Introduction Situation Analysis of Child Drowning in Thailand Eng Version

6 According to a survey of injuries in children aged 0–17 years conducted by UNICEF in five countries in the Asia Bangladesh, China, the Philippines, Vietnam, and Thailand, drowning is the number one cause of fatalities in children, followed by road traffic injuries 3 see Figure 1. Figure 1: Fatal injury rates per 100,000 children aged 0–17 years in five a Asian countries Source: World Report on Child Injury Prevention. WHO, 2009. 7 According to the data of WHO in 2004, when cconsidering the drowning death rates in children under 20 years of age per 100,000 children of the same age group by WHO region and Member country, it was found that the countries with a low and middle income in the Western Pacific Region had the highest rate, at 13.9, followed by the African Region, the Eastern Mediterranean Region, and the South-East Asia Region, respectively. 2 In Thailand, the rate is 8.2, which is higher than the average for the South-East Asia Region of 6.2 4 see Figure 2. Figure 2: Fatal drowning rates per 100,000 children by WHO region and country income level, World, 2004 These data refer to those under 20 years of age. HIC = High income countries; LMIC = Low and middle income countries Source: WHO 2008. Global Burden of Disease, 2004 update. 8 All over the world, the rate of fatal drownings in children under 15 years of age is 135,585 per year, or 372 per day on average. In the South-East Asia Region, the rate of fatal drownings is 32,744 per year, or 90 per day on average 3 see Table 2. Table 2: Estimated numbers of drowning deaths by age group, WHO region and country income level, 2004 WHO region Income level Age range years 1 1–4 5–9 10–14 15–19 20 World All 10,200 48,267 39,010 38,107 39,708 175,293 High 168 958 500 393 956 2,974 Low 9,916 47,263 38,467 37,680 38,699 172,025 African Region Low 4,445 10,178 4,060 4,618 5,452 28,752 Region of the Americas All 272 2,487 1,395 1,654 2,785 8,592 High 68 445 146 155 333 1,148 Low 203 2,042 1,248 1,499 2,452 7,444 South-East Asia Region Low 2,850 9,362 11,662 8,870 11,027 43,771 European Region All 133 2,334 1,251 1,181 1,051 5,950 High 21 189 86 53 166 515 Low 112 2,145 1,165 1,128 885 5,435 Eastern Mediterranean Region All 1,021 4,605 3,711 3,253 4,342 16,932 High 51 217 117 92 302 779 Low 970 4,388 3,595 3,161 4,040 16,153 Western Pacific Region All 1,363 19,255 16,889 18,497 14,998 71,002 High 27 107 151 93 155 532 Low 1,336 19,148 16,738 18,404 14,843 70,469 Source: World Report on Child Injury Prevention. WHO, 2008. 9 Objectives 1. To investigate the scope and severity of problems and risk factors for drownings among children in Thailand. 2. To derive at a proposal on prevention of child drowning in Thailand as well as on developmentimprovement of the existing child drowning surveillance system in Thailand. Scope of study The present study analyzed the data elicited from existing databases which have a systematic data storage system and reports on drownings on an individual basis. The data, which are continuously compiled and reported, can be categorized according to the age groups of children. The data can be used to analyze the situations of drowning including trends and risk factors of drowning among children in Thailand, to further develop or improve the child drowning surveillance system to ensure comprehensiveness and completeness, and to devise a plan or measure to prevent drowning among children in Thailand. The data used in the present analysis were retrieved from three databases, namely the database of death certificates compiled by the Bureau of Policy and Strategy, MOPH, 5 the database of individual inpatients also compiled by the Bureau of Policy and Strategy, 6 and the Injury Surveillance System IS; operated by the Bureau of Epidemiology, DDC, MOPH. 7 The research team of the present analysis hoped to obtain the data which were as up to date as possible. However, as each database has its own objectives, data acquisition periods, and constraints in data acquisition, the data presented in the present analysis varied in a number of issues. The first important issue was the durations presented in each of the databases. The data retrieved from the death certificates were presented in a period of 10 years from 1999 to 2008, while the data retrieved from the individual inpatients database were presented in a period of 3 years from 2005 to 2007. This was because the Bureau of Policy and Strategy began its coordinated efforts with the National Health Security Office, the Comptroller General’s Department of the Ministry of Finance reimbursements of medical expenses of government officials and family members and the Social Security Office in 2005. Therefore, the data on individual inpatients compiled before that time were not complete or comprehensive. In addition, the data retrieved from the Injury Surveillance System IS were presented in a period of 10 years from 1998 to 2007. The second important issue was the age group. In this study, only data on drownings in children under 15 years of age were analyzed and presented. That was because even though the data collected in the aforementioned databases were individual data, the data in each database were analyzed with a programme which categorized individuals into the following age groups: under 1 year, 1–4 years, 5–9 years, 10–14 years, and 15–19 years. 10 Due to such limitations, in the present study only the data regarding drowning in children aged under 15 years are presented with differences in durations. Such presentation is not different from other reports on child drowning surveillance conducted in other countries where similar limitations could be found. Definition of terms “Child” refers to an individual who is under 15 years of age. “Injury” refers to damage of the body which results from sudden exposure to heat energy, mechanical energy, electricity, or chemicals. It also refers to lack of necessities such as heat or oxygen, which can be either intentional or accidental. At present, the term “injury” has been used to replace the term “accident” as the latter may be misleading, making individuals misunderstand that it is unpredictable or unforeseeable. 5, 6 “Drowning” refers to a process in which an individual loses hisher breathing or the breathing becomes weakened because all body parts, including the respiratory system, are completely immersed in water, or at least the face or the respiratory system is submerged in water or another fluid, and the outcome is death or body’s abnormality or non-abnormality. 10 According to the International Standard Classification of Disease and Related Health Problem ICD-10, the disease codes for morbidity and mortality from drowning are W65–W74. “ICD-10” 8 refers to the international standard diagnostic classification of diseases and health problems that are the causes of morbidity and mortality. W65 refers to drowning and submersion while in a bathtub. W66 refers to drowning and submersion following fall into a bathtub. W67 refers to drowning and submersion while in a swimming pool. W68 refers to drowning and submersion following fall into a swimming pool. W69 refers to drowning and submersion while in natural water. W70 refers to drowning and submersion following fall into natural water. W73 refers to other specified drowning and submersion. W74 refers to unspecified drowning and submersion. “Severe injury” 12 refers to an injured individual who has been dead before arrival DBA at hospital, an injured individual who died in an emergency departmentroom, and an injured individual who is observed in or admitted to hospital. 11 “Admitted patient or admission” 13 refers to the admission of an injured individual as inpatient with an admission number. “Case” 13 refers a visit or admission as inpatient at hospital. “Alcohol consumption” 14 refers to the fact that an injured individual has drunk alcohol, as stated by the injured individual; as observed from hisher gait, speech, or body odor; or as observed from breathing and blood examination as mg, signifying the level of blood alcohol content as determined by an alcohol breath tester or analyzer or with the laboratory results of blood or urine examination. “Average cost of medical care” 13 refer to the average cost of medical services an inpatient has to pay each time heshe seeks medical care or treatment at hospital. “Mean length of hospital stay” 13 refers to the number of days an inpatient spends at hospital from admission to discharge, as calculated by dividing the total number of days of hospital stay of all discharged patients by the total number of patients discharged during the same period. “Location of drowning” 14 refers to the place where the drowning injury has occurred. House and compound of the house refers to place of living of an individual which is not a temporary living place. Dormitory, prison, nursery, or military base refers to a place of living of a group of individuals who share certain similar characteristics, which is not a house or residence of a family or an individual. Hospital, school or temple refers to a building and its compound which is used by a group of individuals or the public for various purposes such as an auditorium except a building under construction, a residence or a sportsathletic field. Public sports arena refers to a venue where the general public exercise, play sports, or participate in a sportsathletic event. Street or highway refers to a route of public transportation that an individual uses to travel from one place to another including the components of such a route. Place for trading goods and services refers to a place that is meant for selling and buying goods and services such as a bank or a market. Construction site or factory refers to a building and its compound that is used for manufacturing a large quantity of products or goods, either small or large in size, including any building and site under construction. Paddy field, farm or garden refers to an area that is used for agricultural and livestock raising purposes, including a construction used for such purposes such as a temporary shelter on the farm. 12 Methodology 1. Secondary data were retrieved from the following three databases: 1 Data from death certificates 15 Death certificate data were compiled from 1999 to 2008 by the Bureau of Policy and Strategy, MOPH, which elicited the civil registration data from the Bureau of Registration Administration, Department of Provincial Administration, Ministry of Interior, and then coded the causes of death on an individual basis based on ICD-10. Limitations of the database The causes of death were not complete, and the “unknown” causes of death accounted for more than 30 of the total causes. Even in the cases where the causes of death were specified, some items were ambiguous and possibly inaccurate because the “mode of death” was specified instead of the “cause of death”, resulting in erroneous or incomplete causes of death. In particular, if the person who specified the causes of death was not a physician, it was even more likely that the causes of death specified in the death certificates would be inaccurate. Management and examination of accuracy of data 1 The data were examined record by record on a periodical basis. 2 The causes of death were coded on an individual basis based on ICD-10. 2 Data on individual inpatients 13 Data retrieved from the individual inpatients database were compiled from 2005 to 2007 by the Bureau of Policy and Strategy after it began to coordinate with the National Health Security Office, the Comptroller General’s Department reimbursement of medical expenses of government officials and family members and the Social Security Office in 2005. Therefore, the data on individual inpatients were the data that the hospitals directly sent to the funds which covered all health-care settings with more details on gender, age group, diseasesyndrome, and the level of health-care settings, etc. Limitations of the database The data did not comprehensively cover all inpatients who were admitted to hospita l because they were data of only the inpatients who had the rights to reimbursements for medical expenses. 13 Management and examination of accuracy of data 1 The data were examined record by record on a periodical basis. Important disease codes, feasibility of data, gender, age, and coding were also examined, particularly the accuracy of the disease codes of serious diseases that required close monitoring and surveillance such as smallpox and plague. Attention was paid to external causes of injuries as well. 2 Erroneous data regarding the coding of important communicable diseases and specification of external causes of injuries were referred back to the related agencies for examination and verification. 3 The National Injury Surveillance System IS The data retrieved from the Injury Surveillance System IS were compiled between 1998 and 2007. Established in 1994, the database is run by the Bureau of Epidemiology, Department of Disease Control, with an objective of utilizing the database to develop health services delivery systems and referral systems at the provincial level. The data is expected to be utilized as baseline data to devise a plan to prevent and solve problems of injuries and accidents at both provincial and national levels. The data compiled at this database are those on injured or deceased individuals with all external causes ICD-10, Chapter 20: External causes of morbidity and mortality, Codes V01–Y36, which take place within seven days and which make the individuals seek medical services at the emergency departmentroom of a large hospital in Bangkok or other provinces across the country. This is considered a provincial surveillance network that has been continuously expanded. At present, there are 29 hospitals in the injury surveillance network, so-called sentinel sites, namely Maharaj Nakhon Ratchasima Hospital, Maharaj Nakhon Si Thammarat Hospital, Lampang Hospital, Ratchaburi Hospital, Chon Buri Hospital, Yala Hospital, Sawanpracharak Hospital Nakohn Sawan, Lerdsin Hospital, Nopparat Ratchathani Hospital, Saraburi Hospital, Khon Kaen Hospital, Songkhla Hospital, Prapokklao Hospital Chanthaburi, Chiang Rai Prachanukhro Hospital, Sappasitthiprasong Hospital Ubon Ratchathani, Phra Nakhon Si Ayutthaya Hospital, Chaopraya Yommaraj Hospital Suphan Buri, Udon Thani Hospital, Surat Thani Hospital, Trang Hospital, Rayong Hospital, Nakhon Pathom Hospital, Buddhachinaraj Hospital Phitsanulok, Chao Phraya Abhaibhubejhr Hospital Prachin Buri, Uttaradit Hospital, Buri Ram Hospital, Surin Hospital, Pra Nangklao Hospital Nonthaburi, and Chachoengsao Hospital. Since 2001, the format of injury surveillance has been improved, and the hospitals that are the sentinel sites are required to document only severe injury cases – injured individuals who are dead 14 before arrival DBA, injured individuals who are pronounced dead at the emergency room, and injured individuals who are observed at, or admitted to, hospital. They are also required to submit the records to the Bureau of Epidemiology for subsequent compilation in the database and the national surveillance reports. Management and examination of accuracy of data 1 The data were examined to ensure their completeness and accuracy by examining the printouts and the electronic files sent by the hospitals that are the sentinel sites using the injury surveillance analysis program. If any errors or discrepancies were found, the responsible hospitals in the network would be informed for revision and resubmission to the Bureau of Epidemiology. 2 Data regarding injury surveillance were compiled, organized, and recorded using the IS on Windows program revised version 2007 to document data regarding severe injuries caused by 19 different causes including traffic accidents. 3 The surveillance data were analyzed using the IS program in terms of descriptive statistics to determine the number, percentage, proportion, ratio, rate of admissions, case-fatality rate, etc. 2. Data were analyzed by means of descriptive statistics. 3. The findings were summarized and the recommendations were proposed. 15

Chapter 2 Findings of Situation Analysis of Child Drowning Surveillance

in Thailand Mortality According to the analysis of death certificates collected at the MOPH’s Bureau of Policy and Strategy between 2004 and 2007, drowning was the number one cause of death in Thai children under 15 years of age, compared to other causes of mortality including infectious and non-infectious diseases see Figure 3. When considering the five leading causes of injury- related mortality between 1999 and 2008, it was found that drowning was the number one cause of mortality, followed by road traffic injuries; accidental threats to breathing; exposure to electric current, radiation, and temperature; and physical assaults. Drowning accounted for as high as 33.9–46.5 of the total injuries. The rate of drowning deaths ranged from 7.7 to 11.5 per 100,000 children under 15 years of age, and the total number of drowning deaths was 1,420 cases per year or 4 cases per day on average see Table 3 and Figure 4. Figure 3: Numbers of deaths due to leading causes of death in children 15 years in Thailand, 2004–2007 1297 1482 1471 300 600 900 1200 1500 2004 2005 2006 2007 Accidental drowning and submersion Assault Pneumonia Vector borne diseases and dengue h Road traffic injuries Data source: Death certificates. Bureau of Policy and Strategy, Office of the Permanent Secretary, Ministry of Public Health. Analyzed by: Suchada Gerdmongkolgan and Som Ekchaloemkiet, Injury Prevention Group, Bureau of Non- Communicable Diseases, Department of Disease Control, Ministry of Public Health, Thailand. 16 Table 3: Numbers, percentage and rates of child deaths per 100,000 children 15 years due to the five leading causes of death in Thailand, 1999–2008 Cause of death Year 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

1. Accidental drowning and submersion W65–W74

Number 1,249 1,412 1,444 1,588 1,472 1,471 1,549 1,482 1,297 1,229 Rate 7.7

8.9 9.1

11.2 10.5

10.7 11.5

11.1 9.8

9.4 Percentage 39.4 40.0 33.9 43.3 42.5 39.2 46.5 35.5 40.6 41.3

2. Road traffic injuries V01–V89

Number 700 864 773 829 723 762 649 659 594 636 Rate 4.3 5.4 4.9 5.9 5.2 5.5 4.8 4.9 4.5 4.9 Percentage 22.1 24.5 18.1 22.6 20.9 20.3 19.5 15.8 18.6 21.4

3. Other accidental threats to breathing W75–W84

Number 29 44 65 72 95 71 96 75 85 77 Rate 0.2 0.3 0.4 0.5 0.7 0.5 0.7 0.6 0.6 0.6 Percentage 0.9 1.2 1.5 2.0 2.7 1.9 2.9 1.8 2.7 2.6 4. Exposure to electric current, radiation and extreme ambient air temperature and pressure W85–W99 Number 78 98 89 96 82 99 93 119 91 71 Rate 0.5 0.6 0.6 0.7 0.6 0.7 0.7 0.9 0.7 0.5 Percentage 2.5 2.8 2.1 2.6 2.4 2.6 2.8 2.9 2.9 2.4

5. Assaults X85–Y09

Number 159 182 93 100 86 48 67 69 87 52 Rate 1.0 1.1 0.6 0.7 0.6 0.3 0.5 0.5 0.7 0.4 Percentage 5.0 5.2 2.2 2.7 2.5 1.3 2.0 1.7 2.7 1.7 Data source: Death certificates. Bureau of Policy and Strategy, Office of the Permanent Secretary, Ministry of Public Health. Analyzed by: Suchada Gerdmongkolgan and Som Ekchaloemkiet, Injury Prevention Group, Bureau of Non- Communicable Diseases, Department of Disease Control, Ministry of Public Health, Thailand.