Key Findings and Recommendations 61 References 67

List of Tables Page Table 1: Leading causes of death in children, both sexes, World, 2004 5 Table 2: Estimated numbers of drowning deaths by age group, WHO region and country income level, 2004 8 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 16 Table 4: Numbers and rates of child drowning deaths per 100,000 children 15 years in Thailand, 1999–2008 19 Table 5: Numbers and rates of child drowning deaths per 100,000 children 15 years in Thailand by region, 2004–2008 20 Table 6: Top ten provinces in Thailand with the highest rates of child drowning deaths per 100,000 children 15 years, 2004–2008 21 Table 7: Top ten provinces in Thailand with the highest numbers of drowning deaths in children 15 years, 2004–2008 22 Table 8: Numbers and rates of child drowning deaths per 100,000 children 15 years in Thailand by gender, 1999–2008 23 Table 9: Numbers and rates of child drowning deaths per 100,000 children 15 years in Thailand by region and gender, 2008 24 Table 10: Numbers and rates of drowning deaths in children under 15 years and all age groups per 100,000 children 15 years in Thailand by age group, 1999–2008 25 Table 11: Numbers and rates of child drowning deaths per 100,000 children 15 years in Thailand by region and age group, 2008 29 Table 12: Percentage of severe injuries among children 15 years due to the five leading causes of injuries in Thailand, 1998–2007 30 Table 13: Numbers and rates of child drowning injuries per 100,000 children 15 years in Thailand, 2005–2007 31 Table 14: Numbers and rates of child drowning injuries per 100,000 children 15 years in Thailand by age group, 2005–2007 31 Table 15: Case-fatality rates for severe drowning injuries in children 15 years in Thailand, 1998–2007 33 List of Tables Cont. Page Table 16: Numbers and percentage of drowning deaths in children 15 years in Thailand by month, 1999–2008 36 Table 17: Numbers and percentage of drowning injuries in children 15 years admitted to hospital in Thailand by month, 2005–2007 38 Table 18: Percentage of severe drowning injuries in children 15 years by day of the week, 1998–2007 40 Table 19: Percentage of severe drowning injuries in children 15 years by time period of the day, 1998–2007 42 Table 20: Percentage of severe drowning injuries in children 15 years by type of water source, 1998–2007 10-year average 44 Table 21: Percentage of severe drowning injuries in children 15 years by type of incident site, 1998–2007 45 Table 22: Percentage of severe alcohol-related drowning injuries in children 15 years by age group, 1998–2007 10-year average 46 Table 23: Costs of medical care for children 15 years with drowning injuries admitted to hospital in Thailand, 2005–2007 49 Table 24: Length of hospital stay for children 15 years with drowning injuries admitted to hospital in Thailand, 2005–2007 49 Table 25: Numbers and percentage of severe drowning injuries in children 15 years in Thailand by type of transport to hospital for treatment, 1998–2007 50 Table 26: Numbers and percentage of severe drowning injuries in children 15 years in Thailand by place of death, 1998–2007 52 Table A: Numbers and rates of child drowning deaths ICD-10, W65–W74; per 100,000 children 15 years in Thaialnd by province, 2006–2008 72 Table B: Numbers of drowning deaths ICD-10, W65–W74 in children 15 years in Thaialnd by province and gender, 2006 75 Table C: Numbers of drowning deaths ICD-10, W65–W74 in children 15 years in Thaialnd by province and gender, 2007 82 Table D: Numbers of drowning deaths ICD-10, W65–W74 in children 15 years in Thaialnd by province and gender, 2008 89 List of Figures Page Figure 1: Fatal injury rates per 100,000 children aged 0–17 years in five Asian countries 6 Figure 2: Fatal drowning rates per 100,000 children 20 years by WHO region and country income level, World, 2004 7 Figure 3: Numbers of deaths due to leading causes of death in children 15 years in Thailand, 2004–2007 15 Figure 4: Mortality rates for the five leading causes of death in children 15 years rate per 100,000 children 15 years in Thailand, 1999–2008 17 Figure 5: Numbers and rates of deaths per 100,000 population due to the five leading causes of death in Thailand by age group, 2008 18 Figure 6: Numbers and rates of child drowning deaths per 100,000 children 15 years in Thailand, 1999–2008 19 Figure 7: Numbers and rates of child drowning deaths per 100,000 children 15 years in Thailand by region, 2004–2008 20 Figure 8: Numbers and rates of child drowning deaths per 100,000 children 15 years in Thailand by gender, 1999–2008 24 Figure 9: Numbers and rates of child drowning deaths per 100,000 children 15 years in Thailand by age group, 1999–2008 26 Figure 10: Rates of drowning deaths in children 15 years and in all age groups per 100,000 children 15 years in Thailand by age group, 1999–2008 26 Figure 11: Proportion of drowning deaths in Thailand by age group, 2008 27 Figure 12: Rates of child drowning deaths per 100,000 children 15 years in Thailand by age group and gender, 2008 28 Figure 13: Numbers and rates of child drowning deaths per 100,000 children 15 years in Thailand by region and age group, 2008 29 Figure 14: Rates of child drowning injuries admitted to hospital per 100,000 children 15 years in Thailand, 2005–2007 32 Figure 15: Case-fatality rates for severe drowning injuries in children 15 years in Thailand, 1998–2007 34 List of Figures Cont. Page Figure 16: Numbers of drowning deaths in children 15 years in Thailand by month, 1999–2008 10-year average 37 Figure 17: Numbers of drowning injuries in children 15 years in Thailand by month, 2005–2007 3-year average 39 Figure 18: Percentage of severe drowning injuries in children 15 years by day of the week, 1998–2007 10-year average 41 Figure 19: Percentage of severe drowning injuries in children 15 years by time period of the day, 1998–2007 10-year average 43 Figure 20: Percentage of severe alcohol-related drowning injuries in children 15 years by age group, 1998–2007 10-year average 47 Figure 21: Percentage of severe alcohol-related drowning injuries in children 15 years by age group and gender, 1998–2007 48 Figure 22: Percentage of severe drowning injuries in children 15 years in Thailand by type of transport to hospital for treatment, 1998–2007 51 Figure 23: Percentage of severe drowning injuries in children 15 years in Thailand by place of 53 1 Executive Summary This report on the situation analysis of child drowning surveillance in Thailand aims to investigate the scope and severity of child drowning, explore risk factors for child drowning, and propose recommendations for the prevention of child drowning and the development of a surveillance system for child drowning. A systematic analysis was conducted utilizing three databases which had systematically compiled data on individual reports by age as well as ongoing reports. The three databases include: 1 the mortality database on death certificates, 2 the database of individual inpatients, and 3 the Injury Surveillance System IS. The first two databases are operated by the Bureau of Policy and Strategy, Ministry of Public Health MOPH, while the third one is handled by the Bureau of Epidemiology, Department of Disease Control DDC, MOPH. Each database has its own objectives, data acquisition periods, and data acquisition limitations. The three databases were used in the analysis to ensure that the data were as up to date as possible. It is noteworthy that due to the aforementioned limitations, in the present study the data regarding drowning in children under 15 years of age only with variations in terms of duration were used. This is not different from other studies carried out abroad which also have limitations when reporting on drowning of individuals with different age groups and durations. The findings of the present analysis can be summarized as follows: Summary of major points ƒ There are 135,585 children under 15 years of age who die from drowning all over the world each year, or about 372 children per day on average. ƒ In the WHO South-East Asia Region, there are 32,744 drowning deaths each year or 90 deaths per day on average. ƒ In Thailand, the rate of child drowning deaths is 5 to 15 times higher than those for developed countries. ƒ Drowning is the number one cause of death among Thai children under 15 years of age compared to fatalities due to all other causes including infectious and non-infectious diseases. ƒ The number of Thai children under 15 years of age dying from drowning is 2 times higher than that from traffic accidents and 24 times higher than that due to vector-borne viral diseases including dengue hemorrhagic fever. ƒ In Thailand, 1,420 children under 15 years of age die from drowning each year, or about 4 children per day on average 10-year average. 2 ƒ The child drowning death rates per 100,000 children under 15 years of age between 1999 and 2008 ranged from 7.7 to 11.5. ƒ Child drowning deaths had a steadily rising trend between 1999 and 2006 with a downward trend afterwards. ƒ The northeastern region has the highest rate of child drownings, followed by the central, northern, and southern regions, respectively. ƒ Chachoengsao province is one of the top ten provinces with the highest rates of child drownings in Thailand for 5 consecutive years between 2004 and 2008. ƒ Nakhon Ratchasima, Bangkok, Buri Ram, Ubon Ratchathani, Surin, Si Sa Ket, Udon Thani, and Khon Kaen have the highest rates of drowning deaths 5-year average: 2004 to 2008. ƒ Nakhon Ratchasima province had the highest number of drowning deaths in the four-year period between 2005 and 2008, ranging from 59 to 82. ƒ The top ten provinces with the highest rates of drowning deaths between 2004 and 2008 are Surin, Si Sa Ket, Buri Ram, Phitsanulok, Ratchaburi, Phetchabun, and Nakhon Pathom. ƒ The rate of child drowning deaths for males is approximately 2 times higher than that for females. ƒ On average, children in the 0–4 age group ranked first for drowning deaths between 1999 and 2008, followed by the 5–9 age group; but since 2005, the 5–9 age group has ranked first. ƒ The proportion of drowning deaths in children under 15 years of age is as high as 30.2 of drowning deaths in all age groups. ƒ The 0–4 age group has the highest drowning injury rate, 2 times higher than that for the 5–9 age group and 5 times higher than that for the 10–14 age group. ƒ The case-fatality rate of drownings in children under 15 years of age 10-year average: 1998 to 2007 is as high as 41.0. ƒ April is the month with the highest number of drowning deaths of 178 10-year average: 1999 to 2008, followed by May and March at 150 cases and October at 140 cases. All these months are during school breaks. ƒ Weekends Saturdays and Sundays have the highest incidents of severe drowning injuries, accounting for 38.8 of all drowning fatalities 10-year average: 1998 to 2007. ƒ The time period of the day with the highest incidents of severe drowning injuries is between 12:00 noon and 17:59 hrs, accounting for 64.2 of all drowning fatalities 10-year average: 1998 to 2007. 3 ƒ As regards water sources where drownings occur, natural bodies of water rank first, accounting for 49.9 of all drownings, followed by swimming pools and bathtubs at 5.4 and 2.5, respectively 10-year average: 1998 to 2007. ƒ Of the children under 15 years of age who suffered severe drowning injuries, 1.2 had alcohol consumption behavior. ƒ The youngest children who were found to suffer drowning injuries and had drunk alcohol were seven years old. ƒ The average cost of medical care for children with drowning injuries admitted to hospital is 12,125 baht per child per year 3-year average: 2005 to 2007. ƒ Most 81.8 of the children with severe drowning injuries admitted to hospital were rescued and taken to hospital by their relatives or bystanders 10-year average: 1998 to 2007. Recommendations 1. Efforts should be made for drowning prevention to be regarded as a national policy as drowning is the number one cause of fatalities among Thai children. 2. Information on drowning should be publicized more widely through different media. 3. Drowning prevention campaigns should be continuously and consistently carried out all year round, especially during school breaks when drowning incidents are highest. 4. Surveys should be undertaken on water sources that pose a risk of drowning in the households, neighborhoods, and communities. 5. Knowledge of drowning prevention should be disseminated and awareness of this matter should be raised among the core target groups in the following aspects: ƒ Parents and caregivers: making them aware of the necessity to give close and constant care to small children as they are at high risk of drowning. ƒ Children: training them in the survival swimming curriculum. ƒ Parents and caregivers: educating them about correct methods for rescuing drowning children. 6. Preventive measures against child drowning should be rigorously carried out in high-risk provinces such as Chachoengsao, Surin, Si Sa Ket, Buri Ram, Phitsanulok, Ratchaburi, Phetchabun, Nakhon Pathom, Nakhon Ratchasima, Bangkok, Ubon Ratchathani, Udon Thani, and Khon Kaen. 7. Concrete measures should be devised for the management of natural bodies of water which pose a high risk for drowning. 4 8. Research should be conducted to shed more lights on major issues such as the causes of high drowning incidents in the northeastern region, the relationship between drowning and alcohol consumption, and the decline in drowning incidents among older children. Recommendations for development of surveillance systems Community-based surveillance systems should be developed to enable the communities to utilize data to prevent and control child drowning in their localities. Village health volunteers VHVs may be asked to take responsibility for compiling data to be sent to the public health network for subsequent utilization by relevant communities and agencies to solve problems at the local level. This is because the existing surveillance system aims to facilitate the utilization of data on a large scale and it takes time to present the data compiled in each system as the comprehensiveness and completeness of data need to be ensured; therefore, it is not timely to solve local problems. Thus, there are certain limitations when such data are utilized at the district or provincial level. In brief, if the communities are able to develop a community-based surveillance system, it will considerably benefit the operations at the national level. 5

Chapter 1 Introduction

Drowning is a major cause of fatalities in children all over the world. There are 480 children younger than 20 years of age who die from drowning every day. Each year, about 2–3 million children and adolescents are near-drowning victims. Children under five years of age all over the world constitute the most important high-risk group because infants 1 year of age can drown even in shallow water. At present, more than 98 of the children who drowned lived in a country with a low or moderate national income and with open bodies of water such as lakes and streams. As for countries with a high national income, drowning is more likely to occur at swimming pools. 1 According to the 2004 WHO Global Burden of Disease, 2 drowning is one of the 10 leading causes of death in children, especially those aged 5–9 and 10–14 years see Table 1. Table 1: Leading causes of death in children, both sexes, World, 2004 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.