PATTERNS OF DROWNING IN AUSTRALIA
| par 0 |
| IAN J MACKIE AM FRACP | par 1 |
| National Medical Adviser, Royal Life Saving Society Australia | par 2 |
| Suite 409 Henry Lawson Business Centre, Birkenhead Point Shopping Centre, Cary Street, DRUMMOYNE 2047 | par 3 |
|
This is the first revised version of this article. Click here for the final edited version. Click here for the second revised version. Click here to see the original submission. | par 4 |
|
| par 5 |
| par 6 |
| par 7 |
| ABSTRACT | par 8 |
| Objective. To determine profiles for the types of persons who drowned in different locations undertaking different activities in Australia during the six years 1992 to 1997 inclusive. | par 9 |
| Methods. Population figures and details of all drownings were provided by the Australian Bureau of Statistics. The total period was studied with no attempt to make year by year comparisons. Accidental non boating drownings (ICD E910) were divided into locations and activities which were then separately examined for age and sex distribution. Boating incidents, (E830-32), homicide (E964), suicide, (E 954) and other deaths without a drowning E code but with the drowning flag applied were also studied. | par 10 |
| Results. The overall accidental non boating drowning rate was 1.44 per 100,000 population per year. Commonest sites for non boating drowning were ocean/estuary (22%), non-tidal lakes and lagoons (19%), private swimming pools (17%) surfing beach (10%) and 7% in the bathtub. 22% were in the under 5 year age group with a rate of 4.6. Very few toddlers drowned in the ocean or in boating incidents. Boating drownings were 0.29 per 100,000 population per year. 4.7% of all non boating drownings were overseas tourists of whom 89% drowned in the ocean; 25% of all scuba drownings were overseas tourists. The indigenous population had a much higher rate of drowning than the overall figure and their toddler rate was very high. Drowning due to suicide was more frequent than from boating incidents. There were 86 persons drowned in motor vehicle accidents in the six year period. | par 11 |
| Conclusions. Toddler drownings continue to be the greatest challenge for water safety organisations and legislators. Drowning in the indigenous community and tourists require more detailed study and action, probably by government agencies. To assist preventive strategies, the National Water Safety Council will need to clarify the categories described as "ocean/estuary" and " lake, lagoon dam and waterhole". | par 12 |
| INTRODUCTION | par 13 |
| The national drowning study published in 1993 (ref 1) concluded that the risk of accidental drowning in Australia and other countries has steadily decreased since 1920. That study and the later report by Nixon Oldenberg Pearn and Pitt (ref 2), however, were unable to provide detailed national information on where drownings occurred. Further information is now available from the Australian Bureau of Statistics (ABS) and presentation of this new data allows the community to target those most at risk in different locations. | par 14 |
| METHODS | par 15 |
| The Australian Bureau of Statistics (ABS) has provided figures on accidental drownings in Australia dating from 1920. There have since been several variations in the systems of international classification but currently the International Classification of Diseases (ICD) Supplementary Classification of external causes of injury and poisoning codes includes: | par 16 |
| E830: Accident to watercraft causing submersion | par 17 |
| E832: Other accidental submersion or drowning in water transport accident | par 18 |
| E910: Accidental drowning and submersion | par 19 |
| E954: Suicide and self-inflicted injury by submersion (drowning) | par 20 |
| E964: Assault by submersion (drowning) | par 21 |
| E984: Submersion (drowning) undetermined whether accidentally or purposefully inflicted. Drowning is defined by the Medical Commission of the International Lifesaving Federation as death resulting from suffocation within 24 hours of submersion in a liquid medium. | par 22 |
| In 1992 the ABS introduced, in addition to the E codes, a nationally consistent system of flags which form the basis of specialised drowning tables. Implementation issues in 1992 and 1993 resulted in very slight discrepancies in drowning figures. The present study has examined both the international e codes and the ABS flag system (reference 3). | par 23 |
| RESULTS | par 24 |
| NON BOATING DROWNING (ICD E910) | par 25 |
| In the six years reviewed, there were 1551 non boating accidental drownings in Australia. Of these, 77% were males and 23 % were females. The presence of drugs including alcohol was recorded in 148 (14%) of 1096 persons over the age of 14 years. 79% of these were males. Using the ABS population figures for 1996, (reference 4) the national drowning rate was 1.44 per 100,000 of population. | par 26 |
| The age distribution for the 1551 persons is shown in figure 1. The age group 0 to 4 years clearly had the highest prevalence with a rate of 4.6 drownings per 100,000 of population. Males were 64% of toddler drownings and 62% of the age group over 64 years. In two persons the age was unknown. | par 27 |
| Ocean and estuary (tidal) sites were 22% of the total (figure 2). The profile for age and sex shows that 90% of these were male and very few persons were under the age of 15 years. | par 28 |
| Non tidal lagoons and lakes (19%) were the second most frequent sites recorded with age and sex distribution shown in figure 3. This category includes dams and waterholes. Overall, 82% of these drownings were male. There was a high frequency of toddler drownings and variable male to female ratios in the different age groups. | par 29 |
| Private swimming pools accounted for 17% of all drownings. 64% were toddlers, 66% of whom were male (figure 4). A significant feature in this group is that of all private pool drownings over the age of 34 years, 63% were female. | par 30 |
| By comparison, public and "other" pools accounted for 3% of accidental drownings. There were twenty eight drownings in Public Pools (20 male) and 18 drownings in "other " pools (11 male). | par 31 |
| Surfing beaches accounted for a further 10% of drownings with 162 persons; 144 were male (89%) and 18 were female. There were no surfing beach deaths under the age of five years and only seven between the ages of 5 and 14 (figure 5). Comparison of the figures for ocean versus still water drowning is striking in that ocean and surfing beach deaths were almost all over the age of 15 years with a much higher proportion of males than in still water. | par 32 |
| Persons washed from rocks. 5% of accidental drownings were classified as having been washed from rocks, all of these into the ocean. They were in two distinct groups. Fifty four were fishing and only one of these was female. All were over the age of 15 years. The second group comprised 21 persons not fishing, most of them much younger but none under the age of ten years. Five of this group were female. | par 33 |
| A further 36 persons were described as having drowned while fishing in tidal water and of these, 35 were males. The one female was ten years of age. One male was four years old; there were none in the 5 to 14 year age group, then deaths were relatively evenly distributed for age with the greatest number, eight, in the age group 65 years and older. The total of all drownings while fishing, either from rocks or elsewhere in tidal water is therefore 5.8% of all non boating drownings (figure 6). | par 34 |
| 56 drownings occurred while using Scuba equipment. Of these 44 (79%) were male and 12 were female (figure 7). Fifteen (27%) of these 56 were overseas tourists. On a state by state basis, 36% of Scuba deaths occurred in Queensland waters, 21% Western Australia and 18% NSW. | par 35 |
| Skindiving accounted for 15 deaths of whom three were overseas tourists. 11 were male and 4 female. | par 36 |
| 36 (34 male) persons drowned while attempting rescue; 12 in surf, one in a public pool and 23 at other sites. | par 37 |
| Five groups were subjected to detailed analysis. These were toddlers, the elderly, bathtub drownings, the indigenous population and overseas tourists. Table 1 shows in percentage numbers the locations of drowning in these groups. | par 38 |
| TODDLER DROWNINGS | par 39 |
| Children under the age of five years comprised 22% of all drownings but are only 7% of the population. There were 345 drownings in this age group and the most frequent locations are shown in fig 8 as percentages of the total. Again, "lake" includes lagoons, dams and waterholes. | par 40 |
| Males comprised 64% of the total and the rate of 4.6 per 100,000 population per year (figure 1) for the six year period compares with 4.7 in the five years 1986 to 1990. (Ref 1) | par 41 |
| There were 37 drownings in infants in their first year of life. 26 were in the bathtub, almost 2% of all Australian drownings. 22 were male and 15 female. The other locations were: private pool 4, object such as bucket 3, lake 2, ocean and irrigation canal 1 each. | par 42 |
| THE OLDER AGE GROUP | par 43 |
| 12% of all accidental drowning victims were aged 65 or older with a rate of 1.5 per 100,000 population (figure 1). Of these, 38% were female. | par 44 |
| It is notable that females in this age group outnumbered males in the pool (F:M=22:11) and bathtub (F:M=18:4). | par 45 |
| Bathtub drownings were 7% of total drownings and 57% of these were female. Toddlers (47%) and the over 64 age groups (20%) dominated the numbers (figure 9). Alcohol was present in 14% of victims over the age of 15 years. Of these victims, all except one were over the age of 60 years. Three younger persons who drowned in the bathtub had an unspecified drug detected but no alcohol. | par 46 |
| ABORIGINAL POPULATION | par 47 |
| Drowning in the aboriginal population was studied and it is clear that this group requires further examination. There were 63 non boating drownings representing 4.2% of the national total. The 1996 ABS census figures show that 1.8% of the population were classed as Aboriginal and Torres Strait Islanders. The age distribution for drowning was notably different from the overall national figures (figure 10). Like the national trends, toddler drowning was very common, comprising 34% of all aboriginal drownings. 65% of these toddlers were male. | par 48 |
| Unlike the overall national figures, there was a second peak in the 25 to 34 age group which comprised 30% of all aboriginal drownings. In this group, 95% were male. | par 49 |
| Boating drownings in aboriginal people were less common with only seven recorded in six years. All except one were in motorised craft. All were male. | par 50 |
| OVERSEAS TOURISTS | par 51 |
| 88 overseas tourists from 12 different countries drowned in Australia during the six years. 73 were in non boating incidents, 5 were boating deaths and 10 were not specified. | par 52 |
| 38 of these tourists originated from Europe, including 15 from UK and 10 from Germany; 35 were from Asia including 17 from Japan while 7 were from USA. | par 53 |
| 61% of tourist deaths occurred at surfing beaches or elsewhere in "ocean" and a further 24% occurred while diving with or without Scuba equipment. | par 54 |
| 4.7% of all non boating drownings in Australia were overseas tourists, | par 55 |
| 18% of all surf/ocean drownings in Australia were overseas tourists and | par 56 |
| 25% of all scuba/skindiving drownings were overseas tourists. | par 57 |
| 89% of all tourist drownings occurred in the ocean and 11% in fresh water. 16 were female. The oldest tourist to drown was 78 years of age and the youngest three years.(figure 11) Tourists were 1.6% of boating drownings | par 58 |
| BOATING INCIDENTS | par 59 |
| Drowning in boating incidents ( E830 and E832 ) was much less frequent than other accidental drownings. There were 292 Boating drownings, an average of 52 per year and 0.29 per 100,000 population per year. 94% were male. Age incidence is shown in figure 12. Alcohol was reported in 19 of these boating drowning victims and a different drug in two persons, a drug total of 7% of victims, all between the ages of 35 and 54 years. | par 60 |
| Drownings in boating incidents differ from non boating deaths in their lower incidence, very low numbers of toddlers (1%) and the extreme male dominance. | par 61 |
| OTHER ACCIDENTAL DROWNINGS | par 62 |
| During the six years under review there were several other modes of drowning appearing in the details from the ABS but not included as any of the drowning E codes. These were deaths ascribed to other causes but to which the "drowning flag" was also applied. | par 63 |
| Forty six (46) persons with epilepsy drowned in these six years. | par 64 |
| Thirteen (13) persons drowned due to having suffered either heart attack or stroke while in the water. | par 65 |
| Eighty six (86) drowned in motor vehicles accidents in the water. | par 66 |
| SUICIDE (E954) AND HOMICIDE (E964) | par 67 |
| There were 390 suicides in the water with an annual average of 65 persons. This makes suicide in the water more common than drowning in boating accidents (292 persons). | par 68 |
| During the same period there were twenty eight (28) homicides due to drowning. | par 69 |
| DISCUSSION | par 70 |
| The existing knowledge of many aspects of drowning in Australia is comprehensive and correctly has had its emphasis on early childhood. The present study provides national data not previously available and will be a basis for comparison of future preventive strategies. Clearly the toddler problem is not improving significantly and legislators must now consider the prospect of banning private swimming pools which are not fenced to the recommendations of the Australian Standards Association. The figures provide strong backing for the recommendations of Nixon and colleagues (ref 2). | par 71 |
| Detailed information on lake drownings needs further investigation by the recently formed National Water Safety Council in conjunction with Coroners, Police and the National Injury Surveillance Unit. There are many differing locations covered by this category and effective preventive action is dependent on separation of "lake, lagoon, dam and water hole" drownings | par 72 |
| Bathtub drownings are shown to be disturbingly common on a national basis and preventive approaches need to vary according to the age group. The frequency of infant and toddler bathtub deaths has been documented in state reports for two decades (reference 1) but this is the first national survey. Most bathtub deaths require much more careful forensic scrutiny than they have received to date in most countries. The frequency of the bathtub for drowning in Japan, where it is the leading place for immersion deaths and near drowning has been described by Mizuta (REF 5) but earlier reports from many countries indicate a wide variety of factors including carbon monoxide, epilepsy, drugs and alcohol, suicide, cardiac arrest, suicide, homicide and child abuse. There is little doubt that death in the bathtub at any age should be treated with great suspicion and careful investigation be directed at finding natural or deliberate causes. Confirmation of true accidental drowning in this location is likely to be much less common with such an approach. | par 73 |
| Details of drowning of overseas tourists have not previously been published and this is clearly an area in which government must work through the Water Safety Council to reduce the risk. Tourists and new migrants must be provided with suitable information and perhaps increased supervision when near the ocean. The specific areas of greatest risk have been made very clear as being the ocean and recreational diving with or without scuba apparatus. | par 74 |
| Similarly, drowning in our indigenous people is a matter for concern and calls for urgent government action through the appropriate established organisations. The age graph (figure10) is quite unique with very high incidence in toddlers and the 25 to 34 age group. | par 75 |
| ABS advice indicates that "death data for indigenous persons is undernumerated. While indigenous status is now a question on all State and Territory death forms, the ABS only regards data for South Australia, Western Australia and Northern Territory as having sufficient coverage to be of publishable standard". (Personal Communication ABS). | par 76 |
| Dietz and Baker (reference 6) were the first to draw world attention to the variation in drowning incidence in different racial groups and the subject has been widely studied in USA. Branche (ref 7) and Mael (ref 8) reviewed the American experience and scientific literature on the reasons for the increased incidence of drowning in African Americans, American Indians, Alaskan Natives and Hispanic citizens of the USA. | par 77 |
| Prevention of drowning is traditionally described as having three components; Education, Engineering or Science and Legislation. To these should be added Supervision and Enforcement. Carefully compiled accurate information is crucial. Those responsible for boating safety in Australia can point to great success in all areas. | par 78 |
| The most comprehensive review of preventive measures in Australia was published in 1995 by the Commonwealth Dept of Human Services and Health with Nixon, Pearn, Oldenburg and Pitt as authors. (Reference 2) Their publication contains most of the literature references of importance up to 1995. The details contained in the present study will provide the new National Water Safety Council with added information to assist more informed targeting of individual risk groups in specific areas. | par 79 |
| As correctly pointed out by Smith and Langley in 1998 (Reference 3), reliance solely on E codes would result in many drownings remaining unidentified. The eighty drownings in motor vehicle accidents and the many suicides are the most clear examples of the point being made by these authors in surveying drowning incidence. | par 80 |
| Lester reported in 1989 (Reference 9) that the presence of an ocean greatly increases the risk of suicide by drowning so those responsible for ocean surveillance can expect to be confronted with this ever increasing problem. | par 81 |
| ACKNOWLEDGEMENTS | par 82 |
| The author has received great assistance from the officers of the Australian Bureau of Statistics, the executive officers of the Royal Lifesaving Society Australia and Dr. George Stathers. Purchase of the statistical computer disc was funded by the Royal Lifesaving Society Australia. | par 83 |
| REFERENCES | par 84 |
| 1 Mackie I, Tebb N, Eady T, National Drowning Study Parts 1 to 4 Royal Lifesaving Society Australia | par 85 |
| 2 Nixon J, Pearn J, Oldenburg B, Pitt W, Review of countermeasures to reduce drowning, near drowning and spinal injuries fron diving into shallow water. Commonwealth Dept Human Services and Health GPO Box 9848 Canberra ACT 2601 | par 86 |
| 3 Smith G, Langley J, Drowning Surveillance: how well do E codes identify submersion fatalities. Injury Prevention 1998;4:135-139 | par 87 |
| 4 Australian Bureau of Statistics - Population By Age and Sex-3201.0-June 1997 PO Box10 Belconnen ACT 2616 | par 88 |
| 5 Mizuta R, Fugita H, Osamura T, Kidowaki T, Kiwosawa N, Childhood drownings and near drownings in Japan.Acta Paediatr Jpn 1993 Jun ; 35 (3): 186-92. | par 89 |
| 6 Dietz, P and Baker,S.1974 Drowning: epidemiology and prevention. American Journal of Public Health 64:303-12 | par 90 |
| 7 Branche, C. Who Drowns in the United States? Proceedings of International Medical-Rescue Conference1997, ILS 2581 Quivira Court San Diego California | par 91 |
| 8 Mael,F Staying Afloat: Within-group Swimming Proficiency for Whites and Blacks. Journal of Applied Psychology 1995,Vol 80:4,479-490 | par 92 |
| 9 Lester D, The suicide rate by drowning and the presence of oceans. Perceptual and Motor Skills 1989 : 69 ;338. | par 93 |
| 10 Australian Bureau of Statistics-Causes Of Death-3303.0-1997 PO Box 10 Belconnen ACT 2616. | par 94 |
| Figure 1
| par 95 |
Figure 2
| par 96 |
Figure 3
| par 97 |
Figure 4
| par 98 |
Figure 5
| par 99 |
Figure 6
| par 100 |
Figure 7
| par 101 |
Figure 8
| par 102 |
Figure 9
| par 103 |
Figure 10
| par 104 |
Figure 11
| par 105 |
Figure 12
| par 106 |
Table 1
|