Archive for August, 2016

Preventing Falls Among Older Adults

Friday, August 5, 2016 // Prevention



We all want to protect our older family members and help them stay safe, secure, and independent. Knowing how to reduce the risk of falling, a leading cause of injury, is a step toward this goal.

The Reality

Each year, one in every three adults ages 65 or older falls and 2 million are treated in emergency departments for fall-related injuries. And the risk of falling increases with each decade of life. The long-term consequences of fall injuries, such as hip fractures and traumatic brain injuries (TBI), can impact the health and independence of older adults. Thankfully, falls are not an inevitable part of aging. In fact, many falls can be prevented. Everyone can take actions to protect the older adults they care about.

Prevention Tips

You can play a role in preventing falls. Encourage the older adults in your life to:

  • Get some exercise. Lack of exercise can lead to weak legs and this increases the chances of falling. Exercise programs such as Tai Chi can increase strength and improve balance, making falls much less likely.
  • Be mindful of medications. Some medicines—or combinations of medicines—can have side effects such as dizziness or drowsiness. This can make falling more likely. Having a doctor or pharmacist review all medications can help reduce the chance of risky side effects and drug interactions.
  • vision
    Keep their vision sharp.
    Poor vision can make it harder to get around safely. Older adults should have their eyes checked every year and wear glasses or contact lenses with the right prescription strength to ensure they are seeing clearly.
  • Eliminate hazards at home. About half of all falls happen at home. A home safety check can help identify potential fall hazards that need to be removed or changed, such as tripping hazards, clutter, and poor lighting.

Steps for Home Safety

The following checklist can help older adults reduce their risk of falling at home:

  • Remove things you can trip over (such as papers, books, clothes, and shoes) from stairs and places where you walk.
  • Install handrails and lights on all staircases.
  • Remove small throw rugs or use double-sided tape to keep the rugs from slipping.
  • Keep items you use often in cabinets you can reach easily without using a step stool.
  • Put grab bars inside and next to the tub or shower and next to your toilet.
  • Use non-slip mats in the bathtub and on shower floors.
  • Improve the lighting in your home. As you get older, you need brighter lights to see well. Hang lightweight curtains or shades to reduce glare.
  • Wear shoes both inside and outside the house. Avoid going barefoot or wearing slippers.

More Information

CDC offers various materials and resources for all audiences about older adult falls and what can be done to prevent them. These resources are for the general public, public health officials, and anyone interested in programs that aim to prevent falls.


25th Year of Precepting

This marks my 25th year of serving as a community preceptor for medical students at the University of Texas Health Science Center at San Antonio.  My thanks to those patients who have taken time to meet with students.  Here is a comment from one of them:


The past 4 weeks with Dr. Thornton was probably one of my favorite rotations of 3rd year. There is an ample amount of diversity in the types of medical problems seen from routine follow ups to vaccinations needed for world travel as well as more chronic conditions. Dr. Thornton’s attentiveness and laid back personality make him a great instructor. He often provided me with articles he found interesting and we had many conversations about medicine and life in general. He really made me feel like I was part of the treatment team. His staff is extremely nice and personable. I feel very fortunate to have had this rotation.

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Protection against Mosquitoes, Ticks, & Other Arthropods

Friday, August 5, 2016 // Prevention

Roger S. Nasci, Robert A. Wirtz, William G. Brogdon

Vaccines or chemoprophylactic drugs are available to protect against some vectorborne diseases such as yellow fever, Japanese encephalitis, and malaria; however, travel health practitioners should advise travelers to use repellents and other general protective measures against biting arthropods. The effectiveness of malaria chemoprophylaxis is variable, depending on patterns of drug resistance, bioavailability, and compliance with medication, and no similar preventive measures exist for other mosquitoborne diseases such as dengue, chikungunya, Zika, and West Nile encephalitis or tickborne diseases such as Lyme borreliosis, tickborne encephalitis, and relapsing fever.

The Environmental Protection Agency (EPA) regulates repellent products in the United States. CDC recommends that consumers use repellent products that have been registered by EPA. EPA registration indicates the materials have been reviewed and approved for both efficacy and human safety when applied according to the instructions on the label.


Avoid outbreaks. To the extent possible, travelers should avoid known foci of epidemic disease transmission. The CDC Travelers’ Health website provides updates on regional disease transmission patterns and outbreaks (

Be aware of peak exposure times and places. Exposure to arthropod bites may be reduced if travelers modify their patterns or locations of activity. Although mosquitoes may bite at any time of day, peak biting activity for vectors of some diseases (such as dengue and chikungunya) is during daylight hours. Vectors of other diseases (such as malaria) are most active in twilight periods (dawn and dusk) or in the evening after dark. Avoiding the outdoors or taking preventive actions (such as using repellent) during peak biting hours may reduce risk. Place also matters; ticks and chiggers are often found in grasses, woodlands, or other vegetated areas. Local health officials or guides may be able to point out areas with increased arthropod activity.

Wear appropriate clothing. Travelers can minimize areas of exposed skin by wearing long-sleeved shirts, long pants, boots, and hats. Tucking in shirts, tucking pants into socks, and wearing closed shoes instead of sandals may reduce risk. Repellents or insecticides, such as permethrin, can be applied to clothing and gear for added protection. (Additional information on clothing is below.)

Check for ticks. Travelers should inspect themselves and their clothing for ticks during outdoor activity and at the end of the day. Prompt removal of attached ticks can prevent some infections. Showering within 2 hours of being in a tick-infested area reduces the risk of some tickborne diseases.

Bed nets. When accommodations are not adequately screened or air conditioned, bed nets are essential in providing protection and reducing discomfort caused by biting insects. If bed nets do not reach the floor, they should be tucked under mattresses. Bed nets are most effective when they are treated with a pyrethroid insecticide. Pretreated, long-lasting bed nets can be purchased before traveling, or nets can be treated after purchase. Effective, treated nets may also be available in destination countries. Nets treated with a pyrethroid insecticide will be effective for several months if they are not washed. Long-lasting pretreated nets may be effective for much longer.

Insecticides and spatial repellents. More spatial repellent products are becoming commercially available. These products, containing active ingredients such as metofluthrin and allethrin, augment aerosol insecticide sprays, vaporizing mats, and mosquito coils that have been available for some time. Such products can help to clear rooms or areas of mosquitoes (spray aerosols) or repel mosquitoes from a circumscribed area (coils, spatial repellents). Although many of these products appear to have repellent or insecticidal activity under particular conditions, they have not yet been adequately evaluated in peer-reviewed studies for their efficacy in preventing vectorborne disease. Travelers should supplement the use of these products with repellent on skin or clothing and using bed nets in areas where vectorborne diseases are a risk or biting arthropods are noted. Since some products available internationally may contain pesticides that are not registered in the United States, it may be preferable for travelers to bring their own. Insecticides and repellent products should always be used with caution, avoiding direct inhalation of spray or smoke.

Optimum protection can be provided by applying the repellents described in the following sections to clothing and to exposed skin (Box 2-03).

Box 2-03. Maximizing protection from mosquitoes and ticks

To optimize protection against mosquitoes and ticks and reduce the risk of diseases they transmit:

  • Wear a long-sleeved shirt, long pants, and socks.
  • Treat clothing with permethrin or purchase pretreated clothing.
    • Permethrin-treated clothing will retain repellent activity through multiple washes.
    • Repellents used on skin can also be applied to clothing but provide shorter duration of protection (same duration as on skin) and must be reapplied after laundering.
  • Apply lotion, liquid, or spray repellent to exposed skin.
  • For Mosquitoes
    • Ensure adequate protection during times of day when mosquitoes are most active.
    • Dengue, yellow fever, and chikungunya vector mosquitoes bite mainly from dawn to dusk.
    • Malaria, West Nile, and Japanese encephalitis vector mosquitoes bite mainly from dusk to dawn.
    • Use common sense. Reapply repellents as protection wanes and mosquitoes start to bite.
  • For Ticks
    • Check yourself daily (your entire body) and remove attached ticks promptly.


CDC has evaluated information published in peer-reviewed scientific literature and data available from EPA to identify several types of EPA-registered products that provide repellent activity sufficient to help people reduce the bites of disease-carrying mosquitoes. Products containing the following active ingredients typically provide reasonably long-lasting protection:

  • DEET (chemical name: N,N-diethyl-m-tolua-mide or N,N-diethyl-3-methyl-benzamide). Products containing DEET include, but are not limited to, Off!, Cutter, Sawyer, and Ultrathon.
  • Picaridin (KBR 3023 [Bayrepel] and icaridin outside the United States; chemical name: 2-(2-hydroxyethyl)-1-piperidinecarboxylic acid 1-methylpropyl ester). Products containing picaridin include, but are not limited to, Cutter Advanced, Skin So Soft Bug Guard Plus, and Autan (outside the United States).
  • Oil of lemon eucalyptus (OLE) or PMD (chemical name: para-menthane-3,8-diol), the synthesized version of OLE. Products containing OLE and PMD include, but are not limited to, Repel and Off! Botanicals. This recommendation refers to EPA-registered repellent products containing the active ingredient OLE (or PMD). “Pure” oil of lemon eucalyptus (essential oil not formulated as a repellent) is not recommended; it has not undergone similar, validated testing for safety and efficacy, is not registered with EPA as an insect repellent, and is not covered by this recommendation.
  • IR3535 (chemical name: 3-[N-butyl-N-acetyl]-aminopropionic acid, ethyl ester). Products containing IR3535 include, but are not limited to, Skin So Soft Bug Guard Plus Expedition and SkinSmart.

EPA characterizes the active ingredients DEET and picaridin as “conventional repellents” and OLE, PMD, and IR3535 as “biopesticide repellents,” which are either derived from or are synthetic versions of natural materials.

Repellent Efficacy

Published data indicate that repellent efficacy and duration of protection vary considerably among products and among mosquito and tick species. Product efficacy and duration of protection are also markedly affected by ambient temperature, level of activity, amount of perspiration, exposure to water, abrasive removal, and other factors. In general, higher concentrations of active ingredient provide longer duration of protection, regardless of the active ingredient. Products with <10% active ingredient may offer only limited protection, often 1–2 hours. Products that offer sustained-release or controlled-release (microencapsulated) formulations, even with lower active ingredient concentrations, may provide longer protection times. Studies suggest that concentrations of DEET above approximately 50% do not offer a marked increase in protection time against mosquitoes; DEET efficacy tends to plateau at a concentration of approximately 50%. CDC recommends using products with ≥20% DEET on exposed skin to reduce biting by ticks that may spread disease.

Recommendations are based on peer-reviewed journal articles and scientific studies and data submitted to regulatory agencies. People may experience some variation in protection from different products. Regardless of what product is used, if travelers start to get insect bites they should reapply the repellent according to the label instructions, try a different product, or, if possible, leave the area with biting insects.

Ideally, repellents should be purchased before traveling and can be found online or in hardware stores, drug stores, and supermarkets. A wide variety of repellents can be found in camping, sporting goods, and military surplus stores. When purchasing repellents overseas, look for the active ingredients specified above on the product labels; some names of products available internationally have been specified in the list above.

Repellency Awareness Graphic

The Environmental Protection Agency (EPA) allows companies to apply for permission to include a new repellency awareness graphic on the labels of insect repellents that are applied to the skin (Figure 2-01( The graphic helps consumers easily identify the time a repellent is effective against mosquitoes and ticks. EPA reviews products that apply to use the graphic to ensure that their data meet current testing protocols and standard evaluation practices. Use of this graphic by manufacturers is voluntary. For more information, visit

Repellents and Sunscreen

Repellents that are applied according to label instructions may be used with sunscreen with no reduction in repellent activity; however, limited data show a one-third decrease in the sun protection factor (SPF) of sunscreens when DEET-containing insect repellents are used after a sunscreen is applied. Products that combine sunscreen and repellent are not recommended, because sunscreen may need to be reapplied more often and in larger amounts than needed for the repellent component to provide protection from biting insects. In general, the recommendation is to use separate products, applying sunscreen first and then applying the repellent. Due to the decrease in SPF when using a DEET-containing insect repellent after applying sunscreen, travelers may need to reapply the sunscreen more frequently.

Repellents and Insecticides for Use on Clothing

Clothing, hats, shoes, bed nets, jackets, and camping gear can be treated with permethrin for added protection. Products such as Permanone and Sawyer, Permethrin, Repel, and Ultrathon Permethrin Clothing Treatment are registered with EPA specifically for use by consumers to treat clothing and gear. Alternatively, clothing pretreated with permethrin is commercially available, marketed to consumers in the United States as Insect Shield, BugsAway, or Insect Blocker.

Permethrin is a highly effective insecticide-acaricide and repellent. Permethrin-treated clothing repels and kills ticks, chiggers, mosquitoes, and other biting and nuisance arthropods. Clothing and other items must be treated 24–48 hours in advance of travel to allow them to dry. As with all pesticides, follow the label instructions when using permethrin clothing treatments.

Permethrin-treated materials retain repellency or insecticidal activity after repeated laundering but should be retreated, as described on the product label, to provide continued protection. Clothing that is treated before purchase is labeled for efficacy through 70 launderings. Clothing treated with the other repellent products described above (such as DEET) provides protection from biting arthropods but will not last through washing and will require more frequent reapplications.

Precautions when Using Insect Repellents

Travelers should take the following precautions:

  • Apply repellents only to exposed skin or clothing, as directed on the product label. Do not apply repellents under clothing.
  • Never use repellents over cuts, wounds, or irritated skin.
  • When using sprays, do not spray directly on face—spray on hands first and then apply to face. Do not apply repellents to eyes or mouth, and apply sparingly around ears.
  • Wash hands after application to avoid accidental exposure to eyes or ingestion.
  • Children should not handle repellents. Instead, adults should apply repellents to their own hands first, and then gently spread on the child’s exposed skin. Avoid applying directly to children’s hands. After returning indoors, wash your child’s treated skin and clothing with soap and water or give the child a bath.
  • Use just enough repellent to cover exposed skin or clothing. Heavy application and saturation are generally unnecessary for effectiveness. If biting insects do not respond to a thin film of repellent, apply a bit more.
  • After returning indoors, wash repellent-treated skin with soap and water or bathe. Wash treated clothing before wearing it again. This precaution may vary with different repellents—check the product label.

If a traveler experiences a rash or other reaction, such as itching or swelling, from an insect repellent, the repellent should be washed off with mild soap and water and its use discontinued. If a severe reaction has occurred, a local poison-control center should be called for further guidance, if feasible. Travelers seeking health care because of the repellent should take the repellent to the doctor’s office and show the doctor. Permethrin should never be applied to skin but only to clothing, bed nets, or other fabrics as directed on the product label.

Children and Pregnant Women

Most repellents can be used on children aged >2 months. Protect infants aged <2 months from mosquitoes by using an infant carrier draped with mosquito netting with an elastic edge for a tight fit. Products containing OLE specify that they should not be used on children aged <3 years. Other than the safety tips listed above, EPA does not recommend any additional precautions for using registered repellents on children or on pregnant or lactating women.

Useful Links


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There has been a recent resurgence in bedbug infestations worldwide, particularly in developed countries. Although bedbugs do not transmit diseases, their bites may be a nuisance. Travelers can take measures to avoid bedbug bites and avoid transporting them in luggage and clothing (Box 2-04).

Box 2-04. Bedbugs and international travel

A recent resurgence in bedbug infestations worldwide, particularly in developed countries, is thought to be related to the increase in international travel, pest control strategy changes in travel lodgings, and insecticide resistance. Bedbug infestations have been increasingly reported in hotels, theaters, and any locations where people congregate, even in the workplace, dormitories, and schools. Bedbugs may be transported in luggage and on clothing. Transport of personal belongings in contaminated transport vehicles is another means of spread of these insects.

Bedbugs are small, flat insects that are reddish-brown in color, wingless, and range from 1 to 7 mm in length. Although bedbugs have not been shown to transmit disease, their bites can produce strong allergic reactions and considerable emotional stress.

Protective Measures against Bedbugs

Travelers should be encouraged to take the following precautions to avoid or reduce their exposure to bedbugs:

  • Inspect the premises of hotels or other sleeping locations for bedbugs on mattresses, box springs, bedding, and furniture, particularly built-in furniture with the bed, desk, and closets as a continuous structural unit. Travelers who observe evidence of bedbug activity—whether it be the bugs themselves or physical signs such as blood-spotting on linens—should seek alternative lodging.
  • Keep suitcases closed when they are not in use and try to keep them off the floor.
  • Remove clothing and personal items (such as toiletry bags and shaving kits) from the suitcase only when they are in use.
  • Carefully inspect clothing and personal items before returning them to the suitcase.
  • Keep in mind that bedbug eggs and nymphs are very small and can be easily overlooked.

Prevention is by far the most effective and inexpensive way to protect oneself from these pests. The costs of ridding a personal residence of these insects are considerable, and efforts at control are often not immediately successful even when conducted by professionals.


  1. Barnard DR, Xue RD. Laboratory evaluation of mosquito repellents against Aedes albopictus, Culex nigripalpus, and Ochlerotatus triseriatus (Diptera: Culicidae). J Med Entomol. 2004 Jul;41(4):726–30.
  2. Fradin MS, Day JF. Comparative efficacy of insect repellents against mosquito bites. N Engl J Med. 2002 Jul 4;347(1):13–8.
  3. Goodyer LI, Croft AM, Frances SP, Hill N, Moore SJ, Onyango SP, et al. Expert review of the evidence base for arthropod bite avoidance. J Travel Med. 2010 May–Jun;17(3):182–92.
  4. Lupi E, Hatz C, Schlagenhauf P. The efficacy of repellents against Aedes, Anopheles, Culex and Ixodes—a literature review. Travel Med Infect Dis. 2013 Nov–Dec;11(6):374–411.
  5. Montemarano AD, Gupta RK, Burge JR, Klein K. Insect repellents and the efficacy of sunscreens. Lancet. 1997 Jun 7;349(9066):1670–1.
  6. Murphy ME, Montemarano AD, Debboun M, Gupta R. The effect of sunscreen on the efficacy of insect repellent: a clinical trial. J Am Acad Dermatol. 2000 Aug;43(2 Pt 1):219–22.
  7. Pages F, Dautel H, Duvallet G, Kahl O, de Gentile L, Boulanger N. Tick repellents for human use: prevention of tick bites and tick-borne diseases. Vector Borne Zoonotic Dis. 2014 Feb;14(2):85–93.
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Injury Prevention

Friday, August 5, 2016 // Prevention

David A. Sleet, David J. Ederer, Michael F. Ballesteros

According to the World Health Organization (WHO), injuries are among the leading causes of death and disability in the world, and they are the leading cause of preventable death in travelers. Among travelers, data show that injuries are one of the leading causes for consulting a physician, hospitalization, repatriation, and death. Worldwide, injuries are the leading cause of death for young people aged 15–29 years. Estimates have reported that 18%–24% of deaths among travelers in foreign countries are caused by injuries. Infectious diseases accounted for only 2% of deaths to travelers abroad. Contributing to the injury toll while traveling are exposure to unfamiliar and perhaps risky environments, differences in language and communications, less stringent product safety and vehicle standards, unfamiliar rules and regulations, a carefree holiday or vacation spirit leading to more risk-taking behavior, and overreliance on travel and tour operators to protect one’s safety and security.

From 2011 through 2013, an estimated 2,466 US citizens died from non-natural causes, such as injuries and violence, while in foreign countries (excluding deaths occurring in the wars in Iraq and Afghanistan). Motor vehicle crashes—not crime or terrorism—are the number 1 killer of healthy US citizens living, working, or traveling in foreign countries. From 2011 through 2013, 621 Americans died in road traffic crashes abroad (25% of all non-natural deaths to US citizens abroad). Another 555 were victims of homicide (23%), 392 committed suicide (16%), and 309 were victims of drowning (13%) (Figure 2-02( Other less common but serious injuries are related to natural disasters, aviation accidents, drugs, terrorism, falls, burns, and poisoning.

If a traveler is seriously injured, emergency care may not be available or acceptable by US standards. Trauma centers capable of providing optimal care for serious injuries are uncommon outside urban areas in many foreign destinations. Travelers should be aware of the increased risk of certain injuries while traveling or residing abroad, particularly in developing countries, and be prepared to take preventive steps.


Globally, an estimated 3,300 people are killed each day, including 720 children, in road traffic crashes involving cars, buses, motorcycles, bicycles, trucks, and pedestrians. Annually, 1.24 million are killed and 20–50 million are injured in traffic crashes—a number likely to double by 2030. Although only 53% of the world’s vehicles are in developing countries, >90% of road traffic casualties occur in these countries.

International efforts to combat road deaths command a tiny fraction of the resources deployed to fight diseases such as malaria and tuberculosis, yet the burden of road traffic injuries is comparable. In response to this crisis, in March 2010 the 64th General Assembly of the United Nations described the global road safety crisis as “a major public health problem” and proclaimed 2011–2020 as “The Decade of Action for Road Safety.” On April 19, 2012, the United Nations General Assembly adopted a new resolution (A/66/PV.106) to improve global road safety by implementing plans for the decade, setting ambitious targets, and monitoring global road traffic fatalities.

According to Department of State data, road traffic crashes are the leading cause of injury deaths to US citizens while abroad (Figure 2-02( Of the 621 US citizens killed in road traffic crashes from 2011 through 2013, approximately 110 (18%) deaths involved motorcycles. Unlike in the United States, in many countries, 2- and 3-wheeled vehicles outnumber cars, and travelers unfamiliar with driving or riding motorcycles may be at higher risk of crashing. Most non-natural American deaths in Thailand and Vietnam, popular travel destinations, were related to motorcycle use. Motorcycle use is also dangerous for travelers in countries where motorcycles are not the primary mode of transportation. The reported rate of motorbike injuries in Bermuda is much higher in tourists than in the local population, and the rate is highest in people aged 50–59 years. Motor vehicle rentals in Bermuda and some other small Caribbean islands are typically limited to motorbikes for tourists, possibly contributing to the higher rates of motorbike injuries. Loss of vehicular control, unfamiliar equipment, and inexperience with motorized 2-wheelers contributed to crashes and injuries, even at speeds <30 miles per hour.

Road traffic crashes are common among foreign travelers for a number of reasons: lack of familiarity with the roads, driving on the opposite side of the road, lack of seat belt use, the influence of alcohol, poorly made or maintained vehicles, travel fatigue, poor road surfaces without shoulders, unprotected curves and cliffs, and poor visibility due to lack of adequate lighting. In many developing countries, unsafe roads and vehicles and an inadequate transportation infrastructure contribute to the traffic injury problem. In many of these countries, motor vehicles often share the road with vulnerable road users, such as pedestrians, bicyclists, and motorcycle users. The mix of traffic involving cars, buses, taxis, rickshaws, large trucks, and even animals increases the risk for crashes and injuries.

Millions of US citizens travel to Mexico each year, and >150,000 people cross the US–Mexico border daily. Travelers should be particularly cautious in Mexico; from 2011 through 2013, 27% of all deaths of US citizens abroad occurred in that country, where >200 Americans died in road traffic crashes.

Strategies to reduce the risk of traffic injury are shown in Table 2-12( The Association for International Road Travel ( and Make Roads Safe ( have useful safety information for international travelers, including road safety checklists and country-specific driving risks. The Department of State has safety information useful to international travelers, including road safety and security alerts, international driving permits, and travel insurance (

Figure 2-02. Leading causes of injury death for US citizens in foreign countries, 2011-20131,2


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1Data from US Department of State. Death of US citizens abroad by non-natural causes. Washington, DC: US Department of State; 2014 [cited 2014 March 26]. Available from:

2Excludes deaths of US citizens fighting wars in Afghanistan or Iraq, and deaths that were not reported to the nearest US embassy or consulate.


Table 2-12. Recommended strategies to reduce injuries while abroad

Road Traffic Crashes
Lack of seat belts and child safety seats Always use safety belts and child safety seats. Rent vehicles with seat belts; when possible, ride in taxis with seat belts and sit in the rear seat; bring child safety seats and booster seats from home for children to ride properly restrained.
Driving hazards When possible, avoid driving at night in developing countries; always pay close attention to the correct side of the road when driving in countries that drive on the left.
Country-specific driving hazards Check the Association for Safe International Road Travel website for driving hazards or risks by country (
Motorcycles, motor bikes, and bicycles Always wear helmets (bring a helmet from home, if needed). When possible, avoid driving or riding on motorcycles or motorbikes, including motocycle and motorbike taxis. Traveling overseas is a bad time to learn to drive a motorcycle or motorbike.
Alcohol-impaired driving Alcohol increases the risk for all causes of injury. Do not drive after consuming alcohol, and avoid riding with someone who has been drinking.
Cellular telephones Do not use a cellular telephone or text while driving. Many countries have enacted laws banning cellular telephone use while driving, and some countries have made using any kind of telephone, including hands-free, illegal while driving.
Taxis or hired drivers Ride only in marked taxis, and try to ride in those that have safety belts accessible. Hire drivers familiar with the area.
Bus travel Avoid riding in overcrowded, overweight, or top-heavy buses or minivans.
Pedestrian hazards Be alert when crossing streets, especially in countries where motorists drive on the left side of the road. Walk with a companion or someone from the host country.
Other Tips
Airplane travel Avoid using local, unscheduled aircraft. If possible, fly on larger planes (>30 seats), in good weather, during the daylight hours, and with experienced pilots. Children <2 years should sit in a child safety seat, not on a parent’s lap. Whenever possible, parents should travel with a safety seat for use before, during, and after a plane ride.
Drowning Avoid swimming alone or in unfamiliar waters. Wear life jackets while boating or during water recreation activities.
Burns In hotels, stay below the sixth floor to maximize the likelihood of being rescued in case of a fire. Bring your own smoke alarm.



Drowning accounts for 13% of all deaths of US citizens abroad. Although risk factors have not been clearly defined, these deaths are most likely related to unfamiliarity with local water currents and conditions, inability to swim, and the absence of lifeguards on duty. Rip currents can be especially dangerous, as are sea animals such as urchins, jellyfish, coral, and sea lice. Alcohol also contributes to drowning and boating mishaps.

Drowning was the leading cause of injury death to US citizens visiting countries where water recreation is a major activity, such as Fiji, the Bahamas, Jamaica, and Costa Rica. Young men are particularly at risk of head and spinal cord injuries from diving into shallow water, and alcohol is a factor in some cases.

Boating can be a hazard, especially if boaters are unfamiliar with the boat, do not know proper boating etiquette or rules for watercraft navigation, or are new to the water environment in a foreign country. From 2011 through 2013, maritime accidents accounted for 8% of deaths to healthy Americans abroad. Many boating fatalities result from inexperience or failure to wear lifejackets.

Scuba diving is a frequent pursuit of travelers in coastal destinations. The death rate among all divers worldwide is thought to be 15–20 deaths per 100,000 divers per year. Travelers should either be experienced divers or dive with a reliable dive shop and instructors. See the Scuba Diving( section later in this chapter for a more detailed discussion about diving risks and preventive measures.


From 2011 through 2013, aviation incidents, drug-related incidents, and deaths classified as “other unintentional injuries” accounted for 22% of deaths to healthy US citizens abroad (Figure 2-02( Fires can be a substantial risk in developing countries where building codes do not exist or are not enforced, there are no smoke alarms, there is no access to emergency services, and the fire department’s focus is on putting out fires rather than on fire prevention or victim rescue.

Travel by local, lightweight aircraft in many countries can be risky. From 2011 through 2013, an estimated 82 US citizens abroad were killed in aircraft crashes. Travel on unscheduled flights, in small aircraft, at night, in inclement weather, and with inexperienced pilots carries the highest risk.

Before flying with children, parents and caregivers should check to make sure that their child restraint system is approved for use on an aircraft. This approval should be printed on the system’s information label or on the device itself. The Federal Aviation Administration (FAA) recommends that a child weighing <20 lb use a rear-facing child restraint system. A forward-facing child safety seat should be used for children weighing 20–40 lb. FAA has also approved a harness-type device for children weighing 22–44 lb.

Travel health providers, vendors of travel services, and travelers themselves should consider the following:

  • Purchasing special travel health and medical evacuation insurance if their destinations include countries where there may not be access to good medical care (see the Travel Insurance, Travel Health Insurance, & Medical Evacuation Insurance section later in this chapter).
  • Because trauma care is poor in many countries, victims of injuries and violence can die before reaching a hospital, and there may be no coordinated ambulance service available. In remote areas, medical assistance and modern drugs may be unavailable, and travel to the nearest medical facility can take a long time.
  • Adventure activities, such as mountain climbing, skydiving, whitewater rafting, dune-buggying, and kayaking, are popular with travelers. The lack of rapid emergency trauma response, inadequate trauma care in remote locations, and sudden, unexpected weather changes that compromise safety and hamper rescue efforts can delay access to care.
  • Travelers should avoid using local, unscheduled, small aircraft. If available, choose larger aircraft (>30 seats), as they are more likely to have undergone more strict and regular safety inspections. Larger aircraft also provide more protection in the event of a crash. For country-specific airline crash events, see
  • When traveling by air with young children, consider bringing a child safety seat approved for use on an aircraft.
  • To prevent fire-related injuries, travelers should select accommodations no higher than the sixth floor. (Fire ladders generally cannot reach higher than the sixth floor.) Hotels should be checked for smoke alarms and preferably sprinkler systems. Travelers may want to bring their own smoke alarm. Two escape routes from buildings should always be identified. Crawling low under smoke and covering one’s mouth with a wet cloth are helpful in escaping a fire. Families should agree on a meeting place outside the building in case a fire erupts.
  • Improperly vented heating devices may cause poisoning from carbon monoxide. Carbon monoxide at the back of boats near the engine can be especially dangerous. Travelers may want to carry a personal detector that can sound an alert in the presence of this lethal gas.
  • Travelers should consider learning basic first aid and CPR before travel overseas with another person. Travelers should bring a travel health kit, which should be customized to the anticipated itinerary and activities (see the Travel Health Kits section later in this chapter).
  • Suicide is the third-leading cause of injury death to US citizens abroad, accounting for 16% of non-natural deaths. For longer-term travelers (such as missionaries and volunteers), social isolation and substance abuse, particularly while living in areas of poverty and rigid gender roles, may increase the risk of depression and suicide. See the Mental Health( section later in this chapter for more detailed information.


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