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Drowning prevention in the South-East Asia Region–2014 1

Defi nition and classifi cation of drowning

Drowning is the process of experiencing respiratory impairment from submersion/immersion in liquid1. This definition was adopted by the World Congress of Drowning in 2002.

To facilitate appropriate drowning prevention, the International Classifi cation of Diseases 10th Revision (ICD 10), Chapter 20 – External causes of morbidity and mortality, has classifi ed it as follows:

● A c c i d e n t a l d r o w n i n g a n d submersion (W65–W74) includes all unintentional drowning and submersion, except those due to transport accidents (V01–V99), water transport accidents (V90–V92) and cataclysm (X34–X39).

● Drowning and submersion by intention is categorized as intentional self-harm by drowning and submersion (X71), assault by drowning and submersion (X92).

● Drowning and submersion is classifi ed as drowning and submersion, undetermined intent (Y21) when

information is insuffi cient to make a distinction between unintentional or intentional2 submersion.

Global burden from drowning

Drowning is the third leading cause of unintentional injury deaths among all populations worldwide following road traffi c injuries and falls. It accounts for 7% of all injury-related deaths. In 2011, an estimated 360 000 people died from drowning globally. Low- and middle-income countries account for 95% of unintentional drowning deaths 3.

Worldwide, for children aged <15 years, drowning accounted for the highest mortality rate among all causes of injury4. Globally, about 23% of all unintentional injury deaths among children are due to drowning and 1.3% of all disability-adjusted life years (DALY) lost for children below 15 years of age in low-income and middle-income countries is from drowning 5. An estimate suggests that 2–3 million children aged 0–14 years survived a drowning incident in 2004 globally. However, about 5% of child drowning survivors were admitted to hospital with neurological damage6.

Globally, the South-East Asia Region has the second highest rate of child fatality from drowning (8.6/100 000 child per year)

Drowning Preventionin the South-East Asia Region–2014

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Drowning prevention in the South-East Asia Region–20142

Drowning can be a serious impediment to achieving Millennium Development Goal7.

Magnitude of drowning in the South-East Asia Region

Drowning is one of the major causes of mortality in the South-East Asia Region. India, as a whole, has an average drowning death rate of 6.6 per 100 000 population per year. One person drowns every 8 minutes in India8 which has particularly high drowning mortality rates. It also contributes 43% of the world's drowning deaths and 41% of the total global DALY lost related to drowning together with China3.

A hospital-based study by the Nepal Health Research Council during 2008–2009 documented 37 973 injuries, showing that drowning constituted 0.07% of all injury deaths9.

Myanmar ’s Health Management Information System has reported that drowning is the leading cause of injury deaths accounting for 1257–1511 deaths/year since 2005. This number increased remarkably in 2008 to 7625 deaths (15.97 deaths/100 000 population per year)10.

In Maldives, 1.9% of the total deaths were due to drowning. The age-adjusted death rate in 2011 was 7.33 per 100 000 of population11.

Child fatality from drowning in the South-East Asia Region

According to Global Health Estimates by the World Health Organization, child fatality from drowning in the South-East Asia Region is 8.6/100 000 children8. This rate is second only to the African Region (Figure 1).

Figure 1: Fatal drowning rates per 100 000 children aged <20 years by WHO region and

country income level, 2011

10.09.08.07.06.05.04.03.02.01.00.0

LMIC

9.1

LMIC LMIC LMIC LMIC LMICHIC HIC HIC HIC

AFR AMR SEAR EUR EMR WPR

2.0

3.4

8.6

0.6

4.2

2.2

7.5

0.7

5.1

Source: WHO Global Health Estimates, cause-of-death estimates for 2011 **Age-standardized death rate/100 000 children aged less than 20 years. HIC = High-income countries; LMIC = low-income & middle-income countries.

A five-country community survey in Bangladesh, China, Philippines, Thailand and Viet Nam in 2008 revealed an average rate of drowning deaths at 30 per 100 000 children under the age of 18 years12. Among these countries Bangladesh has the highest number of such cases every year (16 570 cases). In Thailand 2 645 children die due to drowning each year13.

Drowning is the leading cause of death in children aged 1–17 years in Bangladesh, (28.6 per 100 000 children ≤17 years) in 200314.

In India, death registration data 2001–2003 show that unintentional injuries were reported to be the sixth leading cause of death among children of ≤5 years. Most of the childhood drowning deaths were in rural areas15.

The Thai death registry report of 1999–2012, revealed drowning as the leading cause of death among children (≤15 years) with an age-specific rate of 7.7–11.5 per 100 000 children. Drowning accounted for 33.9–46.5% of all Thai child injury deaths16.


Risk of drowning in the South-East Asia Region

Age

In most of the countries, drowning rates are often the highest in the 1–4 years age group and then rapidly decline as age increases. The median age of drowning is over 10 years1. In general, children under five have the highest drowning mortality rates worldwide17.

In Bangladesh, the highest rates of drowning and near drowning have been observed among children of the 1–4 years age group. In Thailand, the drowning rate is the highest among the 1–4 years age group, but near-drowning events occurred mostly in the 5–9 years age group14.

In Nepal, 39% of the drowning victims were below 18 years of age and 24% below 11 years during 2005–201018. The ‘India Million Death Study’ reported that the peak age of drowning was 1–2 years of age. The

proportion of drowning deaths decreases while the proportion of road traffic injury-related deaths increases after the age of two years; however, the number is still less than that due to drowning19.

In Bangladesh, based on the rate reported in the Bangladesh Health and Injury Survey (BHIS, 2005) almost 17 000 children drowned, or about 46 deaths per day. The number of near-drowning cases was about four times of this (over 68 000). 26% of all deaths in children of 1–4 years were due to drowning20.

In Thailand, it was found that most drowning deaths occur in toddlers who die at a rate of 40 deaths per 100 000 children annually. The highest incidence (86.3/100 000 children ≤15 year old) was in children aged 1–4 years and comprised more than one quarter (26%) of all deaths21.

Sex

The drowning rate of males is higher than those of females in all age groups. Nearly 80% of deaths from drowning occur in males22. This might be due to increased exposure to water and riskier behaviour such as swimming alone, drinking alcohol before swimming alone and boating23.

In Thailand, boys have about twice the fatal drowning rate than girls in both 0–4 years and 5–9 years age groups24 (Figure 2).

Inadequate supervision

Almost all drowning occurred during daylight hours (97%) and most infant and young children drowned when the supervisor or mother were distracted25. Young children who escaped the supervision of their caretakers drowned in unprotected water sources. Their caretakers were often unaware of the drowning for an hour or longer.

© Chumpolburi Hospital, Thailand

Training on rescuing drowning persons by a community hospital team


Figure 2: Fatal drowning rates per 100 000 children aged 0–14 years

in Thailand by sex, 1999–201216

14

12

10

8

6

4

2

01999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

male

female

Source: Death certificates, Bureau of Health Policy and Strategy, Ministry of Public Health, Thailand.

Access to water

Increased access to water is another risk factor for drowning. In low-income countries, those involved in commercial fishing or fishing for subsistence, using small boats are more prone to drowning. Children who live near open water sources, such as ditches, ponds, irrigation channels, or pools, are especially at risk1. Evidence shows that about 70% of drowning deaths occurred in ditches and ponds; mostly (85%) infants and very young children drowned in water bodies within 20 metres of their homes25. A study from the United States of America showed that between 1996 and 1999, children under five died from complications of products related to drowning in and around the home. The products most frequently involved in drowning deaths included bathtubs, five-gallon buckets, spas, hot tubs, and toilets26. The South-East Asia Region may have the same problem which needs to be investigated.

The Thailand National Sentinel Injury Surveillance (IS) 1998–2007 reported that children below 15 years of age drowned mostly by playing in natural water sources (39.9%), followed by drowning

after falling into natural water sources (8.3%), swimming pools (5%), and bath tubs (2.5%)16.

Large numbers of drowning deaths are related to natural disasters and water transport. Unsafe or overcrowded water transportation, and vessels lacking flotation devices for passengers increase the risk of drowning. In southern India, 12 people drowned and 20 others remained missing after a crowded boat carrying pilgrims capsized in a river on 30 January 201027. Majority of the victims were women (27 including three pregnant women) and children (7), which may also be the case for similar incidents in the Region.

Residents of areas prone to floods and other cataclysmic events like flash floods and tsunamis are at higher risk. Children accounted for about one third of those who died during the Indian Ocean tsunami in 20045. Living near the sea, rivers or other water bodies increases the risk of drowning.

Time of occurrence

January, April, September, and December were the four months with the most deaths in Bangladesh and almost all (97%) drowning occurred in daylight between 06:00 and 18:00.14 Thailand IS showed that child drowning deaths peaked in April, followed by May and March (period of annual long school holiday from March to mid-May) and October (mid-year school holiday). The highest incidence of serious drowning injuries occurred during weekends; the number for weekends alone accounted for 38.8% of all drowning fatalities. The time of the day with the highest occurrence of drowning was between 15:00 and 17:59, followed by 12:00 and 14:59, and together constituted 64% of all fatal drowning16.


Other factors

In many countries, lower socioeconomic status and rural residence are associated with drowning risk.1

Illiteracy of mothers and low family income were identified as risk factors for childhood drowning in many countries like Bangladesh28. In Bangladesh, children whose mothers had only primary education were at a significantly greater risk of drowning compared to children whose mothers had secondary or higher education29.

Child drowning risk increased as maternal age and family size increased.

Tourists unfamiliar with local water risks and features, people with medical conditions such as epilepsy 30, and those using alcohol near or in the water22 faced higher risk of drowning.

Drowning prevention in some South-East Asia countries

Drowning prevention in Bangladesh

The Centre for Injury Prevention and Research, Bangladesh (CIPRB) conducted a large quasi-experimental community research in four sub districts (about 174 000 households with an average population of 813 000 per sub district). The programme used local resources, relying on local community participation to create a culture of water safety. An International Drowning Research Centre was also developed under the umbrella of CIPRB. Age-specific drowning prevention interventions of CIPRB are:

For children under five years of age ● Home safety counselling: A community

volunteer counsels the household

occupants, especially mothers, for removal of drowning hazards in, at and near the home on a monthly basis.

● Establishment of crèches: Community crèches have been established to accommodate around 25 children under the direct supervision of a trained volunteer supervisor while parents are busy with their normal daily work.

For children 5–10 years of age ● CIPRB in collaboration with The

Alliance for Safe Children (TASC) and Royal Life Saving Society Australia (RLSSA) developed the SwimSafe programme to teach survival swimming.

● Some natural ponds are designated as community ponds based on suitability and availability. Trained community swimming instructors (CSIs) (certified by the Bangladesh Swimming Federation) provide swimming and water safety training at community ponds. Training involves knowledge and practical skills in the delivery of the ‘Swim for Life’ programme, pond management and promotion of drowning prevention across the community.

CSI providing swimming and water safety instruction at community pond. Fencing to prevent child drowning.

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For all children ● After any fatal drowning occurs in the

village, courtyard meetings and social autopsy meetings are conducted with people to identify the cause.

● Street theatre and video-shows on water safety themes are organized. Booklets and posters are distributed at school.

● Collaboration is undertaken with relevant agencies to implement survival swimming curriculum and prevention programmes.

Along with these programmes, CIPRB has established a community-based active surveillance system in the project areas to report all injury mortality including drowning.

After implementation of the programme in Bangladesh, the mortality rate of child drowning (per 100 000 children) in three piloted sub-districts decreased from 11.1 in 2006 to 9.8 and 9.3 in 2007 and 2008, respectively.

Thailand National Drowning Prevention Programme

The injury management unit of the Ministry of Public Health (MOPH) Thailand has embarked on a data and policy-driven project “Childhood drowning prevention” since 2006. Mass media campaigns were conducted to raise awareness on childhood drowning problems through provision of scientific evidence and practical preventive measures and advocate for substantial national policy. Subsequently, the health minister declared childhood drowning prevention as an important policy of the MOPH and the National Multisectoral Child Drowning Prevention Committee was formed.

Implementation of national drowning prevention programme

● A public policy forum was organized to determine measures for child drowning prevention.

● Child survival swimming policy was established and the recommendation “children should be able to swim from six years of age” added in the mother and child health record book.

● The Day of Child Drowning Prevention was commemorated for raising awareness.

● Parents were educated on child drowning prevention at all public health centres.

● Information on drowning prevention was disseminated through mass media with support from the private sector.

● A pilot project for model development of childhood drowning prevention was set up in four provinces which has expanded to 30 (out of total 77).

● Capacity-building of health personnel and networks in preventing childhood drowning, and expediting adjustment of the related legislation were undertaken.

Thailand National childhood drowning prevention committee

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● Childhood drowning surveillance and investigation was conducted.

After implementation of the drowning prevention programme, the mortality rate of childhood drowning (<15 years) decreased from 11.1/100 000 children per year to 8.4 in 2012.

Drowning prevention initiatives in other countries of the Region

● Project: Swim International is operating in India (Swim India) and Nepal (Swim Nepal) in educating mainly schoolchildren in drowning prevention (swimming lessons and resuscitation skills)31. The Rashtriya Life Saving Society (RLSS) is operating a Swim and Survive programme in India in four States. The curriculum of the programme has been designed to teach children the skills of basic swimming, treading water and rolling over onto one’s back as part of the first level. The programme is supported officially in Kerala at the state level for schoolchildren.

● The Ministry of Health and Sri Lanka Red Cross Society are the main organizations to take initiatives in

Sri Lanka. Several meetings of stakeholders have been conducted and compilat ion of a nat ional report on drowning through the Drowning Prevention Association of Sri Lanka is in the pipeline. Training curriculum on basic water safety skills and information, education and communication (IEC) materials are under review for national-level endorsement.

Limitations and challenges of drowning prevention programmes in the South-East Asia Region

Low priority issue

Most countries in the South-East Asia Region have no national policy/strategy on drowning prevention.

Population characteristics ● Most of the population of the Region

resides in rural areas where water hazards are abundant in or around the home and throughout the community.

● There is a lack of or low education and awareness.

Non-availability of data ● Population-based data are appropriate

in identifying and prioritizing the burden of drowning, but are not usually available. Drowning is underreported in hospital-based data. Distinctions between unintentional and intentional injuries may be unclear, and intentional drowning deaths (such as suicide, assaults) are mostly not reported or misclassified32. Shri Oomen Chandy, Hon Chief Minister, Govt. of Kerala during

inauguration of the project at St Mary’s School, Pattom Swim N Survive in Kerala, India.

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Diverse nature of prevention ● Comprehensive prevention strategies

are required according to the population and exposure. Different prevention strategies are needed to address different exposures33.

Strategies and measures for prevention

Primary prevention

1. Data and generating evidence ● The burden of drowning must be

defined. ● Many interventions still require

rigorous evaluation.

2. Engineering methods to eliminate exposure

● Unnecessary accumulation of water should be drained.

● Wells or open cisterns should be covered.

● Safe drainage systems, piped water systems, and flood control embankments should be established in flood-prone areas34.

● Four-sided pool fences or barriers should be built35 to create and maintain safe water zones for recreation.

3. Enforcement and legislation ● Mandatory four-sided fences should be

installed around pools with adequate enforcement and verification system for closure.

● Water safety laws should be developed, upgraded and enforced for water transport including adequate personal floating devices for all passengers, regular safety checks, prohibiting alcohol use while boating or swimming and during leisure on the beach.

● Legislation and enforcement is strongly needed to ensure availability of sufficient number of properly-fitted and appropriate personal flotation devices in commercial passenger boats/ship.

4. Educating individuals and communities

● Education on drowning awareness, risks associated with drowning and training on water survival skills appear to be promising strategies to prevent drowning.

5. Adapting interventionsTo maximize their effectiveness, prevention strategies and measures against drowning should be adapted to the child’s developmental stage and sociocultural norms. Affordability and availability are important factors. Fencing works well for swimming pools, but it may not be the solution in regions where canals and irrigation ditches and large water reservoirs i.e. ponds are abundant. Risk-spot location is important with special surveillance, warning signs and installation of rescue equipment at sites where fencing is not possible.

Swimming training session in a portable swimming pool, Thailand.

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Secondary prevention

Rescuing a drowning person ● Get a long stick or pole and reach

it towards the drowning person, or throw the drowning person a rope. Tell him to grab it and pull him to safety. If no rope is available, at least throw any floating device.

● Never get in the water to swim to rescue the drowning person if not specially trained as a lifeguard. There have been too many cases of rescuers drowning.

Pre-hospital management of drowning patients

The most important and detrimental consequence of submersion is hypoxia. Therefore, oxygenation, ventilation, and perfusion should be restored as rapidly as possible following activation of the emergency medical services (EMS) system36

Basic steps of pre-hospital management of drowning are:

● get help or call for help ● check for breathing and pulse ● start CPR (cardiopulmonary

resuscitation), if there is no pulse

● repeat if the person is still not breathing.

Chest compression is not the best way to resuscitate near-drowning/drowning victims because the person’s primary problem is lack of oxygen. It is advised to use the ABC (airway, breathing, chest compressions) method and start mouth-to-mouth breathing first before chest compression for heartbeat. Detailed CPR instructions are available from: http://www.mayoclinic.com/health/first-aid-cpr/FA00061

● If the victim vomits, turn the victim’s mouth to the side and remove the vomitus using a finger, a cloth, or suction to void airway obstruction. Consider also other associated injuries, i.e. head injury or spinal cord injury.

References(1) World Health Organization. Drowning. Geneva:

WHO. http: / /www.who.int /v iolence_injury_prevention/ other_injury/drowning/en/index.html - accessed 09 April 2014.

(2) World Health Organization. ICD-10 version: 2010. Geneva: WHO. http://apps.who.int/classifications/ icd10/browse/ 2010/en - accessed 09 April 2014.

(3) World Health Organization. Drowning. Fact sheet no. 347, Oct 2012. Geneva: WHO, 2012. http://www. who.int/mediacentre/factsheets/fs347 /en/index.html - accessed 09 April 2014.

Demonstation on rescuing a drowning person

© Suchada Gerdmongkolgan, Som Ekchaloemkiet

Alternate measures for drowning prevention where water body fencing is not possible, Thailand.

© Hinlad Subdistrict Administrative Organization, Burirum Province


(4) Peden MM, McGee K. The epidemiology of drowning worldwide. Injury control and safety promotion. 2003;10(4):195-199.

(5) World Healh Organization. World report on child injury prevention. Geneva: WHO. 2008. http://www.who.int/ violence_injury_prevention/child/injury/world_report/en/index.html - accessed 09 April 2014.

(6) Lincoln JM, Conway GA. Preventing commercial fishing deaths in Alaska. Occupational and Environmental Health. 1999;56(10):691-695.

(7) Linnan Michael, et al. Child drowning: evidence for a newly recognized cause of child mortality in low and middle income countries in Asia. Working Paper 2012-07. Special Series on Child Injury No. 2. Florence: UNICEF Office of Research, 2012. http://www.unicef.or.jp/library/ pdf/Child_Drowning_FINAL_Office_of_Research.pdf - accessed 09 April 2014.

(8) World Health Organization. Global health estimates (GHE). Geneva: WHO. http://www.who.int/healthinfo/ global_burden_disease/en/ - accessed 09 April 2014.

(9) Nepal Health Research Council. Epidemiological study on injury and violence in Nepal. Kathmandu: NHRC, 2009.

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(11) Health profile: Maldives. Top 20 cause of death. World Health Ranking, Live Longer Live Better. http://www.worldlifeexpectancy.com/country-health-profile/maldives - accessed 10 April 2014.

(12) Linnan Michael, et al. Child mortality and injury in Asia: an overview. Innocenti Working Paper 2007-04. Special Series on Child Injury No. 1. Florence: UNICEF Innocenti Research Centre, 2007. http://www.unicef-irc.org/publications/pdf/iwp_2007_04.pdf - accessed 10 April 2014.

(13) The Alliance for Safe Children. Fact sheet - Drowning: a public health emergency. TASC. http://www.tasc-gcipf.org/downloads/ drowning.pdf - accessed 10 April 2014.

(14) Rahman A, Rahman F, Shafinaz S, Linnan M. Bangladesh health and injury survey. Dhaka: DGHS; ICMH; UNICEF; TASC, 2001.

(15) The Registrar General of India. Verbal autopsy for all deaths occurring in 2001-2003 in a nationally representative sample. New Delhi, 2009.

(16) Gerdmongkolgan S, et al. Situation analysis of child drowning surveillance in Thailand. Nonthaburi: Ministry of Public Health, 2009. http://www.thaincd.com/document/ file/download/knowledge/Situation_Analysis_of_Child_Drowning_in_Thailand_Eng_Version.pdf – accessed 10 April 2014.

(17) MacKellar, A. Deaths from injury in childhood in Western Australia 1983 – 1992. Medical Journal of Australia. 1995;162:238–242.

(18) Ep idemio log i ca l p ro f i l e o f d rown ing i n Nepa l . Wor ld Con fe rence on d rown ing prevention, Vietnam, May 2011. http://www.worldconferenceondrowningprevention2011.org/SiteMedia/w3svc1092/Uploads/Documents/WCDP2011_LMIC_Harihar_p59_Abstract.pdf - accessed 10 April 2014.

(19) Jagnoor J, Bassani DG, Keay L, Ivers RQ, Thakur JS, Gururaj G, Jha P. Million death study collaborators: unintentional injury deaths among children younger than 5 years of age in India: a nationally representative study. Injury Prevention. 2011;17(3):151-5. Doi. 10.1136/ip.2010.029934.

(20) Ahmed MK, Rahman M, Ginneken JV. Epidemiology of child deaths due to drowning in Matlab, Bangladesh, International Journal of Epidemiology. 1999;28:306–311.

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(22) Laosee OC, Gilchrist J, Rudd R. Drowning 2005-2009. MMWR. 2012;61(19):344-347.

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(24) Suchada Gerdmongkolgan, Som Ekchaloemkiet. Model-driven community towards the child drowning in Thailand. The World Conference on Drowning Prevention, Vietnam, 10-13 May 2011. Bangkok: Ministry of Public Health. http://www. worldconferenceondrowningprevention2011.org/SiteMedia/w3svc1092/Uploads/Documents/WCDP2011_LMIC_Gerdmongkolgan_p54_Presentation.pdf - accessed 10 April 2014.

(25) Rahman A, Mashreky SR, Chowdhury SM, Giashuddin MS, Shafinaz S, Linnan M, Fazlu AKM. The Bangladesh experience: a research and evidence-based approach to develop an effective, large-scale, sustainable child drowning prevention programme suitable for developing countries. World Conference on Drowning Prevention. International Life Saving Federation. 2007. http://www.ilsf. org/drowning-prevention/library/bangladesh-experience-research-and-evidencebased-approach-develop - accessed 10 April 2014.

(26) United States. Consumer Product Safety Commission. Memorandum. Washington, DC http://www.cpsc.gov/PageFiles/18414/drwnstat.pdf - accessed 10 April 2014.

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(29) Rahman A, Fazlur Rahman AKM, Barua PC, Sheikh GH. Pattern and determinants of child deaths due to drowning in rural Bangladesh. Published abstract. 6th World Conference on Injury Control and Prevention. Montreal, 2002.

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(33) Kobusingye O, Guwatudde D, Lett R. Injury patterns in rural and urban Uganda. Injury Prevention. 2001;7(1):46-50.

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Evidence for key strategies to prevent drowning among children

Strategy

Effe

ctive

Prom

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Insu

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evid

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Inef

fect

ive

Pote

ntial

ly ha

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l

Removing (or covering) water hazards

Requiring isolation fencing (4-sided) around swimming pools

Wearing personal flotation devices

Ensuring immediate resuscitation

Ensuring the presence of lifeguards at swimming areas

Conducting targeted awareness-raising on drowning

Teaching children older than 5 years to swim

Introducing laws on pool fencing

Introducing a law on the use of personal flotation devices

Promoting drowning prevention through doctors

Restricting access to areas unsafe for swimming

Teaching children younger than 5 years to swim

Introducing laws on blood alcohol content for swimmers

Conducting prevention campaigns, such as on advertising hoardings, for drowning

Promoting solar pool coversa

Using baby bath seatsa

a These are not primarily designed as drowning prevention interventions.Source: World report on child injury prevention, 2008.

Sincere thanks are extended to Dr AKM Fazllur Rahman, Center for Injury Prevention and Research, Bangladesh, Dr Adisak Plitponkarnpim, Child Safety Promotion and Injury Prevention Research Center (CSIP), Ramathibodi Hospital, Mahidol University, Ms Suchada Gerdmonkolgarn, Ministry of Public Health Thailand and Rear Admiral Purushottam Sharma, Rashtriya Life Saving Society, India for reviewing the document and providing updated information.

Thanks are also extended to Ms Suchada Gerdmongkolgan, Ms Som Ekchaloemkiet, Mrs Saluckjit Sakunrak, Dr AKM Fazllur Rahman and Rashtriya Life Saving Society for providing photographs for this document. The advice provided by Ms Siriwan Santijiarakul on the art design of the document is appreciated.

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For detailed information, please contact:

Disability & Injury Prevention and Rehabilitation Unit Department of Sustainable Development & Healthy Environments (SDE)

http://www.searo.who.int/entity/disabilities_injury_rehabilitation/topics/disabilityfactsheet2013/en/

World Health HouseIndraprastha Estate,Mahatma Gandhi Marg,New Delhi-110002, Indiawww.searo.who.int