Journal of Forensic and Legal Medicine 31 (2015) 7e11
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Journal of Forensic and Legal Medicine j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / j fl m
Original communication
Drowning-related fatalities during a 5-year period (2008e2012) in South-West Hungary e A retrospective study cz a, Franciska Ko € nczo € l a, Hajnalka Me sza ros b, Zsolt Kozma c, Ma tya s Mayer a, Evelin Ra r a, Katalin Sipos a, * n Porpa czy a, Viktor S. Poo Zolta Department of Forensic Medicine, Faculty of Medicine, University of P ecs, 12 Szigeti str., H-7624 P ecs, Hungary rd, Hungary Institute of Forensic Medicine, Network of Forensic Science Institutes, Ministry of Public Administration and Justice, Szeksza c r, Hungary Institute of Forensic Medicine, Network of Forensic Science Institutes, Ministry of Public Administration and Justice, Kaposva a
b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 18 June 2014 Received in revised form 6 January 2015 Accepted 8 January 2015 Available online 16 January 2015
The purpose of the present study was to investigate all the drowning-related cases in South-West Hungary between 2008 and 2012. It is a retrospective and descriptive study of 114 drowning-related deaths during that 5-year period. The investigation includes both unintentional and intentional drowning cases. We found that the most considerable risk factor of drowning in this area of Hungary is alcohol consumption, because in more than half of the cases the victims were under the influence of alcohol. We also concluded that more than two third of the cases included males. The cause of drowning in younger victims was mostly accident. In both genders subjects aged 50e70 had the highest risk of drowning in the period investigated. Seniors frequently committed suicide by drowning. Drowning deaths occurred in all types of water, mostly in lakes, rivers, canals and other types of catchment in the vicinity of victims' homes (most commonly in wells). This study might help to understand the circumstances and the causes leading to drowning and it may draw the attention to the possible preventive interventions. © 2015 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
Keywords: Forensic medicine Statistics Hungary Drowning Risk factors Accident
1. Introduction Investigation of bodies found in various types of water is an important and sometimes difficult part of the medico-legal examination.1 Drowning was reported by the World Health Organization to be the 3rd leading cause of unintentional death worldwide in 2012, accounting for 7% of all injury-related deaths. WHO estimates indicate that 359 000 people died from drowning in 2011. Accidental non-transport-related drowning and submersion deaths are also common cause of deaths in Hungary.
Abbreviations: BAC, blood alcohol concentration; HS-GC, headspace-gas chromatography; ICD, International Statistical Classification of Diseases and Related Health Problems; PCR, polymerase chain reaction; WHO, World Health Organization. * Corresponding author. Tel.: þ36 72536240. E-mail addresses: [email protected] (E. R acz), [email protected]. € nczo €l), [email protected] (H. Me sza ros), [email protected] hu (F. Ko (Z. Kozma), [email protected] (M. Mayer), [email protected] czy), [email protected] (V.S. Poo r), [email protected] (Z. Porpa (K. Sipos).
Data from the Hungarian Central Statistical Office indicate an average of 174 drowning-related deaths (ICD codes W65-W74) per year in Hungary between 2008 and 2012, the highest number of cases being 203 in 2010, while the lowest number was 156 in 2011. 2. Materials and methods Drowning is defined as “the process of experiencing respiratory impairment from submersion/immersion in liquid” (official definition by World Health Organization, 2005). Many countries including Hungary have no reliable study on major causes and reasons of drowning deaths. The present study was aimed to collect and describe all drowning-related fatalities in Baranya, Somogy and Tolna counties in the South-West region of Hungary from 1 January 2008 till 31 December 2012. There was a total number of 114 drowning-related deaths during those five years. We have focused our attention on the gender, age and the possible alcohol consumption of victims, the location of death (type of water), and other factors contributing to the fatalities including drugs, manner of drowning, etc.
http://dx.doi.org/10.1016/j.jflm.2015.01.001 1752-928X/© 2015 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
cz et al. / Journal of Forensic and Legal Medicine 31 (2015) 7e11 E. Ra
8
This study includes all the cases where autopsy was performed in one of the three counties. Drowning as the cause of death was presumed by autopsy findings and police reports (which also included eyewitnesses' descriptions) and was diagnosed by macroscopic and microscopic findings (histology and diatom test), in some cases it was also confirmed by PCR-based methods (DNA isolation from microalgae).2,3 During complete autopsy natural causes of death were excluded and the most frequent findings included the following: petechial bleeding; voluminous lungs, ballooning, distended; Paltauf's hemorrhages; emphysema aquosum; fluid blood and congestive organs. Histological examination confirmed the autopsy findings. Blood (97 cases) was used as biological material on which the measurement of blood alcohol concentration was conducted using HS-GC-FID Agilent Technologies 7890A automated headspace gas chromatograph with flame-ionization detection. The blood alcohol concentration categories were classified by the official rules applied by National Institute of Forensic Medicine, Hungary. HPLC-DAD (High-Performance Liquid Chromatography with Diode array detector) technology was used for drug screening in plasma (74 cases). Statistical analysis was performed using the GraphPad Prism program for Windows software. The Pearson's Chi-squared test was used for statistical analysis. A P value below 0.05 was considered significant. 3. Results and discussion During the five-year period a total number of 114 drowningrelated deaths in South-West Hungary was investigated. The number of drowning cases remained permanent during the years. The yearly case numbers have not changed significantly (the twotailed P value equals 0.1259). Four out of the 114 cases were unidentified persons, but during autopsy we could classify them by most of their properties (gender, age etc). However, two individuals' time of death remained unknown, not even the exact year of their deaths could be identified (see Table 1). 3.1. Risk factor: gender All studies available in this field report that more males than females get drowned.4e7 In our survey we also found that males (81 out of 114) are at greater risk of drowning than females (33 out of 114) (see Table 2). Death rate of males (71.05%) was more than two times higher than that of females (28.95%). The difference is significant (the two-tailed P value is less than 0.0001). This result correlates with the statistical data provided by the World Health Organization. The reason for this may be the consumption of greater amounts of alcohol by men and their relatively high selfesteem. It is also manifested in the circumstances of deaths (e.g. swimming on their own under the influence of alcohol).
Table 1 The number of drowned individuals during 2008e2012 in South-West Hungary. Years
2008 2009 2010 2011 2012 Unknown Total
Total Number
%
12 25 21 28 26 2 114
10.53 21.93 18.42 24.56 22.81 1.75 100
Table 2 Age distribution of male and female drowning victims who drowned during 2008e2012 in South-West Hungary. Age groups
0e10 11e20 21e30 31e40 41e50 51e60 61e70 71e80 81e90 Unidentified Total
Males
Females
Total
Number
%
Number
%
Number
%
1 12 7 10 8 21 13 6 1 2 81
0.88 10.53 6.14 8.77 7.02 18.42 11.40 5.26 0.88 1.75 71.05
0 1 0 3 4 10 7 5 3 0 33
0 0.88 0 2.63 3.51 8.77 6.14 4.39 2.63 0 28.95
1 13 7 13 12 31 20 11 4 2 114
0.88 11.41 6.14 11.40 10.53 27.19 17.54 9.65 3.51 1.75 100
3.2. Risk factor: age Age distribution of male and female victims is presented in Table 2. The number of drowning fatalities was the highest between ages 51 and 60 (31 of the total 114 cases; 27.19%); moreover, both for men and women the drowning rate was the highest between the ages 51 and 70, in this age group it is 44.73% of all drowning cases during those five years. The youngest victim in this study was a 5 year-old boy seen by his mother submerge in Lake Balaton and a few hours later his body was found. The oldest victim was an 88year-old woman found in a well in her garden. Data from the WHO Factsheet on Drowning indicate that children under five years of age have the highest drowning mortality rate worldwide.7e10 In contrast, we found that children's drowning death rate was surprisingly low in this area of Hungary; there was only one victim in this age group. According to the WHO fact sheet of drowning, adult males in Canada and New Zealand are at high risk of drowning.5,7 In Hungary we found that elderly men are more likely to drown than younger individuals. No data showing a similarly high ratio of elderly victims have been found in other countries, this rate is the highest known in the region of Hungary studied. For a more detailed discussion of the background to this phenomenon see Section 3.6 Risk factor: Manner of drowning death. 3.3. Risk factor: alcohol consumption and drugs 3.3.1. Alcohol consumption From many countries there is no information about alcohol consumption of victims, although WHO data suggest that it is a preliminary condition for accidental drowning deaths.4,7 In our study the blood alcohol concentration could be measured in 68 out of 81 (83.95%) male and 29 out of 33 (87.89%) female victims. In these cases with measurable BAC (97 out of 114), 85.29% of males (58 out of 68) and 51.72% of females (15 out of 29) had consumed alcohol. In nearly two third of all the cases (73 out of 114; 64.04%) the blood alcohol level was above 0.021% (0.021 g of alcohol for every dL of individual's blood) and only 24 victims' BAC (21.05%) was proved negative (BAC 0.020%). In 17 cases (14.91%) the BAC level could not be determined, mostly because of the advanced decay stage of decomposition and/or the lack of blood. Blood alcohol level in male victims was higher than in females on average, there were 8 males with a blood alcohol concentration close to the toxic level (BAC is above 0.351%), however, the cause of death in those cases was also drowning. Among men we could not find correlation between alcohol consumption and age. Female victims have consumed much smaller amounts of alcohol and it
cz et al. / Journal of Forensic and Legal Medicine 31 (2015) 7e11 E. Ra
1 12 7 10 8 21 13 6 1 2 81 e e e 1 4 3 e e e e 8 e e e 3 2 6 2 e e e 13 e 1 e 1 2 1 3 1 e e 9 e e 1 1 e 1 1 e e e 4 e 2 2 e e 1 1 1 e e 7 e 4 3 2 e 2 3 3 e e 17 1 4 1 1 e 2 e e 1 e 10 e 1 e 1 e 5 3 1 e 2 13 0 1 0 3 4 10 7 5 3 0 33 e e e e e e e e e e 0 a
b
e 1 e e 2 3 4 2 2 e 14 e e e 2 1 1 e e e e 4
Reasons: advanced decay stage of decomposition and/or the lack of blood. 0e0.020%e BAC is considered being negative.
e e e e 1 e e e e e 1 e e e e e 2 2 1 e e 5 e e e e e 1 e e e e 1 e e e e e 1 e e e e 1
0e0.020b Cannot be assesseda
Males
Total females 0.350< 0.251e 0.350 0.151e 0.250 0.081e 0.150 0.051e 0.080 0.021e 0.050 0e0.020b Females
BAC
Cannot be assesseda
0e10 11e20 21e30 31e40 41e50 51e60 61e70 71e80 81e90 Unknown Total
Fig. 1. Correlation between the distribution of blood alcohol concentrations (% by vol.) and gender (x-axis: blood alcohol concentration, on the columns: number of drowned individuals; total n ¼ 97) in drowning deaths occurred during 2008e2012 in South-West Hungary. Between the number of the negative (n ¼ 24) and positive (n ¼ 73) cases the difference was significant.
Age
Hungary is rich in rivers and lakes, therefore the majority of fatal drowning cases occurred in natural waterbodies (see Table 5). The highest number of drowning fatalities occurred in the River Danube (30 out of 114; 26.32%) and Lake Balaton (22 out of 114; 19.30%).
Table 3 Distribution of age and blood alcohol concentration (% by vol.) of victims between 2008 and 2012 in South-West Hungary.
3.5. Risk factor: types of waterbodies where the victims were found
0.021e 0.050
3.4. Risk factor: season
e e e 1 e 2 1 2 1 e 7
Total males 0.350< 0.051e 0.080
0.081e 0.150
0.151e 0.250
0.251e 0.350
3.3.2. Drug consumption Toxicology analysis in our laboratories identified drugs in 11 out of the 74 cases (5 cases in females, and 6 cases in males; 14.86%): the most common pharmaceutical drug was benzodiazepine (5 cases), followed by citalopram (2 cases), and carbamazepine, noraminophenazon, ibuprofen, venlafaxine in the rest of the cases. In 3 cases the concentration of drugs in blood was found above the toxic level (benzodiazepine, venlafaxine, citalopram). The ages of the above victims were between 54 and 75 years. We also found amphetamine in three cases (17, 20 and 52 years old males). Compared to other countries, this is a very low number of drug use among drowning victims.6,11
In our statistical analysis drowning occurred mostly in warmer months from March till the end of August (74.56%) (see Table 4). Nearly half of the fatalities (49.12%) happened in summer, and this difference proved to be significant (the two-tailed P value is less than 0.0001). Drowning deaths in autumn and winter are not negligible, either: the causes, similarly to those in other seasons, usually were accidents. However, suicide by drowning happened generally in winter. The seasonal pattern of drowning deaths was similar compared to that of other countries.4,10,12
1 13 7 13 12 31 20 11 4 2 114
Total
was found typical in the elderly group (see Fig. 1). The correlation between the number of positive (n ¼ 73) and negative (n ¼ 24) cases was found to be statistically significant. The distribution of the age and the blood alcohol concentration of the victims is shown in Table 3.
9
cz et al. / Journal of Forensic and Legal Medicine 31 (2015) 7e11 E. Ra
10
Table 4 Seasonal distribution of drowning deaths during 2008e2012 in South-West Hungary. Season
Spring Summer Autumn Winter Unknown Total
Total
Manner of drowning
Number
%
29 56 13 12 4 114
25.44 49.12 11.40 10.53 3.51 100
Indoor drowning deaths were rare: there were only four victims who died in either a swimming pool (1 case) or in bathtubs (3 cases). 13 out of 114 drowning deaths occurred near the victims' home (garden pond, ditch, wine cellar) and three cases in the victim's apartment (3 bathtub deaths). Victims were often found in wells in cases of suicide. All the 4 unidentified bodies were found in the river Danube. The Danube flows across 10 countries, it is also possible that the river brought these bodies across the borders. This factor makes the identification of victims more complicated. 3.6. Risk factor: manner of drowning death Eyewitnesses may contribute to the investigation on the circumstances of fatalities with a lot of data.13 However, there were several cases (29 out of 114) where we did not know anything about the background of drowning deaths (e.g. unknown bodies, no eyewitnesses or no relatives, who would know about the intent). On autopsy it was presumed that most of the drowning deaths with unknown history occurred accidentally or because of suicide as there were no signs of violence in these cases.14 3.6.1. Accidental drowning death Accidents are the main cause of drowning deaths in South-West Hungary (see Table 6). Accidental drowning fatalities happened mainly because of high BAC level, chronic diseases (e.g. diabetes, high blood pressure) or during physical or sports activities.15 We found that swimming in a body of water is still the recreational sports activity during which the largest number of drowning occurs (22 out of 114 cases). We found a few other special cases which happened during water sports activities. There was one person who died while kayaking (BAC was 0.178%). Another one who could not swim and did not wear lifesaving jacket either, fell out of an inflatable boat (BAC was 0.028%). One victim fell into the water from a boat while fishing (BAC was 0.157%) and another one from a pedal boat (BAC 0.040%). One person died while windsurfing in Lake Balaton in March (BAC 0.020%), he did not wear a lifesaving jacket either, and there were no gale warning during that season.
Table 5 Waterbody types where victims were found (2008e2012, South-West Hungary). Waterbody types
Lake River Creek Canal At home Well Other Total
Table 6 Manner of drowning deaths occurred between 2008 and 2012 in South-West Hungary.
Total Number
%
42 39 6 3 8 8 8 114
34.21 36.84 5.26 2.63 7.02 7.02 7.02 100
Suicide Homicide Accident Unknown Total
Males
4 1 53 23 81
Females
11 1 15 6 33
Total Number
%
15 2 68 29 114
13.16 1.75 59.65 25.44 100
All of the individuals who drowned during recreational water sports activities were males. These fatalities occurred under the influence of alcohol. 3.6.2. Suicide by drowning The WHO qualifies the drowning death data as insufficient because they include only “accidental drowning and submersion”, however the incidence of suicidal drowning deaths seem to be considerable.7 We found 15 suicidal drowning cases (13.16% of all the cases) in the five years investigated. Suicide as the cause of a drowning fatality is hard to prove. In this study we regarded such cases as proven when confirmed by eyewitnesses, by victims' farewell letters left behind or by witnesses who were told about the suicidal intention by the victims. Suicidal deaths were more frequent in elderly people (age group of 61e90).16 Consumption of alcohol was not specific in this age group in the case of suicide (some of these victims consumed moderate amounts of alcohol). Females were more likely to choose suicide by drowning than males (11 females and 4 males). Males who committed suicide by drowning were between the ages of 50 and 75, and females were between the ages of 38 and 82. We found that middle-aged males and females who chose this method of suicide were after a family quarrel and left the house right before drowning. In this study the chosen modus operandi of suicidal drowning deaths was jumping in wells or jumping off bridges. International data show that there is a tendency of suicide rate by drowning increasing with age.6,16 3.6.3. Homicide by drowning In the period investigated there were only two homicidal drowning cases, a 16-year-old male and a 58-year-old female. In both cases victims were battered and left in the water, and finally the cause of their deaths was due to the lack of self-rescue capability. 4. Conclusions We have carried out a thorough statistical evaluation of 114 proved drowning fatalities which occurred in a 5-year period at the South-West region of Hungary. We conclude that the features of these death cases show a large number of similarities to the drowning-related deaths all over the world, but some unexpected outcome was also found on the data assessment. Distribution of the gender of the drowned victims in the examined Hungarian region is like what the international statistics show: more than two thirds of the casualties were males.4e7 Considering the age of the victims our study gave different results from those found in the statistical data of other countries: in the latter ones children are threatened more by drowning. In our study children's drowning death rate was very low (only one victim) in this area of Hungary and it is in contrast with WHO findings: children under 5 years of age have the highest drowning mortality rates worldwide.7e9,17 The reason for this can be the high
cz et al. / Journal of Forensic and Legal Medicine 31 (2015) 7e11 E. Ra
attention to children in Hungary. In our country people at the age of 51e70 years have the highest risk of drowning. We found alcohol consumption to be a major contributing factor of drowning deaths: in 31.58% (36 individuals from 114 cases) of the drowning cases blood alcohol levels were above 0.151, which causes impairment in reflexes, prolonged reaction time, decreased motor activity control, and all these can lead to impaired self-rescue capabilities.18 In several international studies the information on alcohol consumption in drowning fatalities is missing.4,16,19 In those statistics, where blood alcohol levels of drowning deaths are shown, there is obvious relationship between drowning and alcohol consumption.6 However, in our study the frequency of high blood alcohol concentration was higher among drowned victims. By contrast to alcohol consumption, we have detected drugs only in 11 cases (out of 74 cases, 14.86%); while other studies show that the presence of drugs in the blood is also a possible risk factor of drowning.6 Seasonal distribution of drowning deaths is similar to what is found in other countries: the majority of the deaths occurred during warm months, from June to August (sports activities and accidents).12,13 It is somewhat unusual that during the winter period suicide was the most frequent cause of drowning deaths. In Hungary the typical way of committing suicide was jumping into wells. Suicidal drowning was prevalent in the elderly group in both genders (it follows the Hungarian pattern: suicidal rate increases with age),16,20 and it occurred mostly from the end of summer till the end of winter. As the South-West region of Hungary is relatively rich in natural water sources, the vast majority of the casualties happened in rivers and lakes. Compared to international data the ratio of drowning indoors or in garden water is much lower in Hungary.6 This may be due to the tendency that drowning in garden water and swimming pools is more frequent in childhood.9,21,22 We could make some interesting observations when examining the data of the manner of drowning deaths. It was surprising, that in comparison with other countries, only few people drowned during water sports activities. Water sports activities are preferred on Lake Balaton (sailing, kayaking, boating and windsurfing), but the low water depth does not make the lake popular for swimming. There is a continuous gale warning during warmer seasons (from April to May) and life jackets in boats and in other water sports equipment are required by the Hungarian National Transport Authority. These two facts can also explain the low number of deaths during water sports.15 We found that none of the individuals who died during water sports activities wore lifesaving jackets, however, a personal flotation device may potentially prevent the fatalities.23 Suicidal drowning was prevalent in the elderly group in both genders (it follows the Hungarian pattern: suicidal rate increases with age), and it occurred mostly from the end of summer till the end of winter. Some studies on situations in other countries also show that the tendency of suicide by drowning increases with age.6,16,20 In summary of the statistical analysis of fatal drowning cases in South-West Hungary we conclude that the major risk factors are: being a male (71.05%), age between 51 and 70 years (44.73%) and alcohol consumption (64.04% of the total number of all deaths). The results of this study may draw the attention to the most vulnerable age group, individuals between 51 and 70 years. In this study it became obvious that alcohol consumption and accidental drowning deaths (and to a lesser extent suicidal drowning) show close correlations. As this inquiry shows, it is necessary to consider these risk factors in drowning cases and to avoid alcohol consumption during water activities, because in addition to increasing self-confidence, it reduces the potential of victims' ability to rescuing themselves.14,19,21e23
11
Conflict of interest The authors state they have no conflict of interest. Funding None declared. Ethical approval None declared. Acknowledgments nes To th, M.D. and Ga bor Simon, M.D. We would like to thank De ber for for the comments and advice on the manuscript; Tünde We her technical assistance and we are especially grateful for the linbor Re be k-Nagy and Brigitta guistic help received from Dr Ga Hajnal. References 1. Piette MH, De Letter E. Drowning: still a difficult autopsy diagnosis. Forensic Sci Int 2006;163(1e2):1e9. 2. Ming M, Meng X, Wang E. Evaluation of four digestive methods for extracting diatoms. Forensic Sci Int 2007;170(1):29e34. 3. He F, Huang D, Liu L, Shu X, Yin H, Li X. A novel PCR-DGGE-based method for identifying plankton 16S rDNA for the diagnosis of drowning. Forensic Sci Int 2008;176(2e3):152e6. 4. Kiakalayeh AD, Mohammadi R, Ekman DS, Chabok SY, Janson B. Unintentional drowning in northern Iran: a population-based study. Accid Anal Prev 2008;40(6):1977e81. 5. The Royal Life Saving Society C. A profile of Ontario drowning and water-related injuries, 1987e2004. The Drowning Report, Ontario. 2008. Available from:, http://www.lifesavingsociety.com/. €rnstig U. Drowning deaths in Sweden with emphasis 6. Ahlm K, Saveman B-I, Bjo on the presence of alcohol and drugs e a retrospective study, 1992e2009. BMC Public Health 2013;13:216. 7. WHO. Drowning fact sheet N 347. 2014. Available from: http://www.who.int/ water_sanitation_health/diseases/drowning/en/#. 8. Donson H, Van Niekerk A. Unintentional drowning in urban South Africa: a retrospective investigation, 2001e2005. Int J Inj Contr Saf Promot 2013;20(3): 218e26. 9. Blum C, Shield J. Toddler drowning in domestic swimming pools. Inj Prev 2000;6(4):288e90. 10. Quan L, Cummings P. Characteristics of drowning by different age groups. Inj Prev 2003;9(2):163e8. € I, Vuori E. Drowning under the 11. Smith GS, Lillsunde P, Valonen K, Ojanpera influence of drugs and alcohol. Presented at the World Conference on Drowning Prevention, Vietnam. 2011. Abstract retrieved from, http://www. worldconferenceondrowningprevention2011.org/SiteMedia/w3svc1092/ Uploads/Documents/WCDP2011_Drown_R_Lunetta_p97_Abstract.pdf. 12. Becker S, Weng S. Seasonal patterns of deaths in Matlab, Bangladesh. Int J Epidemiol 1998;27(5):814e23. 13. Forjuoh SN. Safety at play: let's all help to prevent drowning. Int J Inj Contr Saf Promot 2011;18(2):95e6. 14. Armstrong EJ, Erskine KL. Water-related death investigation: practical methods and forensic applications. CRC Press; 2011. p. 279e304. 15. Pikora TJ, Braham R, Hill C, Mills C. Wet and wild: results from a pilot study assessing injuries among recreational water users in Western Australia. Int J Inj Contr Saf Promot 2011;18(2):119e26. 16. Salib E. Trends in suicide by drowning in the elderly in England and Wales 1979e2001. Int J Geriatr Psychiatry 2005;20(2):175e81. 17. Yang L, Nong Q-Q, Li C-L, Feng Q-M, Lo SK. Risk factors for childhood drowning in rural regions of a developing country: a case-control study. Inj Prev 2007;13(3):178e82. 18. Driscoll TR, Harrison JA, Steenkamp M. Review of the role of alcohol in drowning associated with recreational aquatic activity. Inj Prev 2004;10(2): 107e13. 19. Peden MM, McGee K. The epidemiology of drowning worldwide. Inj Control Saf Promot 2003;10(4):195e9. 20. Cattell H. Suicide in the elderly. Adv Psychiatr Treat 2000;6(2):102e8. 21. Pitt WR, Balanda KP. Childhood drowning and near-drowning in Brisbane: the contribution of domestic pools. Med J Aust 1991;154(10):661e5. 22. Iqbal A, Shirin T, Ahmed T, Ahmed S, Islam N, Sobhan A, et al. Childhood mortality due to drowning in rural Matlab of Bangladesh: magnitude of the problem and proposed solutions. J Health Popul Nutr 2007;25(3):370e6. 23. Cummings P, Mueller BA, Quan L. Association between wearing a personal floatation device and death by drowning among recreational boaters: a matched cohort analysis of United States Coast Guard data. Inj Prev 2011;17(3): 156e9.
Contents lists available at ScienceDirect
Journal of Forensic and Legal Medicine j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / j fl m
Original communication
Drowning-related fatalities during a 5-year period (2008e2012) in South-West Hungary e A retrospective study cz a, Franciska Ko € nczo € l a, Hajnalka Me sza ros b, Zsolt Kozma c, Ma tya s Mayer a, Evelin Ra r a, Katalin Sipos a, * n Porpa czy a, Viktor S. Poo Zolta Department of Forensic Medicine, Faculty of Medicine, University of P ecs, 12 Szigeti str., H-7624 P ecs, Hungary rd, Hungary Institute of Forensic Medicine, Network of Forensic Science Institutes, Ministry of Public Administration and Justice, Szeksza c r, Hungary Institute of Forensic Medicine, Network of Forensic Science Institutes, Ministry of Public Administration and Justice, Kaposva a
b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 18 June 2014 Received in revised form 6 January 2015 Accepted 8 January 2015 Available online 16 January 2015
The purpose of the present study was to investigate all the drowning-related cases in South-West Hungary between 2008 and 2012. It is a retrospective and descriptive study of 114 drowning-related deaths during that 5-year period. The investigation includes both unintentional and intentional drowning cases. We found that the most considerable risk factor of drowning in this area of Hungary is alcohol consumption, because in more than half of the cases the victims were under the influence of alcohol. We also concluded that more than two third of the cases included males. The cause of drowning in younger victims was mostly accident. In both genders subjects aged 50e70 had the highest risk of drowning in the period investigated. Seniors frequently committed suicide by drowning. Drowning deaths occurred in all types of water, mostly in lakes, rivers, canals and other types of catchment in the vicinity of victims' homes (most commonly in wells). This study might help to understand the circumstances and the causes leading to drowning and it may draw the attention to the possible preventive interventions. © 2015 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
Keywords: Forensic medicine Statistics Hungary Drowning Risk factors Accident
1. Introduction Investigation of bodies found in various types of water is an important and sometimes difficult part of the medico-legal examination.1 Drowning was reported by the World Health Organization to be the 3rd leading cause of unintentional death worldwide in 2012, accounting for 7% of all injury-related deaths. WHO estimates indicate that 359 000 people died from drowning in 2011. Accidental non-transport-related drowning and submersion deaths are also common cause of deaths in Hungary.
Abbreviations: BAC, blood alcohol concentration; HS-GC, headspace-gas chromatography; ICD, International Statistical Classification of Diseases and Related Health Problems; PCR, polymerase chain reaction; WHO, World Health Organization. * Corresponding author. Tel.: þ36 72536240. E-mail addresses: [email protected] (E. R acz), [email protected]. € nczo €l), [email protected] (H. Me sza ros), [email protected] hu (F. Ko (Z. Kozma), [email protected] (M. Mayer), [email protected] czy), [email protected] (V.S. Poo r), [email protected] (Z. Porpa (K. Sipos).
Data from the Hungarian Central Statistical Office indicate an average of 174 drowning-related deaths (ICD codes W65-W74) per year in Hungary between 2008 and 2012, the highest number of cases being 203 in 2010, while the lowest number was 156 in 2011. 2. Materials and methods Drowning is defined as “the process of experiencing respiratory impairment from submersion/immersion in liquid” (official definition by World Health Organization, 2005). Many countries including Hungary have no reliable study on major causes and reasons of drowning deaths. The present study was aimed to collect and describe all drowning-related fatalities in Baranya, Somogy and Tolna counties in the South-West region of Hungary from 1 January 2008 till 31 December 2012. There was a total number of 114 drowning-related deaths during those five years. We have focused our attention on the gender, age and the possible alcohol consumption of victims, the location of death (type of water), and other factors contributing to the fatalities including drugs, manner of drowning, etc.
http://dx.doi.org/10.1016/j.jflm.2015.01.001 1752-928X/© 2015 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
cz et al. / Journal of Forensic and Legal Medicine 31 (2015) 7e11 E. Ra
8
This study includes all the cases where autopsy was performed in one of the three counties. Drowning as the cause of death was presumed by autopsy findings and police reports (which also included eyewitnesses' descriptions) and was diagnosed by macroscopic and microscopic findings (histology and diatom test), in some cases it was also confirmed by PCR-based methods (DNA isolation from microalgae).2,3 During complete autopsy natural causes of death were excluded and the most frequent findings included the following: petechial bleeding; voluminous lungs, ballooning, distended; Paltauf's hemorrhages; emphysema aquosum; fluid blood and congestive organs. Histological examination confirmed the autopsy findings. Blood (97 cases) was used as biological material on which the measurement of blood alcohol concentration was conducted using HS-GC-FID Agilent Technologies 7890A automated headspace gas chromatograph with flame-ionization detection. The blood alcohol concentration categories were classified by the official rules applied by National Institute of Forensic Medicine, Hungary. HPLC-DAD (High-Performance Liquid Chromatography with Diode array detector) technology was used for drug screening in plasma (74 cases). Statistical analysis was performed using the GraphPad Prism program for Windows software. The Pearson's Chi-squared test was used for statistical analysis. A P value below 0.05 was considered significant. 3. Results and discussion During the five-year period a total number of 114 drowningrelated deaths in South-West Hungary was investigated. The number of drowning cases remained permanent during the years. The yearly case numbers have not changed significantly (the twotailed P value equals 0.1259). Four out of the 114 cases were unidentified persons, but during autopsy we could classify them by most of their properties (gender, age etc). However, two individuals' time of death remained unknown, not even the exact year of their deaths could be identified (see Table 1). 3.1. Risk factor: gender All studies available in this field report that more males than females get drowned.4e7 In our survey we also found that males (81 out of 114) are at greater risk of drowning than females (33 out of 114) (see Table 2). Death rate of males (71.05%) was more than two times higher than that of females (28.95%). The difference is significant (the two-tailed P value is less than 0.0001). This result correlates with the statistical data provided by the World Health Organization. The reason for this may be the consumption of greater amounts of alcohol by men and their relatively high selfesteem. It is also manifested in the circumstances of deaths (e.g. swimming on their own under the influence of alcohol).
Table 1 The number of drowned individuals during 2008e2012 in South-West Hungary. Years
2008 2009 2010 2011 2012 Unknown Total
Total Number
%
12 25 21 28 26 2 114
10.53 21.93 18.42 24.56 22.81 1.75 100
Table 2 Age distribution of male and female drowning victims who drowned during 2008e2012 in South-West Hungary. Age groups
0e10 11e20 21e30 31e40 41e50 51e60 61e70 71e80 81e90 Unidentified Total
Males
Females
Total
Number
%
Number
%
Number
%
1 12 7 10 8 21 13 6 1 2 81
0.88 10.53 6.14 8.77 7.02 18.42 11.40 5.26 0.88 1.75 71.05
0 1 0 3 4 10 7 5 3 0 33
0 0.88 0 2.63 3.51 8.77 6.14 4.39 2.63 0 28.95
1 13 7 13 12 31 20 11 4 2 114
0.88 11.41 6.14 11.40 10.53 27.19 17.54 9.65 3.51 1.75 100
3.2. Risk factor: age Age distribution of male and female victims is presented in Table 2. The number of drowning fatalities was the highest between ages 51 and 60 (31 of the total 114 cases; 27.19%); moreover, both for men and women the drowning rate was the highest between the ages 51 and 70, in this age group it is 44.73% of all drowning cases during those five years. The youngest victim in this study was a 5 year-old boy seen by his mother submerge in Lake Balaton and a few hours later his body was found. The oldest victim was an 88year-old woman found in a well in her garden. Data from the WHO Factsheet on Drowning indicate that children under five years of age have the highest drowning mortality rate worldwide.7e10 In contrast, we found that children's drowning death rate was surprisingly low in this area of Hungary; there was only one victim in this age group. According to the WHO fact sheet of drowning, adult males in Canada and New Zealand are at high risk of drowning.5,7 In Hungary we found that elderly men are more likely to drown than younger individuals. No data showing a similarly high ratio of elderly victims have been found in other countries, this rate is the highest known in the region of Hungary studied. For a more detailed discussion of the background to this phenomenon see Section 3.6 Risk factor: Manner of drowning death. 3.3. Risk factor: alcohol consumption and drugs 3.3.1. Alcohol consumption From many countries there is no information about alcohol consumption of victims, although WHO data suggest that it is a preliminary condition for accidental drowning deaths.4,7 In our study the blood alcohol concentration could be measured in 68 out of 81 (83.95%) male and 29 out of 33 (87.89%) female victims. In these cases with measurable BAC (97 out of 114), 85.29% of males (58 out of 68) and 51.72% of females (15 out of 29) had consumed alcohol. In nearly two third of all the cases (73 out of 114; 64.04%) the blood alcohol level was above 0.021% (0.021 g of alcohol for every dL of individual's blood) and only 24 victims' BAC (21.05%) was proved negative (BAC 0.020%). In 17 cases (14.91%) the BAC level could not be determined, mostly because of the advanced decay stage of decomposition and/or the lack of blood. Blood alcohol level in male victims was higher than in females on average, there were 8 males with a blood alcohol concentration close to the toxic level (BAC is above 0.351%), however, the cause of death in those cases was also drowning. Among men we could not find correlation between alcohol consumption and age. Female victims have consumed much smaller amounts of alcohol and it
cz et al. / Journal of Forensic and Legal Medicine 31 (2015) 7e11 E. Ra
1 12 7 10 8 21 13 6 1 2 81 e e e 1 4 3 e e e e 8 e e e 3 2 6 2 e e e 13 e 1 e 1 2 1 3 1 e e 9 e e 1 1 e 1 1 e e e 4 e 2 2 e e 1 1 1 e e 7 e 4 3 2 e 2 3 3 e e 17 1 4 1 1 e 2 e e 1 e 10 e 1 e 1 e 5 3 1 e 2 13 0 1 0 3 4 10 7 5 3 0 33 e e e e e e e e e e 0 a
b
e 1 e e 2 3 4 2 2 e 14 e e e 2 1 1 e e e e 4
Reasons: advanced decay stage of decomposition and/or the lack of blood. 0e0.020%e BAC is considered being negative.
e e e e 1 e e e e e 1 e e e e e 2 2 1 e e 5 e e e e e 1 e e e e 1 e e e e e 1 e e e e 1
0e0.020b Cannot be assesseda
Males
Total females 0.350< 0.251e 0.350 0.151e 0.250 0.081e 0.150 0.051e 0.080 0.021e 0.050 0e0.020b Females
BAC
Cannot be assesseda
0e10 11e20 21e30 31e40 41e50 51e60 61e70 71e80 81e90 Unknown Total
Fig. 1. Correlation between the distribution of blood alcohol concentrations (% by vol.) and gender (x-axis: blood alcohol concentration, on the columns: number of drowned individuals; total n ¼ 97) in drowning deaths occurred during 2008e2012 in South-West Hungary. Between the number of the negative (n ¼ 24) and positive (n ¼ 73) cases the difference was significant.
Age
Hungary is rich in rivers and lakes, therefore the majority of fatal drowning cases occurred in natural waterbodies (see Table 5). The highest number of drowning fatalities occurred in the River Danube (30 out of 114; 26.32%) and Lake Balaton (22 out of 114; 19.30%).
Table 3 Distribution of age and blood alcohol concentration (% by vol.) of victims between 2008 and 2012 in South-West Hungary.
3.5. Risk factor: types of waterbodies where the victims were found
0.021e 0.050
3.4. Risk factor: season
e e e 1 e 2 1 2 1 e 7
Total males 0.350< 0.051e 0.080
0.081e 0.150
0.151e 0.250
0.251e 0.350
3.3.2. Drug consumption Toxicology analysis in our laboratories identified drugs in 11 out of the 74 cases (5 cases in females, and 6 cases in males; 14.86%): the most common pharmaceutical drug was benzodiazepine (5 cases), followed by citalopram (2 cases), and carbamazepine, noraminophenazon, ibuprofen, venlafaxine in the rest of the cases. In 3 cases the concentration of drugs in blood was found above the toxic level (benzodiazepine, venlafaxine, citalopram). The ages of the above victims were between 54 and 75 years. We also found amphetamine in three cases (17, 20 and 52 years old males). Compared to other countries, this is a very low number of drug use among drowning victims.6,11
In our statistical analysis drowning occurred mostly in warmer months from March till the end of August (74.56%) (see Table 4). Nearly half of the fatalities (49.12%) happened in summer, and this difference proved to be significant (the two-tailed P value is less than 0.0001). Drowning deaths in autumn and winter are not negligible, either: the causes, similarly to those in other seasons, usually were accidents. However, suicide by drowning happened generally in winter. The seasonal pattern of drowning deaths was similar compared to that of other countries.4,10,12
1 13 7 13 12 31 20 11 4 2 114
Total
was found typical in the elderly group (see Fig. 1). The correlation between the number of positive (n ¼ 73) and negative (n ¼ 24) cases was found to be statistically significant. The distribution of the age and the blood alcohol concentration of the victims is shown in Table 3.
9
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10
Table 4 Seasonal distribution of drowning deaths during 2008e2012 in South-West Hungary. Season
Spring Summer Autumn Winter Unknown Total
Total
Manner of drowning
Number
%
29 56 13 12 4 114
25.44 49.12 11.40 10.53 3.51 100
Indoor drowning deaths were rare: there were only four victims who died in either a swimming pool (1 case) or in bathtubs (3 cases). 13 out of 114 drowning deaths occurred near the victims' home (garden pond, ditch, wine cellar) and three cases in the victim's apartment (3 bathtub deaths). Victims were often found in wells in cases of suicide. All the 4 unidentified bodies were found in the river Danube. The Danube flows across 10 countries, it is also possible that the river brought these bodies across the borders. This factor makes the identification of victims more complicated. 3.6. Risk factor: manner of drowning death Eyewitnesses may contribute to the investigation on the circumstances of fatalities with a lot of data.13 However, there were several cases (29 out of 114) where we did not know anything about the background of drowning deaths (e.g. unknown bodies, no eyewitnesses or no relatives, who would know about the intent). On autopsy it was presumed that most of the drowning deaths with unknown history occurred accidentally or because of suicide as there were no signs of violence in these cases.14 3.6.1. Accidental drowning death Accidents are the main cause of drowning deaths in South-West Hungary (see Table 6). Accidental drowning fatalities happened mainly because of high BAC level, chronic diseases (e.g. diabetes, high blood pressure) or during physical or sports activities.15 We found that swimming in a body of water is still the recreational sports activity during which the largest number of drowning occurs (22 out of 114 cases). We found a few other special cases which happened during water sports activities. There was one person who died while kayaking (BAC was 0.178%). Another one who could not swim and did not wear lifesaving jacket either, fell out of an inflatable boat (BAC was 0.028%). One victim fell into the water from a boat while fishing (BAC was 0.157%) and another one from a pedal boat (BAC 0.040%). One person died while windsurfing in Lake Balaton in March (BAC 0.020%), he did not wear a lifesaving jacket either, and there were no gale warning during that season.
Table 5 Waterbody types where victims were found (2008e2012, South-West Hungary). Waterbody types
Lake River Creek Canal At home Well Other Total
Table 6 Manner of drowning deaths occurred between 2008 and 2012 in South-West Hungary.
Total Number
%
42 39 6 3 8 8 8 114
34.21 36.84 5.26 2.63 7.02 7.02 7.02 100
Suicide Homicide Accident Unknown Total
Males
4 1 53 23 81
Females
11 1 15 6 33
Total Number
%
15 2 68 29 114
13.16 1.75 59.65 25.44 100
All of the individuals who drowned during recreational water sports activities were males. These fatalities occurred under the influence of alcohol. 3.6.2. Suicide by drowning The WHO qualifies the drowning death data as insufficient because they include only “accidental drowning and submersion”, however the incidence of suicidal drowning deaths seem to be considerable.7 We found 15 suicidal drowning cases (13.16% of all the cases) in the five years investigated. Suicide as the cause of a drowning fatality is hard to prove. In this study we regarded such cases as proven when confirmed by eyewitnesses, by victims' farewell letters left behind or by witnesses who were told about the suicidal intention by the victims. Suicidal deaths were more frequent in elderly people (age group of 61e90).16 Consumption of alcohol was not specific in this age group in the case of suicide (some of these victims consumed moderate amounts of alcohol). Females were more likely to choose suicide by drowning than males (11 females and 4 males). Males who committed suicide by drowning were between the ages of 50 and 75, and females were between the ages of 38 and 82. We found that middle-aged males and females who chose this method of suicide were after a family quarrel and left the house right before drowning. In this study the chosen modus operandi of suicidal drowning deaths was jumping in wells or jumping off bridges. International data show that there is a tendency of suicide rate by drowning increasing with age.6,16 3.6.3. Homicide by drowning In the period investigated there were only two homicidal drowning cases, a 16-year-old male and a 58-year-old female. In both cases victims were battered and left in the water, and finally the cause of their deaths was due to the lack of self-rescue capability. 4. Conclusions We have carried out a thorough statistical evaluation of 114 proved drowning fatalities which occurred in a 5-year period at the South-West region of Hungary. We conclude that the features of these death cases show a large number of similarities to the drowning-related deaths all over the world, but some unexpected outcome was also found on the data assessment. Distribution of the gender of the drowned victims in the examined Hungarian region is like what the international statistics show: more than two thirds of the casualties were males.4e7 Considering the age of the victims our study gave different results from those found in the statistical data of other countries: in the latter ones children are threatened more by drowning. In our study children's drowning death rate was very low (only one victim) in this area of Hungary and it is in contrast with WHO findings: children under 5 years of age have the highest drowning mortality rates worldwide.7e9,17 The reason for this can be the high
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attention to children in Hungary. In our country people at the age of 51e70 years have the highest risk of drowning. We found alcohol consumption to be a major contributing factor of drowning deaths: in 31.58% (36 individuals from 114 cases) of the drowning cases blood alcohol levels were above 0.151, which causes impairment in reflexes, prolonged reaction time, decreased motor activity control, and all these can lead to impaired self-rescue capabilities.18 In several international studies the information on alcohol consumption in drowning fatalities is missing.4,16,19 In those statistics, where blood alcohol levels of drowning deaths are shown, there is obvious relationship between drowning and alcohol consumption.6 However, in our study the frequency of high blood alcohol concentration was higher among drowned victims. By contrast to alcohol consumption, we have detected drugs only in 11 cases (out of 74 cases, 14.86%); while other studies show that the presence of drugs in the blood is also a possible risk factor of drowning.6 Seasonal distribution of drowning deaths is similar to what is found in other countries: the majority of the deaths occurred during warm months, from June to August (sports activities and accidents).12,13 It is somewhat unusual that during the winter period suicide was the most frequent cause of drowning deaths. In Hungary the typical way of committing suicide was jumping into wells. Suicidal drowning was prevalent in the elderly group in both genders (it follows the Hungarian pattern: suicidal rate increases with age),16,20 and it occurred mostly from the end of summer till the end of winter. As the South-West region of Hungary is relatively rich in natural water sources, the vast majority of the casualties happened in rivers and lakes. Compared to international data the ratio of drowning indoors or in garden water is much lower in Hungary.6 This may be due to the tendency that drowning in garden water and swimming pools is more frequent in childhood.9,21,22 We could make some interesting observations when examining the data of the manner of drowning deaths. It was surprising, that in comparison with other countries, only few people drowned during water sports activities. Water sports activities are preferred on Lake Balaton (sailing, kayaking, boating and windsurfing), but the low water depth does not make the lake popular for swimming. There is a continuous gale warning during warmer seasons (from April to May) and life jackets in boats and in other water sports equipment are required by the Hungarian National Transport Authority. These two facts can also explain the low number of deaths during water sports.15 We found that none of the individuals who died during water sports activities wore lifesaving jackets, however, a personal flotation device may potentially prevent the fatalities.23 Suicidal drowning was prevalent in the elderly group in both genders (it follows the Hungarian pattern: suicidal rate increases with age), and it occurred mostly from the end of summer till the end of winter. Some studies on situations in other countries also show that the tendency of suicide by drowning increases with age.6,16,20 In summary of the statistical analysis of fatal drowning cases in South-West Hungary we conclude that the major risk factors are: being a male (71.05%), age between 51 and 70 years (44.73%) and alcohol consumption (64.04% of the total number of all deaths). The results of this study may draw the attention to the most vulnerable age group, individuals between 51 and 70 years. In this study it became obvious that alcohol consumption and accidental drowning deaths (and to a lesser extent suicidal drowning) show close correlations. As this inquiry shows, it is necessary to consider these risk factors in drowning cases and to avoid alcohol consumption during water activities, because in addition to increasing self-confidence, it reduces the potential of victims' ability to rescuing themselves.14,19,21e23
11
Conflict of interest The authors state they have no conflict of interest. Funding None declared. Ethical approval None declared. Acknowledgments nes To th, M.D. and Ga bor Simon, M.D. We would like to thank De ber for for the comments and advice on the manuscript; Tünde We her technical assistance and we are especially grateful for the linbor Re be k-Nagy and Brigitta guistic help received from Dr Ga Hajnal. References 1. Piette MH, De Letter E. Drowning: still a difficult autopsy diagnosis. Forensic Sci Int 2006;163(1e2):1e9. 2. Ming M, Meng X, Wang E. Evaluation of four digestive methods for extracting diatoms. Forensic Sci Int 2007;170(1):29e34. 3. He F, Huang D, Liu L, Shu X, Yin H, Li X. A novel PCR-DGGE-based method for identifying plankton 16S rDNA for the diagnosis of drowning. Forensic Sci Int 2008;176(2e3):152e6. 4. Kiakalayeh AD, Mohammadi R, Ekman DS, Chabok SY, Janson B. Unintentional drowning in northern Iran: a population-based study. Accid Anal Prev 2008;40(6):1977e81. 5. The Royal Life Saving Society C. A profile of Ontario drowning and water-related injuries, 1987e2004. The Drowning Report, Ontario. 2008. Available from:, http://www.lifesavingsociety.com/. €rnstig U. Drowning deaths in Sweden with emphasis 6. Ahlm K, Saveman B-I, Bjo on the presence of alcohol and drugs e a retrospective study, 1992e2009. BMC Public Health 2013;13:216. 7. WHO. Drowning fact sheet N 347. 2014. Available from: http://www.who.int/ water_sanitation_health/diseases/drowning/en/#. 8. Donson H, Van Niekerk A. Unintentional drowning in urban South Africa: a retrospective investigation, 2001e2005. Int J Inj Contr Saf Promot 2013;20(3): 218e26. 9. Blum C, Shield J. Toddler drowning in domestic swimming pools. Inj Prev 2000;6(4):288e90. 10. Quan L, Cummings P. Characteristics of drowning by different age groups. Inj Prev 2003;9(2):163e8. € I, Vuori E. Drowning under the 11. Smith GS, Lillsunde P, Valonen K, Ojanpera influence of drugs and alcohol. Presented at the World Conference on Drowning Prevention, Vietnam. 2011. Abstract retrieved from, http://www. worldconferenceondrowningprevention2011.org/SiteMedia/w3svc1092/ Uploads/Documents/WCDP2011_Drown_R_Lunetta_p97_Abstract.pdf. 12. Becker S, Weng S. Seasonal patterns of deaths in Matlab, Bangladesh. Int J Epidemiol 1998;27(5):814e23. 13. Forjuoh SN. Safety at play: let's all help to prevent drowning. Int J Inj Contr Saf Promot 2011;18(2):95e6. 14. Armstrong EJ, Erskine KL. Water-related death investigation: practical methods and forensic applications. CRC Press; 2011. p. 279e304. 15. Pikora TJ, Braham R, Hill C, Mills C. Wet and wild: results from a pilot study assessing injuries among recreational water users in Western Australia. Int J Inj Contr Saf Promot 2011;18(2):119e26. 16. Salib E. Trends in suicide by drowning in the elderly in England and Wales 1979e2001. Int J Geriatr Psychiatry 2005;20(2):175e81. 17. Yang L, Nong Q-Q, Li C-L, Feng Q-M, Lo SK. Risk factors for childhood drowning in rural regions of a developing country: a case-control study. Inj Prev 2007;13(3):178e82. 18. Driscoll TR, Harrison JA, Steenkamp M. Review of the role of alcohol in drowning associated with recreational aquatic activity. Inj Prev 2004;10(2): 107e13. 19. Peden MM, McGee K. The epidemiology of drowning worldwide. Inj Control Saf Promot 2003;10(4):195e9. 20. Cattell H. Suicide in the elderly. Adv Psychiatr Treat 2000;6(2):102e8. 21. Pitt WR, Balanda KP. Childhood drowning and near-drowning in Brisbane: the contribution of domestic pools. Med J Aust 1991;154(10):661e5. 22. Iqbal A, Shirin T, Ahmed T, Ahmed S, Islam N, Sobhan A, et al. Childhood mortality due to drowning in rural Matlab of Bangladesh: magnitude of the problem and proposed solutions. J Health Popul Nutr 2007;25(3):370e6. 23. Cummings P, Mueller BA, Quan L. Association between wearing a personal floatation device and death by drowning among recreational boaters: a matched cohort analysis of United States Coast Guard data. Inj Prev 2011;17(3): 156e9.
