David A. Sleet, L.J. David Wallace, David R. Shlim

Overview

According to the World Health Organization, injuries are among the leading causes of death and disability in the world, and they are the leading cause of preventable death in travelers. Of the approximately five million people killed due to injuries in the world, approximately 1.2 million people died of road traffic incidents, 815,000 from suicide and 520,000 from homicides. In addition to the considerable number of deaths, millions more are wounded or suffer other nonfatal health consequences. Worldwide, among persons aged 5–44 years, injuries account for 6 of the 15 leading causes of death.

In 2007, just over 64 million Americans traveled outside the United States. The vast majority of these trips occurred without any serious health problems, but fatal and serious injuries occur to Americans every year while traveling internationally. Among travelers abroad, injuries are one of the leading causes of death. Compared with injuries, infectious diseases, for example, only account for a small proportion (2%) of deaths to overseas travelers.

The U.S. Department of State collects data on U.S. citizens who die in a foreign country from non-natural causes for the most recent 3-year period and makes these data available on the Department of State website. These deaths are categorized by location where the death occurred, date of death, and cause of death. These deaths should be considered a conservative estimate of the true number of U.S. citizens who die in foreign countries, as some deaths may not be reported to the Department of State. We analyzed these data and found that from 2003 to 2005 an estimated 2,276 U.S. citizens died from injuries and violence while in foreign countries (excluding deaths occurring in Iraq and Afghanistan). Road traffic crashes headed the list of causes (34%), followed by homicide (17%), and drowning (13%) (Figure 2-3). By comparison to U.S. injury fatalities in 2003, road traffic crashes accounted for 27%, homicide 11%, and drowning 2% of all injury deaths.

Depending on travel destination, duration, and planned activities, other common injury and safety concerns include natural hazards and disasters, civil unrest, terrorism, hate crimes against Americans, falls, burns, poisoning, drug-related overdose, and suicide. If seriously injured, emergency care may not be available or acceptable by U.S. standards. Trauma centers which are capable of providing optimal trauma care are uncommon outside urban areas.

Males, compared with females, are more likely to die from injury causes while traveling internationally. Acquaintance rape and sexual assault are among the important risks to women travelers. Travelers should be aware of the increased risk of certain injuries while traveling abroad, particularly in low-income countries, and be prepared to take preventive steps to avoid them.

Road Traffic Injuries

Road traffic injuries are the leading cause of injury-related deaths worldwide. An estimated 3,000 people are killed each day around the world in road traffic crashes involving cars, buses, motorcycles, bicycles, trucks, or pedestrians. Each year another 20 to 50 million are seriously injured. In response to this crisis, in 2008 the United Nations General Assembly, passed resolution 62/244 "Improving global road safety" to strength international cooperation to develop policies and practices to reduce crash risks around the world.

According to U.S. Department of State data, road traffic crashes are also the leading cause of injury death to U.S. citizens while traveling internationally (see Figure 2-3). An estimated 768 Americans were killed in road traffic crashes in the period from 2003 to 2005. Approximately 13% of these road traffic deaths involved motorcycles and 7% were pedestrians. A study from Bermuda reported that tourists sustain a much higher rate of motorbike injuries than the local population, with the highest rate in persons aged 50–59 years. Loss of vehicular control, unfamiliar equipment, and inexperience with motorized two-wheelers contributed to crashes and injuries, even when traveling at speeds less than 30 mph. Road traffic crashes are also a leading cause of nonfatal injury among U.S. citizens requiring emergency transport back to the United States.

Road traffic crashes are common in foreign tourists for a number of reasons: lack of familiarity with the roads, driving on the opposite side of the road than in one’s home country, poorly made or maintained vehicles, travel fatigue, poor road surfaces without shoulders, unprotected curves and cliffs, and poor visibility due to lack of adequate lighting, both on the road and on the vehicle. In many low-income areas of the world, unsafe roads and vehicles and an inadequate transportation infrastructure contribute to the traffic injury problem. A safety concern in low-income countries is the mixing of motor vehicles with vulnerable road users such as pedestrians, bicyclists, and motorbike users. It is common in low-income countries to have cars, buses, and large trucks all sharing the same road with pedestrians, motorbikes, bicycles, rickshaws and even animals. This mixing of road users all in the same travel lane increases the risk for crashes and injuries.

Sometimes travelers have few options in getting to remote areas, but if there are choices, they should look for better-maintained vehicles, daytime travel, seatbelts and a trained and licensed or hired driver.

Prevention of Road Traffic Injuries

Health advisors should counsel the traveler to:

• Use safety belts and child safety seats whenever possible. Safety belts reduce the risk of death in a crash by 45%–60%, child safety seats by 54% and infant seats by 70%. When traveling, rent newer vehicles with safety belts and airbags and bring a child safety seat from home.
• Rent larger vehicles if possible, because they provide more protection in a crash.
• Try to ride only in taxis with functional safety belts and ride in the rear seat.
• Wear helmets when riding motorcycles, motorbikes, and bicycles. If helmets are likely to be unavailable at the destination, they should be brought from home.
• Avoid drinking alcohol and driving or biking. U.S. data show that an alcohol-impaired driver has a 17 times greater risk of being involved in a fatal crash.
• Visit the websites of the Association for Safe International Road Travel (ASIRT) (www.asirt.org) and Make Roads Safe (www.makeroadssafe.org), both NGOs, which have useful safety tips for international travelers, including road safety checklists and country specific driving risks.
• Check the safety and security information from the U.S. Department of State (www.travel.state.gov).
• Consider hiring a driver familiar with the destination, the language and an expert in maneuvering through local traffic.
• Avoid riding on overcrowded, overweight, top heavy busses, or minivans, or riding with any driver who has consumed alcohol.
• Be aware of pedestrians and be aware as a pedestrian of the dangers. Walk with a friend, rather than alone, as this helps with safety.

Water Injuries

Drowning accounts for 13% of deaths of Americans abroad. The risk factors have not been clearly defined, but are suspected to be related to unfamiliarity with local water currents and water conditions. Drowning was the leading cause of injury death to Americans visiting countries where exposure to water recreation was a major activity such as Fiji, Dutch Antilles, Aruba, and Costa Rica. Studies have found that young men are particularly at risk of head and spinal cord injuries from diving into shallow water, with alcohol a factor in some cases. In 2000, approximately 449,000 people drowned worldwide; the exact number of travelers who suffer from nonfatal drowning is not precisely known.

Alcohol is also a suspected contributing factor to both drowning and boating mishaps.

Scuba diving is a frequent pursuit of travelers in ocean destinations. Travelers should either be experienced divers, or dive with a reliable dive shop and instructors. They should be reminded not to dive on the same day they arrive by airplane. The fatality rate among all divers, worldwide, is thought to be 15 to 20 deaths per 100,000 divers per year.

Other Unintentional Injuries

From 2003 to 2005, other than drowning, airplane crashes, natural disasters, and other unintentional injuries accounted for over a third of all injury deaths to Americans in foreign countries (see Figure 2-3). Fires can be a substantial risk in low-income countries where building codes are not present or enforced, where there’s an absence of smoke alarms, where there is no emergency access to 9-1-1 services, and where the fire department focus is on putting out fires rather than on fire prevention or victim rescue.

Preventing Other Unintentional Injuries

Health advisors should counsel the traveler on the following:

• Travelers should consider purchasing special health and evacuation insurance if their destinations include countries where there may not be access to good medical care.
• Because trauma care is poor in many countries, victims of injuries can die before ever reaching a hospital, and there may be no coordinated ambulance services. In remote areas, medical assistance, drugs and medicines may be unavailable and travel can take a long time to the nearest medical facility.
• Where possible avoid using local unscheduled small aircraft. If available choose larger aircraft (greater than 30 seats) as they have undergone more strict and regular safety inspections. Larger aircraft also provide more protection in the event of a crash. From 2003 to 2005 an estimated 83 Americans were killed in airplane crashes in foreign countries (see Figure 2-3). For country-specific airline crash events, see www.airsafe.com.
• To prevent fire-related injuries, select accommodations on the 6th floor or below (fire ladders generally cannot reach above the 6th). If possible, stay in hotels with smoke alarms and preferably sprinkler systems. Be alert for improperly vented heating devices which may cause poisoning from carbon monoxide (CO), a colorless odorless gas and by-product of all fossil fuel combustions. Some travelers choose to carry a personal CO detector. Travelers should identify two escape routes from buildings and remember to escape a fire by crawling low under smoke and by covering one’s mouth with a wet cloth.

Violence-Related Injuries

Violence is a leading worldwide public health problem and a growing concern of travelers. In 2000, about 1.6 million persons lost their lives to violence and only one-fifth were casualties of armed conflicts. Rates of violent deaths in low- to middle-income countries are more than 3 times those in higher-income countries, although there are great variations within countries, depending on regional demographic differences.

Homicide was the second leading cause of injury death among American travelers in foreign countries accounting for almost 400 deaths from 2003 to 2005 (see Figure 2-3). For some low-income countries such as Honduras, Colombia, Guatemala, and Haiti homicide was the leading cause of injury death for Americans accounting for 43%–65% of all injury deaths.

Terrorism-related deaths among Americans in foreign countries, while alarming, are still relatively rare events and accounted for only 2% of all injury deaths (see Figure 2-3). The vast majority of terrorism deaths among Americans occurred in countries of the Middle East. According to data from the State Department, 2003–2005, 82% of the injury deaths among Americans in Saudi Arabia and 55% of injury deaths in Israel/West Bank/Gaza were from terrorism.

Suicide is the fourth leading cause of injury death to U.S. citizens traveling abroad (see Figure 2-3). Factors contributing to homicide and suicide may be different while traveling than at home. Unfamiliarity with a destination, not being vigilant to one’s surroundings, and alcohol involvement may increase risk of assault and homicide. For longer-term travelers (e.g., missionaries and volunteers), social isolation and substance abuse, particularly in the face of living in areas of poverty and rigid gender roles, may increase the risk of depression and suicide.

If a traveler is the victim of a crime overseas, the nearest U.S. embassy, consulate, or consular agency for assistance should be contacted at (www.travel.state.gov).

Prevention of Violence

U.S. travelers are viewed by many criminals as wealthy, naïve targets, who are inexperienced and unfamiliar with the culture and inept at seeking assistance once victimized. Traveling in high poverty areas, civil unrest, alcohol or drug use, and traveling in unfamiliar environments at night increase the likelihood that a U.S. traveler will be the victim of planned or random violence.

To avoid violence while traveling, limit travel at night, travel with a companion, and vary the routine travel habits. Travelers should wear locally available accessories that are more typical of a country-savvy expatriate community and avoid expensive or provocative clothing, or accessories. Accommodations on the ground floor of hotels or immediately next to the stairwell should be avoided. Criminals are less likely to victimize upper level floors. All doors and windows should be locked. Some carry a door intruder alarm, a smoke alarm, and a rubber door stop that can be used as a supplemental door lock. Persons unknown to the traveler should not be invited into one’s accommodations as this can be misinterpreted or against local laws and customs.

The U.S. Department of State website (www.travel.state.gov) has useful information regarding safety and security.

Summary

Injuries and violence are as much a public health problem to travelers overseas as are infectious and chronic diseases—and they are in many ways more deadly. Injuries are still the most frequent cause of death abroad in developing countries. Effective prevention strategies are available, particularly for travelers who find themselves in new environments and who may be more likely to be unaware of risks or complacent in exotic surroundings. Despite greater understanding and increased research efforts in this field, data on the magnitude and severity of injuries is still incomplete or unreliable in many countries. Existing data indicate that injury and violence are among the most important causes of premature death and ill-health to U.S. travelers overseas. Travel health advisors and other health-care providers should alert the public to the known risks and especially about simple and effective preventive measures to implement during international travel.

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