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Injuries and Injury Prevention
50 Injuries and Injury Prevention Stephen W. Hargarten and Tifany Frazer
KEY POINTS • Injuries are a more significant cause of travel-related mortality and morbidity than infectious diseases. • Road traffic crashes are the leading causes of injury mortality and can be prevented by traveling in safe vehicles with seat belts, driven by a qualified driver. Motorcycles and bicycles should be avoided as well as rural travel by road in any vehicle after dark in low-resource countries. Pedestrians are highly vulnerable in unfamiliar environments. • Death by drowning can be avoided by use of personal flotation devices, abstention from alcohol during water-related activities,
and close supervision of children. Fences and safety barriers are often absent overseas. • Data deficiencies and discrepancies in the manner of reporting cause of death have made it challenging to create a profile of injury risk based upon type of tourist, nationality, destination, and travel activity. Better data on injury mortality of travelers (and all causes of mortality) should be maintained, and reviewed by respective embassies and governmental organizations.
INTRODUCTION
tsunamis and earthquakes, airplane crashes, extreme environmental exposures, and animal or marine life bites and stings.2–4 Road traffic crashes have plateaued since 2007 suggesting that recent interventions to improve road safety are effective in addressing mortality.9 Since 2014 five countries have achieved fatality rates of three or less deaths per 100,000 inhabitants: Iceland, Norway, Sweden, Switzerland, and the United Kingdom.2 Conversely, low-income countries have double the fatality rates compared to those in high-income countries.9 Specifically, 90% of road traffic deaths occur in low-income and middle-income countries, yet these countries have just 54% of the globe’s vehicles.9 Nearly half of those dying on the world’s roads are vulnerable road users: pedestrians, cyclists, and motorcyclists.9 In addition to the grief and physical suffering they cause, road traffic crashes result in considerable economic losses to victims, their families, and nations as a whole, costing most countries 1%–3% of their gross national product.9 The Decade of Action for Road Safety (2011–2020) calls on countries to implement the measures identified internationally to make their roads safer. The new target of the United Nations Sustainable Development Goals is to reduce the global number of deaths and injuries from road traffic crashes by 50% by the year 2020.9 The precise number of deaths and proportion of injury deaths of travelers worldwide is not known. Injuries to US citizens traveling internationally occur at a higher proportion than to citizens residing in the United States.4 Injury is also reported to be the cause of deaths among visitors to the United States.10 Figs. 50.1 and 50.2 illustrate mortality data captured by the United States, showing types of injuries and top causes of death for their traveling citizens.11 A review of deaths of Scottish travelers showed trauma and other noninfectious causes being the two most common.12 A study of Finnish travelers identified cardiovascular diseases as the top cause of death.13 Injury deaths occur most commonly in low-income to middle-income America followed by Europe and Eastern Mediterranean countries.3,14
Injuries are one of the leading causes of travel-related mortality worldwide, accounting for up to 25 times more deaths than infectious disease.1 Annually, over 1 million people are killed in car crashes worldwide and several million more are injured during these events.2 Researchers worldwide have reported that noninfectious causes of travel-related deaths, especially injury, pose a serious health risk to travelers.2–6 Injuries to tourists are also a significant burden to hospitals and health care systems—at the tourist destination, during transport, and in terms of continuing care when the patient returns home.7 Tourists tend to be more at risk for an injury because they frequently find themselves in unfamiliar environments and participating in unfamiliar activities.1 Travel to low-resource countries can pose different hazards and outcomes after road traffic crashes or other unintentional injuries and are sometimes more severe with worse outcomes due to limitations in emergency medical systems and health facility resources.3 Injuries are predictable and preventable.3,4,8 It is important for health care providers, travel medicine specialists, tourism professionals, and government agencies issuing travel health advisories to create and communicate evidence-based injury prevention messages tailored for all categories of travelers, travel activities, and travel destinations. This chapter reviews the types of fatal and nonfatal injuries most frequently experienced by travelers, and provides evidence-based prevention and control recommendations.
FATAL INJURY Injury is a leading cause of travel-related mortality worldwide. Most mortality studies report that travelers most frequently die in road traffic crashes and drownings.2 Other causes of travel-related injury death, though less common, include violent events, natural disasters such as
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CHAPTER 50 Injuries and Injury Prevention Abstract
Keywords
Road traffic crashes are the leading causes of injury mortality for travelers. Injuries are a more significant cause of travel-related mortality and morbidity than infectious diseases. Injuries are predictable and preventable. This chapter outlines the injuries that travelers experience and provides injury prevention recommendations for safe travel. This chapter also reviews the types of fatal and nonfatal injuries most frequently experienced by travelers, and provides evidence-based prevention and control recommendations. Specifically, recommendations for road traffic and water safety are outlined. Better data on injury mortality of travelers and all causes of mortality would further strengthen injury prevention recommendations.
Alcohol risk Injury Injury prevention Nonfatal injuries Prevention recommendations Road traffic safety Safety Travel Water-related injuries
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0
Cause of Death
FIG. 50.1 Specific injury-related deaths of US citizens traveling internationally, October 2002–December 2016. (US Department of State. Non-natural Deaths of US Citizens Abroad. 2017 Feb 15. Available at https:// travel.state.gov/content/travel/en/statistics/deaths.html.)
traveler’s embassy or consulate in-country is the first action item. Travelers should review their country’s guidance in preparation for travel.
3% 13% 27%
Vehicle accident Other accident Homicide
19%
Drowning Terrorist action 27%
FIG. 50.2 The top five causes of death for US citizens traveling internationally, October 2002–December 2016. (US Department of State. Non-natural Deaths of US Citizens Abroad. 2017 Feb 15. Available at https://travel.state.gov/content/travel/en/statistics/deaths.html.)
In each of these regions, US citizens have a greater proportion of injury mortality compared to host county nationals.21 Deaths of European travelers to areas of Thailand have shown natural causes were highest.13,15 Overwhelmingly, young males tend to be at greater risk for an injury leading to death during travel.16 The difficulty in counting and categorizing the causes of death among international travelers has been highlighted by the 2004 tsunami disaster in the Indian Ocean, 2010 Haitian earthquake, 2011 Japanese earthquake and tsunami, the 2015 Nepal earthquakes, and the 2015 and 2016 terrorist attacks in France. The precise mortality count for both locals and travelers from these events may never be known. Each government had a different way to count their citizens’ deaths. Apart from obtaining a visa, travelers tend not to register their trip itinerary with their appropriate home government agency. To be accounted for in the event of disaster, travelers may register their travel dates and locations with their own governmental agencies like the Smart Traveler Enrollment Program provided by the US Department of State.17 In the event of a fatality, contacting the
NONFATAL INJURIES Studies focusing on nonfatal health incidents are also important to gain a more complete understanding of the larger travel injury problem. Morbidity studies often rely on data captured by hospital inpatient admissions or emergency department data in a specific geographic locale. These types of studies can reveal injury patterns for a given location, depending upon type of tourist and popular tourist activities at the destination. A review of hospital records in Jamaica showed that injury was the main cause of hospitalization for international tourists, especially among tourists <40 years of age.18 Annually over 7 million tourists visit the Hawaiian Islands each year and surfing, scuba diving, ocean kayaking, parasailing, bicycle tours, and hiking lead to serious injuries requiring treatment at the state’s only trauma center.19 Based on their identification of groups at risk for injury, they were able to recommend specific research-based injury prevention initiatives, including improved warning signs on beaches and targeted education for both tourists and local residents.11 In contrast, reviewing visitor hospital admissions in New Zealand, tourist injuries were most frequently associated with skiing, mountaineering, and trekking.20 Morbidity studies can be useful to develop location-specific, community-based injury prevention recommendations.
A GLOBAL PUBLIC HEALTH APPROACH FOR TRAVEL MEDICINE The public health approach describes the problem, identifies risk factors, and helps to develop and evaluate research-based interventions. Research has demonstrated that injuries have three phases: the preevent, the event, and the postevent.15,21 The preevent phase describes behaviors leading up to the injury and relates to the development of primary prevention strategies; the event phase describes the actual injury incident and efforts to control the severity of the event once it has occurred; and the postevent phase focuses on describing the consequences following the event and controlling the damage.
CHAPTER 50 Injuries and Injury Prevention TABLE 50.1 General Injury Prevention
Recommendations for Travelers 1. 2.
3. 4. 5.
6.
7.
Review travel warnings and travel alerts of the destination. Learn about the common travel safety concerns, health risks, and travel health notices related to the destination as some locations are prone to certain natural disasters. Understand local laws and culture of the destination. Purchase international travel and medical evacuation insurance appropriate for the destination. Register the travel itinerary with the appropriate government agency or embassy to get assistance should an emergency situation arise or natural disaster occur. Governments cannot assist their citizens if they do not know their whereabouts. Develop an emergency response plan, know the name and location of the nearest major medical center and embassy, and know whether or not it is safe to receive blood products in their country/ies of destination. Consume alcohol responsibly and in moderation when in an unfamiliar environment. Alcohol should be avoided if one is operating a vehicle, boat, machinery, or supervising children around water. Alcoholic beverages should not be consumed if one is planning to be in or around the water.
(Adapted from Stewart BT, Yankson IK, Francis A, et al. Road traffic and other unintentional injuries among travelers to developing countries. Med Clin N Am 2016;100:331–43, and US State Department. Online. Available: www.travel.state.gov/travel/tips/safety/ ssafety_1179.htm.)
Increasingly, the effectiveness of injury prevention strategies requires travel medicine leadership to engage and partner in broader global efforts. The World Health Organization has begun to work with governmental and nongovernmental partners worldwide to raise the profile of the preventability of road traffic injuries and promote good practices related to helmet and seatbelt wearing, not drinking and driving, not speeding, and being visible in traffic.2,9,22 May 2011 marked the official launch of the Decade for Action for Road Safety (2011–2020).9,22 International travelers should know the address and phone number of their nearest embassy, and register their trip itinerary with that embassy.3 It is important for travelers to make their presence in the country and their specific whereabouts known in case of an emergency.3 Registration of travelers’ itineraries also helps to improve governments’ surveillance of injury events. It is also recommended that travelers purchase supplemental international travel insurance that includes ransom assistance and emergency evacuation for health care, natural disasters, or political unrest to adequately cover an urgent departure from their intended destinations.3 Travelers’ insurance will also help to bridge the gap should cultural and language barriers exist, provide ambulances or other means of patient transport, and provide support for a travel companion to assist if they need to be hospitalized for a long period of time (Table 50.1).3
ROAD TRAFFIC SAFETY The majority of road traffic crashes (90%) occur in low-income or middle-income countries, and the majority of road crash victims in developing countries are not the motor vehicle occupants, but pedestrians, motorcyclists, bicyclists, and other nonmotorized vehicle occupants.1,3,10,11,23 The number of pedestrians killed in traffic has increased in 10 countries.2 According to US Department of State data, road traffic crashes are also the leading cause of injury death to US citizens while traveling internationally and the leading cause of death to healthy US
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travelers.24 In Argentina, Sweden, New Zealand, the United States, and the United Kingdom pedestrian fatalities increased by more than 10%.2 The Australian tourism and transport authorities found that the rate of tourist deaths on Australian roads was double that for all Australians.3 While much progress has been made in making motor vehicles, roads, and drivers safer worldwide, there has been very little focus specifically on the risk to international travelers.2
Seatbelts and Child Safety Seats The advantage of road travel in high-income countries is that rental vehicles and public roads tend to be maintained at a reasonably safe standard according to government regulations. In countries with less familiar local customs governing driving, fewer resources to support road maintenance and infrastructure, and possibly fewer regulations governing road safety, a traveler may choose to be a passenger rather than a driver. In most cases, hiring a vehicle with a qualified driver is recommended as a safer way to travel than driving oneself.3 In many countries, seatbelts are not required to be fitted in motor vehicles, or may only be required in the front seats.3 Despite local laws, travelers should demand vehicles with the appropriate safety equipment for themselves and their companions, especially if traveling with young children. Appropriately sized child safety seats should be rented or brought with the tourist family.3
Helmets Because of the nonprotective nature of the vehicle, along with other factors such as speed and relative lack of visibility, motorcycle crash victims make up a high percentage of those killed or injured in road traffic crashes worldwide. Helmets have been shown to reduce the risk of head injury mortality in motorcycle riders who crash.25 Head injury also poses the greatest risk to bicyclists with seniors having the highest rates. Although many countries have decreased pedestrian and cyclist fatality rates, the United States has continued to have much higher fatality and serious injury rates.26 Because quality walking and cycling infrastructures are valued in northern European countries, mortality rates are lower.26 A global estimate for the number of travelers affected by bicycle-related injury is not known. What is known however is that bicycle helmets reduce the risk of head and brain injury for riders of all ages by 75%.27 Bike helmets have also been shown to reduce the number of facial injuries among riders by 65%.27 Travelers should pack or rent helmets with bicycle, moped, or motorcycle use. It should not be assumed that helmets will be available. Other evidence-based road traffic safety recommendations for travelers are summarized in Table 50.2.
WATER-RELATED INJURIES Drowning is a serious but mostly preventable injury problem, particularly among international travelers. For water recreation travel destinations, drowning has been cited as the most common cause of death among travelers.3 About 450,000 people drown worldwide each year.28 The exact number of travelers who drown or experience a near-drowning is not known.29 Drowning accounts for 14% of deaths of US citizens abroad.28 Many popular travel destinations are situated in warmer climates near oceans or lakes, or have elaborate pools and feature water-related activities such as surfing, scuba diving, snorkeling, boating, parasailing, and waterskiing. US citizens traveling to Central America, the Caribbean, Oceania, and Mexico have significantly higher proportions of death due to drowning than US residents.10 Drowning is consistently reported as a leading cause of injury death among tourists, while near-drowning or nonfatal submersion commonly
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TABLE 50.2 Road Traffic Safety
TABLE 50.3 Water Safety and Drowning
1.
1. Bring personal flotation devices (PFDs) along if you think they will not be available, especially for adult nonswimmers and children, and use them when in and around the water. Select a proper-sized and Coast Guard–approved PFD by looking at the label to ensure a safe and proper fit. Use PFDs when waterskiing or during towed activities, on personal watercraft, during whitewater boating or sail boarding, and on moving vessels of <26 ft. Children <13 years of age should use them at all times. Identify their location when on board a yacht or cruise ship. 2. Learn cardiopulmonary resuscitation (CPR) prior to departure. CPR is critical in improving the outcome should a near-drowning occur. 3. If traveling with children, inquire whether there is 4-ft climbproof isolation fencing around the pools and/or if there is a barrier between your place of lodging/hotel room and any body of water in which your child may drown. 4. Limit alcoholic consumption to one beverage, preferably none if planning to be in or around the water or on a boat. Alcohol and recreational drugs should be avoided when adults are supervising children around the water. 5. Swim in designated swimming areas, preferably that provide a trained and certified lifeguard. Never swim at night in unguarded areas; if you do, always swim with a “buddy.” The presence of lifeguards will improve the outcome should a near-drowning occur. 6. Learn about animal-related risks and other environmental risks in and near the water in your travel destination. Be aware of signs posting surf and weather conditions or other environmental risks that may be present in natural bodies of water. 7. When diving or participating in more strenuous water-related activity than normal, a reassessment of physical, mental, and medical fitness is recommended prior to travel, at regular intervals, and following an illness or injury.
Recommendations for Travelers
2. 3.
4.
5.
6.
7.
8.
9.
Wear a seatbelt no matter where one is seated in any vehicle. Parents need to bring appropriate car seats or communicate with the vehicle rental agency about availability. Avoid driving if possible and never in rural areas after dark. Look for a reputable company through the embassy, hotel concierge, or other reliable source that employs certified and trained drivers familiar with the driving culture, laws, and roads. Avoid driving at night and with drivers who may be under the influence of drugs or alcohol. Avoid alcohol and recreational drugs, fatigue, jet lag, and all-night driving especially in rural areas and learn local road signs, roads, driving customs, and laws. Check with the embassy in country of destination to understand the requirements for license, road permits, auto insurance, local road rules, driving culture, and road conditions. Rent a vehicle (with or without driver) equipped with seatbelts for all seats (rear and front), airbags, and the LATCH (lower anchors and tethers for children) system if traveling with small children who require child safety seats. Choose commonly available cars when renting (with or without driver), and request that any obvious rental car markings be removed. Travelers should request a map, directions, list of local traffic signs and laws pertaining to road travel, and a full familiarization of their rental vehicle from staff of the rental agency prior to their departure. Take time to inspect the tires, breaks, lights, airbags, and seatbelts. Carry a mobile phone and know how to initiate an emergency response in the travel destination should a crash occur. Do not talk on the phone while driving. Avoid riding on or driving a moped or motorbike while traveling. If travelers rent mopeds, motorbikes, or bicycles, then helmets should be worn by adults and children. Travelers may need to bring appropriately fitting helmets, especially for children, if they plan to rent bicycles or motorized vehicles. Be aware of possible car-jacking schemes and hotspots locally, and keep the doors of the vehicle locked at all times.
(Adapted from Stewart BT, Yankson IK, Francis A, et al. Road traffic and other unintentional injuries among travelers to developing countries. Med Clin N Am 2016;100:331–43, and US State Department. Online. Available: www.travel.state.gov/travel/tips/safety/ ssafety_1179.htm.)
appears as a cause of injury in nonfatal data.3 The risk factors have not been clearly defined, but are most likely related to unfamiliarity with local water currents and water conditions, as rip tides can be especially dangerous, as are sea animals such as urchins, box jellyfish, coral, and sea lice especially in Southeast Asian.3 Swimming in an unfamiliar environment can present difficulties for even the best swimmers, let alone tourists who may have no background, skills, or ability in the water. Primary and secondary prevention measures are extremely important for near-drowning and drowning. Supervision of children around the water deserves special attention. Select lodgings that do not allow direct access by your child to a body of water in which the child could potentially drown. The responsibility of supervising children around water should be delegated only to experienced adults who practice “touch supervision” with their full attention focused on the child, and who know cardiopulmonary resuscitation (CPR), how to initiate an emergency response plan, and have not and will not be consuming alcohol. Even children who may be considered excellent swimmers need supervision in and around water.30
Prevention Recommendations for Travelers30
(Adapted from Stewart BT, Yankson IK, Francis A, et al. Road traffic and other unintentional injuries among travelers to developing countries. Med Clin N Am 2016;100:331–43, and Baker TD, Hargarten SW, Guptill KS. The uncounted dead American civilians dying overseas. Public Health Rep 1992;107:155–9.)
Whether in a pool, open water, or on a boat, certain efforts can substantially lower the risk of drowning—that is, supervise children and use a personal flotation device.3 Table 50.3 has additional evidencebased recommendations for water safety.
ALCOHOL AS A RISK FACTOR Alcohol use during travel is one of the most serious risk factors for travel-related injury. Travelers tend to consume more alcohol while on vacation than in their home environments.24 Alcohol is a major risk factor for road traffic crashes, sexually transmitted infections, and injury in general.31,32 Alcohol also contributes to drowning and boating crashes and is thought to be involved in 30%–50% of adult and adolescent drownings.28 Physicians and travel medicine professionals should address alcohol as a risk factor for injury when advising their patients. It is highly recommended that travelers do not drink alcohol while driving motorized vehicles, driving or riding on motorcycles or motorbikes, operating or riding in a boat, swimming, and supervising children around water.3,31
CHAPTER 50 Injuries and Injury Prevention
CONCLUSION Trends in injuries and fatalities differ by age groups and environments. In almost all countries, there has been a reduction in the number of young people between 15 and 24 years killed in road crashes. But the number of fatalities among senior citizens aged 65 years and over increased in 16 of the 32 countries. In many countries seniors now represent the biggest proportion of pedestrian traffic fatalities.2 After the trip is complete, travelers and travel medicine professionals can still impact destinations through advocacy measures to improve safety standards.3 The World Tourism Organization and World Health Organization recommend that every country should develop a national policy on tourism safety to address and prevent injury to tourists.33 The Association for Safe International Road Travel provides free resources about the countries travelers plan to explore and advocates for safe road travel to decrease injury globally.34 Travel medicine practitioners, along with embassies, governmental agency health, tourism, and transportation partners, need to monitor the risk of injury according to geographic location to provide up-to-date, evidence-based pretravel advice. Injury prevention recommendations need to be communicated effectively to travelers along with other travel health–related advice, preferably prior to departure, by travel medicine professionals, health care providers, travel agents, or through government travel health advisories.
REFERENCES 1. McInnes RJ, Williamson LM, Morrison A. Unintentional injury during foreign travel: a review. J Travel Med 2002;9:297–307. 2. Organisation for Economic Cooperation and Development. International Transport Forum, International Traffic Safety, Data and Analysis Division. Road Safety Annual Report. 2016. 2017 Feb 7. Available at http://dx.doi .org/10.1787/irtad-2016-en. 3. Stewart BT, Yankson IK, Francis A, et al. Road traffic and other unintentional injuries among travelers to developing countries. Med Clin N Am 2016;100:331–43. 4. Tonellato D, Guse C, Hargarten S. Injury deaths of US citizens abroad: new data source, old travel problem. J Trav Med 2009;16:304–10. 5. Paixao ML, Dewar RD, Cossar JH, et al. What do Scots die of when abroad? Scott Med J 1991;36:114–16. 6. MacPherson DW, Guerillot F, Streiner DL, et al. Death and dying abroad: the Canadian experience. J Travel Med 2000;7:227–33. 7. Petridou E, Gatsoulis N, Dessypris N, et al. Imbalance of demand and supply for regionalized injury services: a case study in Greece. Int J Qual Health Care 2000;12:105–13. 8. Grossman DC. The history of injury control and the epidemiology of child and adolescent injuries. Future Child 2000;10:23–52. 9. World Health Organization. Global status report on road safety. Switzerland: Geneva; 2015. 10. Guse CE, Cortés LM, Hargarten SW, et al. Fatal injuries of US citizens abroad. J Travel Med 2007;14:279–87. 11. US Department of State. Non-natural Deaths of US Citizens Abroad. 2017 Feb 15. Available at https://travel.state.gov/content/travel/en/ statistics/deaths.html. 12. Redman CA, MacLennan A, Walker E. Causes of death abroad: analysis of data on bodies returned for cremation to Scotland. J Travel Med 2011; 18(2):96–101.
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13. Lunetta P. Injury deaths among Finnish residents travelling abroad. International Journal of Injury Control and Safety Promotion 2010;17(3):161–8. 14. Wang D. The safety of Chinese citizens abroad: a quantitative interpretation of the special notices for Chinese citizens abroad 2008-2010. J Curr Chin Aff 2013;1:167–98. 15. Pawun V, Visrutaratna S, Ungchusak K, et al. Mortality among foreign nations in Chiang Mai City, Thailand, 2010 to 2011. J Travel Med 2012;19(6):344–51. 16. McInnes RJ, Williamson LM, Morrison A. Unintentional injury during foreign travel: a review. J Travel Med 2002;9:297–307. 17. US Department of State. Smart Traveler Enrollment Program. 2017 Feb 15. Available at https://step.state.gov/step/. 18. Thompson DC, Ashley DV, Dockery-Brown CA, et al. Incidence of health crises in tourists visiting Jamaica, West Indies, 1998 to 2000. J Travel Med 2003;10:79–86. 19. Ho HC, Speck CS, Kumasaki J. Visitor injuries in Hawai’i. Hawaii Med J 2009;68(11):279–83. 20. Bentley T, Meyer D, Page S, et al. Recreational tourism injuries among visitors to New Zealand: an exploratory analysis using hospital discharge data. Tour Manag 2001;22:373. 21. Wilson MH, Baker SP, Teret SP, et al. Saving children. A guide to injury prevention. Oxford University Press; 1991. p. 81. 22. World Health Organization. Saving Millions of Lives. 2011. 2017 Feb 15. Available at http://www.who.int/roadsafety/decade_of_action. 23. Peden M. Global collaboration on road traffic injury prevention. Int J Inj Contr Saf Promot 2005;12:85–91. 24. US Department of State. Death of U.S. Citizens Abroad by Non-natural Causes. Washington, DC; 2016. 2017 Feb 15. Available at http://travel .state.gov/law/family_issues/death/death_600.html. 25. Lui B, Ivers R, Norton R, et al. Helmets for preventing injury in motorcycle riders. Cochrane Database Syst Rev 2004;(2):CD004333. 26. Buehler R, Pucher J. Trends in walking and cycling safety: recent evidence from high-income countries, with a focus on the United States and Germany. Am J Public Health 2017;107:281–7. 27. Thompson DC, Rivara FP, Thompson R. Helmets for preventing head and facial injuries in bicyclists. Cochrane Database Syst Rev 2000;(2):CD001855. 28. CDC. The yellow book, health information for international travel. Oxford University Press; 2018. 29. Peden M, Mc Gee K, Sharma G. The injury chart book: A graphical overview of the global burden of injuries. World Health Organization; 2002. 30. Brenner RA. Committee on Injury and Violence and Poison Prevention. Prevention of drowning in infants, children and adolescents. Pediatrics 2003;112:440–5. Available at: http://www.pediatrics.org/cgi/content/ full/112/440. 2017 Feb 17l. 31. Heng K, Hargarten S, Layde P, et al. Moderate alcohol intake and motor vehicle crashes: the conflict between health advantage and at-risk use. J Alcohol 2006;41(4):451–4. 32. Crawford G, Lobo R, Brown G, et al. HIV, other blood-borne viruses and sexually transmitted infections amongst expatriates and travellers to low- and middle-income countries: a systematic review. Int J Environ Res Public Health 2016;13:1249. 33. World Health Organization. Pedestrian safety: a road safety manual for decision-makers and practitioners. 2013. 2017 Feb 17. Available at http://www.who.int/roadsafety/projects/manuals/pedestrian/en. 34. Association for Safe International Road Travel. Country-specific reports. 2017 Feb 17. Available at http://www.asirt.org/CountryReports.
KEY POINTS • Injuries are a more significant cause of travel-related mortality and morbidity than infectious diseases. • Road traffic crashes are the leading causes of injury mortality and can be prevented by traveling in safe vehicles with seat belts, driven by a qualified driver. Motorcycles and bicycles should be avoided as well as rural travel by road in any vehicle after dark in low-resource countries. Pedestrians are highly vulnerable in unfamiliar environments. • Death by drowning can be avoided by use of personal flotation devices, abstention from alcohol during water-related activities,
and close supervision of children. Fences and safety barriers are often absent overseas. • Data deficiencies and discrepancies in the manner of reporting cause of death have made it challenging to create a profile of injury risk based upon type of tourist, nationality, destination, and travel activity. Better data on injury mortality of travelers (and all causes of mortality) should be maintained, and reviewed by respective embassies and governmental organizations.
INTRODUCTION
tsunamis and earthquakes, airplane crashes, extreme environmental exposures, and animal or marine life bites and stings.2–4 Road traffic crashes have plateaued since 2007 suggesting that recent interventions to improve road safety are effective in addressing mortality.9 Since 2014 five countries have achieved fatality rates of three or less deaths per 100,000 inhabitants: Iceland, Norway, Sweden, Switzerland, and the United Kingdom.2 Conversely, low-income countries have double the fatality rates compared to those in high-income countries.9 Specifically, 90% of road traffic deaths occur in low-income and middle-income countries, yet these countries have just 54% of the globe’s vehicles.9 Nearly half of those dying on the world’s roads are vulnerable road users: pedestrians, cyclists, and motorcyclists.9 In addition to the grief and physical suffering they cause, road traffic crashes result in considerable economic losses to victims, their families, and nations as a whole, costing most countries 1%–3% of their gross national product.9 The Decade of Action for Road Safety (2011–2020) calls on countries to implement the measures identified internationally to make their roads safer. The new target of the United Nations Sustainable Development Goals is to reduce the global number of deaths and injuries from road traffic crashes by 50% by the year 2020.9 The precise number of deaths and proportion of injury deaths of travelers worldwide is not known. Injuries to US citizens traveling internationally occur at a higher proportion than to citizens residing in the United States.4 Injury is also reported to be the cause of deaths among visitors to the United States.10 Figs. 50.1 and 50.2 illustrate mortality data captured by the United States, showing types of injuries and top causes of death for their traveling citizens.11 A review of deaths of Scottish travelers showed trauma and other noninfectious causes being the two most common.12 A study of Finnish travelers identified cardiovascular diseases as the top cause of death.13 Injury deaths occur most commonly in low-income to middle-income America followed by Europe and Eastern Mediterranean countries.3,14
Injuries are one of the leading causes of travel-related mortality worldwide, accounting for up to 25 times more deaths than infectious disease.1 Annually, over 1 million people are killed in car crashes worldwide and several million more are injured during these events.2 Researchers worldwide have reported that noninfectious causes of travel-related deaths, especially injury, pose a serious health risk to travelers.2–6 Injuries to tourists are also a significant burden to hospitals and health care systems—at the tourist destination, during transport, and in terms of continuing care when the patient returns home.7 Tourists tend to be more at risk for an injury because they frequently find themselves in unfamiliar environments and participating in unfamiliar activities.1 Travel to low-resource countries can pose different hazards and outcomes after road traffic crashes or other unintentional injuries and are sometimes more severe with worse outcomes due to limitations in emergency medical systems and health facility resources.3 Injuries are predictable and preventable.3,4,8 It is important for health care providers, travel medicine specialists, tourism professionals, and government agencies issuing travel health advisories to create and communicate evidence-based injury prevention messages tailored for all categories of travelers, travel activities, and travel destinations. This chapter reviews the types of fatal and nonfatal injuries most frequently experienced by travelers, and provides evidence-based prevention and control recommendations.
FATAL INJURY Injury is a leading cause of travel-related mortality worldwide. Most mortality studies report that travelers most frequently die in road traffic crashes and drownings.2 Other causes of travel-related injury death, though less common, include violent events, natural disasters such as
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CHAPTER 50 Injuries and Injury Prevention Abstract
Keywords
Road traffic crashes are the leading causes of injury mortality for travelers. Injuries are a more significant cause of travel-related mortality and morbidity than infectious diseases. Injuries are predictable and preventable. This chapter outlines the injuries that travelers experience and provides injury prevention recommendations for safe travel. This chapter also reviews the types of fatal and nonfatal injuries most frequently experienced by travelers, and provides evidence-based prevention and control recommendations. Specifically, recommendations for road traffic and water safety are outlined. Better data on injury mortality of travelers and all causes of mortality would further strengthen injury prevention recommendations.
Alcohol risk Injury Injury prevention Nonfatal injuries Prevention recommendations Road traffic safety Safety Travel Water-related injuries
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0
Cause of Death
FIG. 50.1 Specific injury-related deaths of US citizens traveling internationally, October 2002–December 2016. (US Department of State. Non-natural Deaths of US Citizens Abroad. 2017 Feb 15. Available at https:// travel.state.gov/content/travel/en/statistics/deaths.html.)
traveler’s embassy or consulate in-country is the first action item. Travelers should review their country’s guidance in preparation for travel.
3% 13% 27%
Vehicle accident Other accident Homicide
19%
Drowning Terrorist action 27%
FIG. 50.2 The top five causes of death for US citizens traveling internationally, October 2002–December 2016. (US Department of State. Non-natural Deaths of US Citizens Abroad. 2017 Feb 15. Available at https://travel.state.gov/content/travel/en/statistics/deaths.html.)
In each of these regions, US citizens have a greater proportion of injury mortality compared to host county nationals.21 Deaths of European travelers to areas of Thailand have shown natural causes were highest.13,15 Overwhelmingly, young males tend to be at greater risk for an injury leading to death during travel.16 The difficulty in counting and categorizing the causes of death among international travelers has been highlighted by the 2004 tsunami disaster in the Indian Ocean, 2010 Haitian earthquake, 2011 Japanese earthquake and tsunami, the 2015 Nepal earthquakes, and the 2015 and 2016 terrorist attacks in France. The precise mortality count for both locals and travelers from these events may never be known. Each government had a different way to count their citizens’ deaths. Apart from obtaining a visa, travelers tend not to register their trip itinerary with their appropriate home government agency. To be accounted for in the event of disaster, travelers may register their travel dates and locations with their own governmental agencies like the Smart Traveler Enrollment Program provided by the US Department of State.17 In the event of a fatality, contacting the
NONFATAL INJURIES Studies focusing on nonfatal health incidents are also important to gain a more complete understanding of the larger travel injury problem. Morbidity studies often rely on data captured by hospital inpatient admissions or emergency department data in a specific geographic locale. These types of studies can reveal injury patterns for a given location, depending upon type of tourist and popular tourist activities at the destination. A review of hospital records in Jamaica showed that injury was the main cause of hospitalization for international tourists, especially among tourists <40 years of age.18 Annually over 7 million tourists visit the Hawaiian Islands each year and surfing, scuba diving, ocean kayaking, parasailing, bicycle tours, and hiking lead to serious injuries requiring treatment at the state’s only trauma center.19 Based on their identification of groups at risk for injury, they were able to recommend specific research-based injury prevention initiatives, including improved warning signs on beaches and targeted education for both tourists and local residents.11 In contrast, reviewing visitor hospital admissions in New Zealand, tourist injuries were most frequently associated with skiing, mountaineering, and trekking.20 Morbidity studies can be useful to develop location-specific, community-based injury prevention recommendations.
A GLOBAL PUBLIC HEALTH APPROACH FOR TRAVEL MEDICINE The public health approach describes the problem, identifies risk factors, and helps to develop and evaluate research-based interventions. Research has demonstrated that injuries have three phases: the preevent, the event, and the postevent.15,21 The preevent phase describes behaviors leading up to the injury and relates to the development of primary prevention strategies; the event phase describes the actual injury incident and efforts to control the severity of the event once it has occurred; and the postevent phase focuses on describing the consequences following the event and controlling the damage.
CHAPTER 50 Injuries and Injury Prevention TABLE 50.1 General Injury Prevention
Recommendations for Travelers 1. 2.
3. 4. 5.
6.
7.
Review travel warnings and travel alerts of the destination. Learn about the common travel safety concerns, health risks, and travel health notices related to the destination as some locations are prone to certain natural disasters. Understand local laws and culture of the destination. Purchase international travel and medical evacuation insurance appropriate for the destination. Register the travel itinerary with the appropriate government agency or embassy to get assistance should an emergency situation arise or natural disaster occur. Governments cannot assist their citizens if they do not know their whereabouts. Develop an emergency response plan, know the name and location of the nearest major medical center and embassy, and know whether or not it is safe to receive blood products in their country/ies of destination. Consume alcohol responsibly and in moderation when in an unfamiliar environment. Alcohol should be avoided if one is operating a vehicle, boat, machinery, or supervising children around water. Alcoholic beverages should not be consumed if one is planning to be in or around the water.
(Adapted from Stewart BT, Yankson IK, Francis A, et al. Road traffic and other unintentional injuries among travelers to developing countries. Med Clin N Am 2016;100:331–43, and US State Department. Online. Available: www.travel.state.gov/travel/tips/safety/ ssafety_1179.htm.)
Increasingly, the effectiveness of injury prevention strategies requires travel medicine leadership to engage and partner in broader global efforts. The World Health Organization has begun to work with governmental and nongovernmental partners worldwide to raise the profile of the preventability of road traffic injuries and promote good practices related to helmet and seatbelt wearing, not drinking and driving, not speeding, and being visible in traffic.2,9,22 May 2011 marked the official launch of the Decade for Action for Road Safety (2011–2020).9,22 International travelers should know the address and phone number of their nearest embassy, and register their trip itinerary with that embassy.3 It is important for travelers to make their presence in the country and their specific whereabouts known in case of an emergency.3 Registration of travelers’ itineraries also helps to improve governments’ surveillance of injury events. It is also recommended that travelers purchase supplemental international travel insurance that includes ransom assistance and emergency evacuation for health care, natural disasters, or political unrest to adequately cover an urgent departure from their intended destinations.3 Travelers’ insurance will also help to bridge the gap should cultural and language barriers exist, provide ambulances or other means of patient transport, and provide support for a travel companion to assist if they need to be hospitalized for a long period of time (Table 50.1).3
ROAD TRAFFIC SAFETY The majority of road traffic crashes (90%) occur in low-income or middle-income countries, and the majority of road crash victims in developing countries are not the motor vehicle occupants, but pedestrians, motorcyclists, bicyclists, and other nonmotorized vehicle occupants.1,3,10,11,23 The number of pedestrians killed in traffic has increased in 10 countries.2 According to US Department of State data, road traffic crashes are also the leading cause of injury death to US citizens while traveling internationally and the leading cause of death to healthy US
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travelers.24 In Argentina, Sweden, New Zealand, the United States, and the United Kingdom pedestrian fatalities increased by more than 10%.2 The Australian tourism and transport authorities found that the rate of tourist deaths on Australian roads was double that for all Australians.3 While much progress has been made in making motor vehicles, roads, and drivers safer worldwide, there has been very little focus specifically on the risk to international travelers.2
Seatbelts and Child Safety Seats The advantage of road travel in high-income countries is that rental vehicles and public roads tend to be maintained at a reasonably safe standard according to government regulations. In countries with less familiar local customs governing driving, fewer resources to support road maintenance and infrastructure, and possibly fewer regulations governing road safety, a traveler may choose to be a passenger rather than a driver. In most cases, hiring a vehicle with a qualified driver is recommended as a safer way to travel than driving oneself.3 In many countries, seatbelts are not required to be fitted in motor vehicles, or may only be required in the front seats.3 Despite local laws, travelers should demand vehicles with the appropriate safety equipment for themselves and their companions, especially if traveling with young children. Appropriately sized child safety seats should be rented or brought with the tourist family.3
Helmets Because of the nonprotective nature of the vehicle, along with other factors such as speed and relative lack of visibility, motorcycle crash victims make up a high percentage of those killed or injured in road traffic crashes worldwide. Helmets have been shown to reduce the risk of head injury mortality in motorcycle riders who crash.25 Head injury also poses the greatest risk to bicyclists with seniors having the highest rates. Although many countries have decreased pedestrian and cyclist fatality rates, the United States has continued to have much higher fatality and serious injury rates.26 Because quality walking and cycling infrastructures are valued in northern European countries, mortality rates are lower.26 A global estimate for the number of travelers affected by bicycle-related injury is not known. What is known however is that bicycle helmets reduce the risk of head and brain injury for riders of all ages by 75%.27 Bike helmets have also been shown to reduce the number of facial injuries among riders by 65%.27 Travelers should pack or rent helmets with bicycle, moped, or motorcycle use. It should not be assumed that helmets will be available. Other evidence-based road traffic safety recommendations for travelers are summarized in Table 50.2.
WATER-RELATED INJURIES Drowning is a serious but mostly preventable injury problem, particularly among international travelers. For water recreation travel destinations, drowning has been cited as the most common cause of death among travelers.3 About 450,000 people drown worldwide each year.28 The exact number of travelers who drown or experience a near-drowning is not known.29 Drowning accounts for 14% of deaths of US citizens abroad.28 Many popular travel destinations are situated in warmer climates near oceans or lakes, or have elaborate pools and feature water-related activities such as surfing, scuba diving, snorkeling, boating, parasailing, and waterskiing. US citizens traveling to Central America, the Caribbean, Oceania, and Mexico have significantly higher proportions of death due to drowning than US residents.10 Drowning is consistently reported as a leading cause of injury death among tourists, while near-drowning or nonfatal submersion commonly
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SECTION 9 Health Problems While Traveling
TABLE 50.2 Road Traffic Safety
TABLE 50.3 Water Safety and Drowning
1.
1. Bring personal flotation devices (PFDs) along if you think they will not be available, especially for adult nonswimmers and children, and use them when in and around the water. Select a proper-sized and Coast Guard–approved PFD by looking at the label to ensure a safe and proper fit. Use PFDs when waterskiing or during towed activities, on personal watercraft, during whitewater boating or sail boarding, and on moving vessels of <26 ft. Children <13 years of age should use them at all times. Identify their location when on board a yacht or cruise ship. 2. Learn cardiopulmonary resuscitation (CPR) prior to departure. CPR is critical in improving the outcome should a near-drowning occur. 3. If traveling with children, inquire whether there is 4-ft climbproof isolation fencing around the pools and/or if there is a barrier between your place of lodging/hotel room and any body of water in which your child may drown. 4. Limit alcoholic consumption to one beverage, preferably none if planning to be in or around the water or on a boat. Alcohol and recreational drugs should be avoided when adults are supervising children around the water. 5. Swim in designated swimming areas, preferably that provide a trained and certified lifeguard. Never swim at night in unguarded areas; if you do, always swim with a “buddy.” The presence of lifeguards will improve the outcome should a near-drowning occur. 6. Learn about animal-related risks and other environmental risks in and near the water in your travel destination. Be aware of signs posting surf and weather conditions or other environmental risks that may be present in natural bodies of water. 7. When diving or participating in more strenuous water-related activity than normal, a reassessment of physical, mental, and medical fitness is recommended prior to travel, at regular intervals, and following an illness or injury.
Recommendations for Travelers
2. 3.
4.
5.
6.
7.
8.
9.
Wear a seatbelt no matter where one is seated in any vehicle. Parents need to bring appropriate car seats or communicate with the vehicle rental agency about availability. Avoid driving if possible and never in rural areas after dark. Look for a reputable company through the embassy, hotel concierge, or other reliable source that employs certified and trained drivers familiar with the driving culture, laws, and roads. Avoid driving at night and with drivers who may be under the influence of drugs or alcohol. Avoid alcohol and recreational drugs, fatigue, jet lag, and all-night driving especially in rural areas and learn local road signs, roads, driving customs, and laws. Check with the embassy in country of destination to understand the requirements for license, road permits, auto insurance, local road rules, driving culture, and road conditions. Rent a vehicle (with or without driver) equipped with seatbelts for all seats (rear and front), airbags, and the LATCH (lower anchors and tethers for children) system if traveling with small children who require child safety seats. Choose commonly available cars when renting (with or without driver), and request that any obvious rental car markings be removed. Travelers should request a map, directions, list of local traffic signs and laws pertaining to road travel, and a full familiarization of their rental vehicle from staff of the rental agency prior to their departure. Take time to inspect the tires, breaks, lights, airbags, and seatbelts. Carry a mobile phone and know how to initiate an emergency response in the travel destination should a crash occur. Do not talk on the phone while driving. Avoid riding on or driving a moped or motorbike while traveling. If travelers rent mopeds, motorbikes, or bicycles, then helmets should be worn by adults and children. Travelers may need to bring appropriately fitting helmets, especially for children, if they plan to rent bicycles or motorized vehicles. Be aware of possible car-jacking schemes and hotspots locally, and keep the doors of the vehicle locked at all times.
(Adapted from Stewart BT, Yankson IK, Francis A, et al. Road traffic and other unintentional injuries among travelers to developing countries. Med Clin N Am 2016;100:331–43, and US State Department. Online. Available: www.travel.state.gov/travel/tips/safety/ ssafety_1179.htm.)
appears as a cause of injury in nonfatal data.3 The risk factors have not been clearly defined, but are most likely related to unfamiliarity with local water currents and water conditions, as rip tides can be especially dangerous, as are sea animals such as urchins, box jellyfish, coral, and sea lice especially in Southeast Asian.3 Swimming in an unfamiliar environment can present difficulties for even the best swimmers, let alone tourists who may have no background, skills, or ability in the water. Primary and secondary prevention measures are extremely important for near-drowning and drowning. Supervision of children around the water deserves special attention. Select lodgings that do not allow direct access by your child to a body of water in which the child could potentially drown. The responsibility of supervising children around water should be delegated only to experienced adults who practice “touch supervision” with their full attention focused on the child, and who know cardiopulmonary resuscitation (CPR), how to initiate an emergency response plan, and have not and will not be consuming alcohol. Even children who may be considered excellent swimmers need supervision in and around water.30
Prevention Recommendations for Travelers30
(Adapted from Stewart BT, Yankson IK, Francis A, et al. Road traffic and other unintentional injuries among travelers to developing countries. Med Clin N Am 2016;100:331–43, and Baker TD, Hargarten SW, Guptill KS. The uncounted dead American civilians dying overseas. Public Health Rep 1992;107:155–9.)
Whether in a pool, open water, or on a boat, certain efforts can substantially lower the risk of drowning—that is, supervise children and use a personal flotation device.3 Table 50.3 has additional evidencebased recommendations for water safety.
ALCOHOL AS A RISK FACTOR Alcohol use during travel is one of the most serious risk factors for travel-related injury. Travelers tend to consume more alcohol while on vacation than in their home environments.24 Alcohol is a major risk factor for road traffic crashes, sexually transmitted infections, and injury in general.31,32 Alcohol also contributes to drowning and boating crashes and is thought to be involved in 30%–50% of adult and adolescent drownings.28 Physicians and travel medicine professionals should address alcohol as a risk factor for injury when advising their patients. It is highly recommended that travelers do not drink alcohol while driving motorized vehicles, driving or riding on motorcycles or motorbikes, operating or riding in a boat, swimming, and supervising children around water.3,31
CHAPTER 50 Injuries and Injury Prevention
CONCLUSION Trends in injuries and fatalities differ by age groups and environments. In almost all countries, there has been a reduction in the number of young people between 15 and 24 years killed in road crashes. But the number of fatalities among senior citizens aged 65 years and over increased in 16 of the 32 countries. In many countries seniors now represent the biggest proportion of pedestrian traffic fatalities.2 After the trip is complete, travelers and travel medicine professionals can still impact destinations through advocacy measures to improve safety standards.3 The World Tourism Organization and World Health Organization recommend that every country should develop a national policy on tourism safety to address and prevent injury to tourists.33 The Association for Safe International Road Travel provides free resources about the countries travelers plan to explore and advocates for safe road travel to decrease injury globally.34 Travel medicine practitioners, along with embassies, governmental agency health, tourism, and transportation partners, need to monitor the risk of injury according to geographic location to provide up-to-date, evidence-based pretravel advice. Injury prevention recommendations need to be communicated effectively to travelers along with other travel health–related advice, preferably prior to departure, by travel medicine professionals, health care providers, travel agents, or through government travel health advisories.
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