Overseas fatalities of United States citizen travelers: An analysis of deaths related to international travel

ORIGINAL CONTRIBUTION overseas travel, fatalities

Overseas Fatalities of United S t a t e s Citizen Travelers: An Analysis of Deaths Related to International Travel Study objective: Studies of travel-related mortality and morbidity have been limited to nonfatal events. Causes of travel-related mortality may differ significantly from mortffdity and thus have different prevention strategies. Design: We examined the overseas fatalities of US citizen travelers for the years 1975 and 1984. The death certificates were abstracted; all deaths under age 60 and a 20% sample of deaths 60 and older were examined. Setting and type of participants: All overseas travel fatalities of US citizens were examined excluding those occurring in Canada. Interventions: None. Results: Cardiovascular events (including myocardial infarctions and cerebrovascular accidents) and injuries accounted for 49% and 25% of the overseas deaths of US citizen travelers, respectively. Infectious diseases other than pneumonia accounted for only 1% of the deaths. Eighty percent of injury deaths occurred outside of hospitals. Injury death rates for male travelers were greater than US age-specific death rates. Conclusions: Greater emphasis on the prevention of fatal events, especially those resulting from injury, must be given by physicians and other individuals and organizations who advise travelers. Further studies are needed to explore the issues of preventable injury deaths, emergency medical services, and overseas travel. [Hargarten SW, Baker TD, GuptilI K: Overseas fatalities of United States citizen travelers: A n analysis of deaths related to international travel. Ann Emerg Med June 1991;20: 622-626.] INTRODUCTION More than 30 million US citizens travel outside the United States each year. I Knowledge of the mortality and morbidity experience of travelers has been limited to describing nonfatal events, g-6 Traditionally, health advice to travelers has primarily emphasized the prevention of infectious disease. 7-1s Mortality patterns of travelers may be quite different from nonfatal events. No studies have examined the mortality experience of US travelers. Hargarten and Baker studied the deaths of Peace Corps volunteers and noted that 70% of the deaths were due to unintentional injury. 16 Accurate knowledge of mortality patterns is essential for physicians and other individuals and organizations who provide travel advice. We investigated a previously unpublished data set of overseas deaths of US citizens to describe the mortality pattern and to determine whether current travel advice is meeting the needs of US travelers.

Stephen W Hargarten, MD, MPH* Milwaukee, Wisconsin Timothy D Baker, MD, MPHIBaltimore, Maryland Katharine Guptill, ScD¢ Berkeley, California From the Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee;* Department of International Health, Johns Hopkins School of Public Health, Baltimore, Maryland;t and College of Natural Resources, Department of Nutritional Science, University of California, Berkeley.¢ Received for publication April 25, 1990. Revision received November 5, 1990. Accepted for publication January 17, 1991. Presented at the First World Travel Medicine Conference in Zurich, Switzerland, April 1988. Supported in part by St Luke's Foundation and St Luke's Medical-Dental Foundation. Address for reprints: Stephen W Hargarten, MD, MPH, Medical College of Wisconsin, Department of Emergency Medicine, 8700 West Wisconsin Avenue, Box 204, Milwaukee, Wisconsin 53226.

MATERIALS A N D METHODS Overseas deaths of US citizens are not recorded or analyzed by the National Center of Health Statistics (personal communication, US Passport Office, Washington, DC). Overseas deaths are reported to the US Passport Office by the consular representatives of the United States or their designated representatives worldwide. The consuls are notified by the local authorities in the event of the death of an individual who carries a US passport. The consuls send the death certificates to the US passport office of the Department of State where the noncomputerized death registers have been maintained.

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TRAVELER FATALITIES Hargarten, Baker & Guptill

FIGURE 1. Overseas travel death of Americans by age and percentage distribution.

30

FIGURE 2. Cause of death in travelers. 20

Military personnel and civilians working on military bases were not included in this analysis. Deaths are not usually reported through the US Consul in Canada and were not analyzed in this study. We examined two years of data. We selected the first year that was available in the US passport office, 1975, and the last year that was complete and available when we initiated the study, 1984. We analyzed all deaths of persons less than 60 years old. Because of the large numbers of deaths in persons more than 60 years old, we s y s t e m a t i c a l l y sampled every fifth case, resulting in a 20% sampling of all deaths of persons more than 60 years old. Data collected from the death certificates were cause of death, country of death, age at death, sex, whether death was medically certified, and whether the death occurred within a hospital. An individual with a permanent address listed on the death certificate was considered a resident; all others were classified as travelers. The ninth revision of the International Classification of Disease was the basis for coding of deaths. 17 To obtain adequate numbers for analysis, we combined the codes for the categories of cardiovascular (included myocardial infarction, cerebrovascular accidents), neoplastic injuries (unintentional and intentional), infections (other than pneumonia and bronchopneumonias), medical (included pneumonias), and ill-defined causes (included "senility" and "natural causes"). The quality of reporting varied considerably; however, the majority of reports were sufficiently detailed to permit coding. Variability of reporting among US embassies was not studied. Results of t h e a n a l y s i s w e r e grouped for the two years because there were no systematic differences noted. In determining the injury and cardiovascular death rates, denominator data on the estimated US tourist population were taken from the World T o u r i s m O r g a n i z a t i o n (WTO). 18 Annual exposure of US 20:6:June1991

%

10

0

<15

15-24

25-34

35-44 45-54 Age Groups (yr)

55-64

65-74

> 75

Cardiovascular Disease

49,0%

Injury (Unintentional)

22.0%

Infectious Disease

1.0%

Others/Unknown

5.5%

Cancer

5.9%

Suicide/Homicide

2.9%

Medical

13.7%

TABLE 1. Distribution of US citizen travel deaths and destination

Region

Western Europe Central American(includesMexico) Caribbean Asia Middle East South America Eastern Europe Australia (includesNew Zealandand South Pacific) Africa Total

No. of Deaths

Distribution of Traveler Deaths (%)

Distributionof Travel Destinations (%)

1,184 463 270 194 157 77 63 36 19 2,463

48 19 11 8 6 3 2.5 1.5 1 100

62 12 6 9 5 2 1.5 1.5 1 100

Data represent averages of study years.

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Avoidance of motorcycles and small, less protective vehicles,when possible;use of largervehicles in preferenceto smaller vehicles and avoidance of riding in the back of open trucks Use of seat belts, whereavailable,including in taxicabs Use of helmets, where available, when using motorcycles and bicycles Avoidance of small, nonscheduledaircraft Careful selectionof swimming areasand avoidance of alcohol while swimming Avoidance of travel or driving at night Encouragementof travel in groups or pairs

350 300 250

NO.

of Deaths of Males per 100,000

200 150 100 50

*Adaptedwith permission.16 0 25-34

35-44

45-54

55-64

65+

Age Groups (yr) •

Less-Developed Countries

[ ] Developed Countries

TABLE 2. Injury deaths of US citizens

for 1975 and 1984 Cause of Deaths

No. of Deaths

% of Total

Motor vehicle crash Drowning Airplane crash Homicide Poisoning* Suicide Burns Electrocution Others Total

163 96 43 52 39 20 21 3 164 601

26.8 16.1 7.2 8.6 6.5 3.4 3.6 0.5 27.4 100.0

*The category of poisoning includes unJnlenlionalacute alcohol intoxication, drug overdose, and carbon dioxide intoxication.

travelers was estimated from total nights in hotels and other lodgings and by estimated nights stayed per traveler. T h e s e were c o n v e r t e d to person years exposure. We were unable to estimate the number of nights travelers spent in private dwellings. Because of the length and permeability of the US-Mexican border, we were unable to obtain reliable estimates of the number of travelers who visit Mexico each year. Thus, Mexico was excluded from all death rate calculations, as was Canada. Mexico traveler deaths have been analyzed separately. 19 Men were used in all death rate calculations because there were adequate numbers of deaths in each age group; these rates were c o m p a r e d 46/624

4

with male death rates in the United States for 1982. (Only e s t i m a t e d crude male traveler death rates are presented.) Data from the World Bank for 1983 were used to define developed and less-developed countries. 20 We defined "less developed" as countries with a per capita gross national product of $2,000 or less and a male life expectancy of 65 years or less. RESULTS

T h e r e were 2,463 deaths of US male and female travelers in 1975 and 1984. Travelers more than 55 years old constituted 65% of all deaths (Figure 1). Only 2% of the decedents were less than 15 years old. Male travelers accounted for 70% of the deaths. C a r d i o v a s c u l a r disease was the leading cause of death (49%) in male and female travelers, followed by intentional and unintentional injuries (25%). Infectious disease was the cause of death in only 25 cases (1%) (Figure 2). The distributions of travel of US citizens and travel deaths are shown by region for the study period (Table 1). Mexico had the greatest number of US traveler deaths during the study period, accounting for 16% of the total deaths (396), followed by Germany (9%), Great Britain (7%), Spain (6%), I t a l y (6%), B a h a m a s (5%), France (3.5%), Switzerland (2.5%), Greece (2%), and Bermuda (1.5%). These ten countries accounted for Annals of Emergency Medicine

FIGURE 3. Injury mortality rates of US citizens. FIGURE 4. Injury prevention strategies. 58.5% of US traveler deaths (1,446). Central America, including Mexico and the Caribbean, accounted for an estimated 18% of US citizens traveling, yet accounted for 30% of the travel deaths. Fifty-nine percent of the travelers (1,453) died outside of hospitals, including 80% of the injury deaths and 73% of the cardiovascular deaths. S e v e n t y - s e v e n p e r c e n t of t h e deaths (1,893) were medically certified; 18% (445) were certified by civil authorities, and 5% (125) were not certified. There were 601 deaths due to injuries in the study period. Motor vehicle crashes were the most common cause of injury deaths (26.8%), followed by drownings (16.1%) (Table 2). Homicides accounted for 52 deaths, and suicides accounted for 20 deaths. Deaths of US travelers from "other" injuries included those from animal mauling (shark, alligator, and elephant) and falls from heights (mountains and buildings). Infectious disease accounted for 1% of the deaths (25) of US travelers. Malaria, typhoid, and h e p a t i t i s B each accounted for one death during the study years. Selected cause and age-specific death rates for m a l e travelers are s h o w n (Table 3). C a r d i o v a S c u l a r death rates are lower than US death rates for those more than 44 years 01d. Injury death rates for male travelers are consistently higher than US rates. 20:6 June 1991

TRAVELER FATALITIES Hargarten, B a k e r & Guptill

Male injury death rates were consistently higher in all age groups in less-developed countries than in developed countries (Figure 3).

DISCUSSION This is the first study describing the death patterns of US citizens traveling outside the United States. The overall distribution of deaths differs from that of US residents who die within the United States. Death due to injuries ranks fourth in the United States, 21 yet injuries are the second most common cause of overseas death for the US traveler. A similar d i s t r i b u t i o n of t r a v e l - r e l a t e d deaths was found in a small study of Scottish travelers. Of the 173 Scottish deaths reported, 57% were due to cardiovascular causes, 23% were due to injuries, and 3% were due to infection (D Reid, JH Cossar, RD Dewar, Ruchill Hospital, Glasgow, Scotland, unpublished data). This study discusses only part of the mortality problem of international travel, and only deaths that occur overseas are presented. We did not examine the deaths to US citizens that occur within the United States after the citizen has returned from overseas traveling. Estimated male trayelers' death rates should be interpreted with caution. We present estimates of cardiovascular and injury death rates. Although our numerator is reliable, the denominator is based on WTO estimates. Cardiovascular disease was the leading cause of death in our study and may reflect risks related to the age and sex of the travelers. Cummins reported on international inflight deaths and noted that 69% of the deaths were due to cardiovascular diseases and occurred among travelers who were classified as having no reported health problems at the time of departure. 22 We found no increase in risk for c a r d i o v a s c u l a r death for travelers during our study years. A major factor contributing to the slightly lower risk of cardio•vascular death seen in our analysis might be self-selection of the traveler population. "Healthy" people tend to travel. We do not know how many individuals r e t u r n to the U n i t e d States and die after suffering a cardiovascular event that occurred while traveling outside the United States. Selected air medical transport sys20:6:June1991

TABLE 3. Mortality rates of US citizen travelers Age Group (yr)

1982 US Rate Injuries Cardiovascular

Injuries

Traveler Rate* Cardiovascular

15 - 24

123

4

338

...

25 - 34

122

15

186

...

35 - 44

98

73

298

94

45 - 54

96

301

185

295

55 - 64

95

809

118

793

65 - 74

113

1,984

224

1,692

75 and over

237

5,871

122

4,141

Rates are for males by age, per 100,000. *Mexico not included in analysis due to lack of reliable denominato~

terns report that acute myocardial infarctions are a leading cause of medical evacuations of US travelers (J Paterson; personal c o m m u n i c a tion}. Higher death rates of males due to injuries, particularly in less-developed countries, were noted in all age groups, suggesting increased exposure and e n v i r o n m e n t a l hazards. Travelers drive, swim, and walk in unfamiliar environments. Roadway design is variable; roadway safety devices such as guardrails are similar to US standards in Western Europe and virtually absent in less-developed countries. Injury outcome is also dependent on available emergency medical services (EMS) with timely transport to c o m p e t e n t m e d i c a l facilities and physicians. In the United States, approximately half of the deaths due to injuries occur outside of hospitals. 23 Our study showed that 80% of all injury deaths occurred outside of hospitals, suggesting increased severity of the event or limited access to medical personnel, EMS, or both. Further studies are needed to explore the issues of preventable injury deaths, EMS, and overseas travel. Injury prevention strategies must be emphasized by US physicians and others to decrease injury morbidity and mortality in patients traveling overseas. Examples of educational prevention strategies for travelers are listed (Figure 4). These strategies include avoidance behaviors such as not driving at night and constructive behaviors such as wearing seat belts and helmets. It is important to note that seat belt, air bag, and infant car seat availability is variable among overseas US car rental agencies. Travelers must clarify the availability of restraint deAnnals of

Emergency Medicine

vices with rental agencies. Providing names of physicians in the country of destination who assist travelers would be helpful to ensure p r o m p t d i a g n o s i s and t r e a t m e n t should acute injuries and illnesses OCCUr.

Appropriate i m m u n i z a t i o n s and medication for travel with risk assessment for illnesses continue to be necessary as indicated by the three deaths from preventable infectious diseases. However, our results may underestimate the risk of death from infectious disease. There were eight deaths that occurred in the United States due to malaria in 1984, presumably from infections contracted outside the United States. 24 There was one death recorded in our study. Other infectious diseases, such as hepatitis and typhoid, may have similar mortality patterns. Additional study is needed to describe the illness and injury mortality patterns of US travelers who have returned to the United States for medical care. Injuries are a leading cause of emergency air medical transport (Reference 25 and J Paterson, personal communication), followed by m y o c a r d i a l i n f a r c t i o n s , cerebrovascular accidents, and infections. Additional research is needed to describe this segment of travel-related morbidity and mortality. CONCLUSION Our results suggest that there is an increased risk of death due to injuries for US citizens who travel overseas. Further studies are needed to describe the degree of risk in a well-defined population of travelers. EMS and preventable injury deaths are areas that require further study. Physicians and others, including organizations, should include injury pre625/47

TRAVELER FATALITIES Hargarten, Baker & Guptill

vention strategies when advising travelers.

6. Pust R, Peate W, Cordes D: Comprehensive care of travelers. J Farn Pract 1986;23:572-579. 7. Gangarosa EJ: Travel and traveler's health. Aviat Space Environ Med 1980;3:265-270.

The authors thank Susan Baker for her comments, Robert Radcliffe for grant support, Verena Valley, MD, for graphic support, and Judy Fellows and Coni Lampien for manuscript preparation.

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8. Jnng EC: The Travel and Tropical Medicine Manual. Philadelphia, WB 8aunders, 1987. 9. Jong EC: Recommendations for patients traveling west. J Med 1982;138:746-751. 10. Mann J: Emporiatric policy and practice. JAMA 1983;249:3323-3325.

Corps. JAMA 1985;10:1326-1329. 17. International Classification of Diseases, Ninth Revision. US Department of Health and Human Services publication No. (PHS) 80-12.60. 18. The World Travel and Tourism Statistics Year Book, vol 37. Madrid, World Tourism Organization, 1975 and 1983. 19. Guptill KS, Hargarten SW, Baker TD: American travel deaths in Mexico: Causes and prevention strate~ gies. West J Med 1991;154:169-171.

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20. World Development Report, International Bank for Reconstruction and Development. Boston, Oxford University Press, 1985.

12. Sears SD, Sack RB: Medical advice for the international traveler, in Baker LR, Burton IR, Zieve PD (eds}: Principles of Ambulatory Medicine. Baltimore, Williams & Wilkins, 1986.

21. Baker SP, O'Neill B, Karpf RS: Injury Fact Book. Lexington, Massachusetts~ Lexington Books~ 1984.

i3. Weber SJ, Lefoeh JL: Health advice for the international traveler. A m Family Physician 1985;32:165-169. i4. Wolfe MS: Protection of travelers, in Hunter's Tropical Medicine, ed 6. Philadelphia, WB 8aunders, 1986, p 1698-1705. 15. Lange RW: Travel medicine resources for the primary care physician. Postgrad Med 1987;8:293-300. 16. Hargarten SW, Baker SP: Fatalities in the Peace

Annals of Emergency Medicine

22. Cummins ROt In-flight deaths during commercial air travel: How big is the problem? JAMA 1988~259: 1983-1988. 23. Trunkey DD: Trauma. Sci A m 1983;249:28-35. 24. Centers for Disease Control: Malaria surveillance, annual summary, 1984. Atlanta, CDC, 1984. 25. Rose SR: 1989 International Travel Health Guide. Northampton, Massachusetts, Travel Medicine Inc, 1989, p 102.

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