Journal of Community Health

, Volume 36, Issue 1, pp 69–75 | Cite as

Drowning Mortality in the United States, 1999–2006

Original Paper

Abstract

Drowning is the fifth leading cause of unintentional fatalities in the US. Our study described demographics and trend analysis of unintentional drowning mortality in the US from 1999 to 2006, and identifies the changes in deaths for specific population subgroups. Mortality data came from the CDC’s Web-based Injury Statistics Query and Reporting System. Trends during 1999–2006 were analyzed by gender, age group and race. Annual percentage change in deaths/rates and simple linear regression was used for time-trend analysis from 1999 to 2006, and examines its significance. During 1999–2006, there were 27,514 deaths; 21,668 (78.8%) males, 21,380 (77.7%) whites, and 4,241 (15.4%) aged 00–04 years. The annual number of drowning mortality varied from a high of 3,529 in 1999 to a low of 3,281 in 2001. Overall, deaths were increased 1.4% from 3,529 during 1999 to 3,579 deaths during 2006 however, the overall mortality rate decreased by 5%. The proportion of deaths was significantly greater among males than females (27.4 vs. 13.7%: p < 0.001) and blacks than among all other races combined (32.5 vs. 21.3%: p < 0.001). Fatalities reported from California (n = 3,234; 11.75%), Florida (n = 2,852; 10.37%) and Texas (n = 2,395; 8.70%) accounted for 30.82% of all such deaths in the US. Sub-group analyses showed that drowning mortality decreased 0.72% for males but increased 9.52% for females, the trend differ significantly among males and females (p < 0.001). Males, American Indians, and blacks appear to have higher risk of drowning mortality. The trend varied among sexes, age and racial groups from 1999 to 2006. Preventive measures and continuous surveillance is warranted to further decrease these drowning mortalities.

Keywords

Drowning Mortality American Indian Blacks Race United States 

Introduction

Drowning is a major global health problem and it affects all age groups throughout the world, but children under age 15 are more victims [1]. According to World Health Organization (WHO), more than 175,000 children and teenagers die each year from drowning [2]. Drowning is the fifth leading cause of unintentional fatalities in the United States [3], where as it is the second leading cause of unintentional related deaths among children aged 1–14 [4]. During 2001–2002, on average 4,174 persons were treated annually in US Emergency Departments and 3,372 persons died in 2001 because of drowning [5]. Similarly, in 2005, there were on average 10 deaths per day in the United States, with males four times more likely than females to die from unintentional drowning [6]. Also, males have 12 times more risk than females in boat-related drowning, with alcohol use being a frequent contributing factor [7]. Mostly toddlers drown in bathtubs and shower, whereas most adolescents drown in natural bodies of water [7]. The characteristics of drowning vary by age group, the proportion among 0–4 years that drowned in pools, bathtubs, and open water were nearly equal. However, bathtub drowning rates were highest among those aged 65 years and older [8].

Among males aged 5–19 years, drowning mortality rates were higher among black, American Indian/Alaska Native, and Asian/Asian Pacific Islander males than among white males [9]. Similarly, American Indian/Alaska Native, black, and Asian/Pacific Islander males, after 5 years of age, have higher drowning rates than do white males of the same age. [9] Geographically, during 1988–1992 the drowning mortality rate in Alaska was almost 10 times higher than the overall US rate [10]. Recently, Florida was found to have the highest swimming pool infant drowning rate in the United States [11].

In order to better understand the recent trends of drowning mortality in the United States by age, race, sex and geographical locations we undertook this study. The primary objectives of the current study were to present demographics and analyze the trends in mortality rates due to drowning in the United States from 1999 to 2006, and identify the changes in deaths and rates for specific population subgroups.

Methods

Web-Based Injury Statistics Query and Reporting System (WISQARS)

Data came from the CDC Web-based Injury Statistics Query and Reporting System (WISQARS). The WISQARS provides mortality data on residents of the US, which was obtained from death certificate information provided by NVSS (National Vital Statistics System). These mortality reports provide tables with the numbers of injury-related deaths and the mortality rates per 100,000 population according to cause, and intent of injury by gender, age group, race and state for the years 1981–2006. These mortality data were from annual data files of the National Center for Health Statistics (NCHS), CDC, and were derived from multiple cause of death data [12]. Age-adjusted rates were calculated by the direct method standardized to the total US population. The year 2000 was chosen as the standard year.

Data Management

Trends during 1999–2006 were analyzed by gender, age group and race while the data were plotted by race only. The coding of mortality data changed significantly in 1999 from ICD-9 to ICD-10, so the number of deaths and death rates from 1998 and before cannot be compared with 1999. We, therefore, excluded the data before 1999 in our analyses. Ages were divided into 18 groups, and the races were divided into 4 groups. The percentage change in deaths and rates were used to measure the linear trend calculated as (the deaths/rate in the ending year−the death/rate in the beginning year)/(the death/rate in the ending year) × 100%.

Data Analysis

We analyzed the data using Microsoft Excel and JMP (version 8). An alpha of p < 0.05 was selected as the level of significance. We compared proportions between groups by using Chi-square test. We used annual percentage change in deaths/rate and simple linear regression for time trend analysis from 1999 to 2006, and examine its significance. In addition, simple linear regression model was used to compare the difference among time trend analysis from 1999 to 2006 among sexes, age groups and races.

Results

During 1999–2006, unintentional drowning fatalities were caused in 27,514 individuals which were 3.2% of total unintentional injury mortalities (864,736) in the United States during this period. Of 27,514 fatalities, 4,241 (15.4%) were 00–04 years old, 21,668 (78.8%) were males, and 21,380 (77.7%) were whites (Table 1). Drowning fatalities reported from California (n = 3,234), Florida (n = 2,852), and Texas (n = 2,395) accounted for 30.8% of all such deaths in the United States (Table 1). The annual number of drowning mortality varied from a high of 3,529 in 1999 to a low of 3,281 in 2001. Overall, death injuries increased 1.4% from 3,529 during 1999 to 3,579 injuries during 2006 however, the overall mortality rate decreased by 5% (Fig. 1). The proportion of injuries was significantly greater among males than females (27.4 vs. 13.7%: p < 0.001) and blacks than among all other races combined (32.5 vs. 21.3%: p < 0.001).
Table 1

Characteristics of fatal unintentional drowning—United States, 1999–2006

Age (years)

Variables

Deaths (N)

Percentages

Age adjusted rate (per 100,000)

00–04

4,241

15.41

 

05–09

1,240

4.51

10–14

1,204

4.38

15–19

2,578

9.37

20–24

2,346

8.53

25–29

1,739

6.32

30–34

1,495

5.43

35–39

1,818

6.61

40–44

1,985

7.21

45–49

1,812

6.59

50–54

1,469

5.34

55–59

1,113

4.05

60–64

853

3.10

65–69

736

2.68

70–74

756

2.75

75–79

720

2.62

80–84

612

2.22

85+

612

2.22

Unknown

185

0.67

Gender

 Male

21,668

78.75

1.90

 Female

5,846

21.25

0.49

Race

 White

21,380

77.71

1.13

 Black

4,526

16.45

1.44

 American Indian

498

1.81

1.98

 Asian Pacific

1,110

4.03

1.15

States

 Alabama

544

1.98

1.53

 Alaska

197

0.72

3.78

 Arizona

709

2.58

1.55

 Arkansas

406

1.48

1.87

 California

3,234

11.75

1.14

 Colorado

358

1.30

1.00

 Connecticut

225

0.82

0.81

 Delaware

56

0.20

0.86

 District of Columbia

23

0.08

0.49

 Florida

2,852

10.37

2.10

 Georgia

921

3.35

1.32

 Hawaii

252

0.92

2.51

 Idaho

159

0.58

1.43

 Illinois

810

2.94

0.80

 Indiana

529

1.92

1.07

 Iowa

220

0.80

0.94

 Kansas

223

0.81

1.01

 Kentucky

449

1.63

1.37

 Louisiana

729

2.65

2.04

 Maine

136

0.49

1.28

 Maryland

396

1.44

0.92

 Massachusetts

370

1.34

0.72

 Michigan

821

2.98

1.03

 Minnesota

432

1.57

1.07

 Mississippi

428

1.56

1.85

 Missouri

476

1.73

1.05

 Montana

124

0.45

1.69

 Nebraska

135

0.49

0.97

 Nevada

215

0.78

1.22

 New Hampshire

87

0.32

0.87

 New Jersey

500

1.82

0.74

 New Mexico

222

0.81

1.50

 New York

928

3.37

0.61

 North Carolina

797

2.90

1.19

 North Dakota

59

0.21

1.16

 Ohio

780

2.83

0.86

 Oklahoma

464

1.69

1.65

 Oregon

435

1.58

1.55

 Pennsylvania

744

2.70

0.76

 Rhode Island

76

0.28

0.88

 South Carolina

513

1.86

1.55

 South Dakota

77

0.28

1.26

 Tennessee

693

2.52

1.49

 Texas

2,395

8.70

1.31

 Utah

207

0.75

1.01

 Vermont

51

0.19

1.04

 Virginia

672

2.44

1.15

 Washington

698

2.54

1.44

 West Virginia

183

0.67

1.31

 Wisconsin

431

1.57

0.99

 Wyoming

73

0.27

1.80

Fig. 1

Unintentional drowning fatalities and rates (per 100,000)—United States, 1999–2006

Fig. 2

Unintentional drowning rates (per 100,000) in males by race—United States, 1999–2006

Subgroup analysis showed that the largest fatal injuries were in Asian Pacific males aged 55–59 years (500%), black females aged 65–69 years (400%), and Asian Pacific females aged 75–79 years with (400%; Table 2). During the period 1999–2006, for all ages combined, there was 0.72% decrease for males and 9.52% increase for females but this change was not statistically significant overtime in both sexes. However, trend analyses for males and females differ significantly among each other (p < 0.001). For all ages and sex combined, there was 4.49% increase for whites, and 37.5% increase in Asian Pacific. However, there was 15.14% decrease among blacks, and 26.47% decrease in American Indians. Except Asian Pacific (p = 0.003 time related trend) none of the other races had statistically significant time related trend. The changes were not consistent among both sexes, and racial groups (Table 2). The changes were also not consistent among different age groups (data not shown).
Table 2

Percentage changes in unintentional drowning mortality of males and females by race/ethnicity, and age—United States, 1999–2006

Age groups (years)

Whites

Blacks

American Indians

Asian Pacific

Males

 00–04

−11.81

1.92

−50.00

40.00

 05–09

−12.68

−43.33

50.00

−16.67

 10–14

−8.20

−56.92

−100.00

−44.44

 15–19

−20.35

6.41

−33.33

−25.00

 20–24

8.81

−19.61

−20.00

0.00

 25–29

34.07

−26.67

−40.00

62.50

 30–34

−22.78

−20.00

−33.33

80.00

 35–39

−22.09

−10.00

−71.43

50.00

 40–44

7.10

−8.00

−20.00

200.00

 45–49

32.87

41.18

0.00

100.00

 50–54

7.38

33.33

50.00

133.33

 55–59

55.26

18.75

0.00

500.00

 60–64

14.29

85.71

−100.00

66.67

 65–69

32.08

−25.00

0.00

−100.00

 70–74

18.87

−33.33

0.00

0.00

 75–79

32.08

−37.50

−100.00

300.00

 80–84

9.09

−100.00

100.00

 85+

50.00

0.00

 Unknown

−71.43

100.00

−50.00

−100.00

Females

 00–04

−7.47

−27.59

66.67

100.00

 05–09

−37.14

−25.00

50.00

 10–14

0.00

−66.67

−100.00

−100.00

 15–19

33.33

−71.43

−100.00

 20–24

40.91

50.00

0.00

 25–29

62.50

−66.67

 30–34

−66.67

−40.00

−100.00

 35–39

−3.03

0.00

 40–44

48.48

33.33

−100.00

200

 45–49

59.38

 50–54

80.00

100.00

−33.33

−50.00

 55–59

69.57

33.33

0.00

 60–64

42.11

0.00

 65–69

63.16

400.00

 70–74

−31.03

133.33

−50.00

 75–79

42.86

−33.33

400.00

 80–84

30.00

−100.00

100.00

 85+

−20.59

33.33

−66.67

 Unknown

−75.00

Among females for all age groups and races combined, the deaths increased by 7% during 2004–2005. Among males, for all age groups and races combined the deaths increased by 7.85% during 2001–2002 and by 8.64% during 2004–2005. However, the deaths decreased in the remaining years among males (Table 3).
Table 3

Percentage changes in deaths and rates per 100,000 per year in unintentional drowning mortality by sex, and race/ethnicity—United States, 1999–2006

Variables

Year

Deaths

Age adjusted rate

Percentage change in deaths per year

Percentage change in rates per year

Sex

 Males

1999

2,794

2.02

  

2000

2,735

1.96

−2.11

−2.97

2001

2,560

1.82

−6.40

−7.14

2002

2,761

1.95

7.85

7.14

2003

2,632

1.83

−4.67

−6.15

2004

2,594

1.79

−1.44

−2.19

2005

2,818

1.93

8.64

7.82

2006

2,774

1.87

−1.56

−3.11

 Females

1999

735

0.51

  

2000

747

0.52

1.63

1.96

2001

721

0.5

−3.48

−3.85

2002

686

0.47

−4.85

−6.00

2003

674

0.45

−1.75

−4.26

2004

714

0.48

5.93

6.67

2005

764

0.51

7.00

6.25

2006

805

0.52

5.37

1.96

Race

 Whites

1999

2,715

1.18

  

2000

2,683

1.16

−1.18

−1.34

2001

2,515

1.08

−6.26

−7.60

2002

2,624

1.12

4.33

3.82

2003

2,622

1.10

−0.08

−1.61

2004

2,565

1.07

−2.17

−2.67

2005

2,819

1.17

9.90

9.01

2006

2,837

1.16

0.64

−0.08

 Blacks

1999

634

1.65

  

2000

593

1.54

−6.47

−7.19

2001

579

1.48

−2.36

−3.57

2002

613

1.58

5.87

6.47

2003

480

1.22

−21.70

−22.61

2004

533

1.35

11.04

10.48

2005

556

1.40

4.32

3.99

2006

538

1.32

−3.24

−5.82

 American Indians

1999

68

2.51

  

2000

79

2.50

16.18

−0.45

2001

52

1.59

−34.18

−36.36

2002

66

2.09

26.92

31.64

2003

62

1.97

−6.06

−5.68

2004

57

1.75

−8.06

−11.41

2005

64

2.05

12.28

17.05

2006

50

1.51

−21.88

−26.02

 Asian Pacific

1999

112

1.04

  

2000

127

1.11

13.39

6.58

2001

135

1.11

6.30

−0.34

2002

144

1.20

6.67

8.82

2003

142

1.17

−1.39

−2.98

2004

153

1.24

7.75

6.55

2005

143

1.15

−6.54

−7.67

2006

154

1.11

7.69

−3.22

Among the races for all age groups and sexes combined the deaths increased by 26.92% in American Indians during 2001–2002, 13.39% among Asian Pacific in 1999–2000, 11.04% among blacks in 2003–2004, and 9.9% among whites in 2004–2005 (Table 3). Within different age groups of combined sexes and races, the highest deaths increased by 34.21% among aged 75–79 in year 2005, however, the highest decrease occurred by 21.36% among aged 30–34 in 2001 (data not shown).

Rates

During the period 1999–2006, subgroup analysis showed that the mortality rate decreased in males (7.43%) while increased in females (1.96%) though the change was not statistically significant overtime in both sexes. However, trend analyses for males and females differ significantly among each other (p < 0.001). For all ages and sex combined there was 1.28% decrease for whites, 20.22% decrease for blacks, 39.66% decrease for American Indians, however Asian Pacific showed 6.76% increase (Table 3). Except blacks (p = 0.030 for time-trend analysis) none of the other races had statistically significant time related trend. Among the races for all age groups and sexes combined, the rate increased by 31.64% in American Indians during 2001–2002, 8.82% among Asian Pacific during 2001–2002, 10.48% among blacks in 2003–2004, and 9.01% among whites during 2004–2005.

Among females for all age groups and races combined, the highest rate increased by 6.67% during 2003–2004. American Indian females had the highest drowning mortality rates in all years except 2001 followed by Asian pacific females (Fig. 3). Among males the rates increased by 7.14% and 7.82% during years 2001–2002 and 2004–2005, respectively (Table 3). American Indian males had the highest drowning mortality rates in all years followed by black males (Fig. 2). The time trend analysis differ significantly among all races when males were compared with females (p < 0.001).
Fig. 3

Unintentional drowning rates (per 100,000) in females by race—United States, 1999–2006

Discussion

The results showed that overall drowning fatalities slightly increased from 1999 to 2006 while the overall rates decreased. The proportion of deaths significantly greater among males than females and blacks among all other races combined. Among all the states California, Florida and Texas had the highest number of unintentional drowning mortalities while Alaska, Hawaii, and Florida had highest age-adjusted rates per 100,000 in the US. During 1999–2006, subgroup analyses showed that the largest increase in deaths were in Asian Pacific males aged 55–59 years and in Asian Pacific females aged 75–79 years.

In the United States, male gender has been described as high risk group for drowning mortality [13]. Decedents vary among different age groups [14, 15], but drowning mortality is common among young children [13, 16, 17]. Drowning mortality is also not uncommon among adults, and mostly occur in recreational/sports water setting [5, 18]. Alcohol drinking, inexperience, and non-use of a personal flotation device are some of the contributing causes among adult drowning [15, 18].

Out study depicts that Alaska, Hawaii, and Florida had the highest age-adjusted rates per 100,000 in the United States. Injury deaths among children aged 0–6 years in Alaska during 1993–1995 and Louisiana during 1994 were mostly attributed to preventable violations of child safety standards, most commonly the supervision standard [19]. In addition, in Alaska, boaters and swimmers are subject to the risks of land-based activities, including falls, burns and cuts [20]. Cold water is a hazard in Alaska, water-related injuries often occur in remote environments, where the nearest trained emergency response teams are several hours away [20]. Similarly, while mapping high-risk geographic areas within United States, drowning rates for young children were high on the West Coast and in Florida [21]. In the US, during 1999–2003 Florida had the highest drowning death rate for children aged 1–4 years (8.9/100,000) and recorded 356 unintentional drowning deaths among children in this age group [22]. Main cause in majority of these happenings was a door leading from the house to the pool area [22].

Overall, in our study we found that American Indians have the highest drowning fatality rates followed by blacks, similar trend over time was found among American Indian males and black males. American Indian/Alaska Natives have an overall injury-related death rate that is twice the US rate for all racial/ethnic populations [23], however during 1989–1998 mortality data by Indian Health Service (IHS) showed substantial improvement over time in drowning [24]. Among age group 5–24 years, drowning rates were found to be highest among black males in 1995–1998 [13]. The study, using retrospective database review of 1994–2000 Massachusetts death and hospital discharge data, has shown that worse outcomes (death or chronic disability) occurred among African American children aged 0–19 years in 1994–2000 [17]. Similarly, poor minority children, specifically African-American and Hispanic/Latino, are at a significant disadvantage concerning swimming ability, with age, race and socioeconomic factors (lunch program and parental education) are significantly associated with children who have low swimming ability among six US cities [25].

The findings in this report are subject to some limitations. The diagnoses provided on the death certificate may be erroneous or incomplete, leading to misclassification of condition under study [26]. Lack of availability of detailed data from death certificates are influenced by varying methods of completion of death certificates. For example, details are lacking on socioeconomic factors, exposure data, individual behaviors, cultural differences, and risk factors that are extremely important for the development of effective interventions. We did not include non-fatal injuries in our analysis, which may be useful in comparative analyses between fatal and non-fatal drowning. Finally, results with small number of age-, race-, and state-specific deaths may be interpreted with caution.

Despite these limitations, our study provides valuable data on current trends of drowning fatalities in the United States. Given the paucity of information on this topic, our findings provide a much-needed foundation for further work in this area, including interventions designed for high risk groups.

Conclusion

Males, American Indians, and blacks appear to have higher risk of drowning mortality. The trend varied among sexes, age and racial groups from 1999 to 2006. Prevention efforts for drowning fatalities in high risk groups should be strengthened and surveillance for these deaths should continue to follow future trends.

Notes

Conflict of interest statement

None declared.

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Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  1. 1.Injury Control Research CenterWest Virginia UniversityMorgantownUSA
  2. 2.Department of Community Medicine, Health Science CenterWest Virginia University School of MedicineMorgantownUSA
  3. 3.Stanford Center for Professional DevelopmentStanford UniversityStanfordUSA
  4. 4.Centers for Disease Control and Prevention (CDC)National Institute for Occupational Safety and Health (NIOSH)MorgantownUSA

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