The Epidemic of Child Drowning in Developing Countries and Interventions Being Trialed Julie Gilchrist, M.D. Dr. Julie Gilchrist is a Pediatrician and Medical Epidemiologist with the National Center for Injury Prevention and Control (NCIPC) at the CDC. She graduated from Rice University with degrees in Human Physiology and Sports Medicine before attending U.T. Southwestern Medical School in Dallas, TX. She completed a pediatrics residency at the University of Pennsylvania s Children s Hospital of Philadelphia and an epidemiology fellowship at CDC. She has been at CDC since 1997. In her current work at NCIPC, she is responsible for research and programs in drowning prevention and water safety promotion, and sports and recreation-related injury prevention, as well as other issues primarily affecting children: choking, suffocation, ingestions, dog bites, playground injuries, etc. She facilitated the development of CDC s research agenda for prevention of injuries in sports, recreation, and exercise and has been recognized for her efforts to establish a sports injury prevention program at CDC. As of 21, she has authored/coauthored more than 54 journal articles and 5 book chapters and is an invited speaker both nationally and internationally. She has earned numerous awards for her efforts and accomplishments in research, communication, and disaster response. Abstract The scale of the child drowning epidemic in Asia has been greatly underestimated by the global public health community. Recent surveys conducted by TASC and UNICEF in Vietnam, Thailand, Bangladesh, China and have shown that drowning is the leading killer of children after infancy. It is responsible for more child deaths than AIDS, tuberculosis, malaria and dengue combined. There are actually two epidemics one in children under five, and one in children over five and both epidemics differ from those in same-aged children in high income countries. Most drowning results from everyday activities rather than recreational activity. It occurs near the home and in water bodies used for household purposes and there is no association with alcohol. Factors associated with the drowning are poverty, lack of education, large family sizes and a very high prevalence of water bodies in the environment. Over the last four years, TASC has worked with UNICEF Bangladesh, the Centre for Injury Prevention Research, Bangladesh and the Royal Life Saving Society Australia to do large scale operational research on the efficacy and cost-effectiveness of village crèches and survival swimming teaching interventions suitable for the low resource setting of a rural LMIC. The program has shown a four-fold reduction in drowning mortality in children early childhood and a five-fold drowning mortality reduction in middle childhood and adolescence. The program is now focused on achieving national scale in Bangladesh and to be used in other LMICs in the Asian region. National Swimming Pool Foundation 4775 Granby Circle Colorado Springs, CO 8919 (719)54-9119 www.nspf.org 1
Dr Michael Linnan Technical Director, The Alliance for Safe Children mlinnan@tasc-gcipf.org LMICs are different from rich countries Rich countries got rich before they got safe They had educated populations And well-developed civil governance structures With enforced building codes and zoning ordinances And large civil services that staffed public safety institutions And were already predominantly urban And then they built a culture of safety on those foundations LMICs have none of that As a general rule, they are: Predominantly rural Environmental hazards are ubiquitous in and around the home and throughout the community Universal primary education is a goal, not a reality Parents, who often have 4 or 5 children must rely on the older children to supervise the younger ones There are few, if any, social services, such as emergency medical and rescue services that extend life saving services outside the hospital and other safety infrastructure That s why they are called developing countries National Swimming Pool Foundation 4775 Granby Circle Colorado Springs, CO 8919 (719)54-9119 www.nspf.org 2
5 Fatal drowning rate Asia LMIC vs Australia 45 4 Rate per 1, 35 3 25 2-4 5-9 1-14 15 1 5 Asia Australia Asia Australia Male Female Cause-specific mortality in n children after infancy (1-17 years) 35 3 Rate per 1, 25 2 15 1 5 Drowning causes over half of all child deaths after infancy National Swimming Pool Foundation 4775 Granby Circle Colorado Springs, CO 8919 (719)54-9119 www.nspf.org 3
more than dengue fever more than AIDS more than malaria National Swimming Pool Foundation 4775 Granby Circle Colorado Springs, CO 8919 (719)54-9119 www.nspf.org 4
more than SARS or Avian flu combined more than tetanus, whooping cough and polio put together Bangladesh shows the problem and the solution 2 18 < 4 = supervise > 4 = teach to swim 1 9 16 8 14 7 Drowning rate per 1, 12 1 8 6 6 5 4 3 Percent able to swim 4 2 2 1 Infant 1 yr 2 yrs 3 yrs 4 yrs 5 yrs 6 yrs 7 yrs 8 yrs 9 yrs 1 yrs 11 yrs 12 yrs 13 yrs 14 yrs 15 yrs 16 yrs Drowning death rates Swimming ability National Swimming Pool Foundation 4775 Granby Circle Colorado Springs, CO 8919 (719)54-9119 www.nspf.org 5
It s not pools, it s not beaches, and there is no association with alcohol use it s just daily life Cause-specific mortality in n children after infancy (1-17 years) 35 3 Rate per 1, 25 2 15 1 5 3 25 Non-fatal Fatal Rate per 1, 2 15 1 5 Bangladesh Bangladesh Bangladesh Bangladesh Bangladesh Bangladesh Infant 1-4 5-9 1-14 15-17 -17 Age group (years) and Country National Swimming Pool Foundation 4775 Granby Circle Colorado Springs, CO 8919 (719)54-9119 www.nspf.org 6
1 8 Female Male Rate per 1, 6 4 2 Infant 1-4 5-9 1-14 15-17 -17 Age group (years) and Country 1 8 Urban Rural Rate per 1, 6 4 2 Infant 1-4 5-9 1-14 15-17 -17 Age group (years) and Country 1% Thailand 8% 6% 4% 2% % Fine weather Monsoon floods Heavy rain Other Weather at time of drowning National Swimming Pool Foundation 4775 Granby Circle Colorado Springs, CO 8919 (719)54-9119 www.nspf.org 7
1% Cumulative proportion 75% 5% Fatal Non fatal 25% % Age (years) 1% Bangladesh 8% 6% 4% 2% % Trained resuscitation Untrained resuscitation No resuscitation given Not known given given Resuscitation received by drowning victim Untrained resuscitation Generally fell into three categories of methods: attempts to expel water from the drowned child s body by physical force (e.g. whirling the child overhead, pressing or jumping on the child s chest and stomach) attempts to expel water from the drowning child by inciting vomiting or coughing forcing rotten food into the child s mouth to induce vomiting, or inserting sticks into the child s trachea to induce coughing attempts to expel water from the drowned child s body through other physical means that involved drying packing the child in ashes, covering the child in mud, heating the child s body over a warm fire National Swimming Pool Foundation 4775 Granby Circle Colorado Springs, CO 8919 (719)54-9119 www.nspf.org 8
Where The Children Are Living No swimming pools No life guards or instructors No training infrastructure Water everywhere in daily life Child drowning Prevention of Child Injuries through Social Intervention and Education (PRECISE and follow-on program) The Alliance partners UNICEF Bangladesh The Centre for Injury Prevention Research Bangladesh Royal Life Saving Society Australia The Alliance for Safe Children Australian Agency for International Development UNICEF Innocenti Research Centre National Swimming Pool Foundation 4775 Granby Circle Colorado Springs, CO 8919 (719)54-9119 www.nspf.org 9
Prevention of Child Injuries through Social Intervention and Education (PRECISE and follow-on program) Improved supervision of children and safer environments (-5 years) Establishment of community crèches (Anchals) Home safety counseling (home visits of community crèche mother) Promotion of external hazard fencing, door barriers and play pens Prevention of Child Injuries through Social Intervention and Education (PRECISE and follow-on program) Water safety survival and rescue skills (4+ years) SwimSafe program Water safety including parental involvement Certified curriculum and teachers Using specially modified ponds Safe rescue skills Avoidance of ineffective or harmful resuscitation practices Ongoing monitoring for safety, increased risk-taking and outcomes Anchal a village-based community crèche Institutional supervision, most vulnerable time for injury, most vulnerable age groups Children 1 5 year olds 25 3 children Live in 6 7 households cluster Anchal Mother Woman from the community Age 18 35 years old Secondary level education Assisted by one assistant Centre for Injury Prevention and Research Bangladesh (CIPRB) National Swimming Pool Foundation 4775 Granby Circle Colorado Springs, CO 8919 (719)54-9119 www.nspf.org 1
Community awareness building Courtyard meeting Courtyard meetings Participatory theatre Video shows Social autopsy Social autopsy held at every injury death to increase community awareness Parents describe the event Moderator explores why it occurred Community discuss possible counter measures Education on other injury prevention measures Community commits to interventions Community Swimming Center National Swimming Pool Foundation 4775 Granby Circle Colorado Springs, CO 8919 (719)54-9119 www.nspf.org 11
Community Swimming Instructor (CSI) Selected by village 18 years+ Good swimmer Secondary level education Volunteer Acceptable by the community Can be taught: Swim-teaching Pond maintenance Rescue & resuscitation SwimSafe Children learning to swim Children learning rescue technique Over 134, children learnt swimming during 26-21 through SwimSafe programme Centre for Injury Prevention and Research Bangladesh (CIPRB) Does It Work? National Swimming Pool Foundation 4775 Granby Circle Colorado Springs, CO 8919 (719)54-9119 www.nspf.org 12
PRECISE intervention numbers Community crèche program 64 community crèches, 2, children attending SwimSafe survival swimming and water safety program 134, graduates from 25 training ponds Community Crèche Outcome Summary Drowning Death Rate (per 1, child-years) RR CI P Intervention 11.67.156.47.533 <.1 Non-Intervention 74.76 Enrolled Non Enrolled Mean Duration 2.1 2. # 12,43 12,43 child years 26,46 24,86 SwimSafe Outcome Summary Death Rate (per 1, child-years) RR CI P Drowning Intervention 1.8.51.7.393 <.1 Non-Intervention 21.1 Enrolled Non Enrolled Mean Duration 1.6 1.6 # 56,233 56,233 Child years 89,972 89,972 National Swimming Pool Foundation 4775 Granby Circle Colorado Springs, CO 8919 (719)54-9119 www.nspf.org 13
What about safety of the intervention? 64 crèches, 4 years and 2, children 25 ponds, 4 years and 134, children injuries, adverse events What does PRECISE tell us? Child drowning can be prevented in the setting of rural Bangladesh Effectively with low resource use Acceptably for the community Safely for the children If this is their walk to school shouldn t they know how to swim and about water safety? National Swimming Pool Foundation 4775 Granby Circle Colorado Springs, CO 8919 (719)54-9119 www.nspf.org 14
If this is how they go to the store, shouldn t they know how to swim? If this is their backyard, shouldn t they know how to swim? If they live on a boat Shouldn t they know how to swim? National Swimming Pool Foundation 4775 Granby Circle Colorado Springs, CO 8919 (719)54-9119 www.nspf.org 15
If they are unsupervised, Or together, shouldn t they know how to swim? Portable pools Beach site National Swimming Pool Foundation 4775 Granby Circle Colorado Springs, CO 8919 (719)54-9119 www.nspf.org 16
Thank you If you would like to help or be involved in our ongoing research in Asia, we would welcome your involvement. Contact me at mlinnan@tasc-gcipf.org Fatal injury by type and age group, survey composite Rate per 1, 75 7 65 6 55 5 45 4 35 3 25 2 15 1 5 animal assault burns drowning falls poison rta suicide sharp objects suffocation Infant 1-4 yrs 5-9 yrs 1-14 yrs 15-17 yrs Child mortality by cause, age 1-17 years Province, China Rate per 1, 9 8 7 6 5 4 3 2 1 UNICEF Injury NCD Infection UTD Total Unknown Pneumonia Meningitis Appendicitis Malnutrition Epilepsy Cirrhosis Muscular Vascular Cancer Animal bite Violence Falls RTA Drowning National Swimming Pool Foundation 4775 Granby Circle Colorado Springs, CO 8919 (719)54-9119 www.nspf.org 17
Prevention efficacy methodology Intervention cohorts: Children 18mos 5 yrs attendee/graduates of community crèche only Children 4-12 yrs graduates of SwimSafe only Non-intervention cohorts: Age- and sex-matched community crèche non-participants Age- and sex-matched SwimSafe non-participants Comparison of survival between the intervention and control Equal time of exposure to home and community environments Matched for the main risk factors of age, sex and geographic area National Swimming Pool Foundation 4775 Granby Circle Colorado Springs, CO 8919 (719)54-9119 www.nspf.org 18