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Chapter 2 The Pre-Travel Consultation Counseling & Advice for Travelers

Injuries & Safety

David A. Sleet, Douglas R. Roehler, Michael F. Ballesteros


According to the World Health Organization (WHO), injuries are among the leading causes of death and disability in the world, and they are the leading cause of preventable death in travelers. Among travelers, data show that injuries are one of the leading causes for consulting a physician, for hospitalization, for repatriation, and for death. Worldwide, among people aged 5–29 years, injuries account for 7 of the 15 leading causes of death. US citizens abroad are 10 times more likely to die as the result of an injury than from an infectious disease; injuries cause 23% of deaths of US citizens while abroad, compared with only 2% caused by infectious diseases. Contributing to the injury toll while traveling are exposure to unfamiliar and perhaps risky environments, differences in language and communications, less stringent product safety and vehicle standards, unfamiliar rules and regulations, a carefree holiday or vacation spirit leading to more risk-taking behavior, and overreliance on travel and tour operators to protect one’s safety and security.

From 2009 through 2011, an estimated 2,773 US citizens died from nonnatural causes, such as injuries and violence, while in foreign countries (excluding deaths occurring in the wars in Iraq and Afghanistan). Motor vehicle crashes—not crime or terrorism—are the number 1 killer of healthy US citizens living, working, or traveling in foreign countries. From 2009 through 2011, road traffic crashes accounted for 27% of deaths to US citizens abroad. Other common causes of death included homicides (22%), suicides (14%), and drowning (12%) (Figure 2-01). Other less common but serious injuries are related to natural disasters, aviation accidents, drugs, terrorism, falls, burns, and poisoning.

If a traveler is seriously injured, emergency care may not be available or acceptable by US standards. Trauma centers capable of providing optimal care for serious injuries are uncommon outside urban areas in many foreign destinations.

Although men are more likely than women to die from injuries while abroad, acquaintance rape and sexual assault are special risks to female travelers. Travelers should be aware of the increased risk of certain injuries while traveling or residing abroad, particularly in low- and middle-income countries (LMICs) and be prepared to take preventive steps. Injuries are the primary reason for US citizens abroad to be transported back to the United States by air medical transport.


Globally, an estimated 3,500 people are killed each day, including 720 children, in road traffic crashes involving cars, buses, motorcycles, bicycles, trucks, and pedestrians. Annually, 1.3 million are killed and 20–50 million are injured in traffic crashes—a number likely to double by 2030. More than 90% of these casualties (and 96% of child injury deaths) occur in LMICs. Table 2-13 lists the countries with the highest death rates from road traffic crashes.

International efforts to combat road deaths command a tiny fraction of the resources deployed to fight diseases such as malaria and tuberculosis, yet the burden of road traffic injuries is comparable. In response to this crisis, in March 2010 the 64th General Assembly of the United Nations described the global road safety crisis as “a major public health problem” and proclaimed 2011–2020 as “The Decade of Action for Road Safety.” On April 19, 2012, the United Nations General Assembly adopted a new resolution (A/66/L.43) to improve global road safety by implementing plans for the decade, setting ambitious targets, and monitoring global road traffic fatalities.

According to Department of State data, road traffic crashes are the leading cause of injury deaths to US citizens while abroad (Figure 2-01). Recent estimates show that 743 US citizens were killed in road traffic crashes from 2009 through 2011. Approximately 16% of these road traffic deaths involved motorcycles, and 7% involved pedestrians. A study from Bermuda reported that the rate of motorbike injuries is much higher in tourists than in the local population, and the rate is highest in people aged 50–59 years. Motor vehicle rentals in Bermuda and some other small Caribbean islands are typically limited to motorbikes for tourists, possibly contributing to the higher rates of motorbike injuries. Loss of vehicular control, unfamiliar equipment, and inexperience with motorized 2-wheelers contributed to crashes and injuries, even at speeds <30 miles per hour.

Road traffic crashes are common among foreign travelers for a number of reasons: lack of familiarity with the roads, driving on the opposite side of the road, lack of seat belt use, the influence of alcohol, 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. In many LMICs, unsafe roads and vehicles and an inadequate transportation infrastructure contribute to the traffic injury problem. In many of these countries, motor vehicles often share the road with vulnerable road users, such as pedestrians, bicyclists, and motorcycle users. The mix of traffic involving cars, buses, taxis, rickshaws, large trucks, and even animals (on one road or in a single travel lane) increases the risk for crashes and injuries.

Millions of US citizens travel to Mexico each year, and >150,000 people cross the US–Mexico border daily. Travelers should be particularly cautious in Mexico; from 2009 through 2011, 27% of all deaths of US citizens abroad occurred in Mexico, where >220 lost their lives in motor vehicle crashes, and another 299 were victims of homicide.

Traffic death rates in 20 countries most frequented by US citizens are listed in Table 2-14. Strategies to reduce the risk of traffic injury are shown in Table 2-15. The Association for International Road Travel ( and Make Roads Safe ( have useful safety information for international travelers, including road safety checklists and country-specific driving risks. The Department of State has safety information useful to international travelers, including road safety and security alerts, international driving permits, and travel insurance (

Before flying with children, parents and caregivers should check to make sure that their child restraint system is approved for use on an aircraft. This approval should be printed on the system’s information label or on the device itself. The Federal Aviation Administration (FAA) recommends that a child weighing <20 pounds use a rear-facing child restraint system. A forward-facing child safety seat should be used for children weighing 20–40 pounds. FAA has also approved a harness-type device for children weighing 22–44 pounds.

Figure 2-01. Leading causes of injury death for US citizens in foreign countries, 2009–20111,2

Figure 2-1. Leading causes of injury death for US citizens in foreign countries, 2009–2011

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1Data from US Department of State. Death of US citizens abroad by non-natural causes. Washington, DC: US Department of State; 2012. Available from:
2Excludes deaths of US citizens fighting wars in Afghanistan or Iraq.


Table 2-13. Ranking of the countries with the 20 highest estimated traffic death rates

Eritrea 81 48.4
Cook Islands (New Zealand) 6 45.0
Egypt 15,983 41.6
Libya 2,138 40.5
Afghanistan 1,179 39.0
Iraq 1,932 38.1
Angola 2,358 37.7
Niger 570 37.7
United Arab Emirates 1,056 37.1
The Gambia 54 36.6
Iran 22,918 35.8
Mauritania 262 35.5
Ethiopia 2,441 35.0
Sudan 2,227 34.7
Mozambique 1,952 34.7
Tunisia 1,497 34.5
Kenya 3,760 34.4
Guinea-Bissau 512 34.4
Tanzania 2,595 34.3
Chad 814 34.3
1Data from World Health Organization. Global Status Report on Road Safety: Time for Action. Geneva: WHO; 2009. Available from: (PDF).
2Deaths reported in the local population in 2006 or 2007. For comparison, the reported number of traffic deaths in the United States in 2007 was 42,642, with an estimated traffic death rate of 13.9 per 100,000 population.

Table 2-14. Estimated traffic death rates in the 20 countries most frequently traveled by US citizens

Mexico 22,103 20.7
The Philippines 1,185 20.0
Dominican Republic 1,838 17.3
India 105,725 16.8
China 96,611 16.5
Costa Rica 688 15.4
South Korea 6,166 12.8
Jamaica 350 12.3
Colombia 5,409 11.7
Italy 5,669 9.6
Spain 4,104 9.3
Canada 2,889 8.8
Ireland 365 8.5
France 4,620 7.5
Germany 4,949 6.0
Israel 398 5.7
United Kingdom 3,298 5.4
Japan 6,639 5.0
Switzerland 370 4.9
The Netherlands 791 4.8
1Hong Kong, Aruba, and Taiwan excluded due to incomplete data.
2Data from the US Department of Commerce. 2011 United States resident travel abroad. Washington, DC: US Department of Commerce; 2011. Available from: (PDF)
3World Health Organization. Global Status Report on Road Safety: Time for Action. Geneva: WHO; 2009. Available from: (PDF)
4Deaths reported in the local population in 2006 or 2007. For comparison, the number of reported traffic deaths in the United States in 2007 was 42,642, with an estimated traffic death rate of 13.9 per 100,000 population.

Table 2-15. Recommended strategies to reduce injuries while abroad

Road Traffic Crashes
Seat belts and child safety seats Always use safety belts and child safety seats. Rent vehicles with seat belts; when possible, ride in taxis with seat belts and sit in the rear seat; bring child safety seats and booster seats from home for children to ride properly restrained.
Driving hazards When possible, avoid driving at night in low- and middle-income countries; always pay close attention to the correct side of the road when driving in countries that drive on the left.
Country-specific driving hazards Check the Association for Safe International Road Travel website for driving hazards or risks by country (
Motorcycles, motor bikes, and bicycles Always wear helmets (bring a helmet from home, if needed). When possible, avoid driving or riding on motorcycles or motorbikes, including motocycle and motorbike taxis. Traveling overseas is a bad time to learn to drive a motorcycle or motorbike.
Alcohol-impaired driving Alcohol increases the risk for all causes of injury. Do not drive after consuming alcohol, and avoid riding with someone who has been drinking.
Cellular telephones Do not use a cellular telephone or text while driving. Many countries have enacted laws banning cellular telephone use while driving, and some countries have made using any kind of telephone, including hands-free, illegal while driving.
Taxis or hired drivers Ride only in marked taxis, and try to ride in those that have safety belts accessible. Hire drivers familiar with the area.
Bus travel Avoid riding in overcrowded, overweight, or top-heavy buses or minivans.
Pedestrians Be alert when crossing streets, especially in countries where motorists drive on the left side of the road. Walk with a companion or someone from the host country.
Other Tips
Airplane travel Avoid using local, unscheduled aircraft. If possible, fly on larger planes (>30 seats), in good weather, during the daylight hours, and with experienced pilots. Children <2 years shoudl sit in a child safety seat, not on a parent's lap. Whenever possible, parents should travel with a safety seat for use before, during, and after a plane ride.
Drowning Avoid swimming alone or in unfamiliar waters. Wear life jackets while boating or during water recreation activities.
Burns Reside below the sixth floor to maximize rescue in case of a fire. Bring your own smoke alarm.
Country-specific The Department of State provides useful safety information for international travelers. Read the consular information sheets, travel warnings, and any public announcements for country-specific personal security risks and safety tips (
Assault When in low- and middle-income countries or high-poverty areas, avoid traveling at night in unfamiliar environments. Use alcohol in moderation, and do not travel alone. If confronted, give up all valuables, and do not resist attackers.



Drowning accounts for 2% of all deaths of US citizens abroad. Although risk factors have not been clearly defined, these deaths are most likely related to unfamiliarity with local water currents and conditions, inability to swim, and the absence of lifeguards on duty. Rip currents can be especially dangerous, as are sea animals such as urchins, jellyfish, coral, and sea lice. Alcohol also contributes to drowning and boating mishaps.

Drowning was the leading cause of injury death to US citizens visiting countries where water recreation is a major activity, such as Fiji, The Bahamas, Jamaica, and Costa Rica. Young men are particularly at risk of head and spinal cord injuries from diving into shallow water, and alcohol is a factor in some cases.

Boating can be a hazard, especially if boaters are unfamiliar with the boat, do not know proper boating etiquette or rules for watercraft navigation, or are new to the water environment in a foreign country. Many boating fatalities result from inexperience or failure to wear lifejackets.

Scuba diving is a frequent pursuit of travelers in coastal destinations. The death rate among all divers worldwide is thought to be 15–20 deaths per 100,000 divers per year. Travelers should either be experienced divers or dive with a reliable dive shop and instructors. See the Scuba Diving section later in this chapter for more a more detailed discussion about diving risks and preventive measures.


From 2009 through 2011, aviation incidents, drug-related incidents, and deaths classified as “other unintentional injuries” accounted for 18% of all injury deaths to US citizens abroad (Figure 2-01). This figure includes 120 Americans who died as a result of the January 12, 2010, Haiti earthquake. Fires can be a substantial risk in LMICs where building codes do not exist or are not enforced, there are no smoke alarms, there is no emergency access to 9-1-1 services, and the fire department’s focus is on putting out fires rather than on fire prevention or victim rescue.

Travel by local, lightweight aircraft in many countries can be risky. From 2009 through 2011, an estimated 83 US citizens abroad were killed in aircraft crashes. Travel on unscheduled flights, in small aircraft, at night, in inclement weather, and with inexperienced pilots carries the highest risk.

Travel health providers, vendors of travel services, and travelers themselves should consider the following:

  • Travelers should consider purchasing special travel health and medical evacuation insurance if their destinations include countries where there may not be access to good medical care (see the Travel Insurance, Travel Health Insurance, & Medical Evacuation Insurance section later in this chapter).
  • Because trauma care is poor in many countries, victims of injuries and violence can die before reaching a hospital, and there may be no coordinated ambulance service available. In remote areas, medical assistance and modern drugs may be unavailable, and travel to the nearest medical facility can take a long time.
  • Adventure activities, such as mountain climbing, skydiving, whitewater rafting, dune-buggying, and kayaking, are popular with travelers. The lack of rapid emergency trauma response, inadequate trauma care in remote locations, and sudden, unexpected weather changes that compromise safety and hamper rescue efforts, can delay access to care.
  • Travelers should avoid using local, unscheduled, small aircraft. If available, choose larger aircraft (>30 seats), as they have most likely undergone more strict and regular safety inspections. Larger aircraft also provide more protection in the event of a crash. For country-specific airline crash events, see
  • When traveling by air with young children, consider bringing a child safety seat approved for use on an aircraft.
  • To prevent fire-related injuries, travelers should select accommodations no higher than the sixth floor. (Fire ladders generally cannot reach higher than the sixth floor.) Hotels should be checked for smoke alarms and preferably sprinkler systems. Travelers may want to bring their own smoke alarm. Two escape routes from buildings should always be identified. Crawling low under smoke and covering one’s mouth with a wet cloth are helpful in escaping a fire. Families should agree on a meeting place outside the building in case a fire erupts.
  • Improperly vented heating devices may cause poisoning from carbon monoxide. Carbon monoxide at the back of boats near the engine can be especially dangerous. Travelers may want to carry a personal detector that can sound an alert in the presence of this lethal gas.
  • Travelers should consider learning basic first aid and CPR before travel overseas with another person. Travelers should bring a travel health kit, which should be customized to the anticipated itinerary and activities (see the Travel Health Kits section later in this chapter).


Violence is a leading worldwide public health problem and a growing concern of US citizens traveling, working, or residing abroad. Each year, >1.6 million people lose their lives to violence, and only one-fifth are casualties of armed conflicts. Rates of violent deaths in LMICs are >3 times those in higher-income countries, although there are variations within countries.

Homicide is the second-leading cause of injury death among US citizens abroad; it accounted for >600 deaths from 2009 through 2011 (Figure 2-01). For some LMICs, such as the Dominican Republic, Honduras, Mexico, and the Philippines, homicide was the leading cause of injury death for US citizens, accounting for 41% of all US citizen injury deaths in those 4 countries.

Travelers to foreign countries are viewed by many criminals as wealthy, naïve targets, who are inexperienced, unfamiliar with the culture, and inept at seeking assistance once victimized. Traveling in high-poverty areas or regions of civil unrest, using alcohol or drugs, and traveling in unfamiliar environments at night increase the likelihood that a traveler will be the victim of violence.

To avoid violence while abroad, travelers should limit travel at night, travel with a companion, and vary routine travel habits. Travelers abroad should not wear expensive clothing or accessories. Criminals are less likely to victimize upper floors of buildings, so travelers should avoid accommodations on the ground floor and avoid rooms immediately next to the stairs. Travelers should lock all doors and windows and may even consider carrying and using a door intruder alarm and a rubber doorstop that can be used as a supplemental lock. If confronted, travelers should give up all valuables and not resist attackers. Victims of a crime overseas should contact the nearest US embassy, consulate, or consular agency for assistance.

Suicide is the third-leading cause of injury death to US citizens abroad (13%). For longer-term travelers (such as 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. See the Mental Health & Travel section later in this chapter for more detailed information.


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