CATMAT Statement: Risk of injury and travel

Examples of unintentional injuries include motor vehicle collisions, falls, fires, burns, animal encounters, and drowning. Examples of intentional injuries include deliberate acts such as homicides, suicides, terrorism, and war, which are beyond the scope of this statement. The focus of this paper will be on unintentional injury in travellers.

Worldwide in 2000, motor vehicle injuries represented the highest proportion of injury fatalities (25%); Drowning and falls represented 9% and 6% of global injury fatality respectively.(6) In an American report on individuals requiring emergency air medical transport, the most commonly reported causes of injuries amongst travellers are motor vehicle injuries, falls and injuries from water-sports.(7) Several studies have shown that the rates of all injuries whether fatal or non-fatal are higher in tourists than nontourists.( 8;9) Risk factors for injury while abroad include lack of familiarity with surroundings, trying new activities, abusing alcohol/drugs, and “holiday euphoria”.(9) A new breed of tourists, adventure travellers, deserve special mention since they bear a unique spectrum of risk.(7) Thus, the pre-travel advisor requires a detailed assessment of risk behavior of the traveller, their medical history, and specific knowledge of their travel itinerary.

The purpose of this paper is to educate the public, travel agencies, policy makers, and especially travel medicine providers on the magnitude of unintentional injury risk and strategies to reduce this risk while travelling abroad. Evidence available on injury prevention, especially in travellers, is limited. Where possible, the evidence will be graded according to CATMAT standards (see table 1).

Demographics

In 2000, people 15-44 years of age represented the highest proportion of injury-related mortality.⁽⁶⁾ Road traffic injuries are the ninth leading cause of disability adjusted life years lost (DALYs) lost and are predicted to rise to third place by 2020.^(7;10;11) Males outnumber females in road traffic fatalities by three to one.⁽⁶⁾ Children under 5 years suffer 25% of drowning deaths and approximately 15% of fire-related deaths.⁽⁶⁾

With respect to travellers, there is reason to believe that their demographics and health determinants differ from nontravellers. Even between traveller types from short-term tourists to business travellers and “visiting friends and relatives”(VFRs), there are differences in health risks.⁽⁵⁾ A study comparing diagnoses related to environmental hazards among tourists and expatriates in Nepal showed that injuries were most common in both groups representing 38% and 68% of all environment-related conditions respectively.⁽¹²⁾

Road Traffic Injuries

In 2000, there were approximately 1.26 million deaths due to road traffic injuries. This is equivalent to 20.8 per 100,000 population that were killed in road traffic injuries globally.⁽⁶⁾ Ninety percent of road traffic injuries occur in low income and middle income countries⁽⁶⁾ despite people from these countries owning only 40% of the world’s vehicles.⁽¹⁾ Pedestrians, passengers, and cyclists, rather than drivers, are more often killed in mainly urban centers of developing countries.^(13;14) This group represents the poorer population who take cheaper modes of transportation such as overloaded buses or taxis. Travellers, especially budget travellers, also take these forms of transportation and thus are also at increased risk. A study on Canadian deaths abroad reported to consular services in 1995 reported that in 71% of deaths resulting from a motor vehicle accident, the individual killed was a passenger.⁽¹⁵⁾ Among developed countries, the primary mode of transportation is by private vehicle. The Southeast Asian and Western Pacific regions accounted for greater than 50% of all road traffic fatalities globally in 2000.⁽¹⁾ One of the reasons is population growth and thus increasing numbers of vehicular travellers, especially in India which has the highest motor vehicle fatality rate that is projected to get worse.⁽⁶⁾ According to the World Tourism Organization, there will be a 10% annual increase in global tourism with most of these tourists visiting Asia and the Pacific⁽¹⁶⁾ leading to subsequent anticipated increases in traveller injuries.⁽⁸⁾

Travellers on bicycles and other two-wheelers are particularly at risk of head injuries since helmet laws are lacking in some countries. Cyclists are also at higher risk of rabies from stray dog bites.⁽⁷⁾

Higher motor vehicle fatality rates in low income countries are due to several factors:

• poor road conditions
• poor traffic enforcement
• poor street lighting and signage
• congestion (from cars, trucks, animal drawn carriages, bicycles, motorcycles, rickshaws, and four-wheelers) sharing roads with pedestrians
• poor road maintenance
• lack of /or dysfunctional safety features on the road
• Drivers with inappropriate testing
• Vehicles on the road that are not roadworthy

In comparison, several safety standards put in place in developed countries have largely reduced their road traffic fatality rates. Seat belt laws, vehicle crash pads, traffic-calming strategies such as barriers and lines put on roadways to slowdown or re-direct traffic, as well as traffic law enforcement have all proven effective.⁽¹⁾ An economic analysis of seat belt use in South Africa provides an example of a program where an investment of US$300,000 per year would reduce the incidence of motor vehicle injuries and fatalities and is estimated to result in a net value to society of US$1.7 million.⁽¹⁷⁾

A lack of pre-hospital care and ambulance transport is a primary barrier to health care in developing countries. The reasons for this include a lack of adequate vehicles and the inability to pay for them. Instead, people are often taken to hospitals by private vehicles causing further delays in medical care.⁽¹⁸⁾ If they reach the hospital, access to appropriate care is often lacking given the inadequate funding for trauma care, education and equipment. Travellers need to be reminded of such variable access and quality of emergency medical systems in developing countries that can complicate even minor injuries. Furthermore, people in developing nations may be less likely to recognize the serious nature of some road transport incidents unlike those in developed nations where motorized transport has existed for a longer period.

Driver fatigue, distracting scenery, unfamiliarity with road conditions, especially if driving at night and on the opposite side of the road, are significant contributing factors to tourist injuries. A study in Crete, where driving is done on the right side of the road, showed that drivers from left-sided driving areas were injured more often than drivers from right-sided driving areas.⁽¹⁹⁾ Speeding is also a universal factor in motor traffic injury severity.⁽¹⁸⁾

The biggest contributor to traffic injuries in tourists is alcohol use by the driver or drivers in other vehicles.⁽⁸⁾ This was evident in a study in Crete where tourists from Eastern Europe were disproportionately represented in alcohol-related injuries.⁽¹⁹⁾ A report by the World Health Organization (WHO) on alcohol and injury stated that about half of alcohol attributed deaths were due to injuries and about two thirds of these deaths were unintentional.⁽²⁰⁾

Accurate injury surveillance data is important for setting prevention priorities. The magnitude of road traffic injuries is greatly under-estimated since many countries do not have proper reporting systems. It is difficult to distinguish injury rates in travellers compared to citizens as national injury databases often fail to differentiate between foreigners and their residents.⁽²¹⁾ In low and middle income countries, many injured people do not have access to a hospital thus their injuries are not included in overall country statistics. Even in countries where injuries are reported, the actual definitions of serious injury vary depending on whether it is a hospital or police department who records the injury. It is doubtful that police officers are adequately trained to determine injury severity.

Countries need to take an active role in decreasing traffic related injuries. Taiwan instituted strict traffic laws and saw a 27% decrease in traffic-related mortality in 5 years.⁽²²⁾ Their policies included implementation and enforcement of helmet laws, implementation of pre-hospital care, seat belt use and cell phone bans while driving, strict penalties if drinking while driving, and child car seat usage. While travellers cannot do much about the lack of such policies, especially in developing countries, being aware of these omissions helps prepare them for travel risks.

International travellers can access country specific traffic risks at the Association for Safe International Road Travel website (www.asirt.org (External link) ).

Drowning and other water-related injuries

In 2000, an estimated 450,000 people drowned globally.⁽⁶⁾ The highest drowning mortality rates were seen in African countries and China (9.3- 13.1/100,000). Children under 5 years old had the highest drowning mortality rates worldwide. There is evidence to suggest that travellers are more likely than non-travellers to drown.⁽²³⁾ This is likely due to lack of experience with open water or unfamiliar pools and insufficient boat operation training. Also, a lack of supervision of children especially where alcohol is involved plays a large role. Efforts to reduce the incidence of drowning should be aimed at primary and secondary prevention rather than tertiary treatment because medical care has little to offer submersion victims. Similar to pretravel advice about motor vehicle injury prevention, water safety receives little consideration.

In April 2002, approximately 60 experts in the fields of travel health and injury prevention met to develop recommendations for travel health professionals on water safety and drowning prevention as well as to highlight further research needs.⁽²³⁾

Twenty-nine drowning prevention recommendations were made and the evidence supporting these recommendations was evaluated using CATMAT’s grades of evidence. The recommendations were classified in the following topics: general advice, alcohol, travelling with children, and diving/ snorkeling. The recommendations from the meeting with good evidence (based on at least one well designed epidemiological study to support a recommendation) were as follows:

• Drain covers in pools, spas, hot tubs and whirlpool baths should be secure
• It is important that the individual supervising swimmers knows first aid and CPR and can respond appropriately in the case of an emergency.
• Those who drink over one alcoholic beverage should not swim, supervise children who are swimming, or operate or be a passenger on a watercraft.
• If the operator is inexperienced or uncertified, avoid riding in a motorized watercraft with them.
• Swimming pools should be enclosed by a four foot fence with a self-closing gate.
• An adult who is an advanced swimmer and has appropriate first aid skills should be assigned to supervise children and inexperienced swimmers in advance.⁽²³⁾

Despite not having good evidence to support them, the remainder of the recommendations made by this expert panel are important and include having your own personal flotation devices (PFD) with you in the case that they are not available, entering water feet first when unsure of depths of water, and ensuring certification of scuba and snorkeling expedition operators.

This group of experts also recommends that PFDs be worn by non-swimmers, those participating in sports such as water skiing or other towed activities, sail boarding, whitewater boating, and if younger than 13 years old and on a moving boat.⁽²³⁾ It has been estimated that in 1999, up to 80% of drowned boaters in the United States could have been saved had they been wearing a PFD.⁽²³⁾

The impact of alcohol on boating or swimming cannot be underestimated. A case-control study reported that a blood alcohol level of greater than 0.01% had a 16-fold risk of drowning compared to those who did not use any alcohol.⁽²⁴⁾ Alcohol also may contribute to spinal cord injuries from diving into shallow water.

If a drowning should occur and the individual does not have a detectable pulse, initiate cardiopulmonary resuscitation (CPR). Increased survival after submersion injuries have been shown when early CPR is administered.⁽²³⁾ When travelling, it is important that to know how to initiate local emergency response measures. For decompression illness due to diving, the Diver’s Alert Network (www.diversalertnetwork.org (External link) ) is an organization that can identify the closest hyperbaric chamber and help facilitate the treatment.⁽⁷⁾

There is no evidence to support that learning to swim decreases your risk of drowning. The Canadian Paediatric Society recommends swimming lessons for children under the age of four not be promoted as an effective means of preventing drowning.⁽²⁵⁾ Children under the age of four should not swim without supervision by an adult as they are not sufficiently advanced developmentally to master swimming skills.⁽²⁵⁾

More research is necessary to ascertain specific reasons why tourists drown. Data on drowning and other water related injuries should be kept by embassies in order to understand the economic impact of drowning and advocate for future preventive strategies.

Aircraft travel injuries

While commercial aircraft flights are extremely safe, unscheduled non-commercial flights are a known risk for unintentional death and thus the latter should be avoided if possible. Travellers can access the Airsafe website (www.airsafe.com) which lists airline crashes by carrier, type of plane, and total number of crashes. However, this is largely limited to commercial operations. It also offers tips for safe travel.

An Australian analysis of in-flight passenger injuries and medical conditions showed that of the 284 medical incidents reported from 1975-2006, only 5% were due to injuries (most fatal events were due to heart attacks). Most of these were classified as minor musculoskeletal sprains/bruises due to falls, or burns due to drinking hot fluids during turbulence.⁽²⁶⁾ These findings parallel those of other international airline sources.

Extreme tourism

Adventure travel, including mountaineering, hiking, backcountry skiing, adventure racing, and other “extreme” sports, has been increasing in popularity in the global tourism industry.^(8;12) Unfortunately, many travel insurance companies exclude these activities from their coverage and optional riders exist which can be included for an additional cost (see next section). The Department of Foreign Affairs and International Trade webpage is a useful resource for researching the safety and security of over 220 travel destinations and provides the ‘adventure traveller’ some important planning suggestions (www.voyage.gc.ca/publications/adventure-traveller_tourisme-aventure-eng.asp (External link) ).

Extreme travellers are an important risk group since there are several factors that influence their injury rates such as exposure to unfamiliar surroundings in often harsh environmental conditions for prolonged periods which may lead to altitude illness, dehydration, heat or cold illness, animal bites and plant toxicity without timely access to medical care.^(7;12)

According to a study from the GeoSentinel Surveillance Network, 320 animal-related injuries were reported in travellers returning to one of the six travel clinics in the network from 1998-2005.⁽²⁷⁾ Of these, dog, monkey, and cat bites or scratches were the predominant species involved. Also, being female and being less than 15 years old was associated with a higher risk of injury by animal bite. Most animal-related injuries came from South East Asia especially Thailand. Interestingly, despite 75% of cases being from countries endemic for rabies, only 66% of patients received post-exposure prophylaxis. Many of these patients received pre-travel advice which highlights the need for travel medicine providers to discuss rabies vaccination (see CATMAT statement on Rabies for details)⁽²⁸⁾ and reinforce safety around unknown animals especially in children.

The number of mountaineering injuries are increasing yet the fatality rates are not, due to advanced rescue operations.⁽⁸⁾ The main causes of trauma are falls due to slips and equipment failure, head injuries due to falling rocks/ice, and panic especially when stranded. Injuries are more serious in this setting because of the risk of exposure to harsh weather conditions and the higher incidence of lower extremity fractures potentially stranding the victim, frustrating evacuation efforts, and thus delaying definitive medical care. Avalanches pose yet another risk in those travellers venturing into the mountains. Most avalanches occur after a large snow fall and on slopes greater than 30%. Skiers should travel in packs and be equipped with and know how to operate avalanche transceivers, shovels, and CO2 scrubbers. The latter is used to prevent CO2 narcosis which causes death prior to hypoxia or hypothermia in avalanche victims.⁽⁷⁾

In hiking and adventure racing, the risk of musculoskeletal injuries increases with the duration of the trip. Most injuries are minor strains, blisters, bruises, and lacerations if the individual is physically fit. In older travellers, previously unrevealed cardiovascular problems can occur with overexertion. A study of hikers in Yosemite National Park in California showed that 11% had no previous experience and 50% had a prior medical illness requiring more advanced planning.⁽⁸⁾

Expeditions deserve special mention since they require advanced physical fitness and logistical planning. Travellers should not expect all expeditions to have a medical practitioner along to care for them. Also, most tour guides have limited medical knowledge.(29) On a supervised youth expedition to Greenland which included remote trekking on glaciers, 44% of the participants reported injuries; however, most of these were minor and over half could have been prevented by prior training and use of equipment.(30) There is good evidence that supervised expeditions even in high risk activities have low morbidity and mortality rates.(8)

Knowledge of available local health resources and purchasing evacuation insurance is particularly advisable for “extreme sports” tourists.^(5;29)

Travel Insurance Versus Medical Assistance Companies

When a traveller purchases travel insurance, the travel insurance company will reimburse the traveller for eligible medical care while abroad. Thus, travellers should be prepared to pay directly at the time of the medical service. Travellers are advised to ask potential insurers the following questions prior to purchasing your insurance:

1. Do you need prior authorization from the company?
2. What services are covered and are there any exclusions? (read the fine print)
3. What documentation is needed for reimbursement and does it need to be translated?

Medical assistance companies offer the highest level of insurance including evacuation and repatriation and are often linked to insurance companies above. They should have knowledge of the medical care options in the destination country and direct links to medical personnel. They even offer translation and legal services. Some questions to ask of medical assistance companies include:

1. Who arranges medical care and evacuations?
2. How many offices do they have globally and how many medical staff are on-site?
3. How often do they perform evacuations?
4. Do they have their own aircraft or do they have to fly-in from elsewhere?
5. If unhappy with the local care, can you get transported to another site?⁽³¹⁾

The reader is referred to the article by Spira for a detailed list of insurance companies and medical assistance companies.⁽⁸⁾ However, a good starting point for accessing recommended physicians internationally is to go to the IAMAT (International Association for Medical Assistance to Travellers) website at: www.iamat.org (External link) . Other useful websites are: www.shoreland.com (External link) and www.internationalsos.com (External link) .

Conclusion

Injuries are largely preventable. They are the responsibility of the individual, the government, and also the travel health specialist. It is important for travellers to seek pre-travel advice and for the travel health specialist to provide information on injuries as tourism travel and lack of pre-travel advice are independent risk factors for injuries abroad.⁽¹²⁾ Travel health specialists need to be more proactive in offering this information to travellers.

See Table 2 for the Summary Recommendations for Traveller Injury Prevention.

Table 1. Strength and quality of evidence summary sheet ⁽³²⁾

Table 2. Summary Recommendations for Traveller Injury Prevention

References

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⁽⁴⁾ Statistics Canada. Leading Causes of Deaths in Canada 2000-2004. 2009. Report No.: CANSIM Table 102-0563.

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(28) Committee to Advise on Tropical Medicine and Travel. Statement on travellers and rabies vaccine. Can Comm Dis Rep 2005;31(ASC-13):1-20.

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