Death in Venice — And Other Parts of the World

By Carol A. Kemper, MD, FACP

Dr. Kemper reports no financial relationship relevant to this field of study. This article originally appeared in the August 2007 issue of Infectious Disease Alert. It was edited by Stan Deresinski, MD, FACP, and peer reviewed by Connie Price, MD. Dr. Deresinski is Clinical Professor of Medicine, Stanford University; Associate Chief of Infectious Diseases, Santa Clara Valley Medical Center, and Dr. Price is Assistant Professor, University of Colorado School of Medicine. Dr. Deresinski serves on the speaker's bureau for Merck, Pharmacia, GlaxoSmithKline, Pfizer, Bayer, and Wyeth, and does research for Merck. Dr. Price reports no financial relationship relevant to this field of study.

Source: MacPherson DW et al. Death and International Travel - The Canadian Experience: 1996-2004. J Trav Med 2007, 14 (2), 77-84.

Data suggest that death during international travel is increasing, in part because of wilderness and adventure travel, but also because more and more people are traveling. Deaths abroad have considerable impact on friends and family, as well as the pocketbook. As part of the Secure Integrated Global Network established in 1993, the Consular Services Bureau, part of the Foreign Affairs Office in Canada, tracks Canadian deaths abroad, including the cause of death, sex and age. Specific data on the purpose of travel, or whether work or pleasure related was not always available.

From 1996-2004, 2,410 Canadians died while traveling abroad. Interestingly, deaths in the United States (297), Germany (240) and China (115) topped the list, far exceeding deaths in Africa (95), generally considered a riskier destination. Two-thirds of the deaths occurred in men, and the average age was just over 60 years (range, 0 to 101). Natural causes of death occurred in 73%, followed by accidental death in 19%, murder in 4% and suicide in 4%. People who died of natural causes averaged age 66 compared with those who died by accident (45 years), murder (43 years), or suicide (41 years). Annual increases in accidental deaths were observed, most likely because of wilderness and adventure travel.

In examining the top 15 destinations for 2004, deaths per 1000 visits were greatest for China (241), Mexico (82), Italy (43), Japan (31), and Spain (30). Obviously the causes and risks for each of these countries vary considerably, but it is of interest that travel to China was associated with such significant risk.

It would be useful if pre-travel medicine could address these issues but the authors found that most pre-travel advice, vaccines, anti-malarials and diarrhea management would not have prevented most of these fatalities. Violent deaths from vehicular accidents remain a significant problem; traffic fatalities and injuries affect 1.2 million and 50 million persons annually around the world, and are expected to increase 65% during the next 2 decades. Murder was generally associated with robbery, assault, or sexual violence, and aside from usual advice to use common sense, there is little that travel practitioners can offer. Little is known about whether suicides, an unexpected cause of death in 4% of international Canadian travelers, were pre-planned, occurred in persons with mental illness, or as the result of some travel-related event.

Two items that travel practitioners should include in their list for discussion are verification of insurance coverage during illness abroad (for example, some travel insurance provides only limited coverage or coverage solely for "emergencies" with a cap); as well as providing advanced directive, power of attorney and directions on handling remains. For example, shipping a whole body is hugely expensive whereas cremation is inexpensive.