SITUATION ANALYSIS OF CHILD DROWNING SURVEILLANCE IN THAILAND

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2 SITUATION ANALYSIS OF CHILD DROWNING SURVEILLANCE IN THAILAND Research Team Members: Mrs. Suchada Gerdmongkolgan Ms. Som Ekchaloemkiet Mrs. Auraphin Sublon Mrs. Roongjit Termtor Mrs. Kanjanee Dumnakkaew Bureau of Non-Communicable Diseases Department of Disease Control Ministry of Public Health, Thailand Supported by World Health Organization

3 SITUATION ANALYSIS OF CHILD DROWNING SURVEILLANCE IN THAILAND First printing: November 2009 Number of copies:. (English version) Number of pages: 101 Printer: Printing Press, War Veterans Organization of Thailand ISBN Advisors: Dr. Prapon Tangsrikertikul Dr. Panuwat Pankret Dr. Tairjing Siriphanich Research team members: Mrs. Suchada Gerdmongkolgan Ms. Som Ekchaloemkiet Mrs. Auraphin Sublon Mrs. Roongjit Termtor Mrs. Kanjanee Dumnakkaew Cover design: Ms.Thitima Khuntasin Preparared by: Bureau of Non-Communicable Diseases, Department of Disease Control, Ministry of Public Health Tiwanon Road, Mueang District, Nonthaburi Province 11000, Thailand Tel: Fax: Supported by: World Health Organization (WHO) Bureau of Non-Communicable Diseases, DDC, MOPH

4 Acknowledgements This report, entitled Situation Analysis of Child Drowning Surveillance in Thailand, has been completed by the research team in cooperation with a number of other agencies and officials. First, we would like to express our sincere gratitude to Dr. Taejing Siripanich, who is the main driving force behind the preparation of this report. Our profound thankfulness also goes to the Bureau of Policy and Strategy and the Bureau of Epidemiology for their assistance in providing the data on overall child drowning used in the analysis. In addition, we would like to extend our grateful thanks to Dr. Panuwat Panketu, Director of the Bureau of Non-communicable Diseases, for his continued advice and support. Last but not least, our profound thanks go to the World Health Organization (WHO) for financial support. The Research Team October 2009

5 Preface Drowning is a major cause of child fatality in countries all over the world. On average, approximately 135,585 children die from drowning each year, or about 372 children per day. Children under five years of age constitute the age group with the highest risk. More than 98% of child drowning deaths occur in a country with a low or moderate national income. In Thailand, drowning is the number one cause of fatality among children under 15 years of age, and the fatality rate is much higher than those for other causes including infectious and non-infectious diseases. Each year, nearly 1,500 children in Thailand die because of drowning, or about 4 children per day on average, which is a much higher rate compared to those in developed countries such as Australia or the United States. Successful prevention of child drowning depends on a comprehensive and systematic compilation of data in all aspects of drowning to be utilized in devising operational plans and preventive measures. At present, there are three major databases of individual drownings in Thailand: the database for death certificates, the database for individual inpatients, and the Injury Surveillance System (IS). However, these databases have different objectives, data acquisition periods, and limitations in data acquisition. As constructing a new database seems to put too much burden on the operators and data users, the utilization of the data from various existing databases is considered the best option available in outlining the proposals and devising operational plans. Thus, the Bureau of Non-communicable Diseases, Department of Disease Control, whose main responsibility is prevention and control of injuries, has conducted the situation analysis of child drowning surveillance in Thailand with the objectives of investigating the scope and severity of child drowning, exploring risk factors for child drowning, and proposing recommendations for the prevention of drowning so as to further develop and improve the child drowning surveillance system in Thailand. Dr. Panuwat Panket Director, Bureau of Non-Communicable Diseases October 2009

6 Table of Contents Page Executive summary 1 Chapter 1: Introduction 5 Objectives 9 Scope of the study 9 Definition of terms 10 Methodology 12 Chapter 2: Findings of Situation Analysis of Child Drowning in Thailand 15 Mortality 15 - Trends in mortality 19 - Regions 20 - Provinces 21 - Gender 23 - Age 25 Morbidity 30 Case-fatality rate 33 Time of drowning 35 - Month 35 - Day of incident 40 - Time of incident 42 Location of drowning injuries 44 - Water sources 44 - Sites of drowning injuries 45 Risks of alcohol consumption 46 Treatment 48 Accessibility to medical care 49

7 Table of Contents (Cont.) Page Chapter 3: Conclusions and Discussions 53 Drowning-related mortality 53 Morbidity caused by accidental drowning 57 Case-fatality rate 57 Time 57 Locaion of drowning 58 Risks of alcohol consumption 58 Treatment 59 Accessibility to treatment 59 Chapter 4: Key Findings and Recommendations 61 References 67 Appendixes 71 Appendix A: Drowning statistics 72 Appendix B: WHO regions and Member countries 96 Appendix C: Index 100 Appendix D: Report Preparation Team 100

8 List of Tables Page Table 1: Leading causes of death in children, both sexes, World, Table 2: Estimated numbers of drowning deaths by age group, WHO region and 8 country income level, 2004 Table 3: Numbers, percentage, and rates of child deaths (per 100,000 children 16 <15 years) due to the five leading causes of death in Thailand, Table 4: Numbers and rates of child drowning deaths (per 100,000 children 19 <15 years) in Thailand, Table 5: Numbers and rates of child drowning deaths (per 100,000 children 20 <15 years) in Thailand by region, Table 6: Top ten provinces in Thailand with the highest rates of child drowning 21 deaths (per 100,000 children <15 years), Table 7: Top ten provinces in Thailand with the highest numbers of drowning 22 deaths in children <15 years, Table 8: Numbers and rates of child drowning deaths (per 100,000 children 23 <15 years) in Thailand by gender, Table 9: Numbers and rates of child drowning deaths (per 100,000 children 24 <15 years) in Thailand by region and gender, 2008 Table 10: Numbers and rates of drowning deaths in children under 15 years 25 and all age groups (per 100,000 children <15 years) in Thailand by age group, Table 11: Numbers and rates of child drowning deaths (per 100,000 children 29 <15 years) in Thailand by region and age group, 2008 Table 12: Percentage of severe injuries* among children <15 years due to 30 the five leading causes of injuries in Thailand, Table 13: Numbers and rates of child drowning injuries (per 100,000 children 31 <15 years) in Thailand, Table 14: Numbers and rates of child drowning injuries (per 100,000 children 31 <15 years) in Thailand by age group, Table 15: Case-fatality rates for severe drowning injuries* in children <15 years 33 in Thailand,

9 List of Tables (Cont.) Page Table 16: Numbers and percentage of drowning deaths in children <15 years in Thailand by month, Table 17: Numbers and percentage of drowning injuries in children <15 years admitted to hospital in Thailand by month, Table 18: Percentage of severe drowning injuries* in children <15 years by day of the week, Table 19: Percentage of severe drowning injuries* in children <15 years by time period of the day, Table 20: Percentage of severe drowning injuries* in children <15 years by type of water source, (10-year average) Table 21: Percentage of severe drowning injuries* in children <15 years by type of incident site, Table 22: Percentage of severe alcohol-related drowning injuries* in children <15 years by age group, (10-year average) Table 23: Costs of medical care for children <15 years with drowning injuries admitted to hospital in Thailand, Table 24: Length of hospital stay for children <15 years with drowning injuries admitted to hospital in Thailand, Table 25: Numbers and percentage of severe drowning injuries in children <15 years in Thailand by type of transport to hospital for treatment, Table 26: Numbers and percentage of severe drowning injuries in children <15 years in Thailand by place of death, Table A: Numbers and rates of child drowning deaths (ICD-10, W65 W74; per 100,000 children <15 years) in Thaialnd by province, Table B: Numbers of drowning deaths (ICD-10, W65 W74) in children <15 years in Thaialnd by province and gender, 2006 Table C: Numbers of drowning deaths (ICD-10, W65 W74) in children <15 years in Thaialnd by province and gender, 2007 Table D: Numbers of drowning deaths (ICD-10, W65 W74) in children <15 years in Thaialnd by province and gender,

10 List of Figures Page Figure 1: Fatal injury rates per 100,000 children aged 0 17 years in five Asian 6 countries Figure 2: Fatal drowning rates per 100,000 children <20 years by WHO region 7 and country income level, World, 2004 Figure 3: Numbers of deaths due to leading causes of death in children <15 years 15 in Thailand, Figure 4: Mortality rates for the five leading causes of death in children <15 years 17 (rate per 100,000 children <15 years) in Thailand, Figure 5: Numbers and rates of deaths per 100,000 population due to the five 18 leading causes of death in Thailand by age group, 2008 Figure 6: Numbers and rates of child drowning deaths (per 100,000 children 19 <15 years) in Thailand, Figure 7: Numbers and rates of child drowning deaths (per 100,000 children 20 <15 years) in Thailand by region, Figure 8: Numbers and rates of child drowning deaths (per 100,000 children 24 <15 years) in Thailand by gender, Figure 9: Numbers and rates of child drowning deaths (per 100,000 children 26 <15 years) in Thailand by age group, Figure 10: Rates of drowning deaths in children <15 years and in all age groups 26 (per 100,000 children <15 years) in Thailand by age group, Figure 11: Proportion of drowning deaths in Thailand by age group, Figure 12: Rates of child drowning deaths (per 100,000 children <15 years) 28 in Thailand by age group and gender, 2008 Figure 13: Numbers and rates of child drowning deaths (per 100,000 children 29 <15 years) in Thailand by region and age group, 2008 Figure 14: Rates of child drowning injuries admitted to hospital (per 100, children <15 years) in Thailand, Figure 15: Case-fatality rates for severe drowning injuries* in children <15 years 34 in Thailand,

11 List of Figures (Cont.) Page Figure 16: Numbers of drowning deaths in children <15 years in Thailand by month, (10-year average) Figure 17: Numbers of drowning injuries in children <15 years in Thailand by month, (3-year average) Figure 18: Percentage of severe drowning injuries* in children <15 years by day of the week, (10-year average) Figure 19: Percentage of severe drowning injuries* in children <15 years by time period of the day, (10-year average) Figure 20: Percentage of severe alcohol-related drowning injuries* in children <15 years by age group, (10-year average) Figure 21: Percentage of severe alcohol-related drowning injuries* in children <15 years by age group and gender, Figure 22: Percentage of severe drowning injuries in children <15 years in Thailand by type of transport to hospital for treatment, Figure 23: Percentage of severe drowning injuries in children <15 years in Thailand by place of

12 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 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. In the WHO South-East Asia Region, there are 32,744 drowning deaths each year or 90 deaths per day on average. In Thailand, the rate of child drowning deaths is 5 to 15 times higher than those for developed countries. 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. 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. 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). 1

13 The child drowning death rates per 100,000 children under 15 years of age between 1999 and 2008 ranged from 7.7 to Child drowning deaths had a steadily rising trend between 1999 and 2006 with a downward trend afterwards. The northeastern region has the highest rate of child drownings, followed by the central, northern, and southern regions, respectively. 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). 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). Nakhon Ratchasima province had the highest number of drowning deaths in the four-year period between 2005 and 2008, ranging from 59 to 82. 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. The rate of child drowning deaths for males is approximately 2 times higher than that for females. 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. 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. 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 age group. 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%. 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. 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). 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). 2

14 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). Of the children under 15 years of age who suffered severe drowning injuries, 1.2% had alcohol consumption behavior. The youngest children who were found to suffer drowning injuries and had drunk alcohol were seven years old. 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). 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: 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. Children: training them in the survival swimming curriculum. 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. 3

15 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. 4

16 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 years (see Table 1). Table 1: Leading causes of death in children, both sexes, World,

17 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,

18 According to the data of WHO in 2004, when cconsidering the drowning death rates in children under 20 years of age per 100,000 children of the same age group by WHO region and Member country, it was found that the countries with a low and middle income in the Western Pacific Region had the highest rate, at 13.9, followed by the African Region, the Eastern Mediterranean Region, and the South-East Asia Region, respectively. (2) In Thailand, the rate is 8.2, which is higher than the average for the South-East Asia Region of 6.2 (4) (see Figure 2). Figure 2: Fatal drowning rates per 100,000 children* by WHO region and country income level, World, 2004 * These data refer to those under 20 years of age. HIC = High income countries; LMIC = Low and middle income countries Source: WHO (2008). Global Burden of Disease, 2004 update. 7

19 All over the world, the rate of fatal drownings in children under 15 years of age is 135,585 per year, or 372 per day on average. In the South-East Asia Region, the rate of fatal drownings is 32,744 per year, or 90 per day on average (3) (see Table 2). Table 2: Estimated numbers of drowning deaths by age group, WHO region and country income level, 2004 WHO region Income Age range (years) level < <20 World All 10,200 48,267 39,010 38,107 39, ,293 High ,974 Low 9,916 47,263 38,467 37,680 38, ,025 African Region Low 4,445 10,178 4,060 4,618 5,452 28,752 Region of the Americas All 272 2,487 1,395 1,654 2,785 8,592 High ,148 Low 203 2,042 1,248 1,499 2,452 7,444 South-East Asia Region Low 2,850 9,362 11,662 8,870 11,027 43,771 European Region All 133 2,334 1,251 1,181 1,051 5,950 High Low 112 2,145 1,165 1, ,435 Eastern Mediterranean Region All 1,021 4,605 3,711 3,253 4,342 16,932 High Low 970 4,388 3,595 3,161 4,040 16,153 Western Pacific Region All 1,363 19,255 16,889 18,497 14,998 71,002 High Low 1,336 19,148 16,738 18,404 14,843 70,469 Source: World Report on Child Injury Prevention. WHO,

20 Objectives 1. To investigate the scope and severity of problems and risk factors for drownings among children in Thailand. 2. To derive at a proposal on prevention of child drowning in Thailand as well as on development/improvement of the existing child drowning surveillance system in Thailand. Scope of study The present study analyzed the data elicited from existing databases which have a systematic data storage system and reports on drownings on an individual basis. The data, which are continuously compiled and reported, can be categorized according to the age groups of children. The data can be used to analyze the situations of drowning including trends and risk factors of drowning among children in Thailand, to further develop or improve the child drowning surveillance system to ensure comprehensiveness and completeness, and to devise a plan or measure to prevent drowning among children in Thailand. The data used in the present analysis were retrieved from three databases, namely the database of death certificates (compiled by the Bureau of Policy and Strategy, MOPH), (5) the database of individual inpatients (also compiled by the Bureau of Policy and Strategy), (6) and the Injury Surveillance System (IS; operated by the Bureau of Epidemiology, DDC, MOPH). (7) The research team of the present analysis hoped to obtain the data which were as up to date as possible. However, as each database has its own objectives, data acquisition periods, and constraints in data acquisition, the data presented in the present analysis varied in a number of issues. The first important issue was the durations presented in each of the databases. The data retrieved from the death certificates were presented in a period of 10 years (from 1999 to 2008), while the data retrieved from the individual inpatients database were presented in a period of 3 years (from 2005 to 2007). This was because the Bureau of Policy and Strategy began its coordinated efforts with the National Health Security Office, the Comptroller General s Department of the Ministry of Finance (reimbursements of medical expenses of government officials and family members) and the Social Security Office in Therefore, the data on individual inpatients compiled before that time were not complete or comprehensive. In addition, the data retrieved from the Injury Surveillance System (IS) were presented in a period of 10 years (from 1998 to 2007). The second important issue was the age group. In this study, only data on drownings in children under 15 years of age were analyzed and presented. That was because even though the data collected in the aforementioned databases were individual data, the data in each database were analyzed with a programme which categorized individuals into the following age groups: under 1 year, 1 4 years, 5 9 years, years, and years. 9

21 Due to such limitations, in the present study only the data regarding drowning in children aged under 15 years are presented with differences in durations. Such presentation is not different from other reports on child drowning surveillance conducted in other countries where similar limitations could be found. Definition of terms Child refers to an individual who is under 15 years of age. Injury refers to damage of the body which results from sudden exposure to heat energy, mechanical energy, electricity, or chemicals. It also refers to lack of necessities such as heat or oxygen, which can be either intentional or accidental. At present, the term injury has been used to replace the term accident as the latter may be misleading, making individuals misunderstand that it is unpredictable or unforeseeable. (5, 6) Drowning refers to a process in which an individual loses his/her breathing or the breathing becomes weakened because all body parts, including the respiratory system, are completely immersed in water, or at least the face or the respiratory system is submerged in water or another fluid, and the outcome is death or body s abnormality or non-abnormality. (10) According to the International Standard Classification of Disease and Related Health Problem (ICD-10), the disease codes for morbidity and mortality from drowning are W65 W74. ICD-10 (8) refers to the international standard diagnostic classification of diseases and health problems that are the causes of morbidity and mortality. W65 refers to drowning and submersion while in a bathtub. W66 refers to drowning and submersion following fall into a bathtub. W67 refers to drowning and submersion while in a swimming pool. W68 refers to drowning and submersion following fall into a swimming pool. W69 refers to drowning and submersion while in natural water. W70 refers to drowning and submersion following fall into natural water. W73 refers to other specified drowning and submersion. W74 refers to unspecified drowning and submersion. Severe injury (12) refers to an injured individual who has been dead before arrival (DBA) at hospital, an injured individual who died in an emergency department/room, and an injured individual who is observed in or admitted to hospital. 10

22 Admitted patient or admission (13) refers to the admission of an injured individual as inpatient with an admission number. Case (13) refers a visit or admission as inpatient at hospital. Alcohol consumption (14) refers to the fact that an injured individual has drunk alcohol, as stated by the injured individual; as observed from his/her gait, speech, or body odor; or as observed from breathing and blood examination (as mg%), signifying the level of blood alcohol content as determined by an alcohol breath tester or analyzer or with the laboratory results of blood or urine examination. Average cost of medical care (13) refer to the average cost of medical services an inpatient has to pay each time he/she seeks medical care or treatment at hospital. Mean length of hospital stay (13) refers to the number of days an inpatient spends at hospital from admission to discharge, as calculated by dividing the total number of days of hospital stay of all discharged patients by the total number of patients discharged during the same period. Location of drowning (14) refers to the place where the drowning injury has occurred. House and compound of the house refers to place of living of an individual which is not a temporary living place. Dormitory, prison, nursery, or military base refers to a place of living of a group of individuals who share certain similar characteristics, which is not a house or residence of a family or an individual. Hospital, school or temple refers to a building (and its compound) which is used by a group of individuals or the public for various purposes such as an auditorium (except a building under construction, a residence or a sports/athletic field). Public sports arena refers to a venue where the general public exercise, play sports, or participate in a sports/athletic event. Street or highway refers to a route of public transportation that an individual uses to travel from one place to another including the components of such a route. Place for trading goods and services refers to a place that is meant for selling and buying goods and services such as a bank or a market. Construction site or factory refers to a building (and its compound) that is used for manufacturing a large quantity of products or goods, either small or large in size, including any building and site under construction. Paddy field, farm or garden refers to an area that is used for agricultural and livestock raising purposes, including a construction used for such purposes such as a temporary shelter on the farm. 11

23 Methodology 1. Secondary data were retrieved from the following three databases: 1) Data from death certificates (15) Death certificate data were compiled from 1999 to 2008 by the Bureau of Policy and Strategy, MOPH, which elicited the civil registration data from the Bureau of Registration Administration, Department of Provincial Administration, Ministry of Interior, and then coded the causes of death on an individual basis based on ICD-10. Limitations of the database The causes of death were not complete, and the unknown causes of death accounted for more than 30% of the total causes. Even in the cases where the causes of death were specified, some items were ambiguous and possibly inaccurate because the mode of death was specified instead of the cause of death, resulting in erroneous or incomplete causes of death. In particular, if the person who specified the causes of death was not a physician, it was even more likely that the causes of death specified in the death certificates would be inaccurate. Management and examination of accuracy of data 1) The data were examined record by record on a periodical basis. 2) The causes of death were coded on an individual basis based on ICD-10. 2) Data on individual inpatients (13) Data retrieved from the individual inpatients database were compiled from 2005 to 2007 by the Bureau of Policy and Strategy after it began to coordinate with the National Health Security Office, the Comptroller General s Department (reimbursement of medical expenses of government officials and family members) and the Social Security Office in Therefore, the data on individual inpatients were the data that the hospitals directly sent to the funds which covered all health-care settings with more details on gender, age group, disease/syndrome, and the level of health-care settings, etc. Limitations of the database The data did not comprehensively cover all inpatients who were admitted to hospital because they were data of only the inpatients who had the rights to reimbursements for medical expenses. 12

24 Management and examination of accuracy of data 1) The data were examined record by record on a periodical basis. Important disease codes, feasibility of data, gender, age, and coding were also examined, particularly the accuracy of the disease codes of serious diseases that required close monitoring and surveillance such as smallpox and plague. Attention was paid to external causes of injuries as well. 2) Erroneous data regarding the coding of important communicable diseases and specification of external causes of injuries were referred back to the related agencies for examination and verification. 3) The National Injury Surveillance System (IS) The data retrieved from the Injury Surveillance System (IS) were compiled between 1998 and Established in 1994, the database is run by the Bureau of Epidemiology, Department of Disease Control, with an objective of utilizing the database to develop health services delivery systems and referral systems at the provincial level. The data is expected to be utilized as baseline data to devise a plan to prevent and solve problems of injuries and accidents at both provincial and national levels. The data compiled at this database are those on injured or deceased individuals with all external causes (ICD-10, Chapter 20: External causes of morbidity and mortality, Codes V01 Y36), which take place within seven days and which make the individuals seek medical services at the emergency department/room of a large hospital in Bangkok or other provinces across the country. This is considered a provincial surveillance network that has been continuously expanded. At present, there are 29 hospitals in the injury surveillance network, so-called sentinel sites, namely Maharaj Nakhon Ratchasima Hospital, Maharaj Nakhon Si Thammarat Hospital, Lampang Hospital, Ratchaburi Hospital, Chon Buri Hospital, Yala Hospital, Sawanpracharak Hospital (Nakohn Sawan), Lerdsin Hospital, Nopparat Ratchathani Hospital, Saraburi Hospital, Khon Kaen Hospital, Songkhla Hospital, Prapokklao Hospital (Chanthaburi), Chiang Rai Prachanukhro Hospital, Sappasitthiprasong Hospital (Ubon Ratchathani), Phra Nakhon Si Ayutthaya Hospital, Chaopraya Yommaraj Hospital (Suphan Buri), Udon Thani Hospital, Surat Thani Hospital, Trang Hospital, Rayong Hospital, Nakhon Pathom Hospital, Buddhachinaraj Hospital (Phitsanulok), Chao Phraya Abhaibhubejhr Hospital (Prachin Buri), Uttaradit Hospital, Buri Ram Hospital, Surin Hospital, Pra Nangklao Hospital (Nonthaburi), and Chachoengsao Hospital. Since 2001, the format of injury surveillance has been improved, and the hospitals that are the sentinel sites are required to document only severe injury cases injured individuals who are dead 13

25 before arrival (DBA), injured individuals who are pronounced dead at the emergency room, and injured individuals who are observed at, or admitted to, hospital. They are also required to submit the records to the Bureau of Epidemiology for subsequent compilation in the database and the national surveillance reports. Management and examination of accuracy of data 1) The data were examined to ensure their completeness and accuracy by examining the printouts and the electronic files sent by the hospitals that are the sentinel sites using the injury surveillance analysis program. If any errors or discrepancies were found, the responsible hospitals in the network would be informed for revision and resubmission to the Bureau of Epidemiology. 2) Data regarding injury surveillance were compiled, organized, and recorded using the IS on Windows program (revised version 2007) to document data regarding severe injuries caused by 19 different causes including traffic accidents. 3) The surveillance data were analyzed using the IS program in terms of descriptive statistics to determine the number, percentage, proportion, ratio, rate of admissions, case-fatality rate, etc. 2. Data were analyzed by means of descriptive statistics. 3. The findings were summarized and the recommendations were proposed. 14

26 Chapter 2 Findings of Situation Analysis of Child Drowning Surveillance in Thailand Mortality According to the analysis of death certificates collected at the MOPH s Bureau of Policy and Strategy between 2004 and 2007, drowning was the number one cause of death in Thai children under 15 years of age, compared to other causes of mortality including infectious and non-infectious diseases (see Figure 3). When considering the five leading causes of injuryrelated mortality between 1999 and 2008, it was found that drowning was the number one cause of mortality, followed by road traffic injuries; accidental threats to breathing; exposure to electric current, radiation, and temperature; and physical assaults. Drowning accounted for as high as 33.9% 46.5% of the total injuries. The rate of drowning deaths ranged from 7.7 to 11.5 per 100,000 children under 15 years of age, and the total number of drowning deaths was 1,420 cases per year or 4 cases per day on average (see Table 3 and Figure 4). Figure 3: Numbers of deaths due to leading causes of death in children <15 years in Thailand, Accidental drowning and submersion Assault Pneumonia Vector borne diseases and dengue h Road traffic injuries Data source: Death certificates. Bureau of Policy and Strategy, Office of the Permanent Secretary, Ministry of Public Health. Analyzed by: Suchada Gerdmongkolgan and Som Ekchaloemkiet, Injury Prevention Group, Bureau of Non- Communicable Diseases, Department of Disease Control, Ministry of Public Health, Thailand. 15

27 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, Cause of death Year Accidental drowning and submersion (W65 W74) Number 1,249 1,412 1,444 1,588 1,472 1,471 1,549 1,482 1,297 1,229 Rate Percentage Road traffic injuries (V01 V89) Number Rate Percentage Other accidental threats to breathing (W75 W84) Number Rate Percentage Exposure to electric current, radiation and extreme ambient air temperature and pressure (W85 W99) Number Rate Percentage Assaults (X85 Y09) Number Rate Percentage Data source: Death certificates. Bureau of Policy and Strategy, Office of the Permanent Secretary, Ministry of Public Health. Analyzed by: Suchada Gerdmongkolgan and Som Ekchaloemkiet, Injury Prevention Group, Bureau of Non- Communicable Diseases, Department of Disease Control, Ministry of Public Health, Thailand. 16

28 Figure 4: Mortality rates for the five leading causes of death in children <15 years (per ,000 children <15 years) in Thailand, Accidental drowning and submersion Road traffic injuries Accidental threats to breathing Exposure to electric current, radiation, and extreme ambient air temperature and pressure Assaults Data source: Death certificates. Bureau of Policy and Strategy, Office of the Permanent Secretary, Ministry of Public Health. Analyzed by: Suchada Gerdmongkolgan and Som Ekchaloemkiet, Injury Prevention Group, Bureau of Non- Communicable Diseases, Department of Disease Control, Ministry of Public Health, Thailand. 17

29 When categorizing the causes of injury-related mortality by age group in 2008, it was found that the numer one cause of mortality in children under one year of age was accidental threats to breathing (4.9 per 100,000 population). However, the number one cause of mortality in the 1 4 and 5 9 age groups was drowning (13.8 and 12.0 per 100,000, respectively). As for the children aged 10 years and older, the number one cause of mortality was road traffic injuries. When considering the rates of deaths in all age groups, it was discovered that road traffic injuries ranked first (15.3 per 100,000), followed by drowning (6.4 per 100,000) (see Figure 5). 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 Data source: Death certificates. Bureau of Policy and Strategy, Office of the Permanent Secretary, Ministry of Public Health. Analyzed by: Suchada Gerdmongkolgan and Som Ekchaloemkiet, Injury Prevention Group, Bureau of Non- Communicable Diseases, Department of Disease Control, Ministry of Public Health, Thailand. 18

30 Trends in mortality During the 10-year period from 1999 to 2008, drowning rates in children aged under 15 years steadily increased between 1999 and 2006, ranging from 7.7 to 11.5 per 100,000 children under 15 years, before it began to decrease afterwards (see Table 4 and Figure 6). Table 4: Numbers and rates of child drowning deaths (per 100,000 children <15 years) in Thailand, Year Child drowning deaths Number Rate , , , , , , , , , , Data source: Death certificates. Bureau of Policy and Strategy, Office of the Permanent Secretary, Ministry of Public Health Analyzed by: Som Ekchaloemkiet and Suchada Gerdmongkolgan, Injury Prevention Group, Bureau of Non- Communicable Diseases, Department of Disease Control, Ministry of Public Health, Thailand. Figure 6: Numbers and rates of child drowning deaths (per 100,000 children <15 years) in Thailand, Number 1,800 1,600 1,400 1,200 1, number rate Rate per 100,000 children

31 Regions The findings revealed that the northeastern region had the highest rate of drowning deaths in children under 15 years of age, followed by the central region, the northern region, and the southern region; the rates per 100,000 children under 15 years in 2008 were 11.6, 9.1, 7.9, and 6.8, respectively (see Table 5 and Figure 7). Table 5: Numbers and rates of child drowning deaths (per 100,000 children <15 years) in Thailand by region, Year Region Number Rate Number Rate Number Rate Number Rate Number Rate Northern Northeastern Central Southern Data source: Death certificates. Bureau of Policy and Strategy, Office of the Permanent Secretary of the Ministry of Public Health Analyed by: Som Ekchaloemkiet and Suchada Gerdmongkolgan, Injury Prevention Group, Bureau of Non- Communicable Diseases, Department of Disease Control, Ministry of Public Health, Thailand. Figure 7: Numbers and rates of child drowning deaths (per 100,000 children <15 years) in Thailand by region, Northern Northeastern Central Southern Data source: Death certificates. Bureau of Policy and Strategy, Office of the Permanent Secretary, Ministry of Public Health. Analyzed by: Som Ekchaloemkiet and Suchada Gerdmongkolgan, Injury Prevention Group, Bureau of Non- Communicable Diseases, Department of Disease Control, Ministry of Public Health, Thailand. 20

32 Provinces The top ten provinces which had the highest rates of drowning deaths (per 100,000 children under 15 years) in children under 15 years of age for at least three consecutive years between 2004 nad 2008 were Chachoengsao, Rayong, Nakhon Nayok, Prachin Buri, and Nakhon Phanom (see Table 6). However, when considering specifically only the numbers of drowning deaths, it could be seen that Nakhon Ratchasima, Bangkok, Buri Ram, Ubon Ratchathani, Surin, Si Sa Ket, Udon Thani, and Khon Kaen had the highest numbers of deaths per year at 70, 62, 51, 50, 48, 47, 45, and 44, respectively on average (see Table 7). Table 6: Top ten provinces in Thailand with the highest rates of child drowning deaths (per 100,000 children <15 years), Rank Province (rate, number) Rayong (20.6, 26) Trat (40.1, 19) Rayong (21.1, 27) Nakhon Nayok (26.9, 13) Prachin Buri (21.1, 20) 2 Saraburi (20.3, 27) Nakhon Nayok (24.1, 12) Sing Buri (20.8, 8) Sing Buri (21.1, 8) Surin (18.7, 57) 3 Petchaburi (19.3, 18) Pichit (22.4, 25) Prachin Buri (20.7, 20) Ratchaburi (19.8, 33) Nakhon Pathom (16.8, 28) 4 Chachoengsao (18.2, 26) Rayong (22.2, 28) Phitsanulok (19.6, 32) Trat (19.4, 9) Nakhon Nayok (16.7, 8) 5 Prachin Buri (18.2, 18) Pang-nga (19.7, 11) Uttaradit (18.1, 16) Ang Thong (17.0, 9) Nakhon Panom (16.6, 26) 6 Buri Ram (17.9, 66) Chachoengsao (19.3, 27) Phatthalung (17.6, 19) Chachoengsao (16.7, 23) Chachoengsao (16.1, 22) 7 Chumphon (17.9, 19) Chanthaburi (18.9, 20) Nakhon Panom (17.4, 28) Samut Sakhon (16.7, 17) Sa Kaeo (15.8, 19) 8 Nakhon Nayok (17.7, 9) Sa Kaeo (17.7, 22) Mukdahan (17.1, 13) Rayong (16.1, 21) Uttaradit (15.3, 13) 9 Surin (15.8, 52) Si Sa Ket (17.6, 58) Chachoengsao (16.6, 23) Ranong (16.1, 7) Chanthaburi (14.7, 15) 10 Phetchabun (15.8, 34) Kanchanaburi (17.3, 31) Saraburi (16.3, 21) Nakhon Panom (15.8, 25) Si Sa Ket (14.3, 45) Data source: Death certificates. Bureau of Policy and Strategy, Office of the Permanent Secretary, Ministry of Public Health. Analyzed by: Som Ekchaloemkiet and Suchada Gerdmongkolgan, Injury Prevention Group, Bureau of Non- Communicable Diseases, Department of Disease Control, Ministry of Public Health, Thailand. 21

33 Table 7: Top ten provinces in Thailand with the highest numbers of drowning deaths among children <15 years, Rank Province (number) Bangkok (68) Nakhon Ratchasima (74) Nakhon Ratchasima (82) Nakhon Ratchasima (75) Nakhon Ratchasima (62) 2 Buri Ram (66) Bangkok (61) Bangkok (65) Bangkok (67) Surin (57) 3 Ubon Ratchathani (60) Si Sa Ket (58) Khon Kaen (56) Buri Ram (45) Bangkok (51) 4 Nakhon Ratchasima (59) Buri Ram (53) Ubon Ratchathani (55) Surin (45) Si Sa Ket (45) 5 Surin (52) Udon Thani (53) Buri Ram (48) Udon Thani (45) Buri Ram (43) 6 Udon Thani (50) Ubon Ratchathani (52) Si Sa Ket (48) Ubon Ratchathani (39) Ubon Ratchathani (43) 7 Si Sa Ket (46) Surin (44) Udon Thani (45) Si Sa Ket (38) Khon Kaen (41) 8 Khon Kaen (46) Sakon Nakhon (43) Surin (41) Ratchaburi (33) Chaiyaphum (30) 9 Songkhla (40) Khon Kaen (42) Roi Et (38) Khon Kaen (33) Udon Thani (30) 10 Chon Buri (35) Roi Et (38) Phitsanulok (32) Phetchabun (29) Nakhon Pathom (28) Data source: Death certificates. Bureau of Policy and Strategy, Office of the Permanent Secretary, Ministry of Public Health. Analyzed by: Som Ekchaloemkiet and Suchada Gerdmongkolgan, Injury Prevention Group, Bureau of Non- Communicable Diseases, Department of Disease Control, Ministry of Public Health, Thailand. 22

34 Gender According to the analysis of death certificates collected at the Bureau of Policy and Strategy, between 1999 and 2008, the rate of fatal drownings for males was approximately 2 times higher than that for females. The rate steadily increased from 1999 to 2006 before beginning to decline in 2007, similar to the overall picture of drowning situations (see Table 8 and Figure 8). The rate for males in the southern region was approximately 2.5 times higher than that for females in the same region (see Table 9). Table 8: Numbers and rates of child drowning deaths (per 100,000 children <15 years) in Thailand by gender, Gender Year Male Number , Rate Female Number Rate Total Number 1,249 1,412 1,444 1,588 1,472 1,471 1,549 1,482 1,297 1,229 Rate Data source: Death certificates. Bureau of Policy and Strategy, Office of the Permanent Secretary, Ministry of Public Health. Analyzed by: Som Ekchaloemkiet and Suchada Gerdmongkolgan, Injury Prevention Group, Bureau of Non- Communicable Diseases, Department of Disease Control, Ministry of Public Health, Thailand. 23

35 Figure 8: Numbers and rates of child drowning deaths (per 100,000 children <15 years) in Thailand by gender, Rate per 100,000 children Male Female Data source: Death certificates. Bureau of Policy and Strategy, Office of the Permanent Secretary, Ministry of Public Health. Analyzed by: Som Ekchaloemkiet and Suchada Gerdmongkolgan, Injury Prevention Group, Bureau of Non- Communicable Diseases, Department of Disease Control, Ministry of Public Health, Thailand. Table 9: Numbers and rates of child drowning deaths (per 100,000 children <15 years) in Thailand by region and gender, 2008 Gender Region Male Female Number Rate Number Rate Northern Northeastern Central South Total Data source: Death certificates. Bureau of Policy and Strategy, Office of the Permanent Secretary, Ministry of Public Health. Analyzed by: Som Ekchaloemkiet and Suchada Gerdmongkolgan, Injury Prevention Group, Bureau of Non- Communicable Diseases, Department of Disease Control, Ministry of Public Health, Thailand. 24