According to the World Health Organization (1), injuries are among the leading causes of death and disability in the world, and they are the leading cause of preventable deaths in travelers. An estimated 5 million people died from injuries in 2000, and more than 90% of these injury deaths occurred in lower and middle-income countries. Worldwide, among persons ages 5-44, injuries account for 6 of the 15 leading causes of death (1).

In 2005, just over 63.5 million Americans traveled outside the United States (2). 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. Compared with injuries, infectious diseases, for example, only account for a small proportion (2%) of deaths of overseas travelers (3).

The U.S. State Department collects data for 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 State Department website. These deaths are categorized by location where the death occurred, date of death, and cause of death (4). 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 State Department (4). The data may not include some deaths of U.S. military or U.S. government officials. Road traffic crashes headed the list of causes (34%), followed by homicide (17%), and drowning (13%). (By comparison to U.S. injury fatalities in 2003, road traffic crashes accounted for 27%, homicide 11%, and drowning 2% of all injury deaths [5]).

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 a traveler is seriously injured, emergency care may not be available or acceptable by U.S. standards. Trauma centers capable of providing optimal trauma care are uncommon outside urban areas.

Males are more likely than females to die from injury causes while traveling internationally (3,6). Males account for 65% to 75% of all injury deaths to US citizens (3,7). 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 (8). An estimated 3,000 people are killed each day in road traffic crashes involving cars, buses, motorcycles, bicycles, trucks or pedestrians (9). Each year, another 20 to 50 million people are seriously injured (8). In 2000, more than 1 million traffic-related deaths occurred in low- and middle-income countries, and that number is likely to double by 2020 (8).

According to U.S. State Department data, road traffic crashes are also the leading cause of injury death in U.S. citizens while traveling internationally. An estimated 768 Americans were killed in road traffic crashes 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 age 50-59. Loss of vehicular control, unfamiliar equipment, and inexperience with motorized two-wheelers contributed to crashes and injuries, even for travel at speeds less than 30 mph (10). Road traffic crashes are also a leading cause of nonfatal injury among U.S. citizens requiring emergency transport back to the United States (11).

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, lack of universal safety standards in 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 (3). 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. In low-income countries, cars, buses, and large trucks commonly all share 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 (12).

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 to 60%, child safety seats by 54% and infant seats by 70% (13). When traveling, rent newer vehicles with safety belts and airbags, and bring your own child safety seats and booster seats from home.
• Rent larger vehicles if possible, for greater protection in a crash.
• Ride only in marked taxis with functional safety belts, ride in the rear seat and consider offering the driver a bonus for driving in a manner you determine “safe.”
• Be alert when crossing streets, looking right, left, and then right again and pay close attention to the correct side of the road when driving in countries that drive on the left.
• Wear helmets when riding motorcycles, motorbikes, and bicycles. If helmets are not available at the destination, consider bringing one. Bike riders should bring their own helmets from home. Recognize that unless you ride motorcycles regularly, you will be a novice rider competing in traffic with much more experienced drivers and riders who are familiar with the terrain and the driving culture.
• Avoid excessive alcohol. Alcohol is a risk factor for injuries, especially for pedestrians, drivers, and passengers riding with drinking drivers. Travelers may have a more carefree attitude while away from home that predisposes them to driving under the influence of alcohol. Research in the United States has shown an alcohol-impaired driver has a 17 times greater risk of being involved in a fatal crash.
• Avoid riding in overcrowded, overweight, or top-heavy buses or minivans.
• Check with the Association for International Road Travel for useful safety information for international travelers, including road safety checklists and country-specific driving risks (14). (http://www.asirt.org.)
• Check with the US State Department which has safety information useful to international travelers, including road safety and security, international driving permits, and insurance. (15) (http://www.travel.state.gov. )
• Check the World Report on Road Traffic Injury Prevention (see reference 8) which contains a section on interventions directed to the road, the vehicle and the driver that may help travelers select appropriate prevention strategies.
• Consider hiring a driver familiar with the city and expert in maneuvering through local traffic.

Other Unintentional Injuries

During 2003-2005, drowning, airplane crashes, natural disasters, and other unintentional injuries accounted for over a third of all injury deaths to Americans in foreign countries. Drowning was the leading cause of injury death to Americans visiting countries where water recreation was a major activity, such as Fiji, Dutch Antilles, Aruba, and Costa Rica (4). Risks for drowning and prevention meas-ures are covered in the Swimming and Recreational Water Safety section. Studies have found that young men are particularly at risk of head and spinal cord injuries from diving into shallow water, with alcohol being a factor in some cases (3).

Fires can be a substantial risk in low-income countries, where building codes are not present or enforced, emergency access via 9-1-1 equivalent does not exist, and where fire departments are only involved in fire suppression (not fire prevention or victim rescue).

Travel by local commercial air carriers in many countries carries greater risk than appreciated. During 2003-2005, an estimated 83 Americans were killed in airplane crashes in foreign countries. Travel on unscheduled flights, in small aircraft, at night, in inclement weather, and with pilots who have limited flying hours carries the highest risk.

Prevention of Other Unintentional Injuries

• Injuries account for a substantial proportion of evacuations of tourists from low-income countries. Travelers should consider purchasing special health and evacuation insurance if their destinations include countries where there may not be access to good medical care (see Chapter 2).
• Because trauma care is poor in many countries, victims of injuries can die before reaching a hospital, and there may be no coordinated ambulance services. In remote areas, medical assistance, drugs, and medicines may be unavailable, and travel to the nearest medical facility can take a long time.
• Adventure travel activities, such as mountain climbing, whitewater rafting, and kayaking in low-income countries, are popular with Americans. Because quality emergency trauma care is lacking in many countries, travelers should consider this when planning the difficulty of their adventures.
• Travelers should avoid using local unscheduled small aircraft. Larger aircraft (greater than 30 seats), have usually undergone more strict and regular safety inspections and may provide more protection in the event of a crash. For country-specific airline crash events see http://www.airsafe.com.
• To prevent fire-related injuries, travelers should select accommodations on the 6th floor or below (fire ladders generally can not reach above the 6th floor). If possible, hotels should be chosen that have smoke alarms and sprinkler systems. Improperly vented heating devices may cause poisoning from carbon monoxide (CO), a colorless, odorless gas and by-product of all fossil fuel combustions. Travelers should identify two escape routes from buildings and remember to escape a fire by crawling low under smoke, and covering the mouth with a wet cloth.

Other Injury Prevention Tips

The U.S. State Department maintains a website that features a section on International Travel both for tourists and business travelers, which covers current country-specific travel warnings, emergencies, physical security, safety tips, crisis awareness and preparedness, consular information, and special services. When traveling to countries with developing economies or through regions with the potential for geopolitical instability, travelers should check with the State Department or the country’s US Embassy for Country-Specific Travel Warnings. These advisories are updated regularly. The State Department issues Consular Information Sheets ([[forward label=([http://travel.state.gov/travel/travel_1744.html]) link=([])]]) for every country of the world that include information such as crime, areas of instability, and location of the nearest embassy or consulate in the subject country. Public announcements are used to disseminate information quickly about terrorist threats and other relatively short-term conditions that pose significant risks or disruptions to Americans overseas.

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 20% 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 (16).

Homicide was the second leading cause of injury death among American travelers in foreign countries, accounting for almost 400 deaths during 2003-2005. 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% to 65% of all injury deaths.

Terrorism-related deaths among U.S. citizens in foreign countries, while alarming, are still relatively rare events and accounted for only 2% of all injury deaths. The vast majority of terrorism deaths among Americans occurred in countries of the Middle East. According to data for 2003-2005 from the State Department, 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. 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 poverty and rigid gender roles, may increase the risk of depression and suicide.

Prevention of Violence-Related Injuries

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, those with civil unrest, or in unfamiliar environments at night, increase the likelihood that a U.S. traveler will be the victim of planned or random violence. Drug or alcohol use will also increase the risk.

To avoid violence travelers should limit travel at night, travel with a companion, and vary routine travel habits. They should wear locally available accessories that would associate you with the country-savvy expatriate community, and avoid expensive or provocative clothing or accessories. Avoiding accommodations on the ground floor of hotels and immediately next to the stairs as well as locking all doors and windows are helpful as well. Criminals are less likely to victimize upper-level floors. Travelers can carry a portable door intruder alarm, a smoke alarm, and a rubber door stop that can be used as a supplemental door lock. If confronted, travelers should not resist attackers, but rather give up their car and all valuables.

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. 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 are still incomplete or unreliable in many countries. 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.

References

1. Peden M, McGee K, Sharma G. The injury chart book: a graphical overview of the global burden of injuries. Geneva, Switzerland: World Health Organization; 2002. Available from http://www.who.int/violence_injury_prevention/publications/other_injury/en/index.html. (Accessed 27 March 2007).
2. Office of Travel and Tourism Industries. http://tinet.ita.doc.gov/outreachpages/inbound.total_intl_travel_volume_1995-2005.html (Accessed 4 April 2007).
3. McInnes RJ, Williamson LM, Morrison A. Unintentional injury during foreign travel: a review. J Travel Med. 2002;9:297-307.
4. U.S. Department of State, U.S. Citizen Deaths from Non-Natural Causes by Foreign Country http://travel.state.gov/family/family_issues/death/death_594.html. (Accessed 4 April 2007).
5. CDC. Web-based Injury Statistics Query and Reporting System (WISQARS) [online]. Available from: URL: www.cdc.gov/ncipc/wisqars. (Accessed 4 April 2007).
6. MacPherson DW, Guerillot F, Streiner DL, Ahmed K, Gushulak BD, Pardy G, et. al. Death and dying abroad: the Canadian experience. J Travel Med. 2000;7:227-33.
7. Hargarten SW, Baker TD, Guptill K. Overseas fatalities of United States citizen travelers: an analysis of deaths related to international travel. Ann Emerg Med. 1991;20:622-6.
8. Peden M, Scurfield R, Sleet D, et al. World report on road traffic injury prevention. Geneva, Switzerland: World Health Organization; 2004. Available from: http://www.who.int/world-health-day/2004/infomaterials/world_report/en. (Accessed 27 March 2007.)
9. Sleet DA, Branche CM. Road safety is no accident. J Safety Res. 2004;35(2):173-4.
10. Carey MJ, Aitken ME. Motorbike injuries in Bermuda: a risk for tourists. Ann Emerg Med. 1996;28:424-9.
11. Hargarten S, Bouc G. Emergency air medical transport of U.S. citizen tourists: 1988 to 1990. Air Med J. 1993;12:398-402.
12. Barss P, Smith G, Baker S, et al. Injury prevention: an international perspec-tive. New York: Oxford University Press; 1998.
13. Zaza S, Sleet DA, Shults RA, et al. Reducing injuries to motor vehicle occupants. Chapter 8 in The Guide to Community Preventive Services: What works to promote Health? Zaza S, Briss P, Harris K, eds. New York: Oxford University Press; 2005:329-84.
14. The Association for International Road Travel, available from http://www.asirt.org. (Accessed 4 April 2007).
15. U.S. Department of State, International Travel website available from http://www.travel.state.gov. (Accessed 4 April 2007).
16. Krug EG, Dahlberg LL, Mercy JA, et al. World report on violence and health. Geneva, Switzerland: World Health Organization; 2002 Available from: http://www.who.int/violence_injury_prevention/violence/world_report/en. (Accessed 27 March 2007).

L.J. DAVID WALLACE, DAVID SLEET