienced or uncertified driver or a driver under the influence of alcohol or drugs. 29 Event Recommendations: Protecting Individuals Should a Drowning or Water-Related Injury Occur The recommendations in the event category are designed to protect individuals against injury should an injury-producing event occur. The recommendations in this category relate to things travelers can do during water exposure to reduce the likelihood that they will drown or experience a water-related injury. Recommendations related to boating, swimming, and scuba training relate to skills or certifications that travelers need to acquire in advance but will help to avoid or minimize injury while exposed to water. Drowning Survival, Water Safety, and Basic Swimming Education It has been recommended by the World Congress on Drowning and the American Academy of Pediatrics that all people, after their fourth birthday, know drowning survival skills, familiarize themselves with safety around the water, and learn basic swimming skills. 48,59 However, despite what appears to be a very sound recommendation, there is no scientific evidence that increased swimming ability decreases one s likelihood of drowning. 41,52,92,93 In fact, some studies have indicated that at a population level, increased swimming skill could increase one s exposure to risk and therefore may lead to an increase of drowning rates. 89,90 More adept swimmers may take more risks around the water. Some limited studies have shown that swimming lessons improve swimming ability, but there

8 28 Cortés et al. is no evidence that shows that swimming lessons decrease one s risk of drowning Knowing how to swim in one environment does not mean that children or adults will be as safe in an unfamiliar swimming environment. Even the best young swimmers need adult supervision, and adults who know how to swim should swim with a buddy preferably in designated swimming areas supervised by a lifeguard. 48 Though swimming lessons are widely available, they are not recommended for children until after their fourth birthday. This is primarily because children are not developmentally ready until this age. In addition, parents may become lulled into a false sense of security and not supervise their children because they think their children can swim. To date, no conclusive scientific studies have been done that indicate whether swimming lessons are effective or not in the prevention of drowning. In addition, few well-designed studies have been done that have investigated an age-appropriate time to start a child in swimming lessons. Until these questions have been answered by research, our recommendation to learn to swim appears to make sense, but more research is needed to document this. Boating Training Travelers should be discouraged to operate watercraft without required training and appropriate experience. Though it is recommended that travelers take a boating-safety course if they plan to use boats or other water-recreation vessels such as jet skis, sailboards, and other small watercraft, research offers inconclusive evidence at best regarding the effectiveness of these courses in the prevention of drowning. 58,59 Some studies have shown that boater training increases exposure and therefore could potentially increase risk. An unexpected association was found in one study between boater training and unsafe boating practices such as consumption of alcohol by the driver and failure of occupants to use a PFD. The investigators concluded that this unexpected association was due to reduced risk perception among boaters after training and inadequacies of boater-training programs. 58,59 Two other studies examined different types of boater-training programs (MSEA and NASBLA) and found relationships between training programs and safe behavior. 99,100 These studies either were too small to make conclusions about overall effectiveness or had a weak study design. 101 The role of boater-training courses in reducing deaths from drowning requires further study. Courses need to address reduced risk perception among frequent boaters regarding alcohol use in, on, and around water and PFD use. Scuba and Snorkeling The World Congress on Drowning has concluded that self-regulation within the worldwide recreational diving industry regarding scuba safety should be continued. 55 Scuba diving should be done only if travelers are certified or part of a certification class and divers can adhere to rules and regulations taught in class. Certification in scuba is offered by several different agencies. Rules and standards governing scuba are developed by the certification agency and can differ depending upon the agency travelers select. It is important that travelers feel that their instructor has the appropriate credentials and ability to train well regardless of the type of agency they choose to train with. Generally, it is recommended that travelers dive or snorkel with a buddy. 64,65 While diving or snorkeling, limit your hands, feet, or body from touching reefs, plant, and animal life to reduce the risk of sting bites and other injuries. 64,65 Divers should be identified with a diver-down flag that they drag along with a buoy and a line or mounted from a vessel. 64,65 In addition, it is recommended that travelers planning to dive obtain from a trained medical professional a reassessment of their physical, mental, and medical fitness at regular intervals and following an illness or an injury. 55 Swimming in Designated Swimming Areas To minimize the likelihood of an unexpected submersion or drowning, swim in designated swimming areas. Swimming in remote locations without lifeguards contributes to the drowning of adolescents. 68 It is important to understand surf and weather conditions and other potential hazards such as the presence of dangerous animal life. Murky water can mask unsafe underwater objects, unexpected drop offs, and aquatic plant life that could pose potential hazards. Big waves and strong 15 17,48 53 tides and currents should be avoided. Feet-First Entry into the Water A feet-first entry into the water is important to avoid head and spinal cord injury. Inconclusive evidence exists regarding the effectiveness of education programs to promote safe diving; this area needs further study Minimum depths for safe head-first entry have been debated Travelers should not assume that pools with diving boards have been created with adequate depth to prevent head and spinal cord injury from a head-first entry.

9 Water Safety and International Travel 29 Supervision of Children Requires Touch Supervision It is possible for children to drown in only a few inches of water even if they have had swimming instruction. Children older than 4 years should be taught to swim, but swimming lessons do not make a child drown-proof. Children should never swim without adult supervision or alone. 48,49,94 Children require touch supervision, which is that the adult supervisor be within an arm s length of the child at all times in or near the water. The job of supervision should be done by an adult only (who has not been drinking alcohol) and who has been CPR-trained. Older children should not be designated as supervisors of younger children around the water. Swimming in designated swimming areas with lifeguard supervision greatly improves outcomes should submersion occur. 48,68 Use of PFDs It is recommended that people wear PFDs to minimize the likelihood of submersion and drowning if they are not swimmers, when participating in water skiing or other towed activities, when operating personal watercraft such as jet skis, during white water boating activities, and while sail boarding or are younger than 13 years and on a moving vessel with a length of less than 26 ft. 43 Though uses of new designs and materials have made PFDs more wearable, boaters still are not wearing these lifesaving devices. Statistics show a decrease in drowning fatality rates of US boaters to a low of 517 in Of the 517 drowned, however, 450 (80%) might have been saved if they had only been wearing a life jacket ( pfd.htm ). Alcohol Use The topic of alcohol use during travel in general deserves special attention in the pretravel advice issued by physicians and other travel-medicine professionals. It is highly recommended that travelers be advised not to drink alcohol beverages while boating, swimming, or around the water in general. It has been well documented that alcohol is a major risk factor for drowning and boating-related deaths. Alcohol is thought to be involved in between 30 and 50% of adult and adolescent drownings. 49,68 Thirteen studies in various countries have detected the presence of alcohol in between 20 and 60% of boaters who drowned. Alcohol was estimated to be the direct causal factor of drowning in 10% to 20% of these cases. 81 A case - control study showed that boaters with blood alcohol levels of 100 mg/dl (0.01) or greater had a 16 times greater risk of drowning than those with no alcohol in their blood. 29 This study showed that drinking alcohol increases the relative risk of dying while boating even at low levels, with risk increasing as blood alcohol content increases. The travel industry tends to encourage heavy alcohol use in and around the water, with swim-up alcohol bars located inside hotel pools or adjacent to pools, beaches, and other recreational water areas. Alcoholic drinks are frequently served poolside without any regulations regarding consumption. During spring break season, the tourism industry promotes travel among college-age students to warmer climates and beach destinations where binge drinking is strongly encouraged. Server regulations are rarely imposed because it is not profitable. One study indicated that travelers tend to consume more alcohol while on vacation than in their home environments. 102 Postevent Recommendations: Minimizing the Consequences of Drowning or Water-Related Injury Register Travel Itinerary with Embassy It is highly recommended that travelers register their international travel plans with their country s embassy Registration is most important for travelers who plan to travel for more than 1 month or who plan to visit a country with an unstable political climate or a recent natural disaster. It is the job of embassies to help their citizens during an emergency situation, when a medical situation occurs, or to evacuate them from a country when necessary. Embassies cannot assist travelers if they do not know that they are in the country nor their whereabouts. In addition, travelers should check their government s travel advisory Web sites and country-specific health information posted at the Figure 2 Pool bar on a Caribbean cruise ship.

10 30 Cortés et al. World Health Organization ( ), the US CDC 38 ( ), or other reliable sources prior to travel. Cardiopulmonary Resuscitation If a drowning occurs, rescue breathing should be initiated immediately along with chest compressions when circulation is absent. Early CPR has been shown to be effective in increasing survival after submersion. 55 Research has shown that children who do not receive CPR until they reach the hospital have a poor prognosis, which may lead to neurological damage. 4,48,66,72 75 It should be recommended that travelers learn CPR from a certified instructor prior to departure if they plan to be exposed to water-recreation activities at their travel destination. The Heimlich maneuver should not be used to expel water from the airway before the onset of rescue breathing and chest compressions 48,68,70,71. Lifeguard Supervision Swim in areas supervised by a lifeguard. The presence of lifeguards has been shown to increase favorable outcomes should a submersion injury occur Short submersion time is the best prognostic factor for survival after a near-drowning incident. 63 There is no evidence, however, that lifeguards reduce factors that may lead to injury. Knowing whether hotels or other types of lodging offer lifeguard supervision of designated water-recreation areas is important. Evacuation Insurance and Initiating an Emergency Response Travelers should be advised to purchase adequate medical insurance for each traveler in their party that includes medical air evacuation adequate for the travel destination. Each traveler should know how to initiate a local emergency response in his or her destination as well as how to access medical air evacuation if necessary. Though the purchase of travel insurance is something travelers will need to do prior to departure, it relates to the postevent phase of the Haddon s Matrix because it would only be used if an injury has occurred. Limits As part of the Cochrane review effort, systematic reviews of drowning-prevention strategies have been done by the Injury Control Research Center at Harborview Medical Center and are available for viewing on the Internet. 101 Of the 11 water-related interventions reviewed, pool fencing is the only intervention that has been scientifically proven to be effective through a direct causal relationship. There have been several epidemiological research studies conducted on the precise type of fencing and gate that are most effective in preventing childhood drowning. In addition, the role of alcohol as a risk factor for increased likelihood of drowning while boating or around the water has also been well documented. The effectiveness of educational strategies and enforcement of legislation regarding alcohol has not been well studied. The other nine interventions reviewed (adult supervision, boater-safety training, lifeguards, PFDs, pool alarms, pool covers, swimming lessons, and other general educational programs) had largely inconclusive findings. Unfortunately, little is known about the effectiveness of educational efforts to decrease drowning in general. Educational strategies are difficult to evaluate well. This is an area that deserves much greater attention. In topic areas where scientific evidence may be lacking, recommendations have been made based upon expert opinion and recommendations from professional organizations such as the International Maritime Organization, The World Congress on Drowning, The International Society of Travel Medicine, The American Academy of Pediatrics, and the US Coast Guard. There are many specific travel-related water activities not covered by these recommendations such as surfing, glass-bottom touring boats, fishing boats, local ferries, river boats, and waterfalls among others. These recommendations are intended to cover general water safety and directly reflect the state of knowledge on this topic in the scientific literature with regard to the strength and the evidence of effectiveness of existing interventions. Conclusions Implications for Practice These evidence-based recommendations are intended for use by travel-medicine professionals or others that prepare individuals planning to travel by providing them health-related travel information. Drowning is an important preventable health problem affecting travelers that can lead to serious and oftentimes fatal consequences. Information regarding the destination and the traveler s exposure to water should be ascertained by the practitioner on a regular basis should ascertain activities, and recommendations should be tailored accordingly. Special care should be taken when counseling

11 Water Safety and International Travel 31 travelers who plan to visit warm climates known for their water-related destinations like Central America, the Caribbean, and the Pacific Islands. Beach and other water-related destinations in Australia, United States, and within the European Union are also of special concern. Implications for Research Clear and conclusive scientific evidence of several of the available interventions to prevent drowning is lacking in general. Further epidemiological investigations are necessary to better understand their true effectiveness. Even less information exists that describes the drowning problem among travelers. Additional randomized-controlled trials, Cochrane reviews, and other well-designed studies to evaluate the effectiveness of existing interventions are urgently needed. Better data on drowning-related deaths of tourists should be maintained by embassies. Improved data sources will prove valuable for future epidemiologic studies on drowning and the associated risk factors. Travel-medicine professionals should consider advocating for improved data on the morbidity and mortality of travelers and the continual development of evidence-based recommendations for all types of injuries that affect this population. Funding for these types of studies and for implementing effective strategies is essential, yet lacking. Acknowledgments The authors would like to acknowledge the contribution of the Planning Committee and participants from the Water Safety and Drowning Prevention Session from the Safe Travel and Injury Prevention for the US International Traveler Symposium held in April Views and opinions expressed in this manuscript do not necessarily reflect the views of those that reviewed this material and contributed to the conference. Chairpersons of Water Safety Group : Gordon Smith, PhD, Liberty Center for Safety Research; Christine Branche, PhD, National Center for Injury Prevention and Control. Participants of Water Safety Group : Ruth Brenner, MD, MPH, National Institute of Child Health and Human Development, US Department of Health and Human Services; Leslie M. Cortes, MHS, Injury Research Center Medical College of Wisconsin; Susan Galleghar, MPH, Education Development Center; Margo Nowalkowski, MBA, MPP, Office of International & Refugee Health; Carol Runyan, PhD, North Carolina Injury Control Research Center; Ellen Schmidt, Education Development Center; Camilla Taft, MPH, SAFE KIDS Worldwide; Katie White, MS, Peace Corps. Conference Planning Committee: Stephen W. Hargarten, MD, MPH, Injury Control Research Center Medical College of Wisconsin; Rick Waxweiler, PhD, National Center for Injury Control and Prevention; Tim Davis, MD, National Center for Injury Control and Prevention; Leslie M. Cortes, MHS, Injury Control Research Center Medical College of Wisconsin. Others: Catherine Feldhusen and Mary Czinner, Research Assistants, Injury Research Center Medical College of Wisconsin Jeannette Hudson, Resource Librarian, Children s Safety Network Captain Angel C. Rovira and Parguera Divers. Declaration of Interests Financial support for this project was provided through a contract by the National Center for Injury Prevention and Control, CDC no / , and a grant from the National Center for Injury Prevention and Control, Center for Disease Control and Prevention for the Injury Control Research Center Medical College of Wisconsin no. PHS-CDC-R49-CCR References 1. Peden M, McGee K, Sharma G. The injury chart book: a graphical overview of the global burden of injuries. Geneva, Switzerland : World Health Organization, Vyrostek SB, Annest JL, Ryan GW. Office of Statistics and Programming, National Center for Injury Prevention and Control, USA. Nonfatal and fatal drownings in recreational water settings United States, MMWR Morb Mortal Wkly Rep 2004 ; 53 : Geddis DC. The exposure of pre-school children to water hazards and the incidence of potential drowning accidents. N Z Med J 1984 ; 97 : Wintemute JG. Childhood drowning and neardrowning in the United States. Am J Dis Child 1990 ; 144 : Spyker DA. Submersion injury: epidemiology, prevention and management. Pediatr Clin North Am 1985 ; 32 : Cornall P, Howie S, Sumner V, et al. Drowning of British children abroad. Seventh World conference on injury prevention and safety promotion; 2004

12 32 Cortés et al. Jun 6 9; Vienna Convention Center, Vienna, Austria. Available at : final_programme.php. (Accessed 2005 Apr 11) 7. Fenner P. Drowning awareness. Prevention and treatment. Aust Fam Physician 2000 ; 29 : Lindholm P, Steensberg J. Epidemiology of unintentional drowning and near-drowning in Denmark in Inj Prev 2000 ; 6 : Hargarten SW, Baker TD, Guptill K. Overseas fatalities of United States citizens travelers: an analysis of deaths related to international travel. Ann Emerg Med 1991 Jun ; 20 : Hargarten S, Maas L. Injury fatalities to international travelers: an endemic problem. Fifth World Conference in Injury Prevention ; 2000 Mar 5 8; New Delhi, India. 11. Cortes L, Hargarten S, Hennes H. Trends of injuries to U.S. International travelers. Seventh World Conference on Injury Prevention and Safety Promotion ; 2004 Jun 6 9 ; Vienna Convention Center, Vienna, Austria. Abstract presented by Guse C. Available at : final_programme.php. (Accessed 2005 Apr 11) 12. Cortes L, Guse C, Hennes H, Hargarten S. Fatal injuries of U.S. international travelers: revisiting an endemic problem. Eighth Conference of the International Society of Travel Medicine ; 2003 May 7 11, New York. Published Abstract Free Communications, p 3. Available at : talley/abstracts-free_communications.pdf. (Accessed 2005 Apr 11) 13. Guse CE, Cortes LM, Hargarten SW, Hennes HM. Injury deaths to US citizens abroad. Injury and violence in America Conference ; 2005 May 10 ; Denver, Colorado. 14. Guptill KS, Hargarten SW, Baker TD. American travel deaths in Mexico. Causes and prevention strategies. West J Med 1991 ; 154 : Brenner RA, Smith GS, Overpeck MD. Divergent trends in childhood drowning rates, 1971 through JAMA 1994 ; 271 : Quan L, Gore EJ, Wentz K, et al. Ten-year study of pediatric drownings and near-drownings in King County, Washington : lessons in injury prevention. Pediatrics 1989 ; 83 : Wintemute GJ, Kraus JF, Teret SP, Wright M. Drowning in childhood and adolescence: a population-based study. Am J Public Health 1987 ; 77 : Pearn JH, Wong RY, Brown J, et al. Drowning and near-drowning involving children: a fiveyear total population study from the city and county of Honolulu. Am J Public Health 1979 ; 69 : Lunetta P, Smith GS, Penttila A, Sajantila A. Unintentional drowning in Finland : a population-based study. Int J Epidemiol 2004 ; 33 : Tan RM. The epidemiology and prevention of drowning in Singapore. Singapore Med J 2004 ; 45 : Kyriacou DN, Arcinue EL, Peek C, Kraus JF. Effect of immediate resuscitation on children with submersion injury. Pediatrics 1994 ; 94 : Centers for Disease Control and Prevention. Motor vehicle occupant injury: strategies for increasing the use of child safety seats, increasing use of safety belts, and reducing alcohol-impaired driving: a report on recommendations of the task force on Community Preventive Services. MMWR Morb Mortal Wkly Rep 2001 ; 50 ( RR-7) : Dinh-Zarr TB, Sleet DA, Shults RA, et al. Reviews of evidence regarding interventions to increase the use of safety belts. Am J Prev Med 2001 ; 21 ( Suppl 4) : Hargarten SW, Baker SP. Fatalities in the Peace Corps a retrospective study: 1962 through JAMA 1985 ; 254 : Krug EG, Sharma GK, Lozano R. The global burden of injuries. Am J Public Health 2000 ; 90 : Odero W, Garner P, Zwi A. Alcohol and road traffic accidents in developing countries: a review of the evidence. Trop Med Int Health 1997 ; 2 : Roberts I, Bunn F, Wentz R. How can we discover what works in the prevention of road traffic crashes?. BMC News and Views 2001 ; 2 : Shults R, Elder RW, Sleet DA, et al. Am J Prev Med 2001 ; 21 ( Suppl 4) : Smith GS, Keyl PM, Hadley JA, et al. Drinking and recreational boating fatalities, a population-based case control study. JAMA 2001 ; 286 : The Cochrane Injuries Group Driver Education Reviewers. Evidence based road safety: the Driving Standards Agency s schools programme. Lancet North Am Ed 2001 ; 358 : Zaza S, Sleet DA, Thompson RS, et al. Reviews of evidence regarding interventions to increase use of child safety seats. Am J Prev. Med 2001 ; 21 ( Suppl 4) : Zaza S, Thompson RS, eds. The guide to community prevention services: reducing injuries to motor vehicle occupants. Systematic reviews of evidence, recommendations from the task force on Community Preventive Services and Expert Commentary. Am J Prev Med (Whole issue) 2001 Nov : 21 ( Suppl 4 ). 33. Macpherson DW. Evidence-based medicine. CCDR 1994 ; 20 : Wilson MH, Baker SP, Teret SP, et al. Saving children. A guide to injury prevention. New York : Oxford University Press, Current travel warnings from the US Department of State. Available at : warnings_current.html. ( Accessed 2005 Apr 11 ) 36. Counselor information sheets from the US Department of State. Available at : state.gov/travel/warnings_counsular.html. (Accessed 2005 Apr 11)