Connexin 26 35delG does not represent a mutational hotspot

Recent evidence suggests that the susceptibility to respiratory distress syndrome (RDS) is partly explained by genetic variation in the surfactant proteins (SP) SP-A and SP-B. The present study was designed to evaluate the concordance difference method and candidate gene analysis, in parallel, for the investigation of genetic susceptibility to RDS. We studied 100 same-sex twin pairs with established RDS in at least one twin. The difference in RDS concordance rates between the monozygotic (MZ) and dizygotic (DZ) twin pairs as evidence of a genetic influence was evaluated, and the SP-A and SP-B genes were investigated for potential associations with the susceptibility to RDS. The concordance rates of RDS were 54 and 44% in the MZ and DZ pairs, respectively. The concordance difference of 10% was not significant [95% confidence interval (CI) -0.1 to +0.3, P=0.32], suggesting a low hereditary impact. However, the SP-B Ile131Thr polymorphism was associated with RDS. The threonine allele was associated with an increased risk of RDS [odds ratio (OR) 2.2, 95% CI 1.4-3.5, P=0.0014]. This was particularly apparent in first-born male infants (OR 6.2, 95% CI 2.4-16.3, P<0.001). The degree of prematurity (<32 weeks OR 2.0, 95% CI 1.1-3.7, P=0.021) and birth order (second-born OR 3.1, 95% CI 1.3-7.4, P=0.009) were the clinical variables affecting the risk of RDS. An association between the SP-B Ile131Thr polymorphism and RDS was found. The threonine allele was associated with the risk of RDS, particularly in the first-born twin infants. The concordance difference between MZ and DZ twin pairs underestimates the genetic impact on the risk of RDS. The traditional twin concordance study is insufficient to evaluate genetic predisposition to RDS or other diseases that are confounded by the birth order or multiple pregnancy in itself.     

Is carbon monoxide-mediated cyclic guanosine monophosphate production responsible for low blood pressure in neonatal respiratory distress syndrome?

Infant respiratory distress syndrome (RDS) involves inflammatory processes, causing an increased expression of inducible heme oxygenase with subsequent production of carbon monoxide (CO). We hypothesized that increased production of CO during RDS might be responsible for increased plasma levels of vasodilatory cGMP and, consequently, low blood pressure observed in infants with RDS. Fifty-two infants (no-RDS, n = 21; RDS, n = 31), consecutively admitted to the neonatal intensive care unit (NICU) between January and October 2003 were included. Hemoglobin-bound carbon monoxide (COHb), plasma cGMP, plasma nitric oxide (NOx), and bilirubin were determined at 0-12, 48-72, and at 168 h postnatally, with simultaneous registration of arterial blood pressure. Infants with RDS had higher levels of cGMP and COHb compared with no-RDS infants (RDS vs. no-RDS: cGMP ranging from 76 to 101 vs. 58 to 82 nmol/l; COHb ranging from 1.2 to 1.4 vs. 0.9 to 1.0%). Highest values were reached at 48-72 h [RDS vs. no-RDS mean (SD): cGMP 100 (39) vs. 82 (25) nmol/l (P < 0.001); COHb 1.38 (0.46) vs. 0.91 (0.26)% (P < 0.0001)]. Arterial blood pressure was lower and more blood pressure support was needed in RDS infants at that point of time [RDS vs. no-RDS mean (SD): mean arterial blood pressure 33 (6) vs. 42 (5) mmHg (P < 0.05)]. NOx was not different between groups and did not vary with time. Multiple linear regression analysis showed a significant correlation between cGMP and COHb, suggesting a causal relationship. Mean arterial blood pressure appeared to be primarily correlated to cGMP levels (P < 0.001). We conclude that a CO-mediated increase in cGMP causes systemic vasodilation with a consequent lower blood pressure and increased need for blood pressure support in preterm infants with RDS.     

Association between the surfactant protein A (SP-A) gene locus and respiratory-distress syndrome in the Finnish population

Respiratory-distress syndrome (RDS) in the newborn is a major cause of neonatal mortality and morbidity. Although prematurity is the most-important risk factor for RDS, the syndrome does not develop in many premature infants. The main cause of RDS is a deficiency of pulmonary surfactant, which consists of phospholipids and specific proteins. The genes underlying susceptibility to RDS are insufficiently known. The candidate-gene approach was used to study the association between the surfactant protein A (SP-A) gene locus and RDS in the genetically homogeneous Finnish population. In the present study, 88 infants with RDS and 88 control infants that were matched for degree of prematurity, prenatal glucocorticoid therapy, and sex were analyzed for SP-A genotypes. We show that certain SP-A1 alleles (6A2 and 6A3) and an SP-A1/SP-A2 haplotype (6A2/1A0) were associated with RDS. The 6A2 allele was overrepresented and the 6A3 allele was underrepresented in infants with RDS. These associations were particularly strong among small premature infants born at gestational age <32 wk. In infants protected from RDS (those that had no RDS, despite extreme prematurity and lack of glucocorticoid therapy), compared with infants that had RDS develop despite having received glucocorticoid therapy, the frequencies of 6A2 (.22 vs.71), 6A3 (.72 vs.17), 6A2/1A0 (.17 vs.68), 6A3/1A1 (.39 vs.10), and 6A3/1A2 (.28 vs.06) in the two groups, respectively, were strikingly different. According to the results of conditional logistic-regression analysis, diseases associated with premature birth did not explain the association between the odds of a particular homozygous SP-A1 genotype (6A2/6A2 and 6A3/6A3) and RDS. In the population evaluated in the present study, SP-B intron 4 variant frequencies were low and had no detectable association with RDS. We conclude that the SP-A gene locus is an important determinant for predisposition to RDS in premature infants.     

Causes of death and case fatality rates among infants with down syndrome in metropolitan Atlanta

BACKGROUND: There is limited population-based information on the extent of underreporting of congenital heart defects (CHD) as a cause of death among infants with Down syndrome (DS) and on the variation in case fatality by presence of CHD and age at death. METHODS: Using data from the Metropolitan Atlanta Congenital Defects Program (MACDP), we identified infants with DS born 1979-2003. We used data from Georgia death certificates and the National Death Index to determine vital status and identify causes of death. Using MACDP records as a reference, we calculated the sensitivity and positive predictive value of reports of CHD as any cause of death or contributing condition in death certificates. We calculated race-specific case fatality rate by infant's age at death and presence of CHD. RESULTS: CHD was the most frequently reported cause of death from death certificates; however, a review of causes of death and birth defects data indicated a potentially greater impact of CHD among DS infant deaths than could be determined from the reported cause of death. The case fatality rate among infants with DS was significantly higher among blacks than whites, with the greatest racial disparity observed among infants without CHD who died in the post-neonatal period. CONCLUSIONS: Efforts are needed to improve reporting of causes of death related to CHD among infants with DS that would allow for a clearer assessment of determinants of case fatality among DS infants and identification of possible ways to reduce the racial disparities.     

Postnatal triiodothyronine replacement and respiratory distress syndrome of the preterm infant

Improvements in the management of respiratory distress syndrome (RDS) include pre- and postnatal stimulation of pulmonary maturity, and triiodothyronine (T3) is believed to influence directly surfactant production. Its circulating levels are low in premature infants with RDS probably due to a low thyroxine T4-T3 hepatic conversion mechanism. While a state of hypotriiodothyroninemia exists at birth, we studied the influence of postnatal intravenous T3 administration on the course of RDS in preterm infants of less than 32 weeks' gestation. Fifty preterm infants with RDS were studied (mean gestational age 30.4 +/- 1.2 weeks and birth weight 1,180 +/- 220 g). They were at random assigned to treatment with 50 micrograms L-T3 (Thyrotardin) or to the control group. Mortality rate, peak oxygen concentrations, duration of artificial ventilation and development of major complications of RDS were the criteria to estimate the influence of T3 treatment on RDS. We failed to detect a statistically significant difference between the two groups in all of the mentioned criteria except for FiO2 concentrations required to maintain PaO2 between 50 and 60 mm Hg (p less than 0.05). These observations suggest a relative beneficial effect of T3 replacement on the course of RDS in preterm infants of less than 32 weeks of gestation.     

Hospital admission for acute pancreatitis in an English population, 1963-98: database study of incidence and mortality

Objectives To investigate trends in the incidence of acute pancreatitis resulting in admission to hospital, and mortality after admission, from 1963 to 1998.Design Analysis of hospital inpatient statistics for acute pancreatitis, linked to data from death certificates.Setting Southern England.Subjects 5312 people admitted to hospital with acute pancreatitis.Main outcome measures Incidence rates for admission to hospital, case fatality rates at 0-29 and 30-364 days after admission, and standardised mortality ratios at monthly intervals up to one year after admission.Results The incidence of acute pancreatitis with admission to hospital increased from 1963-98: age standardised incidence rates were 4.9 per 100 000 population in 1963-74, 7.7 in 1975-86, and 9.8 in 1987-98. Age standardised case fatality rates within 30 days of admission were 14.2% in 1963-74, 7.6% in 1975-86, and 6.7% in 1987-98. From 1975-98, standardised mortality ratios at 30 days were 30 in men and 31 in women (compared with the general population of equivalent age in the same period = 1), and they remained significantly increased until month 5 for men and month 6 for women.Conclusions Incidence rates for acute pancreatitis with admission to hospital rose in both men and women from 1963 to 1998, particularly among younger age groups. This probably reflects, at least in part, an increase in alcoholic pancreatitis. Mortality after admission has not declined since the 1970s. This presumably reflects the fact that no major innovations in the treatment of acute pancreatitis have been introduced. Pancreatitis remains a disease with a poor prognosis during the acute phase.     

Chickenpox in Canada, 1924-87.

Because of the lack of an effective vaccine and the difficulty in implementing any effective control measures, physicians and public health practitioners have paid little attention to understanding the epidemiologic features of chickenpox. No data on the incidence rate in Canada are available for 1959-85. However, Ontario data suggest an overall decrease in the annual rate during the 1960s and a stable rate since the mid-1970s. High incidence rates are expected among children 5 to 9 years of age because of their susceptibility and their greater exposure in school. Low incidence rates among older age groups are expected, because most of these people have already been exposed to the virus. The disease is more serious among infants than among other children. The risk of death from chickenpox is also highest among infants. More patient-specific information and improved collection of incidence data are required to measure any impact from future control procedures, including the use of vaccines currently being developed.     

Expression of SP-C and Ki67 in lungs of preterm infants dying from respiratory distress syndrome

This study aimed at exploring the expression of Surfactant protein-C (SP-C) and Ki67 in autopsy lung tissues of premature infants dying from respiratory distress syndrome (RDS) who were exposed to mechanical ventilation and elevated oxygen concentrations. The possible influence of pulmonary surfactant (PS) on the expression of SP-C and Ki67 was also investigated. Thirty preterm infants were selected who were histologically and clinically diagnosed as RDS. Preterm infants with RDS were divided into 4 groups, according to the time of death: infants ventilated for 1–3 days, 4–8 days, 9–16 days and >6 days. Five premature infants died within 1 day after delivery for non- pulmonary reasons served as controls. The expression of SP-C and Ki67 in lungs was detected by immunohistochemistry. Compared with the control group, the expression of SP-C and Ki67 in RDS infants decreased significantly after 1–3 days of ventilation, but increased after 4 days and reached peak value after 9–16 days. No significant difference in the expression of SP-C and Ki67 was found between infants treated with PS and those without. Thus our results suggest SP-C and Ki67 may have participated in the pulmonary pathological process in ventilated/oxygen treated preterm infants with RDS, and exogenous surfactant had no effect on the expression of SP-C and Ki67 in the lungs of ventilated/oxygen treated preterm infants with RDS.Key words: respiratory distress syndrome, surfactant protein-C, Ki67, preterm.     

Trends in suicide and unemployment in Scotland, 1976-86.

To establish whether a correlation exists between unemployment and suicide the trends in the rates of both among men in Scotland during 1976-86 were studied. Both rates showed rapid increases in the late 1970s and then much slower increases after 1982. In contrast, among women, although the rate of unemployment followed a similar pattern, there was a gradual fall in the rate of suicide. The trends in regional unemployment for men during 1971-81 were compared with the suicide rates for the period before the increase (1974-7) and the period after the rapid increase (1983-6). No association was observed between trends in suicide and unemployment when analysed by health board areas or aggregates of local government districts. These data do not support the hypothesis that the rise in unemployment is a direct cause of the rise in suicide rates among men.     

The role of arginine-vasopressin in the regulation of water metabolism in preterm infants in the first days of life

We studied the role of arginine-vasopressin (AVP) in the regulation of fluid homeostasis in preterm infants. Group 1 was fed orally, groups 2 and 3 received fluids parenterally, and group 3 developed respiratory distress syndrome (RDS) and had to be ventilated. The infants of group 3 were not able to excrete the administered fluid, gained weight and consecutively developed hyponatremia. 1-min Apgar scores as well as log FiO2 correlated significantly with urinary AVP excretion on day 1. We conclude that nonosmotic stimuli are involved in the release of AVP and therefore disturb fluid homeostasis in severely ill infants with RDS.     

Congenital central nervous system malformations and vinyl chloride monomer exposure: a community study

Incidence rates for central nervous system (CNS) malformations in infants born to residents of Kanawha County, West Virginia, 1970-1974, were significantly higher than comparable United States rates during those years. Since Kanawha County contains a polyvinyl chloride (PVC) polymerization plant, a case-control study was conducted on the possible relationship between the occurrence of CNS defects and parental occupational or residential exposure to vinyl chloride monomer emissions from this plant. No relationship with parental occupation was found. While a tendency was noted for residences of case families to be located in an area northeast of the plant, this observation did not entirely correlate with existing data on local patterns of wind direction and air pollution.     

Those ubiquitous fertility trends: United States, 1945-1979

1970-79 US fertility trends among differnet racial, regional, age, educational, parity, and socioeconomic subgroups in the population were examined, using own children data from the 1976 Survey of Income and Education (SIE) and the March Current Population Surveys (CPS) from 1968-80. In addition, cross-sectional differences in fertility for the subgroups were compared for 1970 and 1976, using multiple regression analysis. 1st, the appropriateness of using fertility rates obtained from own children data was assessed by comparing fertility rates obtained from the SIE data with those derived from vital statistic and census data. The comparative analysis confirmed that the SIE data yielded an accurate estimate of period fertility rates for currently married women, provided the subgroup samples were sufficiently large. CPS fertility estimates were also judged to be accurate if data from 3 adjacent survey years was pooled to increase sample size. Fertility trends for 5 educational groups were assessed separately for 1967-73. During this periold, there was a marked decline in fertility for all 5 groups; for the group with 5-8 years of education the decline was only 14%, but for the other 4 groups, which included women with 9-16 or more years of education, the decline in fertility ranged from 26-29%. In assessing the 1970-76 trends, the sample was restricted to own children, aged 3 years or less, of currently married women, under 40 years of age. Among whites, there was an overall 20% decline in fertility between 1970-76 and an overall fertility increase of about 2% between 1976-79. These trends were observed in all 28 white subgroups. A similar pattern was observed for blacks. There was an overall fertility decline of 24% between 1970-76, and this decline was apparent for all subgroups except women with college degrees. Betwen 1976-79, black fertility rates, unlike white rates, continued to decline, but the rate of decline was only 3%. Furthermore, the decline in almost all the black subgroups was markedly less than in the 1970-76 periold, and for many of the subgroups the trend was reversed and fertility increased. In summary, the fertility trends noted for 1970-79 were pervasive for almost all the subgroups for both blacks and whites; i.e., there was a marked decline in fertility between 1970-76 and than a reversal or slowing down of the decline during the 1976-79 for all black and white subgroups. Cross-sectional fertility differences in the subgroups in 1970 and in 1979 were quite similar, and fertility rates differed markedly for the separate subgroups. These differences do not, of course, explain the pervasive trends observed in the analysis of the fertility rates over time. A similar study assessing fertility trends among subgroups for the early 1940's through the late 1960s also revealed the pervasive nature of period fertility trends. Demographers have not as yet been able to explain these shifts in fertility that cut across all subgroups in the US and which also characterize the period fertility rates in other developed countries. Tables provided information on 1) total fertility rates by educational level and by geographical region for 1945-1975; 2) % change in number of own children less than 3 years of age among women under age 40 by maternal age, maternal education, initial parity, geographical region, and husband's income; and 3) mean number of own children less than 3 years of age among women under age 40 by maternal age, education, parity, region, and husband's income.     

Respiratory distress syndrome: evaluation of genetic susceptibility and protection by transmission disequilibrium test

Based on epidemiological data and genetic association studies, neonatal respiratory distress syndrome (RDS) is a complex disease with a multigenic background. The genes coding for surfactant proteins (SP) A and B have been assigned as the most likely genes in the etiology of RDS. The major factor predisposing to RDS is prematurity, and thus the phenotype of a very premature newborn infant that does not develop the disease can be regarded as hypernormal. Altogether 107 father-mother-offspring trios were divided into two sets according to the proband's phenotype, to evaluate familial segregation of candidate gene polymorphisms by the transmission disequilibrium test. A set of 76 trios were analyzed for transmission disequilibrium from parents to affected offspring. Another set of 31 trios were studied for allele transmission from parents to hypernormal offspring born very prematurely before the gestational age of 32 weeks. SP-A1-A2 haplotype 6A(2)-1A(0) showed significant excess transmission to affected infants and SP-A1 allele 6A(2) decreased transmission to the hypernormals. The present family study provides strong support for a direct or indirect role of the SP-A alleles as genetic predisposers to RDS in premature infants. The inclusion of parent-hypernormal offspring trios in transmission disequilibrium test is a useful approach to test for genetic protection against a disease.     

Descriptive epidemiology of lipomyelomeningocele, Hawaii, 1986-2001

BACKGROUND: The epidemiology of neural tube defects (NTDs) may depend on the type of the defect and its location. There is little epidemiologic information on lipomyelomeningocele, a type of NTD. The objective of this investigation was to describe the epidemiology of lipomyelomeningocele. METHODS: Cases were obtained from a Hawaii birth defect registry and consisted of all infants delivered during 1986-2001 with lipomyelomeningocele. Lipomyelomeningocele rates per 10,000 births were calculated for various factors. RESULTS: A total of 17 cases of lipomyelomeningocele were identified, for a total rate of 0.57. When the lipomyelomeningocele rate was examined with respect to the time period of folic acid fortification of cereal grains in the United States, the rate was 0.57 during 1986-1996 (prefortification), 0.57 during 1997-1998 (voluntary fortification), and 0.58 during 1999-2001 (mandatory fortification). A total of 11 (64.7%) of the cases were female. Lipomyelomeningocele rates were higher among infants born to mothers in younger and older age groups. The rate was highest among Pacific Islanders, followed by Filipinos and Far East Asians, and lowest among whites. Rates were greater with lower birth weight and gestational age and among multiple births. CONCLUSIONS: Lipomyelomeningocele rates were not found to be affected by folic acid fortification. The majority of cases were female. Other demographic and clinical factors appear to be associated with lipomyelomeningocele risk. None of the differences in rates between the various subgroups were statistically significant, and due to the small number of cases, the 95% confidence interval (CI) ranges were wide. However, the findings suggest possible patterns of occurrence. Additional studies involving larger numbers of cases are recommended.     

Peroxidase-catalyzed oxidation of 3,3',5,5'-tetramethylbenzidine in the presence of 2,4-dinitrosoresorcinol and polydisulfide derivatives of resorcinol and 2,4-dinitrosoresorcinol

A comparative study of the kinetics of peroxidase-catalyzed oxidation of 3,3',5,5'-tetramethylbenzidine (TMB) in the presence of 2,4-dinitrosoresorcinol (DNR), its polydisulfide derivative [poly(DNRDS)], and resorcinol polydisulfide [poly(RDS)], substances that competitively inhibit the formation of TMB conversion product, was carried out. The inhibition constants, Ki for DNR, poly(DNRDS), and poly(RSD) were determined at 20 degrees C and pH 6.4 to be 110, 13.5, and 0.78 microM, respectively. The stoichiometric coefficients of inhibition were calculated to be 0.38 and 76 for poly(DNRDS) and poly(RDS), respectively. In the pH range 6.4-7.0, the initial rates of the peroxidative oxidation of TMB, and its mixtures with DNR and poly(DNRDS) and the Ki value for poly(RDS) substantially decreased with increasing pH. The kinetic parameters of poly(RDS) (Ki 0.22-0.78 microM and f76) suggest that it is the most efficient inhibitor of peroxidase oxidation of TMB: in micromolar concentrations, it completely stops this process and can be used in EIA.     

Changes in the association of low birth weight with socioeconomic status in Hawaii: 1970-1990

This study examines rates of low birth weight (LBW) in the state of Hawaii and changes in the association of LBW with socioeconomic status from 1970 to 1990. The analysis is based on aggregate data for census tracts. Rates of low birth weight were calculated for each census tract. Relative socioeconomic scores were calculated from average household income and years of education. The results show that (1) there was a decrease in the rate of low birth weight infants in Hawaii; and (2) that the correlation between socioeconomic status and low birth weight was substantially reduced, though a significant correlation remains. The paper suggests likely ceiling effects, but that the progressive public health policies and expansion of access to primary health care in Hawaii during this period played a major role in reducing the rate of low birth weight infants and in decreasing socioeconomic inequality on this important health indicator.     

Acute Purulent Meningitis in Alaska Natives: Epidemiology,Diagnosis and Prognosis

During the period 1957-1964, 69 cases of purulent meningitis were treated at the U.S. Public Health Service Hospital in Bethel, Alaska, a 65-bed facility serving about 10,000 Eskimos and Indians in the remote Yukon-Kuskokwim Delta area. Nearly two-thirds of the patients were infants, among whom the case fatality rate was 37.2%, compared with the overall fatality rate of 30.4%. In 52% of the cases no causative organism could be demonstrated on smear or culture. Of the bacteriologically positive cases, one-third were due to pneumococci and one-third to meningococci. Prognosis was not affected by previous treatment or recovery of the organism. Since 1957, an annual average of one out of 74 infants in the area has had purulent meningitis; one out of 200 has died of the disease. Chronic otitis media, poor nutrition, a high incidence of respiratory disease and the relative inaccessibility of medical care are significant factors.     

Benefits of using magnesium sulphate (MgSO4) for eclampsia management and maternal mortality reduction: lessons from Kano State in northern Nigeria

ABSTRACT: BACKGROUND: Despite clear emphasis through the Millennium Development Goals, the problem of high maternal mortality persists especially within low and middle income countries. Various studies report remarkably high maternal mortality rates in northern Nigeria, where maternal mortality rates exceed 1,000 deaths per 100,000 live births and eclampsia contributes approximately 40% of maternal deaths. Across Nigeria, diazepam is routinely used for the management of eclampsia. Prior to February 2008, diazepam was widely used for the management of eclampsia in Kano state (within northern Nigeria) with case fatality rate being over 20%. While magnesium sulphate (MgSO4) is recognized as the most effective drug for the management of eclampsia; this study aims to compare MgSO4 therapy with diazepam therapy in terms of case fatality rates and costs. FINDINGS: This retrospective study, including 1045 patients with eclampsia and pre-eclampsia during the years 2008 and 2009, reports a drop in case fatality rates from 20.9% (95% CI: 18.7, 23.2) to 2.3% (95% CI: 1.4, 3.2) among eclampsia patients following the MgSO4 intervention. The study observed no significant difference in the cost of using MgSO4 therapy compared to diazepam therapy. CONCLUSIONS: The study found a remarkable reduction in case fatality rate due to eclampsia in those who received MgSO4 therapy with minimal increase in costs when compared to diazepam therapy. Concerted efforts should be focused on properly introducing MgSO4 into emergency obstetric protocols especially within developing countries to reduce maternal mortality and also impact on health system performance.     

Drowning Mortality and Morbidity Rates in Children and Adolescents 0-19yrs: A Population-Based Study in Queensland,Australia

ObjectiveTo redress the lack of Queensland population incidence mortality and morbidity data associated with drowning in those aged 0-19yrs, and to understand survival and patient care.ResultsDrowning death to survival ratio was 1:10, and two out of three of those who survived were admitted to hospital. Incidence rates for fatal and non-fatal drowning increased over time, primarily due to an increase in non-fatal drowning. There were non-significant reductions in fatal and admission rates. Rates for non-fatal drowning that did not result in hospitalisation more than doubled over the seven years. Children aged 5-9yrs and 10-14yrs incurred the lowest incidence rates 6.38 and 4.62 (expressed as per 100,000), and the highest rates were among children aged 0-4yrs (all drowning events 43.90; fatal 4.04; non-fatal 39.85–comprising admission 26.69 and non-admission 13.16). Males were over-represented in all age groups except 10-14yrs. Total male drowning events increased 44% over the seven years (P<0.001).ConclusionThis state-wide data collection has revealed previously unknown incidence and survival ratios. Increased trends in drowning survival rates may be viewed as both positive and challenging for drowning prevention and the health system. Males are over-represented, and although infants and toddlers did not have increased fatality rates, they had the greatest drowning burden demonstrating the need for continued drowning prevention efforts.