NEHA
Reducing Drownings through Epidemiology and Interventions
Hello everyone and welcome to the presentation, "Reducing Drownings through Epidemiology and Interventions."To ask questions about this presentation, please join the presenter in the networking lounge at the designated time listed on the agenda.I would now like to introduce Eric Wiegert, a principal sanitarian at the New York State Department of Health.
Hi everyone, and thank youto the National EnvironmentalHealth Association and the conference organizers and to all the attendees out there on the web.It's a pleasure to share some of our work and on our epidemiological approach, reducing drownings at our public pools and beaches here at the New York State Department of Health.Just a quick standard disclaimer before we get started.The findings, conclusions and opinions in this presentation are mine and do not necessarily represent the views of the New York State Department of Health.And with that we'll move onto the content.
My presentation today will cover some background information into the philosophy and foundations of our program, an overview of the process and methods used to implement it, an overview of some of the findings that we have identified over the years, a review of some of our prevention efforts, and lastly, we'll have time for some chat during the chat session.We'll first start off with a little bit of background and context about our program.
Public swimming pools and beaches are a valuable public resource here in New York State.As many of you are aware, we have a fairly large population with well-developed public infrastructure, and that affords us tremendous access to recreational water venues.New York State has approximately 600 miles of Atlantic Ocean and Great Lakes coastline; over 7,500 lakes, ponds, and reservoirs; and over 70,000 miles of rivers and streams.We have almost 8,000 public swimming pools and around 1,500 public bathing beaches.All this access to water is great for relaxation, recreation, and exercise for good health, but results in a substantial public health issue with a large population at risk for drowning.Yet, despite our large population and ease of access to recreational water, New York State consistently has the lowest or nearly the lowest drowning rate in the United States since the late 1990s, and we'd like to believe that our epidemiological approach has had something to do with that.
Conceptually, as public health practitioners, we can all agree that drownings are preventable, and through developing and understanding why drowning incidents occur and assessing related factors, it can lead to development of effective interventions to prevent future occurrences.New York State has been conducting what we have called epidemiologically-complete investigations into drowning at regulated public swimming pools and bathing beaches since the 1980s.These investigations have informed our regulation and policy-making with tremendous success.
Public swimming pools and beaches in New York are permitted and regulated by 46 local county or city health departments or state health department district offices, which I'll refer to those as field offices collectively.As is the same for many states, the pool and beach regulatory program is analogous with what a food service inspection regulatory program would be, with design and operational requirements and mandatory inspections and enforcement.
The program also includes required surveillance for injuries, illness, and serious incidents, including fatal or non-fatal submersions.Our regulations require facility operators to report serious incidents to the local health department within 24 hours, and the incidents are investigated by local health departments with the assistance of regional or central office staff from the New York State Department of Health.And this applies to approximately 1500 bathing beaches and almost 8,000 swimming pools regulated by the field offices, and also to those that are operated by state agencies.
And for the intent of some background and context for the presentation today we're referring to fatal drownings that have occurred at regulated facilities during operational hours as the setting that had the most regulatory jurisdiction and control and to investigate those that occur outside the regulated areas or outside of operational hours and apply new interventions as needed.However, for the intent of today's presentation, we'll be focusing on those incidents that occurred during the regulated operational setting.
Now I'd like to discuss the conceptual process of the program.Here's a pictorial representation of a very high level overview of the process.So going around the pie slices here, sowe investigate and collect information, we assess the information, identify opportunities for prevention, and then determine the best mechanism for prevention, such as regulations, policies, or tools or outreach, and then we apply the interventions, either actively or passively, depending on the nature of the intervention, be it facility design requirements or operational requirements or education-based in order to reduce exposure and occurrences of the submersion.
To accomplish this, the program is grounded in basic epidemiological principles of the epidemiological model.The model depicts the relationship between the agent, which in the case of drowning is the interference with physiological processes involved in respiration, and the host, of course, is the affected person, and the environment is everything outside the host.Removal or lessening the magnitude of any of these interactions can prevent a drowning.
In addition to the epidemiological model, our program is also grounded in the principles of the Haddon Matrix.The Haddon Matrix is a tool used to organize and evaluate the factors from the epidemiological model across the timeline of the incident.William Haddon was the leading traffic safety engineer and injury investigator in the 1960s.He was the first head of the National Highway Safety Bureau, who developed this methodology to investigate automobile-related injuries.He applied the epidemiological model to the study of injuries,and in turn developed what was deemed the Haddon Matrix to aid in this process.
The matrix has been used throughout public health and has also seen a resurgence in developing terrorism defense strategies.As you can see from the graphic, the timeline of the incident is broken down into three phases, pre-event, event, and post-event.By investigating and collecting information on drownings while being mindful of this matrix helps ground the investigation process and ensures a complete investigation.Admittedly, in a drowning incident there is not much to be completed in the middle agent row.For the post row, things like preexisting medical conditions, traits or behaviors certainly are applicable.And for the environment category, which, again, is technically anything outside of the host, such as physical characteristics of a facility, supervision, or environmental conditions, they're all important to assess after an incident.
Now I'm moving away from concepts and philosophy and on to the process of investigation and collecting of data.So, moving on to that slice of the pie.Running investigations are a lengthy, comprehensive process, and we collect a fair amount of data under the broad categories of both the epidemiological model and Haddon Matrix.Things such as data that's relevant to the facility, including the type of the facility, the nature of operation and setting, such as open swim or lap swim or lessons or summer camp, and the types of activities occurring when the incident occurred, such as underwater breath-holding or hyperventilation, which I believe New York City staff will be presenting at some point during the e-conference.
We also collect information on physical environment and conditions, things such as water clarity, bottom slope, marking, water depth, drop-offs, current, waves, or type status, among many others.Supervision is one of the most expansive data categories that we collect because of its dynamic and facility-specific nature, and also because of the human element and the potential variability that results from that.We collect type of supervision present, lifeguarded or other, what type of certification from what provider, any facility-specific or in-service training that they may have had, of course number of lifeguards deployed, their positioning, zones of coverage, and also the knowledge of the staff to see if they understood and have retained their training and their scanning technique, and their knowledge of instinctive grounding response and other victim recognition skills.
And then moving to the post-event phase, we collect data on event response, things such as, again, victim recognition is relevant, communications, victim recovery, assessment, treatment, including treatment from any non-aquatic staff, EMS, and medical providers.Now, the primary method that's used to collect these comprehensive data is through interviewing, and this would include supervisory staff, witnesses, other facility staff, and emergency responders.And we also interview family and friends in order to best determine host factors, which can be extremely difficult for both parties.But in the end, we found that most family members or those close to the victim are very appreciative of our efforts and are cooperative with our investigation.We also obtain official records that could be valuable, including police, EMS, hospital, and autopsy reports, including toxicology and microscopy, and on some occasions genetic testing and predisposing factors such as lung QT.
Our process is a data-driven process, so it's critical to have the data that standardizes best as we can.To help with this, we developed an investigation tool in order to maintain data uniformity and completeness.The need for comprehensive, organized investigation process and detailed findings are critical, so we developed a set of tools for our local and regional offices to use when investigating emergent incidents.
The investigation tool contains the data categories that I previously discussed, including environmental, supervision, and victim factors, but we've also organized by categories of people likely to provide the information and have interview tools for lifeguards, other facility staff, bystanders and close contacts of the victims, such as family or companions, on the day of the incident.While the process is data-driven and we've gone through an extensive process to make the data elements as precise as possible, it is nearly impossible to eliminate at least some qualitative narrative type information in order to best have an understanding of the incident, and we've designed the tools to reflect that.
So we've covered some background and concepts, and covered some methods.Now we'll move on to a brief discussion of some of the findings and conclusions that we have drawn over the years.To qualify, again, this information is related to fatal drownings that occurred at regulated or public swimming pools and bathing beaches during operational or what we would call regulated hours.And this set of data here depicts the period from 1987 through 2014.Currently, on average, we have a little under eight fatal drownings per year at our regulated facilities during operational hours.The number of drowning incidents can vary greatly from year to year, but we have an overall trend of reducing the average number of occurrences.
Another point I'd like to make regarding these data is the number of drownings compared to the number of pools versus beaches in New York State.You may recall that earlier on in the presentation I described the number of swimming pools in New York State at almost 8,000, and there's around 1,500 beaches, but the number of drownings that occur at the pools and beaches is roughly the same.So you can see how collecting information such as number of bathers present and other environmental factors, such as currents or waves or bottom conditions and water clarity that are unique to beaches can be really important in trying to develop an understanding of the nature of the incident.And those types of factors are very likely associated with this disparity in the number of drownings that occur at beaches versus swimming pools.
This set of charts here depict the same period of data shown in the proportion of fatal drownings at both pools and beaches, further divided into operation-type categories that we use here in New York State.Those labeled "Part 6" are those that are typically freestanding municipal-type facilities, water parks or health club type pools.And then we have hotels and campgrounds, and children's camps, either overnight or day camps, which, in themselves, are also a very robust regulatory program for public health protection here in New York State.And lastly, our state parks, which are some of the largest facilities in New York State with the largest bather exposure for both swimming pools and beaches.
Before we depict the data showing ages of victims, which is also then divided by sex of the victim, it is commonly believed that toddlers are the most at risk of drowning, and this may be the case in other settings, however, for the data at our public pools and beaches, the majority of drowning victims have been between 11 and 25 years old.Another significant finding from these data is that males are four times more likely to be a drowning victim than females.Historically, young adult males of the "risk-taking" age have been the most frequent occurrences at our New York State bathing facilities.Recently, however, we've seen an increase in the number of older adults, here at the far right of the chart, who most often have been swimming for low impact physical exercise.
On identifying this trend, we looked at the data over time.And while we can clearly see while the occurrence of fatal drowning incidences decreasing over time, as indicated in the blue, as we saw in the previous slide, as depicted in the purple series, the average age of victims is clearly increasing, which from a pure public health perspective is a success story in and of itself as we're decreasing years of life lost, but this also signifies a prevention opportunity.Perhaps outreach to lifeguards and facility managers at senior lap swim periods should be a time of enhanced vigilance, much the way operators enhance surveillance when many young children are present, or perhaps some outreach to medical providers when advising older patients to exercise or maybe even advise them to do so in a terrestrial setting if they have, like, a preexisting cardiac or other medical condition.
Another interesting data trend collected over the years is the depth of water where the incident occurred.It's commonly believed that most drownings occur in deep water, however our data show that a significant number of drownings occur in water less than five feet deep.The take-home message here for regulators, facility operators, and even caregivers is that diligence and supervising bathers is needed for any depth of water, not just deeper water.
Now I'd like to move on to cover some of our historical contributing factor data.These data are from a shorter, earlier grouping of data from 1987 through 2001.And part of the reason for the difference in this year period covered is that we have a long-term ongoing project that redesign and rebuild the database to include enhanced data elements that increase the data resolution for a number of data categories.And we're still in the midst of this project.We're currently in the stage of reviewing and coding retrospective data to include these new data elements, and hope to have that completed this year, which will then give us the opportunity to analyze and present data in new ways and develop new interventions.I guess, at this point, I could take the opportunity for a shameless plug here.If there's anybody who's really interested in this type of work and looking for a potential internship opportunity, please feel free to contact me and we can have a discussion about that.
The way that contributing factors have been historically presented and categorized use a similar approach to epidemiological model and Haddon Matrix, however we've pulled the supervision factors out of the environment category as sort of a subset and given it its own category as it is something that is very much within our regulatory authority and responsibility.And as you can see, it's also the largest proportion of the contributing factors that we've identified over the years.And with that said, I'll now speak to the environmental contributing factors.
For example, here, we can see that water clarity has been frequently identified.I think we'd all agree that it's certainly something that can be controlled in a swimming pool through proper design and operation of filtration and disinfection equipment.And also glare has been identified as a major contributing factor, but not only at outdoor facilities but also at indoor facilities.And again, here's an opportunity to provide education to operators [BREAK IN AUDIO] and staff about the need to identify potential glare issues, and also to address them preemptively during design and plan review phases, and be proactive during operation, things like lighting management and lifeguard positioning.