The Epidemic of Child Drowning in

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 2010, 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 Cambodia 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.
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Cambodia
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
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Fatal drowning rate – Asia LMIC vs Australia
50
45
40
Rate per 100,000
35
0-4
30
5-9
25
10-14
20
15
10
5
0
Asia
Australia
Asia
Male
Australia
Female
Cause-specific mortality in Cambodian children after infancy (1-17 years)
35
Rate per 100,000
30
25
20
15
10
5
0
Drowning causes over half of all
child deaths after infancy
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more than dengue fever
more than AIDS
more than malaria
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more than SARS or Avian flu
combined
more than tetanus, whooping
cough and polio put together
Bangladesh shows the problem– and the solution
200
100
> 4 = teach to swim
90
160
80
140
70
120
60
100
50
80
40
60
30
40
20
20
10
0
Percent able to swim
Drowning rate per 100,000
< 4 = supervise
180
0
Infant
1 yr
2 yrs
3 yrs
4 yrs
5 yrs
6 yrs
7 yrs
8 yrs
Drowning death rates
9 yrs 10 yrs 11 yrs 12 yrs 13 yrs 14 yrs 15 yrs 16 yrs
Swimming ability
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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 Cambodian children after infancy (1-17 years)
35
25
20
15
10
5
0
300
Non-fatal
Fatal
250
200
150
100
Infant
10-14
Jiangxi
Cambodia
Bangladesh
Jiangxi
15-17
Cambodia
Bangladesh
Jiangxi
Cambodia
Bangladesh
Jiangxi
5-9
Cambodia
Bangladesh
Jiangxi
1-4
Cambodia
Bangladesh
Jiangxi
0
Cambodia
50
Bangladesh
Rate per 100,000
Rate per 100,000
30
0-17
Age group (years) and Country
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100
Female
Male
Rate per 100,000
80
60
40
Infant
1-4
5-9
10-14
15-17
Jiangxi
Cambodia
Bangledesh
Jiangxi
Cambodia
Bangledesh
Jiangxi
Cambodia
Bangledesh
Jiangxi
Cambodia
Bangledesh
Jiangxi
Cambodia
Bangledesh
Jiangxi
Bangledesh
0
Cambodia
20
0-17
Age group (years) and Country
100
Urban
Rural
Rate per 100,000
80
60
40
Infant
1-4
5-9
10-14
15-17
Jiangxi
Cambodia
Bangledesh
Jiangxi
Cambodia
Jiangxi
Bangledesh
Cambodia
Bangledesh
Jiangxi
Cambodia
Bangledesh
Jiangxi
Cambodia
Bangledesh
Jiangxi
Bangledesh
0
Cambodia
20
0-17
Age group (years) and Country
100%
Jiangxi
Cambodia
Thailand
80%
60%
40%
20%
0%
Fine weather
Monsoon floods
Heavy rain
Other
Weather at time of drowning National Swimming Pool Foundation ∙ 4775 Granby Circle ∙ Colorado Springs, CO 80919 ∙ (719)540-9119 ∙ www.nspf.org
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Cumulative proportion
100%
75%
50%
Fatal
Non fatal
Jiangxi
Cambodia
No resuscitation given
Not known
25%
0%
Age (years)
100%
Bangladesh
80%
60%
40%
20%
0%
Trained resuscitation
given
Untrained resuscitation
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
–
•
attempts to expel water from the drowning child by
inciting vomiting or coughing
–
•
(e.g. whirling the child overhead, pressing or jumping on the
child’s chest and stomach)
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
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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
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Prevention of Child Injuries through Social Intervention and Education
(PRECISE and follow-on program)
Improved supervision of children and safer environments (0-5 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
 25‐30 children
 Live in 60‐70 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)
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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
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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 134,000 children learnt swimming during 2006-2010
through SwimSafe programme
Centre for Injury Prevention and Research Bangladesh (CIPRB)
Does It Work ?
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PRECISE intervention numbers
Community crèche program –
640 community crèches, 20,000 children attending
SwimSafe survival swimming and water safety program
134,000 graduates from 250 training ponds
Community Crèche Outcome Summary
Death Rate
(per 100,000
child-years)
RR
CI
P
Intervention
11.67
0.156
.047 – .533
< 0.001
Non-Intervention
74.76
Drowning
Enrolled Non‐Enrolled
Mean Duration
#
child ‐years
2.1
12,403
26,046
2.0
12,403
24,806
SwimSafe Outcome Summary
Death Rate
(per 100,000
child-years)
Drowning
Intervention
Non-Intervention
1.08
21.10
RR
CI
0.051
P
.007 – .393 < 0.001
Enrolled Non‐Enrolled
Mean Duration
#
Child‐years
1.6
56,233
89,972
1.6
56,233
89,972
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What about safety of the intervention?
• 640 crèches, 4 years and 20,000 children
• 250 ponds, 4 years and 134,000 children
• 0 injuries, 0 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?
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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?
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If they are
unsupervised,
Or together,
shouldn’t they know
how to swim?
Portable pools
Beach site
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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
75
70
Rate per 100,000
65
60
55
50
animal
assault
burns
drowning
falls
poison
rta
suicide
sharp objects
suffocation
45
40
35
30
25
20
15
10
5
0
Infant
1-4 yrs
5-9 yrs
10-14 yrs
15-17 yrs
Child mortality by cause, age 1-17 years
Jiangxi Province, China
Unknown
90
Pneumonia
80
Meningitis
Rate per 100,000
70
Appendicitis
Malnutrition
60
Epilepsy
50
Cirrhosis
Muscular
40
Vascular
30
Cancer
20
Animal bite
Violence
10
Falls
0
UNICEF Injury
RTA
NCD
Infection
UTD
Total
Drowning
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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
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