Traumatic Travels – A Review of Accidental Death and Injury in International Travellers

With the rapid growth of globalised travel, forecasted to exceed 1.8 billion arrivals by 2030,1 it is essential that travellers should be made more aware of the risk of traumatic injury and death in unfamiliar environments and possible prevention strategies. Traumatic death in a traveller is particularly distressing and repatriation is especially complicated.2 Despite this, a recent bibliometric analysis of travel medicine literature confirms the lack of emphasis on this subject in academic travel medicine.3 The scope of this review is to consider the various facets of physical trauma during international travel and to stimulate further original research in this area. Although there is a wide range of causes of travel-related mortality, this narrative review article will focus on road traffic collisions (RTCs), adventure sports, wildlife attacks, and homicides.


Introduction
With the rapid growth of globalised travel, forecasted to exceed 1.8 billion arrivals by 2030, 1 it is essential that travellers should be made more aware of the risk of traumatic injury and death in unfamiliar environments and possible prevention strategies.Traumatic death in a traveller is particularly distressing and repatriation is especially complicated. 2Despite this, a recent bibliometric analysis of travel medicine literature confirms the lack of emphasis on this subject in academic travel medicine. 3he scope of this review is to consider the various facets of physical trauma during international travel and to stimulate further original research in this area.Although there is a wide range of causes of travel-related mortality, this narrative review article will focus on road traffic collisions (RTCs), adventure sports, wildlife attacks, and homicides.

Search Strategy
English-language articles indexed on Scopus and PubMed databases published through November 2017 were retrieved using variations of the search terms 'accidental death' or 'trauma' combined with 'international travel' and 'travel' .Use of the search terms 'travel AND trauma' alone yielded 1987 articles on the PubMed database, a small proportion of which were relevant to travel medicine.Article titles and abstracts were screened to assess relevance to the theme of traumatic travel.Additional publications were obtained from the reference lists of articles.Articles published in the last 10 years were given preference.

Trauma-Related Mortality
In 2010, out of 52.8 million deaths globally, 65% was attributable to non-communicable diseases and approximately half of these were due to cardiovascular diseases. 4The next most common causes of death were infectious diseases and injuries.6][7][8] RTCs are the most prevalent cause of injury (25%-60%) resulting in traveller fatalities. 9Other causes of injuries include falls, human stampedes, animal attacks, injuries sustained while engaging in adventure sports, aviation crashes, natural disasters, and homicide.Although the probability of any of these events occurring is lower than vehicular trauma, they make a notable contribution to the overall mortality burden.

Road Traffic Collisions
Road traffic accidents are the leading cause of death in overseas travellers, exacerbated by the fact that travellers are at a greater risk of being involved in a collision than local inhabitants.This is evident from a US-based study, where the figure for US citizens' injuries abroad due to vehicular crashes was 13% higher than that for local citizens.The same study drew similar conclusions in seven out of the ten regions studied. 5Additionally, in Bermuda, road trauma involving motorcycle usage among tourists was six times greater than the rate for the local population. 10Underlying contributory factors include tourists' disorientation in a new environment, travellers' alcohol consumption, the socio-economic circumstances of the destination country and the level of local enforcement of safety regulations.One of the significant factors contributing to RTCs is tourists' disorientation when entering a foreign environment.2][13][14] Alcohol consumption among travellers is a significant contributor to motorist trauma.One study demonstrated that alcohol consumption was the primary cause of RTCs among travellers to Greece, particularly among those of Eastern European nationality. 15In addition, studies have shown that tourists are less likely to observe local drinking and driving laws, thereby compounding the problem. 11he economic status of a country is also a key factor when considering the prevalence of RTCs; a study conducted by the World Health Organization showed that RTCs are most prevalent in low-and middle-income countries. 16This is primarily due to poorly financed and managed national transportation and medical infrastructure, which manifests in ill-maintained roads that lack basic safety infrastructure such as street lighting, guard rails and hard shoulders. 11,12The problem is magnified by poorly qualified drivers, and badly maintained vehicles.In severe vehicular accidents, most victims do not have access to pre-hospital emergency care services and rely on other road users for assistance. 11It has been reported that up to 80% of patients die before reaching a medical facility. 13Furthermore, in many medical facilities in economically deprived areas of Africa and Southeast Asia, over 45% of emergency healthcare providers lack specific trauma care training. 17This leads to reduced capacity to effectively treat the injured, leading to increased mortality, for otherwise potentially treatable trauma.In contrast, 7% of the world's population, mainly in high income countries, have access to sufficient funding and an adequate safety framework. 11This translates to as few as 21% of accident victims dying before reaching a medical facility. 18he level of enforcement and safety regulations is also a key factor in the prevalence of RTCs.The lack of rigorous enforcement of laws against drunk driving and the non-use of safety helmets may increase the risk of RTCs.Drunk driving legislation is not well established for over a third of the world's population.This is supported by a study which reported that in places such as Ghana, 21% of randomly selected drivers displayed blood alcohol concentrations above 80 mg/dL, while only 0.4% of their Danish counterparts tested positive for high alcohol concentrations. 19,20While Ghana reports a total of 26.6 road traffic deaths per hundred thousand of their population, Denmark has a more acceptable figure of 3.5. 20,21nly 33% of countries adequately enforce motorcyclist and cyclist helmet use. 21This is despite helmets being proven to reduce the death rates among motorcyclists by 42% in geographical areas with well-established health care systems. 11

Adventure Sports
Adventure sports tourism is a growing travel industry but it also constitutes a significant proportion of death in travellers.The ocular risks of trauma resulting from bungee-jumping and sky-diving have been discussed previously in this journal. 22ter Sports Water sports-related accidents constitute a significant proportion of deaths from adventure sports among travellers.In one study, drowning was suspected to be responsible for up to 20% of traumatic deaths in travellers, depending on the location.23 Further analysis has elucidated that, apart from the risks associated with lack of knowledge, experience and negligence towards safety precautions, travellers participating in these activities are especially susceptible to dangers in the sea, such as envenomation or traumatic wounds sustained from marine creatures or corals.All of these could potentially result in death by drowning.24 In particular, research demonstrates that travellers who died while snorkeling, either by drowning, cardiac events or hypoxia, were found to lack experience, physical or mental fitness, and proper equipment.Moreover, those who participated in scuba-diving tended to disregard pre-established plans; many died from barotrauma, air emboli and decompression illness.12 Watersports can also include the use of motorised vehicles which carry an inherent risk of injury.In one reported case, a passenger ferryboat, which was sailing in an area restricted to parasailers, collided with a speedboat that was towing a parasailer.24 In another instance, two travellers riding on separate jet skis accidentally collided, resulting in the death of one traveller.24

Mountaineering and Trekking
Adventure sports such as mountaineering and trekking are also a significant cause of death in travellers.A study conducted in the Himalayas found that the death rate among mountaineers, mostly well-acclimatised elite mountaineers, on peaks of above 8000 m was 1.63%. 25A similar study conducted on Mount Blanc found that the death rate of mountaineers scaling the mountain was 12%. 26hese fatalities were often due to equipment failure, panic, poor judgment, overconfidence and avalanches.However, the greatest cause of casualties was as a result of falls; high altitude illness in trekkers could conceivably have contributed to some of these fatal falls. 27Fatalities from trekking were frequently attributable to trauma, illness and acute mountain sickness.Additionally, deaths during trekking activities may be exacerbated by absence of medical support staff on expeditions. 27High altitude trekkers should be familiar with the clinical presentation of high altitude pulmonary and cerebral oedema and should be familiar with how to achieve a safer ascent profile and use acetazolamide prophylaxis in some cases. 28In summary, adventure sports' accidents often involve the lack of proper equipment, experience, preparation or safety protocols; these factors expose the traveller to the risk of traumatic injuries.

Wildlife Attacks
Another notable cause of death among travellers is large mammal attacks, worsened by the growing popularity of safaris and other tourist attractions.Being in close proximity to wildlife carries inherent risks, which primarily stem from the ignorance of how to safely interact with wild animals.This is evident in a study where seven tourists were killed in encounters with wild animals in South Africa, caused by lions, hippopotami and an elephant.Three of the deaths by lions were due to the failure of the tourists to heed warnings to stay within the safe confines of their vehicles.The remaining death had resulted from the lack of adequate security and warning notifications by the nature reserve's management.The deaths caused by the hippopotami were due to a tourist's breach of the fenced safety area and another tourist who deliberately approached a hippo.The last death was caused by a distressed elephant, which attacked a vehicle and gored the victim to death.These tragic cases illustrate the need to raise further awareness of safety precautions when interacting with these animals, and for the safari travel industry to bolster safety protocols to ensure the safety of their visitors. 29,30micide and Terrorist Attacks Homicide is dissimilar from the above causes of death as it is not purely accidental.Several studies have shown that homicides may account for 16% of traveller deaths, although this figure varies widely between regions.31 Africa accounted for the highest number of homicides, followed by Asia and Latin America.The lowest rates were recorded in Eastern Europe.Such deaths can be attributed to the use of firearms, knives, cutting or drilling equipment, battery, suffocation or blast.The use of firearms, which had the highest incidence of mortality, accounted for 34% of deaths in one study.31 Homicide victims are often first subject to other crimes such as robbery and sexual assault.The risk of sexual assault and rape, especially among lone female travellers, during international travel has been discussed previously.32 Homicides also tend to cluster around hotels, bars and nightclubs, and also occur more frequently in the evening. Stdies have shown that these crimes are typically caused by being in unfamiliar surroundings, being inattentive, showcasing jewelry and money, and a general lack of understanding of local criminal methods.12 Increasingly, travellers are advised to consult a reputable source of travel security information, such as the British Foreign and Commonwealth Office 33 or other foreign affairs agency, in evaluating the level of threat of terrorist attacks in a given destination.A comprehensive treatment of terrorist attack risks is beyond the scope of the current review.

What Is Already Known?
Road traffic collisions are the single greatest cause of death in international travellers, yet there has been very little emphasis placed on travel-related traumatic injury and death in the travel medicine literature.

What This Study Adds?
This narrative review article describes the major traumatic risks associated with travel across international boundaries.Statistics on travel trauma-related mortality and road traffic deaths are provided.The risks posed by adventure sports, including water sports and high altitude trekking, are highlighted.Large mammal attacks in the context of safari travel are also discussed.Homicide and terrorist attacks and physical trauma resulting from stampedes at mass gatherings are explored.A checklist of travel health recommendations will serve as a guide to travel medicine practitioners counselling patients in travel health clinics.

Ceremonies and Stampedes
Mass gatherings, such as religious pilgrimages, sporting events and music festivals, present a risk of physical trauma as a result of stampedes and traumatic asphyxia.Pilgrims, sports tourists and festival goers should be counselled about the risk of stampede and how best to respond in the event of an emergency.Manoochehry and Rasouli describe stampede as the "most dreaded trauma risk" in Muslim Hajj pilgrims. 34The Hajj stampede of 2015 led to the tragic death of 2431 pilgrims at Mina in Saudi Arabia.The fatalities mostly resulted from head injury and traumatic asphyxia.The authors advocate heightened safety measures by the Ministry of Health, including more effective disaster planning, development of triage systems for dealing with mass casualties, crowd management and deployment of more trauma surgeons at overcrowded pilgrimage sites.The use of computer technology and camera surveillance may help to locate missing pilgrims and alert their tour group leaders to their location.Telemedicine also has potential for use in this disaster setting.Similar approaches may be effective at major international sporting events such as the Olympic Games and the World Cup football tournament.Additional traumatic risks at international music festivals include lightning strikes in outdoor venues, fires, and tympanic membrane rupture from loud music.

Conclusion and Travel Health Recommendations
Travel medicine has a role in reducing the burden of international travel-related trauma.A recent study revealed that travellers attending a pre-travel health clinic place high priority on personal safety and that it ranks as their major concern alongside accessing medical care abroad. 35ravellers should be educated about the traumatic risks of their intended travel activities and encouraged to plan their travels prudently as nearly 66% of injuries sustained among travellers are preventable. 36This is particularly relevant in the case of last minute travellers or travellers whose itineraries are uncertain. 37To supplement pre-travel health consultations, travellers visiting travel agencies, GPs and travel clinics should be equipped with a comprehensive checklist outlining travel-associated injury risks and the appropriate precautions they should observe (Table 1).