Injury & Trauma

CDC Yellow Book 2024

Environmental Hazards & Risks

Author(s): Michael Ballesteros, Erin Sauber-Schatz

In 2017 and 2018, >1,500 US citizens died from nonnatural causes in foreign countries, excluding deaths in the wars in Iraq and Afghanistan. Motor vehicle crashes—not crime or terrorism—are the number 1 cause of nonnatural deaths among US citizens living, working, or traveling abroad (Figure 4-02). In 2017 and 2018, 431 Americans died in vehicle crashes in foreign countries (28% of nonnatural deaths). Another 291 were victims of homicide (19%), 266 drowned or died as a result of a boating incident (17%), and 218 died of suicide (14%).

Travel destinations might lack emergency care that approximates US standards; trauma centers capable of providing care for serious injuries are uncommon outside urban areas, if they exist at all. Make travelers aware of their increased risk for injuries when traveling or residing internationally, particularly in low- and middle-income countries, and to take preventive steps to reduce the chances of serious injury.

Figure 4-02 Leading causes of injury death for U.S. citizens in foreign countries, 2016 & 20171,2,3,4

Figure 4-02 Leading causes of injury death for U.S. citizens in foreign countries, 2016 & 2017

View Larger Figure

1Data from U.S. Department of State. Deaths of US citizens in foreign countries by nonnatural causes. Washington, DC: US Department of State. Available from:

2Excludes deaths of US citizens fighting wars in Afghanistan or Iraq, and deaths not reported to the US embassy or consulate.

3Motor Vehicle includes deaths classified as “vehicle accidents,” including the following subcategories: auto, bus, motorcycle, pedestrian, train, and other.

4All Other includes deaths classified as armed conflict, natural disaster, other accident, and undetermined/unknown.

Road Traffic Injuries

Globally, approximately 3,700 people are killed each day in motor vehicle crashes involving bicycles, buses, cars, motorcycles, trucks, and pedestrians. In 2017 and 2018, among the 431 US citizen road traffic deaths abroad, 62% were among drivers and occupants of passenger vehicles (e.g., cars, trucks, sport utility vehicles), and 21% were people on motorcycles. The countries with the most US citizen road traffic deaths were Mexico (n=126; 29%), Thailand (n=29; 7%), and Vietnam (n=17; 4%). For information on motor vehicle crashes and road safety, see Sec. 8, Ch. 5, Road & Traffic Safety.


Violence, including suicide and homicide, is a leading worldwide public health problem that affects US citizens traveling, working, or residing internationally. Each year, >1.6 million people lose their lives to violence, and only one-fifth of that total is due to armed conflict. Rates of violent deaths in low- and middle-income countries are 3 times those in higher-income countries, although variations exist within countries. For longer-term travelers, social isolation and substance abuse might increase the risk for depression and suicide; these risks might be amplified in areas with poverty and rigid gender roles. See Sec. 2, Ch. 12, Mental Health, for more detailed information on suicide prevention.

Mexico, the Philippines, Haiti, and Jamaica have the highest number of homicide deaths among US citizens abroad; Mexico accounts for 52% of all homicide deaths in US citizens living or traveling in foreign countries. Criminals might view US travelers as wealthy, naïve targets, inexperienced and unfamiliar with the culture, and less able to seek assistance once victimized. Traveling in high-poverty areas or regions of civil unrest, using alcohol or drugs, and visiting unfamiliar environments, particularly at night, increase the likelihood of a traveler becoming a victim of violence (see Sec. 4, Ch. 11, Safety & Security Overseas, for more information).

Water & Aquatic Injuries

Drowning is often the leading cause of injury death to US citizens visiting countries where water recreation is a major activity. Although risk factors are not clearly defined, lack of familiarity with local water currents and conditions, inability to swim, and absence of lifeguards on duty likely contribute to drowning deaths. Rip currents can be especially dangerous. Diving into shallow water is a risk factor for head and spinal cord injuries, and young men are affected disproportionately. In some cases of aquatic injuries, alcohol or drug use is a factor.

Boating can be a hazard, especially if boaters are unfamiliar with the equipment they are using, 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 a personal flotation device (lifejacket); boaters should have enough lifejackets on board for all passengers. Children and weak swimmers should always wear a lifejacket whenever boating. Advise travelers not to ride in boats operated by obviously inexperienced, uncertified, or intoxicated drivers.

Scuba diving is a frequent pursuit of travelers to coastal destinations. Researchers estimate the death rate among divers worldwide is ≈16 deaths per 100,000 divers per year. Travelers should either be experienced divers or dive with a reputable dive shop and instructors. See the Sec. 4, Ch. 4, Scuba Diving: Decompression Illness & Other Dive-Related Injuries, for a more detailed discussion about diving risks and preventive measures.

Travelers should not swim alone or in unfamiliar waters and should wear appropriately sized, US Coast Guard–approved lifejackets whenever participating in water recreation activities (e.g., sailboarding, water skiing, whitewater boating or rafting, or operating personal watercraft). If travel includes planned water activities, travelers should consider bringing their own lifejackets. Travelers also can increase the likelihood of survival in an emergency by improving their swimming skills, learning safe rescue techniques (e.g., use of poles or ropes as rescue aids so responders can avoid entering the water), and taking cardiopulmonary resuscitation (CPR) classes prior to traveling.

If overseas with children, an adult with swimming skills should be within arm’s length when infants and toddlers are in or around pools and other bodies of water; even with older children and better swimmers, the supervising adult should focus on the child and not engage in any distracting activities. Travelers with children should remain vigilant, because swimming pools and ponds might not have fences around them to keep children safe. See the World Health Organization drowning resources and the International Life Saving Federation for more information.

Other Unintentional Injuries

Adventure Activities

Adventure activities (e.g., kayaking, mountain biking and climbing, off-roading, whitewater rafting, skiing, skydiving, snowboarding) are popular among travelers. A lack of rapid emergency trauma response, inadequate trauma care in remote locations, and sudden, unexpected weather changes can compromise safety and hamper rescue efforts, delay care, and reduce survivability (see Sec. 9, Ch. 11, Adventure Travel). For recreational activities with a risk for falling, encourage travelers to use a helmet and to bring their own from home if helmets are unlikely to be available at the destination.

Aircraft Crashes

In 2017 and 2018, 25 US citizens abroad died in aircraft crashes. Travel by local, lightweight aircraft can be risky in many countries. Travel on unscheduled flights, in small aircraft, at night, in inclement weather, and with inexperienced pilots carries the greatest risks. Travelers should avoid using local, unscheduled, small aircraft, and refrain from flying in bad weather and at night, if possible. If available, travelers should choose larger aircraft (>30 seats), because these are more likely to have undergone stricter and more regular safety inspections. Larger aircraft also provide more protection in a crash.

Carbon Monoxide Poisoning

Carbon monoxide (CO) inhalation, poisoning, and death can occur during fires, but also can result from exposure to improperly vented heating devices. Travelers might want to bring a personal CO detector that can sound an alert in the presence of this lethal gas. Engine exhaust is a dangerous, unanticipated source of CO poisoning; remind travelers to avoid diving and swimming off the back of boats where exhaust fumes typically discharge.


In developing countries where building codes are not enforced or do not exist, fires represent a risk to traveler health and safety. Many locations have no smoke alarms or access to emergency services, and the fire department’s focus is on putting out fires rather than on fire prevention or victim rescue.

To prevent fire-related injuries, travelers should select accommodations no higher than the 6th floor (fire ladders generally cannot reach higher than the 6th floor) and confirm that hotels have smoke alarms and, preferably, sprinkler systems. Suggest to travelers that they might want to bring their own smoke alarms with them, and that they should always identify ≥2 escape routes from buildings. Crawling low under smoke and covering one’s mouth with a wet cloth are helpful for escaping a fire. Families should agree on a meeting place outside the building in case of a fire. The National Fire Protection Association has additional guidance (Hotel & Motel Safety [PDF]) that could be useful internationally.

Travel Preparation Tips

When planning or arranging for a trip outside the United States, health care providers, vendors of travel services, and travelers themselves should consider taking the additional actions listed in Box 4-11.

Box 4-11 Additional travel preparation tips for mitigating injury & trauma: a checklist for travelers

☐ Purchase special travel health and medical evacuation insurance if destinations include countries where access to good medical care might not be available (see Sec. 6, Ch. 1, Travel Insurance, Travel Health Insurance & Medical Evacuation Insurance).
☐ Learn basic first aid and CPR before traveling internationally with another person.
☐ Bring a travel health kit, customized to anticipated itinerary and activities.
☐ Review US Department of State travel advisories and alerts and check the US embassy or consulate for country-specific personal security risks and safety tips.
☐ Enroll in the US Department of State’s Smart Traveler Enrollment Program. Enrolled travelers receive emails about safety conditions at their destination and direct embassy contact in case of natural disasters and man-made emergencies (e.g., political unrest, rioting, terrorist activity).

The following authors contributed to the previous version of this chapter: Erin M. Parker, Erin K. Sauber-Schatz, David A. Sleet, Michael F. Ballesteros

Balaban V, Sleet DA. Pediatric travel injuries: risk, prevention, and management. In: Kamat DM, Fischer PR, editors. American Academy of Pediatrics textbook of global child health, 2nd edition. Elk Grove Village (IL): American Academy of Pediatrics; 2015:315–38.

Cortés LM, Hargarten SW, Hennes HM. Recommendations for water safety and drowning prevention for travelers. J Travel Med. 2006;13(1):21–34.

Denny SA, Quan L, Gilchrist J, McCallin T, Shenoi R, Yusuf S, et al. Prevention of drowning. Pediatrics. 2019;143(5):e20190850.

Guse CE, Cortes LM, Hargarten SW, Hennes HM. Fatal injuries of US citizens abroad. J Travel Med. 2007;14(5):279–87.
Krug EG, Mercy JA, Dahlberg LL, Zwi AB. The world report on violence and health. Lancet. 2002;360(9339):1083–8.

McInnes RJ, Williamson LM, Morrison A. Unintentional injury during foreign travel: a review. J Travel Med. 2002;9:297–307.

US Department of State. Traveler’s checklist. Available from:

Vann RD, Lang MA, editors. Recreational diving fatalities. Proceedings of the Divers Alert Network 2010 April 8–10 workshop. Durham (NC): Divers Alert Network; 2011.

World Health Organization. Global health estimates 2016: deaths by cause, age, sex, by country and by region, 2000–2016. Geneva: The Organization; 2018.

World Health Organization. Global report on drowning: preventing a leading killer. Geneva: The Organization; 2014. Available from: