Chapter 2The Pre-Travel ConsultationCounseling & Advice for Travelers

David A. Sleet, Michael F. Ballesteros

OVERVIEW

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. Worldwide, among people aged 5–44 years, injuries account for 7 of the 15 leading causes of death. Tourists are 10 times more likely to die as the result of an injury than from an infectious disease; injuries cause 23% of tourist deaths 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 2007 through 2009, an estimated 2,352 US citizens died from 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 one killer of healthy US citizens traveling in foreign countries. From 2007 through 2009, road traffic crashes accounted for 32% of tourist deaths due to injuries, followed by homicide (18%) and drowning (14%) (Figure 2-01).

Depending on the travel destination, duration, and planned activities, other common injury and safety concerns include natural hazards and disasters, civil unrest, terrorism, falls, burns, poisoning, drug overdose, and suicide. If a traveler is seriously injured, emergency care may not be available or acceptable by US standards. Trauma centers capable of providing optimal trauma care are uncommon outside urban areas.

Men are more likely than women to die from injuries while traveling internationally. Acquaintance rape and sexual assault are 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. Injuries are the primary reason for US travelers to be transported back to the United States by air medical transport; the main nonfatal causes are motor vehicle traffic crashes (45%), falls (8%), aircraft crashes (2.5%), and burns and electrical shocks (1%).

ROAD TRAFFIC INJURIES

An estimated 3,500 people are killed each day, including 1,000 children, around the world in road traffic crashes involving cars, buses, motorcycles, bicycles, trucks, or pedestrians. Annually, 1.3 million are killed and at least 50 million are injured each year from traffic injuries—a number likely to double by 2020. More than 85% of these casualties (and 96% of child deaths) occur in low- and middle-income countries. Table 2-11 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 other diseases like 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.”

According to Department of State data, road traffic crashes are also the leading cause of injury death to US citizens while traveling internationally (Figure 2-01) and the leading cause of death to healthy US travelers. Recent estimates show that 745 US citizens were killed in road traffic crashes from 2007 through 2009. Approximately 13% of these road traffic deaths involved motorcycles and 5% 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. As noted in Chapter 4, The Caribbean, 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 less than 30 miles per hour. Road traffic crashes are also a leading cause of nonfatal injuries among US citizens who require emergency transport back to the United States. 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, 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, both on the road and on the vehicle. In many low-income areas of the world, 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 motorbike 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.

Traffic death rates in the 20 countries most frequented by US travelers are listed in Table 2-12. These data show that travelers should be particularly concerned in Mexico. In 2008, 20.3 million travelers visited Mexico. From 2007 through 2009, over 280 US travelers lost their lives in motor vehicle crashes in Mexico, the nation most frequently visited by US citizens.

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, international driving permits, and insurance (www.travel.state.gov).

WATER AND AQUATIC INJURIES

Drowning accounts for 14% of deaths of US citizens abroad. The risk factors have not been clearly defined but are most likely related to unfamiliarity with local water currents and water conditions. Rip tides 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 travelers 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 boats, do not know boating etiquette, 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 (see the Scuba Diving section later in this chapter). Travelers should either be experienced divers or dive with a reliable dive shop and instructors. They should be reminded not to dive on the same day they arrive by airplane. The death rate among all divers, worldwide, is thought to be 15–20 deaths per 100,000 divers per year.

OTHER UNINTENTIONAL INJURIES

From 2007 through 2009, aviation incidents, drug-related incidents, and other unintentional injuries accounted for more than one-third of all injury deaths to US travelers in foreign countries (Figure 2-01). Fires can be a substantial risk in low-income countries where building codes are not present or 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 commercial air carriers in many countries can be risky. From 2007 through 2009, an estimated 74 US travelers were killed in airplane crashes in foreign countries. Travel on unscheduled flights, in small aircraft, at night, in inclement weather, and with inexperienced pilots carries the highest risk.

Travel health providers and travelers should consider the following:

• 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 the Travel Health Insurance and Evacuation Insurance section later in this chapter).
• 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 and modern drugs 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, are popular in foreign countries. Risks include the lack of rapid emergency trauma response when injured, inadequate trauma care in remote locations, and sudden, unexpected weather changes that compromise safety and hamper rescue efforts.
• Travelers should avoid using local, unscheduled, small aircraft. If available, choose larger aircraft (more than 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 www.airsafe.com.
• 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. 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.
• 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 carry a personal detector that can alert to 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-RELATED INJURIES

Violence is a leading worldwide public health problem and a growing concern of travelers. In 2000, about 1.6 million people lost their lives to violence, and only one-fifth 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 variations within countries.

Homicide was the second-leading cause of injury death among US travelers in foreign countries, accounting for over 400 deaths from 2007 through 2009 (Figure 2-01). For some low-income countries, such as Honduras, Colombia, Guatemala, and Haiti, homicide was the leading cause of injury death for US travelers, accounting for 38%–52% of all injury deaths.

US travelers 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, civil unrest, alcohol or drug use, and traveling in unfamiliar environments at night increase the likelihood that a US traveler will be the victim of planned or random violence.

To avoid violence while traveling, travelers should limit travel at night, travel with a companion, and vary routine travel habits. Travelers should not wear expensive clothing or accessories. Since criminals are less likely to victimize upper floors, travelers should avoid accommodations on the ground floor of hotels and avoid rooms immediately next to the stairs. It is important to lock all doors and windows. Travelers may even consider carrying and using a door intruder alarm, a smoke alarm, and a rubber doorstop that can be used as a supplemental door 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 fourth-leading cause of injury death to US citizens abroad. 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.

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