Reserch Articles Unintentionl Drownings Among New York Stte Residents, 1988 1994 Mrilyn L. Browne, MS Elizbeth L. Lewis-Michl, PhD Alice D. Strk, MPH, DrPH SYNOPSIS Objective. This study exmines situtions in which drownings occur (environmentl risk fctors) nd the victims personl risk fctors (ge, gender, use of personl flottion device, medicl condition, lcohol or drug use) to provide guidnce for future drowning prevention efforts. Methods. The uthors investigted 883 non-bthtub drownings mong New York Stte residents for the yers 1988 to 1994 using medicl exminer, coroner, police, nd/or hospitl records in ddition to deth certificte dt. Results. Mles, children ges 0 4 yers, nd Africn Americn mles ges 5 14 yers residing in New York Stte outside New York City experienced the highest rtes of drowning. The mjority of drownings occurred in nturl body of wter for ll ge groups, with the exception of children ges 0 4 yers. Most drownings mong children ges 0 4 yers occurred in residentil swimming pools. The child usully gined ccess to the pool vi indequte fencing, n open or ineffective gte, or ldder (to n bove-ground pool) left in the down position. Less thn 10% of victims of wtercrft-relted drownings were wering personl flottion devices. Blood lcohol concentrtion (BAC) tests were positive for 44% of 250 persons 15 yers of ge nd older for whom vlid toxicology results were provided; 30% hd BACs of 100 mg/dl or more. Conclusions. Suggested prevention efforts include stricter enforcement of fencing requirements for residentil swimming pools nd drowning prevention eduction stressing personl flottion device use while boting nd the dnger of mixing lcohol nd wter-relted ctivities. Bureu of Environmentl nd Occuptionl Epidemiology, New York Stte Deprtment of Helth, Troy, NY Address correspondence to: Mrilyn L. Browne, MS, Flnign Sq., 547 River St., Rm. 200, Troy, NY 12180; tel. 518-402-7990; fx 518-402-7769; e-mil <mlb10@helth.stte.ny.us>. 2003 Assocition of Schools of Public Helth 448
Unintentionl Drownings Among New York Stte Residents, 1988 1994 449 Approximtely 4000 unintentionl drownings occur ech yer in the United Sttes. 1 Deths due to drowning nd other injuries occur t younger ges reltive to mny other cuses of deth, resulting in the loss of substntil number of yers of productive life. The preventble nture of submersion injuries nd deth rgues for ttention to prcticble ctions tht my be tken to reduce their occurrence. To improve prevention efforts, it is importnt to understnd the situtions in which drownings occur (environmentl risk fctors) nd the victims personl risk fctors (ge, gender, use of personl flottion device, medicl condition, lcohol or drug use). Deth certifictes lone do not provide informtion regrding mny of these environmentl nd personl risk fctors. Some epidemiologic studies of drownings hve relied solely on deth certificte dt nd others re limited to drownings mong children. Reltively few popultion-bsed studies tht describe drownings for ll ge groups hve been published. 2 8 Also, observtions mde in one country or region of the United Sttes my not represent the experience in nother region due to demogrphic nd geogrphic differences. For these resons, the New York Stte (NYS) Deprtment of Helth (DOH) conducted study of non-bthtub drownings mong NYS residents using medicl exminer, coroner, police, nd hospitl records s well s deth certifictes. This report discusses ll drownings included in the study. A compnion rticle in this issue focuses on boting sfety issues. 9 METHODS The uthors used the NYS DOH Deth Certificte Sttisticl File to identify the study popultion. This study focuses on non-bthtub drownings of NYS residents tht occurred in NYS from 1988 through 1994. All NYS residents for whom the cuse of deth ws Interntionl Clssifiction of Diseses, 9th Revision (ICD-9) E code 830-832 or 910, excluding 910.4 (drowning in bthtub), nd whose deths occurred in NYS from 1988 through 1994, were selected to be included in the study. Motor vehicle-relted drownings coded s trnsport incidents, nd suicide- or homiciderelted drownings (E codes 954 nd 964) re not included in the study. In the bsence of centrlized repositories for medicl exminer nd coroner (ME/c) reports nd police investigtion reports, we directed requests for records to ech county ME/c office (or to the individul ME/c) nd to the investigting police gency. If the drowning victim ws dmitted to hospitl nd little or no informtion ws vilble from ME/c or police records, hospitl medicl records were requested. The uthors developed dt bstrction form to record demogrphic informtion, cuse of deth, loction of drowning, body of wter, whether lifegurd ws present t the site, ctivity t the time of the incident, wether nd site conditions, presence of compnions/others, whether the incident ws witnessed, rescue ttempt, police/emergency response, use of crdiopulmonry resuscittion (CPR), medicl history, drug nd lcohol consumption (both informtion from scene investigtion nd toxicology results), personl flottion device (PFD) use, supervision of children 14 yers of ge nd younger, nd residentil swimming pool chrcteristics. For wtercrft drownings, we collected dt on the type of wtercrft, number of occupnts, nd the mnner in which the victim entered the wter. In this report, unwitnessed drownings of children 14 yers of ge nd younger not known to hve been swimming were clssified s flls into wter. Life jckets, life vests, buoynt foul wether ger, or buoynt wet suit were clssified s PFDs. Throwble flottion ids such s bot cushions nd ring buoys were not included s PFDs, nor were infltble tubes or swimmies. It ws ssumed tht PFD ws not used if description of the victim did not include mention of PFD. A prticulr drowning incident my involve more thn one drowning victim. Throughout this report, dt re presented in terms of numbers of drowning victims. In exmining toxicology results, we used Wintemute s criteri for nlysis of blood lcohol results: (i) deth must occur within six hours of the onset of immersion (to exclude spuriously low [blood lcohol concentrtion] vlues ssocited with ntemortem ctbolism), unless ntemortem results from within tht time re vilble; (ii) without evidence to the contrry, deth cn be ssumed to hve occurred shortly fter immersion; (iii) blood smpling must occur within 24 hours of deth (to exclude spuriously high vlues due to putrefction); (iv) the time of immersion must be estblished precisely enough to llow these criteri to be pplied; (v) if not otherwise specified, the time of blood smpling should be tken s the time of utopsy. 10 We summrized the dt using descriptive sttistics nd computed verge nnul drowning rtes per 100,000 popultion using county popultion dt from the 1990 United Sttes Census. 11 RESULTS A totl of 1,210 drownings mong NYS residents nd totl of 121 drownings mong nonresidents were iden-
450 Reserch Articles tified using NYS Vitl Records dt for the yers 1988 1994. Six drownings tht occurred in 1994 were not in the NYS Deth Certificte Sttisticl files t the strt of the study nd were not included in the study, leving 1204 drownings. Of the drownings mong NYS residents, 109 were bthtub drownings; n dditionl 174 drownings reported to NYS Vitl Records tht occurred out-of-stte were excluded. ME/c, police, nd in some cses hospitl records were requested for the remining 921 drownings. Informtion obtined from records compiled for this study resulted in the exclusion of 38 subjects (three nonresidents, one out-of-stte incident, 23 bthtub drownings, nd 11 coding errors). The resulting study popultion consists of 883 drowning victims. We obtined both ME/c nd police records for 791 drownings, ME/c or police records for 86, nd hospitl records only for four. Informtion from the deth certificte ws used for the remining two cses. Demogrphic dt Overll, the ge-djusted nnul drowning rte ws 1.25 per 100,000 for mles nd 0.19 per 100,000 for femles. The ge-djusted drowning rte ws 1.24 per 100,000 white mles, 1.26 per 100,000 Africn Americn mles, 0.20 per 100,000 white femles, nd 0.16 per 100,000 Africn Americn femles. Averge nnul drowning rtes by ge group, gender, nd rce re presented in Tble 1. The smll number of femle drownings resulted in unstble nd less meningful rtes when strtified by rce. For this reson, dt strtified by rce re presented for mles only. Of the 883 drowning victims in this study, rce ws recorded s white for 720, Africn Americn for 135, nd other (e.g., Americn Indin, Asin) for 28. The verge nnul drowning rte for whites ws 1.37 per 100,000 popultion for mles nd 0.21 per 100,000 popultion for femles. The rte clculted for other rces ws 0.38 per 100,000 popultion for mles nd 0.08 per 100,000 popultion for femles. The smll number of individuls whose rce ws identified s other thn white or Africn Americn my in prt represent indequcies in identifying other rces on deth records. Wheres census dt on rce rely on self-report, informtion in ME/c nd police reports re bsed on the judgment of the recorder. Since individuls of other rces re probbly often recorded s white, we grouped persons of other rce with whites in both the numertors nd denomintors used in clculting rtes in Tble 1. Wide vrition in drowning rtes ws observed by ge group, gender, nd rce. For ll ges combined, mles hd drowning rtes 6.6 times those of femles. The mle vs. femle discrepncy in drowning rtes rnged from two-fold mong individuls 0 4 yers of ge to 20-fold mong individuls 25 44 yers of ge. Differences were lso observed when compring rtes for mles by rce. Among children 0 4 yers of ge, Africn Americn mles hd lower rtes of drowning thn white mles (see Tble 1), while for children 5 14 yers old, Africn Americn mles hd higher rtes thn white mles. Smller differences were observed for other ge groups, with Africn Americn mles experiencing higher rtes for some ge groups nd white mles hving higher rtes for others. Body of wter More thn 79% of the drownings occurred in nturl body of wter: 532 in freshwter sites such s lkes, ponds, rivers, nd strems, nd 171 in the ocen or Tble 1. Unintentionl drownings mong New York Stte residents by ge, gender, nd rce, 1988 1994 (Rtes re verge nnul rtes per 100,000 popultion.) Age (yers) 0 4 5 14 15 24 25 44 45 64 65+ n rte n rte n rte n rte n rte n rte Sex Mle 69 1.53 77 0.93 171 1.83 284 1.41 95 0.81 65 1.01 Femle 40 0.93 16 0.20 12 0.13 15 0.07 22 0.17 17 0.17 Rce (mles) b Africn Americn 8 0.92 22 1.37 34 2.03 38 1.26 17 1.12 4 0.71 White c 61 1.68 55 0.82 137 1.79 246 1.44 78 0.77 61 1.04 Bthtub drownings nd drownings tht occurred outside New York Stte re excluded. b Rtes strtified by ge, gender, nd rce re listed for mles only due to the smll number of femle drownings. c Individuls whose rce ws identified s other thn white or Africn Americn re grouped with whites (n=28).
Unintentionl Drownings Among New York Stte Residents, 1988 1994 451 Tble 2. Drownings by site nd ge group New York Stte, 1988 1994 Age (yers) 0 4 5 14 15 24 25 44 45 64 65+ Totl n Percent n Percent n Percent n Percent n Percent n Percent n Percent Body of wter Nonresidentil pool/sp 2 1.8 12 12.9 12 6.6 2 0.7 2 1.7 3 3.7 33 3.7 Residentil pool 77 70.6 8 8.6 8 4.4 9 3.0 10 8.5 11 13.4 123 13.9 Nturl body of wter 22 20.2 71 76.3 161 88.0 281 94.0 102 87.2 66 80.5 703 79.6 Miscellneous 8 7.3 2 2.2 2 1.1 7 2.3 3 2.6 2 2.4 24 2.7 Miscellneous includes temporry stnding wter (e.g., puddle, dringe ditch, bucket, vt, sump pump, flooded bsement); drownings in liquids other thn wter re lso included in this ctergory (e.g., mnure pit, septic tnk, vt). sltwter by, inlet, or sound. Residentil swimming pools were the loction of 123 drownings (13.9%), while nonresidentil swimming pools nd sps ccounted for 33 drownings (3.7%). Twenty-four drownings (2.7%) occurred in nother body of wter such s well, bucket, dringe ditch, or sewer. The drowning site vried by ge (see Tble 2). An nlysis of drownings by body of wter nd ge showed the mjority of drownings mong children 0 4 yers old occur in residentil swimming pools, nd drownings for ll other ges most often tke plce in nturl body of wter. Of the 109 drownings mong children 0 4 yers of ge, 77 (70.6%) occurred in residentil swimming pools. Thirty-two of the swimming pool drowning victims were 2 yers old. Among the 76 drownings for which the reltion of the victim to the property owner ws known, the mjority took plce t the child s own home (43; 56.6%). The next most frequent sites were the home of nother reltive (17; 22.4%) nd home of neighbor (8; 10.5%). Of the swimming pools involved, 36 were bove-ground pools, 33 were in-ground, one ws kiddie pool, nd the remining seven were unspecified. Informtion on the presence nd type of fencing ws vilble for 25 in-ground pools (fter excluding two drownings tht occurred when child ws known or llowed to be in the pool re). Of these, four-sided fencing ws in plce for 11 pools (44.0%). For the remining 14 pools, fencing sttus ws reported s three-sided fencing with ccess from the house or grge (4), yrd fenced with no seprte pool fencing (4), fence in disrepir (1), or no fence in plce (5). Among bove-ground pool drownings, informtion on fence nd/or gte ws vilble for 28 drownings tht took plce when the child ws not known or llowed to be in the pool re. In eleven instnces, four-sided fencing ws in plce or fence nd gte seprted the deck from the pool. The remining 17 pools hd either no fence, three-sided fencing (with ccess from the deck or house), or fenced yrd with no pool fencing. Informtion on how the child ccessed the pool ws vilble for 67 of the 77 residentil swimming pool drownings (see Tble 3). Seven drownings occurred when the child ws known or llowed to be in the pool re or hd been in the pool nd re-entered without the responsible person s wreness. Of the remining 60 incidents, ccess ws most commonly ttributed to one of the following situtions: open/ unlocked gte or ineffective gte ltch (17); no fence, no seprte fence, or fence in disrepir (10); ccess directly from the house (10); ldder to bove-ground pool left down (10); or climbed over fence, gte, or side of pool (9). When drownings occurred in swimming pools with four-sided fencing or in bove-ground pools with fence nd gte seprting the deck from the pool, either the gte ws left open, the child ws ble to open the gte, or the child ws ble to climb over the gte or fence. Section AG105 of the New York Stte Uniform Fire Prevention nd Building Code sttes tht the wll of dwelling cn serve s prt of the pool enclosure if door in the wll hs self-closing nd self-ltching device or n lrm, or if the pool hs powered sfety cover. 12 Seven of the drownings mentioned bove involved three-sided fencing with ccess from the house or grge. In six of the seven cses, the child ws believed to hve ccessed the pool through door tht ws open or unlocked. In the seventh incident it ws uncertin whether the child entered the pool re vi gte or through door from the house. None of the reports describing these seven incidents included ny mention of the door hving self-closing or selfltching device. A solr cover ws in plce t the time of the incident for 10 of the 77 residentil swimming pool
452 Reserch Articles Tble 3. Residentil swimming pool drownings mong children 0 4 yers of ge: mens by which the victim ccessed the pool re New York Stte, 1988 1994 Access Number Percent Open/unlocked gte or ineffective ltch 17 28.3 No fence, no seprte fence, or fence in disrepir 10 16.7 Access directly from house 10 16.7 Ldder to bove-ground pool left in down position 10 16.7 Climbed over fence, gte, or side of pool 9 15.0 Automtic cover not in use 1 1.7 Neighbor child pulled down ldder 1 1.7 Fixed steps to bove-ground pool, no gte 1 1.7 Gte broken (not mounted) 1 1.7 Child known/llowed to be in pool re 7 Unknown 10 Excludes 17 children who were known/llowed to be in pool re, or for whom no informtion ws vilble. drownings (13.0%). In t lest three of these situtions, it ws stted tht the cover delyed discovery of the child s submersion. The pool ws checked, the child ws not observed, nd other res were serched before returning to recheck the pool. Dt on the time elpsed from when the child ws lst observed by the responsible person until the time when the child ws relized to be missing or found submerged were vilble for 60 residentil swimming pool drownings mong children ges 0 4 yers. The time reported to hve elpsed ws five minutes or less for 26 incidents (43.3%). The time elpsed ws reported s between six nd 20 minutes for 25 incidents (41.7%). Activity t the time of the incident The ctivity the person ws involved in immeditely prior to drowning is presented in Tble 4. The clssifiction of unwitnessed drownings of children not known to hve been swimming s flls into wter contributed to reltively high proportion of children in tht ctegory nd low proportion in the unknown ctegory. The most common ctivity t the time of the incident shifts from flls into wter for ges 0 4, to swimming for ges 5 24, to wtercrft-relted ctivity for ges 25 64, nd bck to flls into wter for ges 65 nd older. Twenty-two individuls drowned while ttempting to rescue person or pet. In eleven cses, the person or pet being rescued did survive. Twenty-five drownings hppened while the victim ws t work. Three of these 25 individuls (12.0%) hd history of seizures. Of the 16 job-relted drownings for which dequte toxicology dt were provided on lcohol or drug use, seven victims (43.8%) hd been using lcohol or drugs (one of these individuls lso hd history of seizures). Rescue ttempts A rescue cnnot tke plce unless someone is quickly lerted to the drowning in progress. As shown in Tble 5, of the 861 drowning victims for whom informtion bout the presence of compnion ws provided, 527 (61.2%) hd compnion(s) or n uthority figure in the immedite vicinity. An dditionl 102 hd compnion t the site but compnion ws not within view t the time of the incident. The remining 232 victims (26.9%) did not hve compnion t the site, lthough for 30 of these it ws known tht other people were within view of the drowning. Ten drownings mong children 1 4 yers old took plce when person supervising the child ws not t the residence where the drowning occurred. However, seven of the 10 children left the site without the responsible person s wreness. A higher proportion of drownings mong individuls 25 yers nd older took plce when the victim ws lone. Forty-four percent of drownings of victims 45 64 yers old, nd 65% of victims older thn 65 yers old occurred when the victim ws lone, wheres 84% of drownings mong individuls 15 24 yers of ge hppened when one or more compnions were present. A compnion or other person not lso in distress witnessed 393 of the drownings (462 were not witnessed, 28 unknown). Rescue ttempts were reported for 264 victims; rescue ws not ttempted for 78 witnessed drownings, nd ws unknown for 49 (two victims who lter died of submersion injuries left the wter with little or no ssistnce). Of the 255 rescue
Unintentionl Drownings Among New York Stte Residents, 1988 1994 453 Tble 4. Activity immeditely prior to drowning, by ge group New York Stte residents, 1988 1994 Age (yers) 0 4 5 14 15 24 25 44 45 64 65+ Totl n Percent n Percent n Percent n Percent n Percent n Percent n Percent Activity Swimming b 9 8.3 48 52.2 106 61.3 76 28.4 30 29.7 12 17.9 281 34.7 Wtercrft-relted c 0 9 9.8 41 23.7 105 39.2 39 38.6 19 28.4 213 26.3 Flls d 98 89.9 29 31.5 8 4.6 25 9.3 15 14.8 24 35.8 199 24.6 Fishing, not from bot 0 3 3.3 2 1.2 20 7.5 12 11.9 8 11.9 45 5.6 Attempting rescue 0 0 4 2.3 15 5.6 3 3.0 0 22 2.7 SCUBA diving 0 0 3 1.7 12 4.5 0 1 1.5 16 2.0 Fleeing police/uthority 0 0 7 4.0 7 2.6 0 0 14 1.7 Ice-relted 2 1.8 3 3.3 1 0.6 4 1.5 1 1.0 1 1.5 12 1.5 Miscellneous 0 0 1 0.6 4 1.5 1 1.0 2 3.0 8 1.0 other Unknown 0 1 10 31 16 15 73 Totl 109 93 183 299 117 82 883 Percents re bsed on individuls for whom informtion ws vilble. b Jumping/diving into wter, surfing, wding, generl plying in wter re lso included in this ctegory. c Three dditionl wtercrft-relted drownings re clssified under ttempting rescue (two) nd fleeing police/uthority (one). d Includes flls not elsewhere clssifible (e.g., s wtercrft-relted or ssocited with fishing); lso includes unwitnessed drownings of children not known to hve been swimming. ttempts for which the type of rescue ws described, 208 (81.6%) involved individul(s) entering the wter to ssist the victim. Forty-seven rescue ttempts (18.4%) were crried out from shore or from wtercrft. Descriptions were vilble for 253 rescue ttempts. Mny difficulties hmpered rescue efforts nd multiple impediments often existed in single sitution. The most common difficulties included: rescuer could not locte the victim (47); rescuer could not rech the victim before the victim submerged (44); victim ws struggling, fighting, or pulling the rescuer under (39); limited skills or strength of the rescuer (25); wter depth (13); nd wter clrity (13). In 21 instnces, rescues were delyed or not ttempted becuse the would-be rescuer believed the victim ws plying or kidding round. For 36 drownings for which rescue ttempts were described, no mention ws mde of fctors delying the rescue ttempt. In most of these incidents, the victim ws reportedly submerged for only one or two minutes. Injury, known or suspected myocrdil infrction or other hert problem, or seizure ws noted for t lest 15 of these drownings nd my hve ccounted for the poor outcome. The use of CPR ws reported t the scene of the Tble 5. Presence of compnion t the time of drowning New York Stte, 1988 1994 Age (group) 0 4 5 14 15 24 25 44 45 64 65+ Totl n Percent n Percent n Percent n Percent n Percent n Percent n Percent Presence of compnion In immedite vicinity 28 26.4 75 81.5 148 84.1 198 67.6 56 49.1 22 27.5 527 61.2 On site, not within view 67 63.2 13 14.1 8 4.5 9 3.1 3 2.6 2 2.5 102 11.8 Alone/others not reported 10 9.4 3 3.3 17 9.7 70 23.9 50 43.9 52 65.0 202 23.5 Others within sight 1 0.9 1 1.1 3 1.7 16 5.5 5 4.4 4 5.0 30 3.5 Unknown 3 1 7 6 3 2 22 Totl 109 93 183 299 117 82 883 Percents re bsed on individuls for whom informtion ws vilble.
454 Reserch Articles drowning for 394 victims, ws not ttempted for 453, nd ws unknown for 36. The length of submersion ws 30 minutes or more for 97% of victims for whom CPR ws not ttempted (428 of the 439 for whom submersion time ws vilble). In 185 of the 394 circumstnces in which CPR ws used, the first person ttempting CPR ws compnion or nother person t the scene; for the remining 162 incidents, the person inititing CPR ws reported to be n emergency responder such s police officer, firefighter, or emergency medicl technicin. Informtion on CPR trining ws vilble for 69 of the 185 individuls who were not emergency responders. Fifty-six were reported to hve been trined in CPR nd 13 were reported not to be experienced in CPR. For three incidents in which the submersion time ws 20 minutes or less, the rescuers reportedly checked for nd could not find pulse nd therefore did not strt CPR. In nother 24 incidents in which the submersion time ws 20 minutes or less, CPR ws pprently delyed while the rescuer(s) either left to cll for help, wited for someone experienced in CPR to rrive, or crried the victim to neighbor or nother re where CPR ws initited. Personl flottion device use For 12 victims, sufficient description ws not provided to determine whether they were wering PFD t the time of the drowning. Among the totl number of drowning victims (883), 22 (2.5%) were reported to hve been wering PFD. In ddition, two victims hd been using flottion cushions nd two children were in smll infltble tubes (neither of which re considered to be PFDs). Also, four victims hd been wering PFDs or swimmies nd hd removed them just prior to the incident. Of the 22 drownings of individuls wering PFDs, 19 were wtercrft-relted. Injury, hypothermi, or very strong current cusing submersion were fctors in most of these cses. Of the three drownings of victims wering PFDs ctegorized s non-wtercrftrelted, one involved snowmobile, one surfbord, nd one ws child whose PFD cme off while swimming unttended. Medicl conditions nd other personl risk fctors A joint cuse of deth, contributing condition, or significnt condition (other thn lcohol or drug buse) ws reported for totl of 139 drowning victims (15.7%). Medicl conditions reported s joint cuse of deth, contributing condition, or significnt condition re listed in Tble 6. Four individuls were reported to hve two conditions. Injury ws noted in ddition to seizure in three drowning victims, nd in Tble 6. Medicl or other conditions listed s joint cuse of deth, contributing condition, or significnt condition for drowning victims New York Stte, 1988 1994 Condition Number Percent Injury 47 5.3 Hypothermi 18 2.0 Seizure 35 4.0 Hert disese 31 3.5 Other b 12 1.4 Percent of totl drowning victims (N=883). Since more thn one condition ws noted for some cses, percents will totl to greter thn the 15.7% of individuls for whom t lest one condition ws reported. b Other conditions include dibetes, nitrogen nrcosis, trnsient loss of consciousness, nd mentl illness. ddition to mentl illness in one. Among 47 individuls for whom injury ws joint cuse of deth, contributing condition, or significnt condition, the most common cuses of injury were flls from shore, dock, or bridge (11); bot crshes (8); nd bot propellers (5). Thirty-five drowning victims (4.0%) hd history of seizure disorder. Three individuls reportedly hd recent chnge in mediction, two others hd history of errtic mediction use, three were reported not to hve tken their usul medictions tht dy, nd toxicology screens for four other victims showed either no medictions or sub-therpeutic drug levels. Toxicology dt were vilble for 23 of the 35 individuls with history of seizure disorder. Alcohol nd drug use Toxicology reports were received for 528 of the 681 drowning victims who were 15 yers of ge or older. Results re reported for the 250 individuls who met criteri bsed on length of survivl nd smpling time (see Methods). One hundred ten victims (44.0%) tested positive on blood lcohol concentrtion (BAC) nlysis, nd 76 (30.4%) hd BACs of 100 mg/dl or more. BAC levels re presented by ge, gender, rce, nd ctivity t the time of the incident in Tble 7. The percentge of individuls for whom positive BACs were reported rnged from 24.1% mong those 65 yers of ge nd older to 60.0% mong victims 45 64 yers of ge. A slightly higher proportion of mles tested positive for blood lcohol (44.5%) compred to femles (38.1%). A smll difference ws lso observed by rce, with positive BACs observed for 45.5% of whites nd 35.9% of Africn Americns. The proportion testing
Unintentionl Drownings Among New York Stte Residents, 1988 1994 455 Tble 7. Blood lcohol concentrtion (BAC) levels for drowning victims 15 yers nd older by ge, gender, rce, nd ctivity t the time of the incident New York Stte, 1988 1994 BAC (mg/dl) 0/ND b 1 49 50 99 100 199 200 Totl BAC 1 n n n n n n Percent c Age 15 24 52 3 4 8 6 21 28.8 25 44 50 11 7 15 25 58 53.7 45 64 16 4 2 2 16 24 60.0 65+ 22 2 1 2 2 7 24.1 Gender Mle 127 17 14 26 45 102 44.5 Femle 13 3 0 1 4 8 38.1 Rce White 115 16 14 22 44 96 45.5 Africn-Americn 25 4 0 5 5 14 35.9 Activity Intentionlly entered wter d 62 9 5 10 25 49 44.1 Wtercrft-relted 41 7 6 9 9 31 43.1 Fll into wter 23 2 1 6 9 18 43.9 Miscellneous/unknown 14 2 2 2 6 12 46.1 BAC levels were reported nd toxicology smpling criteri (see Methods) were met for 250 drowning victims. b BAC reported s zero, negtive, or none detected. c Row percent: percent with positive BAC (greter thn zero) out of number tested. d Swimming, jumping/diving into wter, surfing, wding, SCUBA diving, nd ttempting rescue included in this ctegory. positive ws similr for the most common ctivity ctegories (see Tble 7). Of the 250 drowning victims for whom vlid toxicology nlyses were vilble, 26 tested positive for illicit drug use. Thirteen tested positive for both lcohol nd illicit drug use nd 13 tested positive for illicit drugs only. Thus, totl of 123 persons 15 yers of ge nd older tested positive for lcohol or drug use (49.2% of those meeting toxicology smpling criteri for blood lcohol). DISCUSSION In this study, we observed disprities in drowning rtes by ge, gender, nd rce. The ptterns observed in the NYS dt re consistent with other studies. Pek drowning rtes hve generlly been observed t ges younger thn 5 yers nd from 15 24 yers of ge, 2,13 with drowning rtes for mles three to six times the rtes for femles. 2,3,13,14 Rtes for Africn Americns re often higher thn for whites with the exception of chil- dren between the ges of 1 nd 4. 2,15 While the difference in risk by gender my be ttributed to incresed time spent in wter-relted ctivities nd risk-tking behviors mong mles, 3,14 the resons for differences by rce re less cler. Suggested explntions include lck of erly exposure to recretionl swimming nd cquisition of swimming skills. 10 The use of the number of residents s the denomintor rther thn number of people t risk limits interprettion of drowning rtes presented. For exmple, mong 162 individuls who drowned while swimming in nturl body of freshwter, only seven were t bech with lifegurds. Eleven of 64 victims who drowned while swimming in the ocen or sound were t bech with lifegurds ( strong current or rough surf ws reported for mny of these). Although we cn document tht reltively few drownings occurred t beches with lifegurds, without dt on usge, comprisons cnnot be mde of the risk of drowning bsed on exposure frequency for beches with lifegurds vs. ungurded beches nd swimming holes.
456 Reserch Articles This discussion focuses on some of the conditions under which drownings occur with n eye towrd prevention strtegies. The prevention pproches described might be considered common sense or generlly known methods for voiding submersion injuries. Nevertheless, this study demonstrtes tht mny drownings could hve been prevented by implementing these strtegies. A combintion of circumstnces my ply role in drowning incident. For exmple, lck of effective fencing nd lpse in prentl supervision my ech contribute to child drowning in residentil swimming pool. Similrly, boter inexperience, bd wether, nd not wering PFD my ech contribute to wtercrft-relted drowning. It is importnt to determine which links cn be most effectively blocked. We hope tht our observtions will support regultory inititives nd community eduction efforts. Generl drowning prevention eduction progrms should stress the dnger of swimming lone or engging in other wter-relted ctivities (fishing, boting) without compnion. It is essentil to hve someone in the immedite re who will be ble to offer ssistnce if needed. Approximtely 40% of drowning victims in this study did not hve compnion in the immedite re t the time of the incident. The risks nd preferred methods of rescuing someone who is drowning should be ddressed in eduction progrms. In this study, 22 individuls drowned while ttempting rescue. The mjority of rescue ttempts involved individul(s) entering the wter to id the victim. This type of rescue involves the gretest mount of risk to the rescuer. Whenever possible, rescuers should ssist the drowning person from shore or from bot (e.g., by reching out to the person with pole, bot hook, or other object; or by throwing buoynt id). Also, it is importnt to educte people on the nture of drownings. Drownings cn occur quickly nd often quietly. A brief lpse in supervision or dely in response cn result in disstrous outcome. Among children 0 4 yers old, lpse in supervision of five minutes or less ws reported for 43% of residentil swimming pool drownings for which this informtion ws vilble. In number of incidents, fmily members were nerby, the victim wndered wy, ws relized to be missing short time lter nd ws found submerged in the homeowner s pool or neighbor s pool. For t lest 21 drownings (ll ges), rescues were delyed or not ttempted becuse the victim ws believed to be kidding round. In some of these cses, it ws believed by compnions tht the victims were feigning distress. In others, the compnion ws unble to recognize tht the victim ws in trouble. One witness reported tht the victim wved to her but she did not tke the wve s n indiction of distress. There my be n expecttion tht person who is drowning will cll out for help. However, person who is drowning is struggling to brethe nd usully will not be ble to cll for help. 17,18 Physicl fetures of nturl bodies of wter A nturl body of wter ws the most frequent site of drowning for ll ges except children younger thn 5 yers. A swift current, deep wter, or sudden drop-off cn increse the likelihood tht n individul will run into difficulty while in the wter. Often drownings occur in body of wter tht the victim is not fmilir with. In this study, one-third of the victims drowned in NYS county other thn their county of residence. Although it my not be fesible or desirble to prevent ccess or otherwise modify res tht pose specil risks, ttempts cn be mde to discourge recretionl ctivities in these res. Possible mesures include posting signs wrning of hzrdous conditions, ptrolling swimming holes, nd providing sfe lterntives such s designted beches monitored by lifegurds. Residentil swimming pool drownings Over 20 yers go, Milliner rgued tht, given evidence vilble t tht time, it seems indefensible tht unfenced pools should be llowed to continue to clim children s lives. 19 Residentil swimming pool drownings most commonly occur mong children 0 4 yers of ge nd the mjority of these children gin ccess to the pool due to ineffective or nonexistent gting or fencing. This ws the cse for 50 of the 67 drownings in this study for which detils on ccess were vilble. Approprite fence construction is n importnt considertion. In seven incidents, threesided fencing ws in plce nd the child ccessed the pool through n open or unlocked door. Of the nine drownings involving child who climbed over fence, gte, or the side of n bove-ground pool, one fence ws wire nd wood snow fence nd nother ws two-foot high lttice riling. Also, two children first climbed onto n object djcent to the fence or the side of the pool tht enbled them to climb over the brrier. These incidents point out the importnce of keeping objects tht might be used s stepping stones cler of the perimeter of bove-ground pools nd pool fences, s well s the need for four-sided pool fencing of dequte height nd construction secured by wellmintined, self-locking gtes. A solr cover ws in plce in 13% of residentil
Unintentionl Drownings Among New York Stte Residents, 1988 1994 457 swimming pool drownings. A young child my try to wlk out onto the surfce of the solr cover. In severl incidents, the presence of solr cover hindered ttempts to locte the child. In this study, mong incidents for which the type of residentil swimming pool ws reported, 52% were bove-ground pools. This is in contrst to previous study tht noted tht only 4% of residentil swimming pool drownings mong children 0 4 yers of ge occurred in bove-ground pools. 20 Often the ldder ws left in the down position or there ws direct ccess from the house to the swimming pool deck. Fencing with self-locking gte should be in plce between the deck nd the pool. Very few residentil swimming pool drownings occurred when n dult knew tht child ws in the pool re. In most cses, the child gined ccess to the pool during only short lpse in supervision. This observtion supports the need for effective brriers to prevent or t lest hinder ccess to the pool re. Medicl conditions The occurrence of medicl condition such s hert problem, seizure, or dibetic event cusing disbility or trnsient loss of consciousness while in wter environment cn result in drowning. Two persons in the study were dibetics who hd experienced recent episodes of hypoglycemic shock. Ech pprently suffered nother hypoglycemic event t the time of the drowning. Thirty-five drowning victims (4.0%) hd history of seizure disorder. This proportion is higher thn the proportion of the generl popultion suffering from seizure disorder (estimtes rnge from 0.5 to 1.0%). 21 A recent chnge in mediction, history of errtic mediction use, or skipping mediction tht dy (or evidence thereof by toxicology) ws indicted for 12 individuls with history of seizure disorder. The use of lcohol or illicit drug use by seven others could hve influenced the effectiveness of nti-seizure medictions. Thus, indequte mediction or mediction effectiveness influenced by drug or lcohol use my hve been influentil in more thn hlf of victims with history of seizure disorder. Ptients should be wrned bout the specil risks ssocited with ctivity ner or in wter during periods in which seizure ctivity is poorly controlled. Severl individuls with history of seizure disorder were swimming in lifegurded bodies of wter but slipped underwter unnoticed. This rgues for the need for direct supervision of seizure disorder ptients (dults s well s children) by individuls who re wre of their medicl history nd cpble of crrying out rescue. Lifegurds in public swimming re cnnot be expected to provide this level of supervision. It is importnt for physicl eduction techers nd other swim instructors to be wre of history of seizure disorder. In study of epilepsy nd submersion injury in children younger thn 19 yers of ge, Diekem et l. 22 observed greter thn 20-fold increse in risk of drowning in swimming pool nd nerly 100-fold elevtion in risk of drowning in bthtub mong children with epilepsy. 22 Authors of nother pper on the subject of epilepsy nd drowning noted, None of the children with primry epilepsy who were supervised t the time of the ccident died, suggesting tht if children with epilepsy re supervised they hve no greter risk of drowning deth thn the generl popultion. 23 In our study, however, prent observed child go into seizure, removed the child from the wter immeditely nd begn CPR (the victim survived five dys). In nother sitution, child ws observed to be doing hndstnds t the bottom of public pool. After wht ws pprently very brief period of time, the child ws observed on the bottom of the pool with bubbles coming from his mouth nd nose (victim survived 10 dys). Also, n dult with history of seizure disorder ws observed by lifegurd to strt to sink to the bottom during lp swimming. The victim ws immeditely rescued, fter one rescue breth the victim strted brething but expired four dys lter. Brief submersion during seizure even with immedite nd proper rescue procedures my hve ftl outcome, further emphsizing the need for cution in wter environments for individuls with seizure disorder. Alcohol nd drug use Among victims for whom smples tht met study criteri were vilble, 44% of BACs were positive nd 30% of BACs were 100 mg/dl or more. These proportions re similr to those reported in met-nlysis of 15 drowning studies. Of subjects tested, 49% of BACs were positive nd 34% of BACs were 100 mg/dl or bove. 24 In our study, positive BACs were observed for 54% of tests of victims 25 44 nd 60% of victims 45 64 yers of ge (see Tble 7). Mles were 17% more likely to test positive thn femles nd whites tested positive 27% more often thn Africn Americns. Although the proportion of positive tests ws firly similr for the most common ctivity ctegories, BACs of 100 mg/dl were ssocited with 32% of drownings in which the victim intentionlly entered the wter, 37% of flls into wter, nd 25% of wtercrft-relted drownings. Although toxicology results meeting our study
458 Reserch Articles criteri were vilble for only 36.7% of drowning victims 15 yers of ge or older, exmintion of test vilbility ccording to personl chrcteristics did not revel differences by sex, ge group, or rce. COMMENTS Bsed on the results of this study, we suggest the following: stricter fencing requirements nd enforcement for residentil swimming pools, nd re-exmintion of boting-while-intoxicted lws with possible extension to include pssengers s well s opertors nd/or other types of wtercrft beyond motorbots. Drowning eduction progrms should stress wering personl flottion device while boting (for dults s well s children), the dnger of mixing lcohol nd wterrelted ctivities, nd recognition tht drownings occur quickly nd often silently (the victim is usully unble to cll out for help). Also, physicins of individuls with seizure disorder should instruct the ptients on the significnce of direct supervision by someone who is wre of their medicl history during wter-relted ctivities long with creful ttention to mediction use, especilly when wter-relted ctivities re plnned. REFERENCES 1. Centers for Disese Control nd Prevention. CDC WISQARS website [cited 2001 Jun 20]. Avilble from: URL: http://cdc.gov/ncipc/wisqrs/ 2. Ptett MJ, Biddinger PW. Chrcteristics of drowning deths in North Crolin. Public Helth Rep 1988;103: 406-11. 3. O Crroll PW, Alkon E, Weiss B. Drowning mortlity in Los Angeles County, 1976 to 1984. JAMA 1988;260:380-3. 4. Wintemute GJ, Krus JF, Teret SP, Wright M. Drowning in childhood nd dolescence: popultion-bsed study. Am J Public Helth 1987;77:830-2. 5. Wintemute GJ, Krus JF, Teret SP, Wright MA. The epidemiology of drowning in dulthood: implictions for prevention. Am J Prev Med 1988;4:343-8. 6. Agocs MM, Trent RB, Russell DM. Activities ssocited with drownings in Imperil County, CA, 1980 90: implictions for prevention. Public Helth Rep 1994;109: 290-5. 7. Steensberg J. Epidemiology of ccidentl drowning in Denmrk 1989 1993. Accid Anl Prev 1998;30:755-62. 8. Drowning Louisin, 1998. MMWR Morb Mortl Wkly Rep 2001;50(20):413-4. 9. Browne ML, Lewis-Michl EL, Strk AD. Wtercrftrelted drownings mong New York Stte residents, 1988 1994. Public Helth Rep 2003;118:459 63. 10. Wintemute GJ, Teret SP, Krus JF, Wright M. Alcohol nd drowning: n nlysis of contributing fctors nd discussion of criteri for cse selection. Accid Anl Prev 1990;22:291-6. 11. Census Bureu (US). Census 2000. Stte nd county quickfcts. Avilble from: URL: http://quickfcts. census.gov/qfd/sttes/36000.html 12. Title 19 NYCRR Chpter XXXIII, Subchpter A Uniform Fire Preventions nd Building Code, Prt 1220, Section AG105; 2002. 13. Hedberg K, Gunderson PD, Vrgs C, Osterholm MT, McDonld KL. Drownings in Minnesot, 1980 85: popultion-bsed study. Am J Public Helth 1990;80: 1071-4. 14. Dietz PE, Bker SP. Drowning: epidemiology nd prevention. Am J Public Helth 1974;64:303-12. 15. Howlnd J, Hingson R, Mngione TW, Bell N, Bk S. Why re most drowning victims men? Sex differences in qutic skills nd behviors. Am J Public Helth 1996; 86:93-6. 16. Fife D, Scipio S, Crne GL. Ftl nd nonftl immersion injuries mong New Jersey residents. Am J Prev Med 1991;7:189-93. 17. Pi F. Observtions on the drowning of non-swimmers. J Physicl Eduction 1974;164-7, 181. 18. Americn Red Cross. Lifegurding tody. St. Louis: Mosby Lifeline; 1995. 19. Milliner N, Pern J, Gurd R. Will fenced pools sve lives? A 10-yer study from Mulgrve Shire, Queenslnd. Med J Aust 1980;2:510-1. 20. Zmul WW. Socil costs of drownings nd nerdrownings from submersion ccidents occurring to children under five in residentil swimming pools. Consumer Product Sfety Commission Report (US), 1987. 21. Glser GH. The epilepsies. In: Wyngrden JB, Smith LH Jr, editors. Cecil textbook of medicine. 16th ed. Phildelphi: WB Sunders Co; 1982. p. 2114. 22. Diekem DS, Qun L, Holt VL. Epilepsy s risk fctor for submersion injury in children. Peditrics 1993;91 :612-6. 23. Kemp AM, Sibert JR. Epilepsy in children nd the risk of drowning. Arch Dis Child 1993;68:684-5. 24. Smith GS, Brns CC, Miller TR. Ftl nontrffic injuries involving lcohol: metnlysis. Ann Emerg Med 1999;33:659-68.