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. An estimated 18%–24% of deaths among travelers in foreign countries are caused by injuries, compared with only 2% of deaths caused by infectious diseases. Contributing to the injury toll while traveling are unfamiliar and perhaps risky environments, differences in language and communications, less stringent product safety and vehicle standards, unfamiliar rules and regulations, and a carefree holiday or vacation spirit leading to more risk-taking behavior.
In 2013 and 2014, an estimated 1,670 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 overseas. In 2013 and 2014, 456 Americans died in road traffic crashes abroad (27% of nonnatural deaths). Another 350 were victims of homicide (21%), 286 committed suicide (17%), and 220 drowned (13%) (Figure 2-2).
If a traveler is seriously injured in a foreign country, 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. Travelers should be aware of the increased risk of certain injuries while traveling or residing abroad, particularly in developing countries, and be prepared to take preventive steps.
Road Traffic Injuries
Globally, an estimated 3,300 people, including 720 children, are killed each day in road traffic crashes involving cars, buses, motorcycles, bicycles, trucks, and pedestrians. Annually, 1.24 million are killed and 20–50 million are injured in traffic crashes—a number likely to double by 2030. Although only 53% of the world’s vehicles are in developing countries, more than 90% of road traffic casualties occur in these countries.
According to US Department of State data, road traffic crashes are the leading cause of injury deaths to US citizens while abroad (Figure 2-2). Motorcycle use is a risk factor for road traffic crashes; in 2013 and 2014, approximately 20% of road traffic deaths while abroad involved motorcycles. Road deaths per million trips are highest in Thailand and Vietnam, and most American deaths were related to motorcycle use in these countries. The reported rate of motorbike injuries in Bermuda is much higher in tourists than in the local population, and the rate is highest among those aged 50–59 years. Motor vehicle rentals for tourists in Bermuda and some other small Caribbean islands are typically limited to motorbikes, possibly contributing to the higher rates of motorbike injuries. Loss of vehicular control, unfamiliar equipment, and inexperience with motorized 2-wheelers contribute 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 developing countries, 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 including cars, buses, taxis, rickshaws, large trucks, and even animals increases the risk for crashes and injuries.
Strategies to reduce the risk of traffic injury are shown in Table 2-13. The Association for International Road Travel (www.asirt.org) and Make Roads Safe (www.makeroadssafe.org) 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 (www.travel.state.gov).
|Mechanism or Type of Injury||Prevention Strategies|
|Road Traffic Crashes|
|Lack of 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 developing 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 (www.asirt.org).|
|Motorcycles, motorbikes, and bicycles||Always wear helmets (bring a helmet from home, if needed). When possible, avoid driving or riding on motorcycles or motorbikes, including motorcycle 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. Penalties can be severe overseas.|
|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 and avoid riding in mountainous terrains, at night, and with a drinking or distracted bus driver.|
|Pedestrian hazards||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.|
|Drowning||Avoid swimming alone or in unfamiliar waters. Wear life jackets while boating or during water recreation activities.|
|Burns||In hotels, stay below the 6th floor to maximize the likelihood of being rescued in a fire. Bring your own smoke alarm.|
Water and Aquatic Injuries
In 2013 and 2014, drowning accounted for 13% 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 is often 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. In 2013 and 2014, maritime accidents resulted in 16 deaths to healthy Americans abroad. 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 a more detailed discussion about diving risks and preventive measures.
Other Unintentional Injuries
In 2013 and 2014, other unintentional injuries such as aviation incidents, drug-related incidents, natural disasters, and deaths classified as “other unintentional injuries” (including fires and falls) accounted for 19% of deaths to healthy US citizens abroad. Fires can be a substantial risk in developing countries where building codes do not exist or are not enforced, there are no smoke alarms, there is no access to emergency services, and the fire department’s focus is on putting out fires rather than on fire prevention or victim rescue.
In 2013 and 2014, an estimated 50 US citizens abroad were killed in aircraft crashes. Travel by local, lightweight aircraft in many countries can be risky. Travel on unscheduled flights, in small aircraft, at night, in inclement weather, and with inexperienced pilots carries the highest risk.
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.
Health care providers, vendors of travel services, and travelers themselves should consider the following:
- Travelers may wish to purchase 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).
- Adventure activities, such as mountain climbing, skydiving, whitewater rafting, dune-buggying, kayaking, skiing, and snowboarding 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 care and reduce survivability.
- Travelers should avoid using local, unscheduled, small aircraft and refrain if possible from flying in bad weather and at night. If available, choose larger aircraft (>30 seats), as they are more likely to have 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 www.airsafe.com.
- When traveling by air with young children, consider bringing a child safety seat approved for use on an aircraft, helmets if considering riding bicycles or motorbikes, and life preservers if travelers will be in the water.
- 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 (CO) at the back of boats near the engine can be especially dangerous. Travelers may want to carry a personal CO 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.
- 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 ed. Elk Grove Village, IL: American Academy of Pediatrics; 2015.
- Ederer D, Parker E, Sleet DA. Motorcycle helmets as a vaccine: CDC and Asia Injury Prevention Foundation Partner in Cambodia and Uganda. CDC’s Division of Global Health Protection; 2014 [cited 2016 Sep. 29]; Spring 2014, Issue 14. Available from: www.cdc.gov/globalhealth/healthprotection/fieldupdates/pdf/dghp-field-updates-2014-spring.pdf.
- Guse CE, Cortes LM, Hargarten SW, Hennes HM. Fatal injuries of US citizens abroad. J Travel Med. 2007 Sep-Oct;14(5):279–87. [PMID:17883458]
- Lawson CJ, Dykewicz CA, Molinari NA, Lipman H, Alvarado-Ramy F. Deaths in international travelers arriving in the United States, July 1, 2005 to June 30, 2008. J Travel Med. 2012 Mar-Apr;19(2):96–103. [PMID:22414034]
- Li G, Pressley JC, Qiang Y, Grabowski JG, Baker SP, Rebok GW. Geographic region, weather, pilot age, and air carrier crashes: a case-control study. Aviat Space Environ Med. 2009 Apr;80(4):386–90. [PMID:19378910]
- Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012 Dec 15;380(9859):2095–128. [PMID:23245604]
- Sherry MK, Mossallam M, Mulligan M, Hyder AA, Bishai D. Rates of intentionally caused and road crash deaths of US citizens abroad. Inj Prev. 2015 Apr;21(e1):e10–4. [PMID:24302480]
- US Department of Commerce. 2015 US travel and tourism statistics. Washington, DC: US Department of Commerce; 2016 [cited 2016 Sep. 29]; Available from: http://travel.trade.gov/outreachpages/outbound.general_information.outboun....
- US Department of State. Tips for traveling abroad. Washington, DC: US Department of State; 2012 [cited 2016 Sep. 22]; Available from: https://travel.state.gov/content/passports/en/go/checklist.html.
- World Health Organization. WHO global status report on road safety 2015. Geneva: World Health Organization; 2015 [cited 2016 Sep. 22] Available from http://www.who.int/violence_injury_prevention/road_safety_status/2015/en/.
David A. Sleet, David J. Ederer, Michael F. Ballesteros