Injury and Death During Travel | Yellow Book

Introduction

In 2019–2021, over 1,500 U.S. citizens died from non-natural causes in foreign countries, with motor vehicle crashes being the leading cause of non-natural deaths, accounting for 26% of non-natural deaths (Figure 3.10.1). Homicide, suicide, and water-related (e.g., drowning, boating-related) deaths were the next most common causes.

Travel destinations might lack emergency care that approximates U.S. standards; trauma centers capable of providing care for serious injuries are uncommon outside urban areas. 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 3.10.1

This graph shows the leading causes of injury death of U.S. citizens in foreign countries with causes (motor vehicle: 402, homicide: 292, suicide: 225, drowning/maritime: 206, aviation: 57, drug-related: 30, terrorist action: 15, and all other: 307) on the y-axis and number of deaths (0-450) on the x-axis.

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Notes

1Data from U.S. Department of State. Deaths of U.S. citizens in foreign countries by non-natural causes. Available from: https://www.travel.state.gov/content/travel/en/international-travel/while-abroad/death-abroad1/death-statistics.html.

2Excludes deaths not reported to the U.S. 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, other accident, and undetermined/unknown.

Road traffic injuries

Each year globally, road traffic crashes involving bicycles, buses, cars, motorcycles, trucks, or pedestrians result in approximately 1.3 million deaths and 20 to 50 million injuries. They are a major cause of death among all age groups and the leading cause of death for children and young adults aged 5–29 years. From 2019 through 2021, among the 402 U.S. citizen road traffic deaths abroad, 62% were among drivers and occupants of passenger vehicles (e.g., cars, trucks, sport utility vehicles), and 19% involved motorcycles. The countries with the most U.S. citizen road traffic deaths were Mexico (141 deaths; 35%), the Dominican Republic (21 deaths; 5%), and Ecuador and Vietnam (each with 16 deaths; 4%).

Risk factors for vehicular crashes, injuries, and deaths include vehicles that fail to meet basic safety standards; roads shared by motor vehicles and vulnerable users; and the mix of traffic, including animals, bicycles, buses, cars, rickshaws, taxis, and large trucks. Other risk factors include vehicle speed, lack of familiarity with the roads, driving on the opposite side of the road, the influence of alcohol and other drugs, poorly made or inadequately maintained vehicles, travel fatigue, poor road surfaces without shoulders, unprotected curves and cliffs, and low or absent lighting creating conditions of poor visibility.

Strategies that travelers can use to reduce the risks for motor vehicle crash injuries include remaining alert and avoiding distractions when cycling, driving, or walking; choosing transportation carefully (e.g., avoiding overcrowded buses); abstaining from alcohol before driving; and not accepting rides from an impaired driver. Travelers should always use seat belts (including in rear seats) and child safety seats and should rent vehicles with seat belts. Whenever possible, travelers should ride only in taxis with seat belts and opt for the rear seats. Travelers also should bring car seats or booster seats for their children from home unless they can be assured of their availability and quality at the destination.

Discourage travelers from driving or riding on motorcycles or motorbikes, including motorcycle and motorbike taxis. For travelers who cannot be dissuaded, strongly recommend that they wear a helmet that meets U.S. safety standards. Additionally, all bicyclists, regardless of age, can help protect themselves by wearing properly fitted bicycle helmets every time they ride. A good-quality helmet can reduce the risk for death by 40% and for severe injury by 70%.

The Department of State has useful safety information for international travelers, including road safety and security alerts, international driving permits, and travel insurance. In addition, the Association for International Road Travel has useful safety information for international travelers, including road safety checklists and country-specific driving risks.

Violence and suicide

Violence is a worldwide public health problem that affects U.S. citizens traveling, working, or residing internationally. Globally every year, about 475,000 people are victims of homicide and more than 700,000 die due to suicide. Rates of violent deaths in low- and middle-income countries are 3 times those in higher-income countries, although variations exist within countries. Over 68% of all homicide deaths in U.S. citizens abroad occurred in Mexico (see Mexico chapter). Criminals might view U.S. 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 Safety and Security Overseas chapter). For longer-term travelers, social isolation might increase the risk for depression and suicide; these risks might be amplified with substance use and in areas with poverty (see Mental Health in Travelers chapter, for more detailed information on suicide prevention).

Water and aquatic injuries

Drowning is a leading cause of injury death to U.S. 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, injuries that affect young men 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. Lifejackets should be appropriately sized and U.S. Coast Guard–approved or comparable. If travel includes planned water activities (e.g., sailboarding, water skiing, whitewater boating or rafting, operating personal watercraft), travelers should consider bringing their own lifejackets. 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 approximately 16 deaths per 100,000 divers per year. Travelers should either be experienced divers or dive with a reputable dive shop and instructors (see Scuba Diving: Decompression Illness and Other Dive-Related Injuries chapter, for a more detailed discussion about diving risks and preventive measures).

Travelers should not swim alone or in unfamiliar waters. 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 or 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. Travelers should use reputable companies, outfitters, and guides when pursuing adventure activities, and assess the situation for unacceptable hazards before engaging in these activities. 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 Adventure Travel chapter). 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

From 2019–2021, 57 U.S. 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 (see Air Quality and Ionizing Radiation During Travel chapter; and Poisonings, Envenomations, and Toxic Exposures During Travel chapter). 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.

Fires

Fires represent a risk to traveler health and safety in many locations, especially in countries where building codes are not enforced or do not exist. 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 that could be useful internationally.

Death during travel

Death of a friend, relative, or coworker can be immensely distressing. The situation is aggravated when the death occurs abroad, where grieving individuals might be unfamiliar with local laws, language, culture, and processes for investigation and release of the body. Whether dealing with the death locally or remotely from another country, next of kin could face large, unanticipated costs and labor-intensive administrative requirements.

Depending on the circumstances surrounding the death, some countries require an autopsy. For travel companions of the deceased, in addition to friends and relatives in other countries, sources of support might include the U.S. consulate or embassy, a travel insurance provider (particularly if coverage included repatriation of remains of a deceased person), the airline or cruise line, a tour operator, faith-based and aid organizations, or the deceased person’s employer. Official identification of the body will likely be needed, and official documents likely will need to be issued by the consular office. A body can be identified by witness statements of those who knew the person well, by analyzing DNA samples, by checking fingerprints, by reviewing dental radiographs, or by inspecting surgical implants.

Obtaining U.S. Department of State assistance following death of a U.S. citizen abroad

Overseas family members, domestic partners, or legal representatives of the deceased should call the Department of State’s Office of Overseas Citizens Services in Washington, DC, from 8 a.m. to 5 p.m. Eastern time, Monday through Friday, at 888-407-4747 (toll-free) or 202-501-4444. For emergency assistance after working hours or on weekends and holidays, call the Department of State switchboard at 202-647-4000 and ask to speak with the Overseas Citizens Services duty officer. If families or legal representatives are also overseas in the same country, they can contact the nearest U.S. embassy or consulate for support.

The Department of State does not fund or pay for the shipment of remains of U.S. citizens who die abroad. U.S. consular officers assist the next of kin by conveying information on how the family can send necessary private funds to cover the cost of funerals or preparing and repatriating the deceased person’s remains to the United States. The U.S. consular officers can also communicate with the appropriate authorities in the foreign country and connect the family with the foreign funeral homes and other resources as necessary. Upon issuance of a local (foreign) death certificate, the nearest U.S. embassy or consulate can prepare a Consular Report of Death Abroad (CRODA). Copies of the CRODA are provided to the deceased person’s next of kin or legal representative to settle estate matters in the United States. If the deceased person has no next of kin or legal representative in the foreign country, a consular officer will act as a provisional conservator of the deceased person’s personal effects.

Transporting human remains to the United States

CDC regulates the importation, and transiting within, of human remains intended for final resting, medical examination or autopsy, and other purposes and provides guidance for this process. All human remains must be fully contained within a leak-proof container that is packaged and shipped in accordance with all applicable legal requirements. The requirements are more stringent if the remains are reasonably suspected to contain an infectious biological agent (e.g., if the person died from a communicable disease), in which case the importer may be required to obtain a permit.

Except for cremated or embalmed remains, human remains intended for burial, entombment, or cremation after entry into the United States must be accompanied by a death certificate stating the cause of death and consigned directly to a licensed mortuary, cemetery, or crematory for immediate and final preparation prior to burial, entombment, or cremation. A death certificate is an official government document that certifies that a death has occurred and provides identifying information about the deceased, including (at a minimum) name, age, and sex. The document must also certify the time, place, and cause of death, if known. If the official government document is not written in English, it must be accompanied by an English-language translation of the official government document, the authenticity of which must be attested to by a person licensed to perform acts in legal affairs in the country where the death occurred. If a death certificate is not available in time for returning the remains, or, if the death certificate is incomplete, remains must be accompanied by:

An importer certification statement confirming that the human remains are not known to contain an infectious biological agent; or

An importer certification statement stating why the human remains are not reasonably suspected of containing an infectious biological agent; or

A Consular Mortuary Certificate from the U.S. embassy or consulate stating whether the person died from a communicable disease.

When a U.S. citizen or lawful permanent resident dies outside the United States, the deceased person’s next of kin or legal representative should notify the closest U.S. embassy or consulate abroad and work with the consular officers to obtain these documents. A person importing human remains into the United States must also meet requirements of the country of origin, air carrier, the Transportation Security Administration, and U.S. Customs and Border Protection.

Exporting human remains from the United States

CDC does not regulate the exportation of human remains outside the United States, although other state and local regulations might apply. In the United States, the U.S. Postal Service is the only courier legally allowed to ship cremated remains. Exporters of human remains and travelers taking human remains out of the United States should be aware that they must meet the importation requirements of the destination country. Information regarding these requirements can be obtained from the foreign embassy or consulate. Air carriers also might have their own requirements, of which individuals transporting remains outside of the United States should be aware.

Death onboard a conveyance destined for the United States

Federal regulations require that all deaths aboard commercial flights and ships destined for the United States be reported to CDC. For details, see Guidance for Airlines on Reporting Onboard Deaths or Illnesses to CDC and Maritime Guidance: Reporting Illness and Deaths on Ships (for more information pertaining to deaths on airplanes or cruise ships, see Air Travel and Cruise Ship Travel chapters).

Recommendations

When planning or arranging for a trip outside the United States, healthcare professionals, vendors of travel services, and travelers themselves should consider taking the additional actions listed in Box 3.10.1.

Box 3.10.1

Acknowledgements

The following authors contributed to the previous version of this chapter: Alida M. Gertz.