Unintentional Injury during Foreign Travel: A Review

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1 REVIEW ARTICLES Unintentional Injury during Foreign Travel: A Review Rhona J. McInnes, Lisa M.Williamson, and Anita Morrison Unintentional injury is a global public health problem. In 1990, an estimated 5 million people worldwide died as a result of an injury or poisoning.this accounted for 10% of deaths from all causes that year, and over half of the estimated 900 million years of life lost in 1990 due to premature death. 1 Although mortality rates for ischemic heart disease, cerebrovascular disease, and cancer are higher, the majority of people dying of these causes are elderly, with far fewer potential years of life to live. Reasons for the increasing public health importance of injury include the decline of infectious disease, the processes of urbanization, industrialization, motorization, and increased opportunities to travel. Travel abroad by United Kingdom residents has increased over the last 2 decades. Between 1977 and 1997 the number of visits to Europe and North America quadrupled, and visits to other countries increased 5- fold. 2 Holiday travel in particular accounted for the greatest proportion of overseas visits and saw the largest increase. 2 The most common holiday destination for UK tourists is European Union-Europe, especially Spain and France, although the United States has also become an increasingly popular holiday destination. Visits varied by age with most visits being made by 45- to 54-year olds followed by 25- to 34- and 35- to 44-year olds, but not by gender. 2 Rhona J. McInnes, PhD: Midwifery Research Centre, School of Nursing & Midwifery, University of Glasgow; Lisa M. Williamson, MPhil: MRC Social and Public Health Sciences Unit, University of Glasgow; Anita Morrison, MPhil: Paediatric Epidemiology and Community Health (PEACH) Unit, Department of Child Health, University of Glasgow, United Kingdom. This review was funded by the Greater Glasgow Health Board. There are no other conflicts of interest to disclose. Correspondence: Dr. Rhona J. McInnes, Midwifery Research Centre, School of Nursing & Midwifery, Oakfield Avenue, University of Glasgow, G12 8LW, UK. J Travel Med 2002; 9: The increase in overseas travel has implications for the health service in terms of services provided preand posttravel and in relation to any campaigns designed to reduce this burden. Since injuries are a frequent cause of morbidity and mortality in the United Kingdom, it is likely that injuries will also feature in overseas travel. 3 This review was undertaken to explore the epidemiology of unintentional injury in relation to foreign travel, to examine any particular evidence on the role of drugs or alcohol, and to identify any travel injury prevention initiatives. Methodology The definition of injury used in this review was an event that has an external cause and is potentially preventable. Intentional injuries (suicides and homicides), poisonings, injuries solely caused by sport (e.g., skiing, mountaineering) where the sport was the reason for the holiday, animal bites, sunburn and skin cancer, and sexually transmitted infections were excluded. These topics were considered to be subjects in their own right,with their own prevention programs, and therefore beyond the scope of this literature review. The electronic databases Medline, BIDS ISI, BIDS Embase, Cinahl, the Cochrane Database, and Cambridge Scientific Abstracts were searched using combinations of the terms: injury, accident, trauma, and travel, holiday, tourist, tourism, foreign holiday, or international travel. The search was carried out between October 1999 and January Additional citations were obtained after reviewing the reference lists of papers and searching through relevant journals. The literature review is presented in two sections, injury mortality and injury morbidity. Incidence, cause, and demographic patterns are discussed for both fatal and nonfatal injuries. Separate consideration is given to the role of alcohol and drugs and to injury prevention initiatives. The appendix gives details of each of the main papers reviewed including the aim, subjects, setting, methods, and main conclusion. Only those papers directly concerned with the epidemiology of travel injury mortality and morbidity are included in the table. 297

2 298 Journal of Travel Medicine, Volume 9, Number 6 Results Fatal Injury Incidence of fatal injury. In the papers that addressed mortality, injury was found to be one of the main causes of death while traveling abroad, whereas infectious diseases accounted for less than 2% of deaths Injury was reported to be responsible for 23% of deaths among visitors to the United States, 18% of Australian short-term (less than 12 months) travelers deaths, and 21% of Scots who died overseas. 4,7,9 In a 4¹ ₂-year study of trekkers in Nepal, the total number of deaths recorded was 40, with injury accounting for 14 of these deaths. 10 A lack of robust data has prevented the actual incidence of injury fatalities from being accurately determined. However, several studies reported that injury fatalities were greater among tourists than nontourists. 5,6,8 Injury was the leading cause of death among 197 US travelers who died in Mexico and the cause-specific mortality ratio for deaths due to injury (unintentional, homicide, suicide) was significantly higher for travelers (51%) than for US residents (7%). 6 Two studies estimated the American tourist population using data from the World Tourist Organization and used this to calculate tourist injury mortality rates. 5,8 One of these calculated a crude death rate of 9.1 per 1,000 for US travelers compared with 7.6 per 1,000 for the US population. 5 The other estimated that the injury death rate was greater for US male travelers than for males residing in the United States. 8 Between 1979 and 1984, 17,988 visitors to the United States were reported to have died and the mortality rate for unintentional injuries was calculated at 25.4 per 1,000,000 tourist arrivals. 4 In a study of Australian citizen travel deaths, the estimated crude mortality rate for short-term travelers was 0.1% per annum. 7 General demography of fatal injury. Many of the mortality studies reported age or gender differences in tourist injury mortality, with the most likely victims of trauma being young men. 4 9,11 In two studies of US nationals, male travelers accounted for 74% and 65% of injury deaths,respectively. 6,8 The increased proportion of injury deaths among male travelers was consistent across all age groups. 6 However, in another study, trauma was responsible for 54% of the deaths of male tourists under 50 years and 67% of the deaths of females under 50 years. 7 In this study, younger women were overrepresented among traffic and nonspecific fatalities. Injury mortality rates varied by age group but apart from over 75 year olds, the injury mortality rate among US male travelers was consistently greater than the rates for US males in the United States. 8 The highest injury mortality rate was 338 per 100,000 US citizen male travelers aged 15 to 24 years. 8 A study of Scottish tourists also found that the injury mortality rate among younger tourists was higher than other cause-specific mortality rates. 9 Geographic location or nationality of tourist may have an influence on injury incidence and outcome. One paper reported that mortality amongst Australian tourists did not correlate with the popularity of different destinations. 7 The safest destination reported was New Zealand, followed by Southeast Asia, whereas mainland Europe was reported to be relatively unsafe, but the highest actual mortality index was recorded in Central and South America. Central America was reported to be relatively unsafe for American tourists, accounting for 30% of travel deaths but only 18% of travelers. 8 This study also reported consistently higher injury mortality rates in less developed countries than in developed countries. In another study, injury mortality rates for males aged 25 to 65 years were considerably higher for travelers to less-developed countries than for US residents but were lower for travelers to developed countries compared with US residents. 5 Residents of Mexico visiting the United States had a higher injury mortality risk than Canadian citizens, except in relation to water transport related injuries. 4 Scottish tourist injury fatalities occur most often in Mediterranean resorts, which may simply reflect the popularity of this destination. 9 Cause of fatal injury. The most common cause of fatal tourist injury was motor vehicle traffic accidents (MVTA), followed by drowning. 4,5,7,8,11 Although MVTA were the main cause of death among US citizens visiting Mexico, the proportion of motor vehicle deaths did not differ between US tourists and US residents. 6 However, the proportion of deaths due to drowning or aircraft crashes was found to be significantly higher in the tourist group. MVTA accounted for 27% of all injury fatalities of American travelers overseas, followed by drowning (16%), and homicide (9%). 8 No comparison with the cause of death among American residents was given. However, the authors suggested that traveler injuries may be more severe or access to treatment may be more limited because 80% of injury deaths overseas occurred outside of hospitals compared with 50% of injury deaths in the United States. MVTA were the leading cause of unintentional injury deaths among tourists visiting the United States, followed by drowning,and air transportation accidents. 4 In a study by Sniezek and Smith, 4 MVTA accounted for 37% and 32% of deaths of non-us residents and US residents, respectively, and drowning accounted for 15% and 4%, respectively. Deaths due to air and water transportation accidents were also higher among nonresidents than residents. The main cause of injury death among Australian travelers was also MVTA, causing at least 31 deaths (7% of all recorded traveler deaths in 1 year). 7 This figure was

3 McInnes et al., Unintentional Injury during Foreign Travel 299 comparable with the annual MVTA mortality rate in Australia. Specific activities identified as causes of fatal tourist injury in other studies were trekking, contact with wild mammals, and use of personal watercraft. 10,12,13 Nonfatal Injury Incidence of nonfatal injury. Although injury as a result of trauma may be the most likely health hazard for the foreign traveler, few studies have actually calculated the incidence of nonfatal travel injuries. 14 A survey of the readers of WHICH Magazine by the Consumers Association in the United Kingdom, suggested that the proportion injured on holiday had doubled to 5% since a survey 4 years previously. 15 Nonfatal injury featured highly in a number of reported studies. It was reported as the primary reason for US citizen tourists to be transported back to the United States by air medical transport and accounted for one-third of Swiss Air Rescue Service flights. 16,17 Injury was also the primary reason for hospital attendance among Australian tourists, accounted for 24% of tourist presentations at a tropical island clinic, and accounted for the majority of child-tourist presentations in a medical center in Yugoslavia. 18,19,20 A 5-year study in Paris suggested that 80 to 100 per 100,000 tourists attended the emergency department for any cause, and although cause and incidence varied by age and nationality, injury was cited as the second most common reason for attending. 21 A total of 255 incidents were recorded in an 18-month period at Ayers Rock, Australia (including tourists), with 108 of these resulting from injury trauma. 22 Over 5,000 patients (including travelers, airport staff, flight crew, and visitors) were reportedly treated each year at Mexico International Airport between 1981 and 1987 with trauma related injury the most common medical problem. 23 It is difficult to make comparisons between tourists and nontourists since the age and general health of each group is likely to differ. However, the incidence of nonfatal injury among tourist populations may be higher than the incidence expected in the local or resident population. Several studies exploring MVTA suggested they were more common among tourists than local residents One study recorded 1.57 motorbike accidents per 1,000 tourists and 1.23 per 1,000 local residents. 25 A later study identified the rate of motorbike injuries among tourists as 94.1 per 1,000 person years at risk compared with 16.6 per 1,000 in the local population. 26 However, in a New Zealand study,the incidence of nonfatal MVTA was comparable to the local population. 28 Two studies reported that tourists were likely to suffer more severe injuries than local residents were. 13,23 Injuries resulting from the use of personal watercraft were more significant among tourists than local residents. 13 Motorbike injuries among tourists to Bermuda were more likely to be moderate or severe when compared with the local population. 23 The incidence of moderate or severe injury was 1.00 per 16,000 tourists but no figures were given for the local population. General demography of nonfatal injury. In most studies, males were reported to be at greater risk of nonfatal injury. 16,22,24,29,30 However,in a study of tourists in Greece, the proportional representation of females injured in MVTA was higher than that of the resident population, and a greater proportion of females than males were reported to have been injured in motorcycle accidents in Bermuda. 25,31 Nonfatal injury type and cause were also found to vary by gender in two other studies. 19,30 There is evidence to suggest that the age profile of nonfatal injury varies according to the location of holiday and cause of injury. Over 60% of injury cases transported back to the United States from the Bahamas involved individuals aged over 44 years and 19% were aged over 74 years. 16 Most of these nonfatal injury cases were the result of falls. Patients attending Parisian emergency departments for trauma treatment were more likely to be aged over 60 years and older tourists were more likely to be injured in motorcycle incidents in Bermuda. 21,25,26 However, in some of the other studies nonfatal injuries were more common in younger age groups (under 24 years). 22,29,30 In a study of tourists to New Zealand, the majority of injury claims were made by 20 to 39 year olds, and males aged 20 to 24 were overrepresented in MVTA involving rented cars. 28 Tourists aged 24 years or less were also reported to be at greater risk of MVTA compared with other age groups in a study in Greece. 24 The type and severity of injury may also vary according to age. Nonfatal injury from personal watercraft use was reported as being more severe in males under 16 years compared with older age groups, although it is not clear what proportion were tourists. 13 Some studies reported that levels of nonfatal injury risk appeared to be related to the nationality of tourists. Japanese and North American tourists were more likely to report an injury to the Accident Compensation Corporation (ACC) in New Zealand than any other nationality, and Americans were also more likely than other nationalities to present with trauma at Parisian emergency departments. 21,28 In Greece, nationals from left-side driving countries were more likely to be involved in nonfatal MVTA than local residents or nationals from right-side driving countries. 31 This risk was supported by a New Zealand study, which found that not keeping to the left was a significant causal factor in nonfatal MVTA. 28 Cause of nonfatal injury. A survey of tourists from Britain reported falls on land and water sports as the commonest

4 300 Journal of Travel Medicine, Volume 9, Number 6 causes of nonfatal injury. 15 MVTA have also been highlighted as a frequent cause of fatal and nonfatal injury and several studies have been designed specifically to explore this issue ,31 The main cause of nonfatal injury among US citizen tourists being transported back to the United States was MVTA (45%), followed by falls (8%), sports injuries, including diving into shallow water (4.5%), boating accidents (2%), aircraft crashes (1.5%), and burns and electrical shocks (1%). 16 Actual cause of the injury varied with the geographical location of the holiday. Two Australian studies based in coastal resorts, identified lacerations and fractures as the main types of nonfatal injury sustained by tourists. 18,19 A third Australian study exploring beach safety suggested that laceration was the most common beach injury requiring treatment. 30 The main causes of these nonfatal injuries were coral cuts, striking against other people or objects, beach litter and rocks, or MVTA. 18,19,30 In all studies, actual cause varied with body site injured. A study at Ayers Rock, Australia, reported that most nonfatal tourist injuries were due to MVTA. 22 Severe spinal injuries associated with balcony falls and diving incidents have been reported. 29,32 Sixty patients with tetraplegia were admitted to spinal injury units in the United Kingdom between 1988 and Two-thirds of these injuries had been sustained during a holiday abroad with the main cause being diving too steeply into shallow water. 29 The potential for nonfatal tourist injury as a result of diving, swimming, and subaqua diving are also discussed in another study. 33 Compared with nontourist populations, tourists are at risk of different types of injuries due to participation in unusual sports or leisure activities and unfamiliarity with the environment Overseas visitors were more likely to lodge claims with the ACC in New Zealand for road, recreation, and sporting accidents than nontourists who were more likely to report home-based accidents. 28 The use of personal watercraft was also identified as a cause of nonfatal injury. 13 Influence of Alcohol or Drugs Reports on the influence of alcohol on tourist injury mortality and morbidity were limited in the reviewed literature. One study stated that alcohol was a risk factor for fatal injury, but did not present any data. 6 Alcohol was shown to be a contributing factor where fatal or nonfatal injury had been caused by wild mammals and was suggested as a contributory factor in balcony falls and diving accidents resulting in spinal injury. 12,29,32 Alcohol was reported as a primary cause of vehicle crashes in significantly higher proportions of foreign tourists to Greece than among Greek nationals. 31 Men were reported as being more likely to drive under the influence of alcohol but this differed according to the nationality of the driver, with higher rates of intoxication reported amongst Eastern European citizens. 31 One study, 27 which explored alcohol-related fatal MVTA suggested that tourism was a contributing factor. However, this study could not identify whether tourism was an independent or dependent variable. None of the reviewed literature reported on the influence of recreational drugs on tourist injury. Injury Prevention The literature review did not identify any evaluations of interventions to reduce injury but a number of articles identified strategies for the reduction of injury among tourists. These included the need to implement major prevention strategies, structural changes, education programs or legislation. 4,13,25,26,29,35 Suggested efforts to reduce fatal and nonfatal injuries would also require cooperation between medical practitioners, travel medicine specialists, and the travel industry. 11,34,37 39 Grundy and colleagues 29 advocated a prevention campaign in the United Kingdom to include a new code of practice and a pilot leaflet warning of the dangers of diving.the leaflet was to be issued to schools and (the authors hoped) to tourists through tour operators. The overall aim was to achieve a decline in preventable injuries associated with diving into shallow water. There was no evidence in the literature that this or any other associated prevention strategy had taken place. There are a number of possible sources of information, such as travel brochures, general practitioners (GPs), and travel clinics, and some research into the use of these sources and the advice they provide was identified. In 1985, only 67% of UK travel brochures contained health information,none of which was destination-specific. 37 Brochures for travel to European destinations were least likely to contain health information (38%). By 1992, health information content had increased, with 77% of brochures relating to European travel destinations providing health information. 40 However, neither study specifically mentioned injury prevention advice. Seventy-five percent of 143 travel brochures studied between 1994 and 1995 contained health information, although this was generally provided in very small print at the end of the brochure,with advice on first aid provided by 21% of the brochures. 41 A questionnaire completed by a random sample of GPs in New Zealand demonstrated that 50% gave advice on personal safety,60% on health and travel insurance,and 54% on finding medical assistance while abroad. 42 The advice given varied according to age, gender, patient case mix, and experience of individual GPs. 42 In a study of 341 travel clinics, 70% of the clinics surveyed usually provided advice on personal safety (with 58% providing written advice and 16% providing audiovisual). 43 This compared

5 McInnes et al., Unintentional Injury during Foreign Travel 301 with 99% of clinics usually providing malaria advice (94% of which was written and 22% audiovisual). Although there is likely to be increased exposure to risk among tourists (e.g., more person hours spent swimming, boating, traveling), 6 the increased risk of injury abroad may also be associated with the differences in safety measures between the United Kingdom and other countries,holiday euphoria,and abuse of alcohol and drugs. 14 Other risk factors identified are unfamiliar environment, unfamiliar activities, and unfamiliar or poorly maintained equipment. 33,35,44 Injury outcome can also be affected by access to care as well as quality and quantity of care. 33,35 Alcohol and the lack of use of seatbelts or helmets were recognized as risk behavior; however, there was very little information available on their roles as contributing factors. In Bermuda for example, helmets were used by the majority of motorcyclists but did not prevent a number of skull fractures, concussions, and the higher rate of injuries among tourists. 26 In general,there was little information in the reviewed literature about the type of activity or circumstances which led to the injury. Risk management was identified as a useful tool for understanding and responding to tourist health requirements. The identification of exposure to, frequency, and severity of potential risks was advocated with prevention through risk avoidance, risk reduction, risk retention or risk transfer. 35 One study advocated the application of an epidemiologic model of host, agent/vehicle, and environment to assist in the reduction of tourist injury. 34 Through this, injury prevention strategies should include scientifically based advice to travelers (host) plus modifications to the agent/vehicle (such as motor cars) and the environment (e.g., roads). Strategies can then be divided into active (e.g., helmets, seat belts, smoke alarms) or passive (e.g., preinstalled airbags, sprinkler systems) and behavior as constructive or evasive. Other measures suggested to reduce the incidence of tourist MVTA included providing drivers rest stops, random breath testing, seat belt legislation, and providing specific advice for tourists. 39 Discussion The literature on the epidemiology of injury was sparse and mainly confined to American or Australian studies. Furthermore, there were a number of methodologic issues impacting on our ability to draw conclusions from the published literature. Significant data deficiencies made it difficult to establish a true profile of injury morbidity and mortality. In general, data were sourced either from routine records or were collected specifically for the research purposes. Routine data sources were often incomplete or inadequate, especially lacking denominator data, that is actual numbers and age/gender distribution of citizens abroad either as travelers, tourists or residents. 4,6,7,24 Routine data appeared to be more accessible for those dying abroad than for those dying after returning home or for those who are injured but survive.this may reflect the laws surrounding the reporting of deaths and disposal of remains. By contrast, injury morbidity data were not routinely available and, since only the more serious injuries requiring treatment are registered, likely to be underreported. The main papers reviewed sourced their data from hospital records, surveys of hospital or other services, or by questionnaires completed by patients or tourists. Depending on the location of the research, data could be sourced from small clinics or treatment centers, accident and emergency departments, hospitals or medical evacuation centers. The incidence, type, and cause of injury therefore vary according to the nature and source of the recorded data. Classification of terminology also varied throughout the literature. A tourist might be someone on holiday or might include business travelers and illegal immigrants. 4,9 A US study included travelers and those living overseas in the analysis. 5 An Australian study classified travelers by duration of time spent abroad rather than reason for being abroad. 7 The classification of injury also varied. In some papers, injury referred to all injuries, whereas others differentiated between intentional and unintentional injury. In at least one paper, injury was analyzed along with poisonings. Furthermore, some studies used the terms trauma or accident to describe injury. Despite deficiencies in the collecting and reporting of data, the majority of papers identified injury as one of the main causes of morbidity and mortality among tourists; with the most likely victims being young men (under 24 years), regardless of differences related to nationality and holiday location. In the literature there appeared to be greater emphasis on infectious disease than injury, and this is reinforced by pretravel advice. One study identified a 1% death rate from infectious disease compared with 25% from injury. 8 Piaxao and colleagues,stated that whereas infection used to be the main cause of death, it is now cardiovascular disease and injury that are more significant. 9 Although MVTA were cited as one of the leading causes of injury, there was some evidence to suggest that the incidence of fatal MVTA may be comparable between some tourist and nontourist populations. 4 9,11,16,45 Further rigorous data collection is needed in order to identify whether this risk is real. There were, however, a number of possible risk factors suggesting that the risk of MVTA could be expected to be higher among tourist groups. These include driving in unfamiliar surroundings with unfamiliar road layouts and distracting scenery,

6 302 Journal of Travel Medicine, Volume 9, Number 6 driving on the correct side of the road, especially if this is different from what the driver is used to, 28,31,39 fatigue, 39 and alcohol, with tourists appearing to be less willing to conform to local drinking and driving legislation. 27,31,39 The review did not identify any evaluations of injury prevention during foreign travel, although a number of articles suggested possible prevention strategies. Whereas injury prevention would require the cooperation of health professionals and the travel industry, the opportunity exists to disseminate travel injury advice through various information sources, such as travel brochures, GPs, and travel clinics. Prevention initiatives ranging from specific advice, such as the use of seat belts and helmets, to more generalized information on injury need to be implemented and their effectiveness evaluated. Conclusion This review goes some way to demonstrate the major public health implications of increased overseas travel. Injury has been identified as one of the leading causes of morbidity and mortality among tourists. However, the extent of the problem has not been clearly defined due to data deficiencies. A system of reporting and recording reliable injury data, which is easily accessible, would assist researchers, health care providers and the tourist industry to further address injury prevention issues. A more rigorous epidemiologic approach in published reports and papers would enable researchers to explore trends and the impact of prevention strategies. Tourists should be provided with more information and advice on injury risks when traveling abroad; travel brochures could be of particular use when presenting this information and research into the impact of pretravel injury prevention information is required. The use of imaginative strategies that are continuously evaluated could further aid injury prevention. Summary Injury is a notable cause of mortality and morbidity among tourists Young men are most at risk, regardless of nationality and holiday location MVTAs are one of the leading causes of injury Data deficiencies and inconsistency in classification make it difficult to establish a true profile of tourist injury A dearth of properly evaluated intervention strategies in the published literature exists Tourist injury prevention initiatives should be implemented and evaluated Acknowledgments This review was conducted as part of a larger study of unintentional injury during foreign travel commissioned and funded by Greater Glasgow Health Board Health Promotion Department. The research was carried out while the authors were employed at the Paediatric Epidemiology and Community Health Unit. We would like to thank Professor David Stone for his support and comments. References 1. Murray CJL, Lopez AD. The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries and risk factors in 1990, projected to USA: Harvard School of Public Health, Wright E, Lovegrove J, Gallagher L, Kaneshanathan N. Travel: a report on the 1997 International Passenger Survey. London: Office for National Statistics, Morrison A, Stone DH, and the EURORISC Working Group. Injury mortality in the European Union: an overview. Euro J Public Health 2000; 10: Sniezek JE, Smith SM. Injury mortality among non-us residents in the United States Int J Epidemiol 1991; 20: Baker TD, Hargarten SW, Guptill KS. The uncounted dead American civilians dying overseas. Public Health Rep 1992; 107: Guptill KS, Hargarten SW, Baker TD. American travel deaths in Mexico. Causes and prevention strategies. Western J Med 1991; 154: Prociv P. Deaths of Australian travellers overseas. Med J Aust 1995; 163: Hargarten SW, Baker TD, Guptill K. Overseas fatalities of United States citizen travellers: an analysis of deaths related to international travel. Ann Emerg Med 1991; 20: Paixao MLT, Dewar RD, Cossar JH, et al. What do Scots die of when abroad? Scot Med J 1991; 36: Shlim DR, Gallie J. The causes of death among trekkers in Nepal. Int J Sports Med 1992; 13(Suppl 1):S Steffen R. Travel medicine: prevention based on epidemiological data. Trans R Soc Trop Med Hyg 1991; 85: Durrheim DN, Leggat PA. Risk to tourists posed by wild mammals in South Africa. J Travel Med 1999; 6: White MW, Cheatham ML. The underestimated impact of personal watercraft injuries. Am Surgeon 1999; 65: McIntosh IB. Accidental trauma and the vacationer. Travel Med Int 1997; 15: Court C. Survey highlights risk of foreign holidays. BMJ 1995; 310: Hargarten SW, Bouc GT. Emergency air medical transport of US citizen tourists: Air Med J 1993; 12:

7 McInnes et al., Unintentional Injury during Foreign Travel Seiler O, Hofliger C. Aeromedical evacuation: 40 years experience of Swiss Air Rescue. Travel Med Int 1990; 8(1): Nicol J, Wilks J, Wood M. Tourists as inpatients in Queensland regional hospitals. Aust Health Rev 1996; 19: Wilks J, Walker S, Wood M, et al. Tourist health services at tropical island resorts. Aust Health Rev 1995; 18: Capar M, Glavas M, Capar M, et al. [Hospital treatment of child-tourists at the Pula Medical Center ].[Serbo- Croatian (Roman)] Lijec Vjesn 1990; 112: English abstract only. 21. Fisch A, Prazuck T, S le C, et al. [Emergency consultations of foreign tourists in Paris in the month of August. 5 years of prospective surveillance ( )]. [French]. Bulletin Societe Patholologie Exotio 1998; 91: Salib MW, Brimacombe JR. A survey of emergency medical care at Uluru (Ayers Rock). Med J Aust 1994; 161: Antunano MJ, Aquino AA. Seven years experience in medical care at Mexico City International Airport. Aviat Space Envir Med 1989; 60: Petridou E, Dessypris N, Skalkidou A, Trichopoulos D. Are traffic injuries disproportionally more common among tourists in Greece? Struggling with incomplete data. Accident Anal Prev 1999; 31: Purkiss SF. Motorcycle injuries in Bermuda. Injury 1990; 21: Carey MJ, Aitken ME. Motorbike injuries in Bermuda: a risk for tourists. Ann Emerg Med 1996; 28: Colon I. The role of tourism in alcohol-related highway fatalities. Int J Addict 1985; 20: Page SJ, Meyer D. Tourist accidents. Ann Tourism Res 1996; 23: Grundy D, Penny P, Graham L. Diving into the unknown. BMJ 1991; 302: Grenfell RD, Ross KN. How dangerous is that visit to the beach? A pilot study of beach injuries. Aust Fam Physician 1992; 21: Petridou E, Askitopoulou H, Vourvahakis D, et al. Epidemiology of road traffic accidents during pleasure travelling: the evidence from the Island of Crete. Accident Anal Prev 1997; 29: Delargy MA. Holiday balcony falls resulting in spinal cord injury. Lancet 1987; 1: McIntosh IB. Travel and trauma. Travel Med Int 1997; 15: Hargarten SW. Injury prevention: a crucial aspect of travel medicine. J Travel Med 1993; 1: Waller JA, Brinks S. Trauma in tourist towns. J Rural Health 1987; 3: Wilks J, Oldenberg B. Tourist health, the silent factor in customer services. Aust J Hosp Manage 1995; 2: Reid D, Cossar JH, Ako TI, Dewar RD. Do travel brochures give adequate advice on avoiding illness? BMJ 1986; 293: Lea G. Doctors and the travel industry collaborate to improve health advice for travellers. Commun Dis Public Health 1998; 1: Wilks J, Watson B, Faulks IJ. International road safety in Australia: developing a national research and management programme. Tourism Manage 1999; 20: Cossar JH, McEachran J, Reid D. Holiday companies improve their services. BMJ 1993; 306: Shickle D, Nolan-Farrell MZ, Evans MR. Travel brochures need to carry better health advice. Commun Dis Public Health 1998; 1: Leggat PA, Heydon JL, Menon A. Safety advice for travellers from New Zealand. J Travel Med 1998; 5: Hill DR, Behrens RH. A survey of travel clinic throughout the world. J Travel Med 1996; 3: Wilks J, Atherton T. Health and safety in Australian marine tourism: a social, medical and legal appraisal. J Tourism Studies 1994; 5: Wilks J. International tourists, motor vehicles and road safety: a review of the literature leading up to the Sydney 2000 Olympics. J Travel Med 1999; 6: Ship at Paarden Bay at Orangestad, Aruba. Submitted by Danielle Gyurich, MD, and Julian Schilling, MD.

8 304 Journal of Travel Medicine, Volume 9, Number 6 Appendix Unintentional Injury during Foreign Travel: Aims, Subjects, Settings, Methods and Conclusions of Reviewed Papers First Author Aim Subjects Setting Methods Main Conclusion Antunano MJ 23 To describe the medical care of 39,320 of the 84,359,212 International Official Trauma was the most common patients at Mexico International passengers who used the Airport, annual presentation, especially contusions, Airport during the 7-year study airport. Mexico reports of superficial injuries, open wounds, period Passengers include medical burns, sprains, dislocations, and travelers, ground staff, activities in fractures airline staff, accompanying the clinic Trauma was also main cause of death people Baker TD 5 To analyze the death data of US US citizens who died International Data from the death Injury was an important cause of death citizens dying overseas overseas, excluding (US citizens) registers of the US especially MVTA and drowning US military personnel Passport Correspondence Death rate higher among travelers than Branch 1975 and 1984 US residents Capar M 20 Describes presentation of 687 child-tourists Former 65% were from other parts of Yugoslavia, child-tourists presenting at the medical Yugoslavia 25% from abroad center during 6-year Injuries and poisonings accounted for study period over 20% of presentations, most commonly superficial injuries, contusions and open wounds, followed by fractures, then poisonings Carey MJ 26 To describe the incidence All patients attending Bermuda Retrospective analysis of More tourists than locals were injured of injuries associated with Trauma after MVTA the medical records at Injured tourists were older than injured motorbike use between July 1, 1993 the only Trauma locals and September 30, 1993 department on the Island More tourist females than local females injured No tourist fatalities Colon I 27 To examine the contribution Columbia, USA Cross sectional analysis Tourism is significantly positively of tourism to alcohol related of 50 states during 1976 associated with single traffic fatalities vehicle fatalities Durrheim DN 12 To determine the incidence of Persons injured or killed South Africa Systematic review of press 7 deaths (3 foreign tourists) and 14 injuries fatal and non fatal attacks by wild mammals records between 1988 and occurred 1997 Rate not calculated as precise denominator unavailable Alcohol played a role in some of the incidents Fisch A 21 To determine the reasons for Foreign tourists attending Paris Prospective collection of Incidence was per 100,000 foreign tourists attending emergency departments in medical data for the Trauma was second most common reason emergency departments Paris during August month of August over 5 and was most common in the over 60 age consecutive years group and among Americans Grenfell RD 30 To determine the profile of All patients injured on the Australia Questionnaires completed Commonest type of injury was laceration beach injuries defined beach and attending at time of injury during (37%), incident highest in age group 4 defined treatment centers the 2 month study period Injury type and incidence varied by age and sex

9 McInnes et al., Unintentional Injury during Foreign Travel 305 First Author Aim Subjects Setting Methods Main Conclusion Grundy D 29 To review causes of tetraplegia 60 patients admitted to UK Information from the Many of the injuries caused by diving too as a result of diving injuries Spinal Units with tetraplegia British Spinal Injuries steeply into shallow water between 1988 and 1989 Review Committee Most victims were young males The most common overseas locations for these injuries were Spain and Greece Alcohol was a risk factor in a number of cases Guptill KS 6 To establish mortality patterns US citizens who died while Mexico Data from death reports Injury was the leading cause of death among US citizens and identify residing in, or traveling in (US citizens) sent to the US Department Commonest cause being MVTA, followed by high risk groups Mexico (2 groups examined of State, Division of drowning separately) Passports, 1975 and 1984 Most injury deaths were young males Injury deaths significantly higher among travelers than US residents but no difference in proportion due to MVTA Hargarten SW 8 To examine causes of travel US citizens who died International Data from the death Unintentional injury was the second most related mortality overseas, excluding US (US citizens) registers of the US passport common cause of death military personnel and those office of the Department MVTA were the commonest cause of injury dying in Canada of State 1975 and 1984 death followed by drowning Young males were at greatest risk Hargarten SW 16 To study the epidemiology of US citizens transported International A retrospective self-reported Injury was the commonest reason with the US citizens becoming ill/injured home by Air Medical (US citizens) survey of Air Medical main cause being MVTA followed by injury while on holiday Services Services between 1988 due to diving into shallow water and 1990 Injury cause varied according to country Older males were most likely victims Nicol J 18 To determine the types of medical 695 overseas and 3,479 Australia Inpatient records from the Injuries and poisoning the main reason for conditions and injuries resulting interstate tourist inpatients 7 regional hospitals between admission of overseas tourists and second in tourists being admitted to in one of the 7 regional 1993 and 1994 reason among interstate tourists hospital hospitals Main injuries were fractures, lacerations, intra-cranial injuries MVTA was main cause among overseas tourists and second among interstate tourists Near drowning more prevalent among overseas tourists Page SJ 28 To explore tourist injury using Claims made to ACC in New Zealand Data from the ACC and Overseas visitor claim rate is well below that of 2 data sources: Accident the year ending June 1994 the LTSA residents Compensation Corporation and data collated by the Visitors aged years make the majority of (ACC) and from the Land LTSA on all road-based overseas claims Transport Safety Authority accidents Visitors more likely to claim for road, (LTSA) recreation, and sporting accidents MVTA fatalities are lower among visitors but not fatal MVTA are equal; year old males are over-represented in rental vehicle crashes

10 306 Journal of Travel Medicine, Volume 9, Number 6 First Author Aim Subjects Setting Methods Main Conclusion Paixao MLT 9 To determine the cause and Scottish travelers dying International Information obtained Trauma was the second commonest cause of country of death of Scottish between 1973 and 1988, (Scottish citizens) from the Scottish Home death overall, and the commonest cause among travelers whose body was returned and Health Department year olds for cremation Most died in Europe, especially in Mediterranean holiday resorts Petridou E 31 To determine the epidemiology All 730 MVTA victims Greece Questionnaire completed Greek: foreign visitor injury ratio = 18:1 of MVTA during pleasure who contacted 1 of 3 for all survivors, but Greek: foreign visitor MVTA ratio = 3:1 traveling hospitals on the Island post mortem details for all Women foreigners were over-represented of Crete, between fatalities among MVTA victims April 1995 and Other risk factors included left side driving September 1995 country national in a rented car Plus 39 fatalities Alcohol abuse was the primary factor in injury events for a significantly greater proportion of foreign nationals Petridou E 24 To indirectly assess the pattern Tourists and locals involved Greece Data collected from the Around 15% of all accidents are traffic related of pleasure traveling-related in MVTA and attending island hospital during among residents but account for 40% among injuries the island hospital tourists Tourist injuries are more serious Increased risk among males and younger age groups Prociv P 7 To determine the number and Australian citizens who died International Data from Australian Trauma was the second commonest cause of causes of deaths of Australian overseas between July 1992 (Australian citizens) embassies, high death, of which the largest cause was MVTA citizens and June 1993 commissions and Injury deaths were more common in younger consulates people and among women The risk of dying overseas was similar to the risk of dying at home Purkiss SF 25 To determine the pattern of All injured moped and Bermuda Retrospective analysis of Accidents were more frequent among tourists motorcycle injuries, relative risks motorcycle riders (local and the medical records at the than locals and implications tourist) attending Trauma only Trauma department Most likely victims were senior tourists or between March 1, 1988 and on the Island young male locals September 30, 1988 Most injuries were mild and there were no fatalities Salib MW 22 To determine the emergency Locals and tourists involved Ayers Rock, Data collected A total of 255 incidents during study, including medicine profile of the Ayers in serious incidents requiring Australia prospectively on all serious 6 deaths Rock population and tourist at least 1.5 hours of incidents for 18 months 108 of the incidents including 2 of the deaths risks emergency medical attention from July 1, 1991 were due to trauma Most trauma injuries due to MVTA Seiler O 17 Discusses the experience of Individuals evacuated by the Switzerland Information from Swiss Trauma accounted for ¹ ₃ of patients organizing aeromedical Swiss Air Rescue Service, and abroad Air Rescue Service transported evacuation includes repatriation These were mainly head injuries and fractures

11 McInnes et al., Unintentional Injury during Foreign Travel 307 First Author Aim Subjects Setting Methods Main Conclusion Shlim DR 10 To monitor changing trends in Trekkers dying between Nepal A retrospective survey by Death rate = 14 per 100,000 (40 deaths in time the deaths of trekkers to Nepal July 1, 1987 and letter and follow-up phone period studied) December 31, 1991 call of all foreign embassies Trauma accounted for 14 deaths and consulates in Nepal Risk factors for trekking deaths were trekking Plus data from the office in organized groups and increasing age issuing trekking permits Sniezeck JE 4 To describe injury mortality in Non-US residents (i.e. US Death certificate data from Injury was second most common cause of death non-us residents visiting the permanent address (non-us citizens) National Center for Health Main cause of injury death was MVTA then United States outside the US) Statistics drowning Young, white males most likely victim White MW 13 To determine the true incidence All persons injured by PWC Florida Evaluation of accuracy of PWC injuries are significantly underreported of personal watercraft (PWC) between January 1993 and data collected by health care (< 8%) to the LAW related injuries December 1997 and treated systems with data from the 68 injuries during time period, within Orlando Regional Law Enforcement Agency mainly young males. Healthcare systems (LAW) One fatality 16% of injuries were to tourists, but tourists tended to have more serious injuries Wilks J 19 To provide a detailed health 1,183 clinic visits by guests Australia 6-month retrospective Injuries accounted for over 24% of profile at 3 tropical island tourist analysis of clinic records presentations with the most common reason resorts being lacerations Lacerations and fractures were more common in males Injuries mainly due to the unfamiliar environment and/or participation in unfamiliar sports/activities MVTA = motor vehicle traffic accidents.

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