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Systematic review of drowning in India: assessment of burden and risk
  1. Caroline Lukaszyk1,
  2. Rebecca Q Ivers1,2,3,
  3. Jagnoor Jagnoor1,2
  1. 1The George Institute for Global Health, University of New South Wales, Sydney, Australia
  2. 2Sydney Medical School, University of Sydney, Sydney, Australia
  3. 3Southgate Institute, Flinders University, Adelaide, Australia
  1. Correspondence to Dr Jagnoor Jagnoor, The Goerge Institute of Global Health, University of New South Wales, Sydney 2042, Australia; jjagnoor{at}


Aim To examine the burden and risk factors for fatal and non-fatal drowning in India.

Methods Relevant literature was identified through a systematic search of 19 electronic databases and 19 national and global, institutional, organisational and government sources of injury data. Search terms used pertained to drowning, injury, trauma, morbidity and mortality in India.

Results A total of 16 research articles and five data sources were included in the review. Three national data sources provided counts of drowning deaths, reporting a range of 1348–62 569 drowning deaths per year. A further three national data sources provided information on drowning-related morbidity; however, each source presented different outcome measures making comparison difficult. Ten research studies investigated risk factors associated with drowning in India. Key risk factors reported were male gender, young age (0–5 years) and individuals residing in the North-Eastern part of the country who have high exposure to water sources within community settings.

Conclusion Drowning-related morbidity and mortality have a significant impact on India, with risk factors identified for this setting similar to those within other low-income and middle-income countries. Regional data which look beyond routinely collected data are required to accurately investigate the burden and impact of drowning, to inform targeted, context-specific approaches for drowning reduction initiatives

  • Drowning
  • India
  • burden
  • risk factors
  • low-income and middle-income countries

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The WHO reports nearly 360 000 drowning deaths each year,1 of which approximately 90% occur in low-income and middle-income countries (LMIC).2 Drowning in high-income countries (HIC) is often associated with leisure activities and predominantly occurs in swimming pools, rivers and at the seaside.3 In many LMICs, exposure to water is a daily occurrence with natural waterbodies within community settings used for a variety of household tasks, transportation and as a source of livelihood. Although exposure to drowning risk is high in LMICs, it is difficult to determine the burden and social impact of drowning in this context. Drowning fatalities are unlikely to be medically certified4 as they often occur in community settings at the time of event, leading to an under-reporting of drowning deaths in routinely collected data. Data on drowning-related morbidity are rarely collected, particularly in low-income and middle-income settings.2 Without an accurate understanding of the burden and risk factors for drowning, it is difficult to identify effective approaches towards prevention.

India contributes significantly to the global burden of drowning, with national drowning deaths accounting for 17% of global unintentional drowning mortality.5 With a coastline of over 8000 km and extensive inland freshwater systems,6 a large proportion of India’s population is regularly exposed to water. Many waterbodies are located within or nearby community settings, particularly in rural areas. Cataclysmic weather events are common in many parts of the country, particularly in North-Eastern states including Assam and West Bengal. Here, weather events such as storms, cyclones and flash floods have been gradually increasing in duration and intensity since the 1970s.7 Over 12% of the country is prone to flooding and river erosion.8 High-risk environments, coupled with limited child supervision, have been previously identified as significant contributors to childhood drowning in India.9

Despite a number of drowning risk factors being common in India and numerous media sources reporting on drowning cases, little empirical data are available on the burden or context of drowning-related morbidity or mortality within the country. A better understanding of the context and trends of fatal and non-fatal drowning is required to inform appropriate prevention strategies. This review aims to examine the burden and risk factors for fatal and non-fatal drowning in India, which can be applied to inform effective approaches towards drowning reduction, specific to this context.


The peer-reviewed literature and grey literature were systematically searched for information on (A) the burden of fatal and non-fatal drowning and (B) risk factors for fatal and non-fatal drowning in India. The search was conducted in April 2017.

Peer-reviewed literature

Relevant peer-reviewed literature was identified through the search of 19 electronic databases selected for their relevance to global injury (table 1).

Table 1

Databases searched by date and number of potentially relevant records corresponding to search terms

Search terms used included: ‘injury, damage, trauma, mortality, morbidity’, ‘India’ and ‘drowning, submersion’ (box 1).

Box 1

Search terms used to identify research studies investigating drowning-related injuries in India

For injury burden and trends

Injur* or damage* or trauma* or wound*

Death or mortality or fatal* or die* or decease* or morbidity



Defining drowning

Drown* or submer*

Combining search

1 and 2 and 3 and 4.

For inclusion in the review, studies were required to: (1) present primary research which analysed either primary or secondary data; (2) specifically investigate unintentional drowning; (3) be published within the last 15 years (from 2002); (4) include data specifically from India; and (5) be written in English. Outcomes of studies performed over 15 years ago were not considered to reflect the current burden of drowning in India and were therefore omitted from the review. Studies meeting these criteria were summarised in a standardised data extraction table (see online supplementary table 1). The quality of each study was measured against the STROBE Statement checklist for observational studies.10 The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist comprised 22 items that assess the strengths or weaknesses of individual studies; results represented in online supplementary table 1. Relevant data from each study were extracted and summarised by one author (CL), reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines.11 A PRISMA flow chart illustrating the different phases of identifying relevant studies for inclusion in the review is included as figure 1.

Supplemental material

Figure 1

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram outlining the study identification and selection process.

Other data sources

A list of 19 national and global, institutional, organisational and government data sources was compiled, each known to report on fatal and/or non-fatal injury in India (box 2).

Box 2

List of data repositories searched for grey literature on data sources related to drowning in India

National data sources

  • Vital registration records.

  • Sample registration system data.

  • District level health survey data/National Sample Survey Organisation data.

  • National Crime Records Bureau.

  • Ministry of Road Transportation and Highways.

  • Central Bureau of Health Intelligence.

  • Ministry of Health and Family Welfare.

  • Ministry of Social Justice (disability and rehabilitation).

  • Ministry of Environment, Forest and Climate Change.

  • Ministry of Labour and Employment.

  • Ministry of Statistics and Programme Implementation.

  • Integrated Disease Surveillance Programme.

  • Central Bureau for Health Intelligence.

  • Open data platforms.

  • Insurance web sites.

International data sources

  • WHO.

  • World Bank.

  • Unicef.

  • Global Burden of Disease Demographic and Health Survey Data.

Data sources which (1) presented data specifically on non-intentional drowning; (2) reported information collected from either individuals, healthcare providers or through other institutional administrative systems; and (3) presented data form the last 5 years (from 2012) were included in the review. Only the most recent data available from each source are presented in this review with the aim to investigate the current burden of drowning in India. Comments were made on the quality and utility of each data source against seven injury surveillance attributes, as recommended in the WHO Injury Surveillance Guidelines12 (see online supplementary table 2). Two researchers (JJ and CL) independently evaluated the data sources against these attributes.

Supplemental material


Peer-reviewed literature

Of the 17 electronic databases searched, five yielded zero results in response to the search terms used. In total, the electronic database search returned 182 research papers. Through screening manuscript titles and abstracts, 62 papers were identified as potentially relevant to the study. Excluded articles were either duplicates (n=43) or did not meet the selection criteria (n=77). From the 62 articles reviewed in full, 16 met the inclusion criteria and are summarised in table 1. The majority of records excluded did not contain data specific to India (n=34), or reported on drowning-related suicide or homicide (n=11).

The most common type of study identified was retrospective reviews, which were performed on autopsy data (n=3),13–15 medical records (n=3),14 16 17 police records (n=2),14 18 injury surveillance data (n=1)19 and/or media reports (n=1).18 Five cross-sectional surveys were identified which were either population based (n=4)20–23 or performed in hospital settings24 (n=1). Three studies used verbal autopsies to collect data4 25 26 and one study conducted focus group discussions with community-level stakeholders.27

Other data sources

Five of the 19 databases provided recent information on drowning-related morbidity and/or mortality within India.28–32 All databases contained routinely collected national data, but each presented data from different sources. Three sources provided information on both drowning-related morbidity and mortality from either secondary data sources or from police records.28 29 32 One source reporting only on morbidity presented data collected from individuals,30 while one source reporting only on mortality presented data from health records.31

Burden of fatal drowning in India

There were large variations in the burden of fatal drowning reported between each data source. Data from the Global Burden of Disease Study (GBD) provided the highest estimates for drowning mortality, reporting 62 569 drowning deaths occurred nationwide in 2016.28 The GBD summarises data from multiple secondary sources, each with their own limitations, and therefore must be interpreted with caution. Police records reported approximately half this number of deaths (299 822) for 2015.29 Numbers of fatal drowning cases from police data are mapped by state in figure 2, and presented graphically by cause and gender in figure 3. Medically certified cause of death records reported smaller numbers of drowning fatalities again, stating 1476 drowning-related deaths occurred across the country during 2015.31 A nationally representative study that used verbal autopsies for data collection attributed 11% of all injury-related deaths to drowning4 while another study, using similar methodology but confined to one city, found 2% of all deaths to be caused by drowning.26 A cross-sectional household survey conducted in Pondicherry reported 0.2% of all deaths to be caused by drowning.20 One hospital-based study from Vellore attributed 20% of all injury-related deaths to drowning,19 while a second from Tamil Nadu reported no drowning deaths to have occurred over a study period of 1 year.23 A review of autopsy records for women aged 12–49 years from one hospital site in Mangalore attributed drowning to 5% of all deaths.15 The burden of fatal drowning by data source is summarised in table 2.

Figure 2

Number of fatal and non-fatal drowning cases reported by the National Crime Records Bureau (NCRB) for 2015, by state, in India.

Figure 3

Number and proportion of fatal and non-fatal drowning cases by cause and gender, reported by the National Crime Records Bureau (NCRB) for 2015, in India.

Table 2

Summary of fatal drowning data identified through systematic review of the literature

Burden of non-fatal drowning in India

Data from the GBD reported 3 442 895 disability-adjusted life years (DALY) lost due to fatal and non-fatal drowning in India during 2016, corresponding to 0.7% of DALYs lost from all causes that year.28 Drowning was reported to cause 3 per 100 000 hospitalisations in 2014 by national hospitalisation data30 while just 481 non-fatal drowning-related injuries were reported in police data nationwide for 2015.29 Numbers of non-fatal drowning cases from police data are mapped by state in figure 2, and presented graphically by cause and gender in figure 3. A cross-sectional study conducted in one costal city showed 12% of the study population to have experienced a near-drowning event in the past year.22 A hospital-based study investigating health outcomes following non-fatal drowning found 55% of patients to be diagnosed with respiratory problems and 21% of patients to be diagnosed with neurological problems during their hospitalisation postdrowning event.16 Patient diagnosis was taken from medical records and nearly all (98%) drowning patients were discharged within 30 days of admission. The burden of non-fatal drowning by data source is summarised in table 3.

Table 3

Summary of non-fatal drowning data identified through systematic review of the literature

Risk factors for drowning in India


All sources presenting drowning incidence by gender reported fatal drowning to be significantly higher among men than women. One nationally representative study reported the male:female drowning mortality ratio as 2:1.4 A second study analysing the same data set reported drowning rates were significantly higher among boys than girls aged 0–5 years (97/100 000 vs 69/100 000, respectively).25 Two studies based on retrospective medical record review reported 85%16 and 78%17 of drowning deaths were in men. National police data reported 77% of fatal drowning cases were men.29


Two studies, one investigating fatal17 and the other non-fatal drowning,16 reported the greatest proportion of drowning cases among people aged 0–33 years. A nationally representative study showed fatal drowning rates were highest in the 0–5 years’ age group before steadily decreasing over the lifespan.4 One review of autopsy data attributed 11% of all fatal child (0–10 years) injury deaths to drowning14 while a second study, using similar methodology in a different setting, attributed 0.5% of all child (1–19 years) deaths to drowning.13 The majority of community members involved in focus group discussions in Tamil Nadu were not aware that drowning was a major cause of death among children in their community.27


Two studies analysing nationally representative data showed the greatest proportion of drowning deaths occurred in North-Eastern India.4 25 A national media review identified the South-Eastern state of Andhra Pradesh as having the greatest number of coastal drowning deaths in the country18 while national police data state that most drowning deaths occur in the Western state of Maharashtra.29 A nationally representative study which used verbal autopsies for data collection showed children aged 0–5 years living in rural areas had three times the drowning rate of those living in urban areas.25


One study which included participants of all ages identified most drowning deaths to occur in ponds/wells (44%) and rivers (30%).17 An analysis of media and police reports found 78% of all coastal drownings were caused by rip currents, 10% by accidents within harbours and 5% by boating accidents.18 Focus group members from community settings in Tamil Nadu identified cement pots storing water in the backyards of their homes, large buckets of water, open irrigation wells, irrigation tanks, abandoned quarries filled with rainwater, small drainage pits and tanks collecting rainwater as high-risk places for child drowning to occur.27 A study investigating drowning-related risk factors reported 33% of households had uncovered water sources close to living areas.21

Predisposing risk factors

A study held within a hospital setting investigated injuries sustained by patients with epilepsy as a result of an epileptic seizure.24 Although the paper states that drowning is the most common cause of fatal accidents for people with epilepsy, only one non-fatal drowning event was reported over the study period.


This review suggests a significant burden of drowning within India, with estimated counts of national drowning deaths as high as 62 569 in 2016.28 Limited existing data indicate that the impact of non-fatal drowning may also be substantial in this context. Within India, men are at higher risk of drowning, as are young people, particularly children aged 0–5 years. Drowning burden among children is high in the North-Eastern area of the country, in community-based water sources. The Indian coastline is spanning over 8000 km6; however, there is scare literature on burden and exposure to drowning risk in coastal community settings. This review has highlighted the need for accurate data on fatal and non-fatal drowning prevalence, together with robust evidence on drowning risk factors, to guide prevention initiatives.

Due to gaps in available data, it is difficult to accurately quantify the burden of drowning in India. While there are a number of routinely collected, national-level sources of health data, none appear to accurately capture fatal and/or non-fatal drowning cases. Poor reporting systems within hospital facilities fail to provide detailed patient data33 while the presence of hospital-based injury surveillance systems in India is rare, as within other LMICs.34 Further, the source for hospitalisation data included in this study contains only drowning cases reported by participating healthcare institutions located in urban areas. This results in poor population coverage, causing the data set to be largely incomplete.35 As the majority of high-risk drowning events result in death at the time of the incident,4 only a small proportion of drowning cases present at medical facilities. Furthermore, self-treatment for injuries is common in LMICs.36 In Bangladesh, traditional methods for treating a child following a drowning event are administered in community settings by a parent or other community member, often with no further medical consultation sought.37 Both factors prevent drowning cases being reflected in health records.

Deaths which occur in community settings are often not registered. This is again demonstrated in Bangladesh where 41% of drowned children are declared as dead by community members with no medical or coronary inquest performed,37 resulting in underestimation of drowning-related mortality. No similar studies were identified in India. Although national police data from India provide the most detail surrounding fatal and non-fatal drowning cases, it only includes cases which have been reported to local police agencies and are therefore registered under the Indian Penal Code. As drowning deaths may not always necessitate police investigation, under-reporting in these data is high, particularly for non-fatal drowning. Under-reporting is likely to be particularly high for drowning in children, where cases have fewer ramifications for property and socioeconomic rights. Second, drowning cases resulting from natural disasters are likely to be unreported due to population displacement. Finally, due to the nature of this data source, intentional drowning cases appear to be highly prevalent, yet are not included within this review due to its focus on non-intentional drowning. The high numbers of drowning deaths from this data source reported for the states of Madhya Pradesh, Maharashtra, Karnataka and Tamil Nadu may reflect better reporting practices in the southern states of India. One national data source identified through this study, the Open Government Data Platform, presented police data for drowning cases with no mention of the original data source, nor its associated limitations.

Risk factors associated with drowning vary between high-income and low-income settings. In HICs, increased drowning risk among adults is associated with participation in recreational activities involving water such as swimming, boating and fishing.3 Risk is increased further if activities are undertaken alone, if personal floatation devices are unavailable or if alcohol is consumed.3 For children in HICs aged below 1 year, most fatal drowning events occur in bathtubs38 while children aged 1–5 years commonly drown in swimming pools and open waterbodies.39 In LMICs, children under 5 years drown in natural waterbodies around the house and are not associated with recreational activities.40

Many drowning-related risk factors specific to India identified through this review are similar to those reported from other LMICs. As in India, fatal drowning primarily affects young children in Cambodia, China, Vietnam and the Philippines.41 In all four countries, drowning is the leading cause of injury-related deaths among children aged 1–4 years. In rural Bangladesh, a lack of child supervision has been associated with high drowning rates among children aged 1–5 years.42 Studies from China, Pakistan and Bangladesh report 84% of fatal drowning cases to occur in rural settings compared with urban settings, attributed to the large number of waterbodies in rural areas.40 The most common places of drowning for children in Bangladesh are waterbodies located in close proximity to households such as ponds, rivers and ditches.43 Similar to India, the drowning rates of men across Southeast Asia are one-third higher than the drowning rates of women.41

Strengths and limitations

To our knowledge, this is the first systematic literature review summarising the burden and risk factors for drowning specifically in India. Multiple data sources were identified and included in the review, with multiple providing national-level data. A further strength of this review was the inclusion of transport and disaster-related injuries.

There was much variation between each source of national data included in the review. The extreme variation in fatal and non-fatal drowning events reported by each national data source prevents accurate assessment of drowning burden. The differences in the nature, quality and coverage of each source prevent the direct comparison of available data.

Each academic study included in the review engaged different study populations, with different participant selection criteria used across various geographical areas making direct comparison between study outcomes difficult. Many academic studies presented mortality outcomes as either a proportion of total deaths or proportion of total injury deaths, making outcomes incomparable. Further, the sample sizes of the academic studies tended to be small, with one study including as few as 58 participants.16 The majority of academic studies were conducted in southern India, highlighting drowning research done only in targeted coastal populations. Risk factors associated with drowning identified through academic studies require further investigation due to the vast geographical and cultural diversity of India.

As a result, this paper was not able to provide accurate estimates on the burden of drowning in India, but rather demonstrates the reporting issues that exist within India and highlights the need for large-scale population-based studies to investigate drowning in this context.

Implications for future research

This study highlights a need for national-level projects that look beyond routinely collected data to investigate the burden and impacts of drowning. Community-based data have shown to be effective in providing accurate estimates of burden.2 Verbal autopsies have been previously used on a national level to collect data on injuries, including drowning, through projects such as the Million Death Study.44 The WHO has developed a verbal autopsy instrument which contains specific questions on drowning deaths and encourages its use when investigating fatal drowning rates in LMIC settings.45 Future research should use this tool to collect more detailed information surrounding drowning cases in community settings within India. It would be valuable to investigate the socioeconomic impacts of drowning, both at an individual and population level. This aligns with the key recommendation from the Global Report on Drowning, released by WHO in 2014,2 which states that improving drowning data in LMICs is necessary to ‘understand the full extent and circumstances of drowning, to target interventions and evaluate their effectiveness.’ Having access to reliable data on drowning burden and risk factors allows priority target populations to be identified and appropriate interventions with the highest likelihood of effectively reducing drowning to be selected for implementation.46


Despite indication that drowning-related morbidity and mortality have a significant impact on the Indian population, few large-scale, population-wide studies investigate the issue, nor focus on identifying effective approaches to its prevention. Many risk factors associated with drowning in India mirror those identified in other LMIC settings. An accurate understanding of the burden and context of drowning is required to inform context-specific approaches for drowning reduction initiatives.

What is already known on the subject

  • Drowning deaths within India are estimated to account for 17% of all global unintentional drowning mortality.

  • It is known that child drowning mortality rates are high in North-Eastern parts of India and that delta regions are frequently exposed to water-related natural disasters.

  • To identify and prioritise effective injury prevention strategies, data on the burden and risk factors associated with injury outcomes are required.

What this study adds

  • This review identifies the limitations of data sources in India, and the need for data reporting on drowning risk factors at regional/state level.

  • Presentation of drowning cases in medical facilities is low, due to nature of drowning injury requiring immediate attention and with high mortality rates.

  • From population data, there are challenges in capturing drowning deaths in known high-risk age group of under-5 years, and drowning deaths associated with water-related disasters.



  • Contributors JJ and RQI conceived the study and its design. CL led the identification of relevant literature, and drafted the manuscript with input and review from both JJ and RQI. All authors were involved in the analysis and interpretation of findings, and approved the final version of the manuscript.

  • Funding The Royal National Lifeboat Institution (RNLI).

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.