In 2022, drowning caused more than 4500 deaths in the USA and remains the leading cause of death among children aged 1–4 years old.¹ Unintentional drowning rates increased after the COVID-19 pandemic era, perhaps affected by limited access to supervised swimming settings during that time.² Two known strategies—pool fencing and wearing a life jacket while boating—have both prevention effectiveness data and related mortality coding to estimate whether these factors were in place prior to a drowning death.^{3 4} The effectiveness of other critically important drowning prevention strategies such as basic swimming and water safety skills training and enhanced child supervision can benefit from further estimation, and the presence of those factors related to a drowning death is not identifiable in publicly available US mortality data. This brief report aimed to estimate the annual health and economic burden of drowning deaths likely attributable to inadequate pool fencing and not wearing life jackets while boating to highlight the unrealised value of these known prevention strategies.

This cross-sectional study of the US population followed CHEERS reporting guidelines, used publicly available data and did not require institutional review board approval (45 CFR §46). A simple mathematical model used the most recent year of final US drowning data (2022) from the Centers for Disease Control and Prevention’s (CDC) WONDER data system in combination with prevention effectiveness estimates from previous studies and CDC’s Web-based Injury Statistics Query and Reporting System (WISQARS) data on the economic cost of injuries to estimate the average annual number of drowning deaths and economic cost that might be prevented annually through: (1) adequate swimming pool fencing to prevent drowning among children aged <5 years and (2) wearing life jackets while boating to prevent drowning among people of all ages.^{1 5}

Deaths among children aged 0–4 years with ICD-10 codes indicating drowning in a swimming pool (W67, W68) were assumed potentially susceptible to prevention by adequate pool fencing (table 1). Adequate pool fencing has a minimum 4 ft height, separates the pool from residences and yards (four-sided fencing), has a self-closing and self-latching gate and is maintained in good condition—as described in the Consumer Product Safety Commission’s Safety Guidelines for Residential Pools.⁶ The most recent investigation of this issue in the USA estimated that 19% of swimming pool drowning deaths among children aged <5 years could be prevented by adequate fencing (table 2).⁷ Deaths among people of all ages with ICD-10 codes indicating watercraft-related drowning (V90, V92) were assumed potentially susceptible to prevention by life jackets (table 1). It was assumed 87% of such deaths could be prevented by life jackets, based on the most recent annual data from the US Coast Guard indicating 87% of people who drowned while boating were not wearing a life jacket (table 2).⁸ The CDC’s WISQARS Cost of Injury website was queried in October 2024 for average medical spending related to drowning deaths (ie, in the case that medical assistance was available prior to death) (table 2).⁹ Avoidable mortality was assessed using the value of statistical life (VSL)—a monetary estimate of the collective value placed on mortality risk reduction as derived in research studies through revealed preferences (eg, observed wage differences for dangerous occupations) or stated preferences from surveys of individuals’ willingness to pay for mortality risk reduction—as applied in CDC WISQARS (table 2).^{10 11} That data source uses the societal perspective with lifetime horizon and undiscounted inflation-adjusted constant 2021 US dollars (at study time).⁹

Based on drowning-related ICD codes, there were 4509 US drowning deaths (table 1). This included 840 deaths in swimming pools and 341 deaths related to watercraft. Adequate swimming pool isolation fencing could prevent an estimated 51 drowning deaths per year, and always wearing a life jacket while boating could prevent an estimated 297 drowning deaths per year, or a total of 348 preventable deaths and an economic cost of US$4.5 billion per year (table 2).

Increased adherence to adequate pool fencing and always wearing a life jacket while boating could avert a substantial number of deaths and enormous economic cost each year in the USA. These known strategies are already helping to prevent drowning incidents, but there remains a substantial unrealised potential for saving more lives. Most fatal and non-fatal drownings involving children less than 5 years old occur in pools owned by family, friends or relatives.⁶ Approximately 75% of American households with pools reported adequate pool fencing in the most recent available studies (based on telephone surveys in 1994 and 2001–2003).^{7 12} Laws regarding pool fencing in newly installed pools vary by jurisdiction, and unfortunately, there is not an authoritative source on new pool fencing regulations nationwide, nor is there more recent robust data on the prevalence of adequate fencing among existing pools. Laws regarding life jacket use also vary by state. An observational study of boaters in Washington State reported only 31% wore life jackets, although life jackets were more frequent among boaters required by state law to wear life jackets such as children, personal watercraft users and people being towed (eg, water-skiers).¹³ Factors associated with reduced life jacket wear include adult age, being male, consumption of alcohol, and perceived discomfort, cost, accessibility, and swimming ability.¹⁴

Despite the long-term known effectiveness of pool fencing and life jackets to prevent drowning, many preventable deaths still occur. The US National Water Safety Action Plan recommends drowning prevention actions for individuals and institutions, including four-sided isolation pool fencing and increasing life jacket use.²² Continuing to highlight the benefits of these known interventions can help inform public attention and support cost-effective public health decision-making.