Overseas Visitor Deaths in Australia, 2001 to 2003

Peter A. Leggat MD, PhD, DrPH, FAFPHM, FACTM, FFTM  ACTM, FFTM  RCPSG, FACRRM, Jeff Wilks PhD, LLB (Hons), MAPS
DOI: http://dx.doi.org/10.1111/j.1708-8305.2009.00302.x 243-247 First published online: 1 July 2009

Abstract

Background The health and safety of international visitors remain an important issue for Australia and other tourist destinations. The death of visitors remains an important indicator of safety. The aim of this study was to provide updated figures on deaths of overseas travelers in Australia.

Methods Data were sourced from the Australian Bureau of Statistics concerning deaths of overseas visitors for the years 2001 to 2003.

Results There were 1,068 overseas visitor deaths (701 males, 66%) during the study period 2001 to 2003. Death by natural causes increased with age, while deaths associated with accidents were more frequent among younger age groups. The majority of deaths were from natural causes (782, 73%), particularly ischemic heart diseases (26%). There were a total of 247 accidental deaths (23% of all deaths) with the main causes being transportation accidents (14% of all deaths) and accidental drowning/submersion (5% of all deaths). The countries contributing the most deaths were the UK (247, 23%), New Zealand (108, 10%) Melanesia/Micronesia (95, 9%), and the United States (57, 5%).

Conclusions Australia remains a relatively safe destination for international travelers, at least in terms of fatalities, which appear to be declining. Most deaths of overseas tourists in Australia are due to natural causes with cardiovascular disease being the predominant cause of death in this group. Accidents remain the most common preventable cause of death of travelers, with road and water safety being the major issues. It is important that tourism and travel medicine groups continue to advocate for improved health and safety of international travelers visiting Australia.

Globally, it was expected that there would be a record of 1 billion international tourist arrivals in 2007.1 It is known that about 50% or more of travelers suffer from some kind of illness, injury, or malaise while they are traveling.2 Common problems among travelers include gastrointestinal illness, which affects up to 50% or more of travelers.2 Fortunately, few travelers die,2 however, each death represents a major concern for travel health advisors and tourism authorities alike. A number of studies have examined the deaths of nationals abroad, mostly using national foreign affairs data. Reports of fatalities among Australian,3 American,4,5 Scottish,6 and Canadian citizens7,8 consistently show that cardiovascular problems were the leading cause of natural death. Accidents or traumatic injuries account for up to 25% of deaths, with motor vehicle accidents and water‐related incidents being the main sources of fatal injury.9,10 Homicides, suicides, and poisonings were also substantial causes of death among travelers, although this varied considerably across the various studies. Interestingly, infectious disease, although a common cause of illness among travelers, was not a commonly reported cause of death.3–8

In general terms, Australia is considered a safe destination for travelers.11 The country has high standards in public health, clean drinking water, a low level of infectious disease, and a well‐equipped and coordinated medical system,9 as evidenced by the holding of the Olympic and Paralympic Games in 2000.12 In 2005 and 2006, Australia attracted more than 5.5 million international visitors each year.13 To maintain a country’s reputation as a safe destination and to identify potential areas where overseas visitors may experience health and safely problems, it is important to monitor available statistics on illness and injury of travelers. Travelers in particular remain concerned about their personal safety.14

Previously, there have been some studies examining serious injuries of travelers coming to Australia. These studies have examined Australian hospital data and have found that motor vehicle accidents and water‐related incidents are major causes of traveler injuries requiring hospitalization.15,16 Major medical conditions requiring hospitalization included circulatory disorders and gastrointestinal problems.15 However, little had been published concerning deaths of inbound travelers, including Australia, until a study by Wilks and colleagues,17 which found that about three‐quarters of deaths were due to natural causes and accidental deaths accounted for most of the remainder during the period 1997 to 2000. The aim of this study was to provide updated figures on deaths of inbound travelers in Australia.

Methods

The Australian Bureau of Statistics (ABS) processes around 130,000 deaths annually. There is a decentralized registration process, with each of the eight State and Territories’ Registrars of Births, Deaths and Marriages being responsible by law for the registration of deaths occurring within their boundaries. The ABS receives from each State or Territory Registrar details for each death as provided on the Medical Certificate of Cause of Death. Generally, the attending medical practitioner certifies the Medical Certificate of Cause of Death where death is due to a natural cause. Deaths that are sudden and unexpected, and most deaths due to external causes, are subject to coronial enquiry, and a coroner then certifies the death certificate.

Experienced mortality coding staff within the ABS use the Automated Coding System provided by the United States National Center for Health Statistics to code information from the Medical Certificate of Cause of Death in accordance with the appropriate version of the International Classification of Diseases (ICD). ICD‐1018 was introduced for coding of deaths registered from 1999.

The present study involved a retrospective analysis of all deaths of those designated as overseas visitors, occurring in Australia over the 3 years from 2001 to 2003. The data selected for this study were chosen on the basis of a usual residence code of “overseas.” Cause of death was then grouped according to the chapters of ICD‐10. Following ABS policy, small cell sizes have not been reported for reasons of confidentiality.

Results

There were 1,068 overseas visitor deaths (701 males: 66%) during the study period 2001 to 2003. Table 1 shows that death by natural causes increased with age, particularly with visitors older than 50 years, while deaths associated with accidents were more frequent among younger people, especially the 15 to 24 and 25 to 34 years age groups.

View this table:
Table 1

Number of deaths for usual residence overseas by 10‐year age groups and cause of death, Australia, 2001 to 2003

Age (years)MaleFemalePersonsNatural causesAccidentsExternal causes
0–14141529npnpnp
15–24662591235668
25–347935114327182
35–44541973422531
45–5494441381072731
55–64110641741432731
65–74143792222031719
75–84122651871731414
85+192039npnpnp
All ages701367*1068*782247*286*
  • np = not published; following Australian Bureau of Statistics protocol, these cells not published due to small cell size and confidentiality.

  • * Includes “not stated.”

  • “External causes” includes accidental deaths, intentional self‐harm (suicide), homicide and events of undetermined intent (ie, the coroner is unable to make a determination of intent).

Table 2 shows that the majority of deaths were from natural causes (782, 73%), particularly ischemic heart diseases (26%) and malignant neoplasms (15%). There were a total of 247 accidental deaths (23% of all deaths) with the main causes being transportation accidents (14% of all deaths) and accidental drowning/submersion (5% of all deaths). For this group of overseas visitors, there were 27 deaths by suicide (3%) and 8 homicides over the 3‐year study period. Homicides are not specifically identified in Table 2 but are included in the “all causes” figures.

View this table:
Table 2

Number of deaths for usual residence overseas by cause of death, Australia, 2001 to 2003

CauseMalesFemalesPersons
Total natural causes507275782
 Ischemic heart disease20468272
 Malignant neoplasms8876164
 All other natural causes200115315
Total accidents16681247
 Transport accidents9253145
 Accidental drowning and submersion411253
 All other accidents331649
Total suicides21627
All causes*701 (66%)367 (34%)1068 (100%)
  • * “All causes” includes natural and accidental deaths, intentional self‐harm (suicide), homicide, and events of undetermined intent (ie, the coroner is unable to make a determination of intent).

Table 3 shows the number and causes of death by usual residence of overseas visitors. Within Oceania, the largest number of deaths involved New Zealand (108, 10%) and Melanesian/Micronesian visitors (95, 9%). For Europe, visitors from the UK predominated (247, 23%), with natural causes (193 cases) being the main cause of death. For Asia, no one country predominated in mortality of overseas visitors to Australia. Deaths by country of residence included 41 from Japan, 37 from India, 34 from China, and 27 from the Philippines. Again, “natural causes” was the leading cause of death of Asian travelers to Australia. For the Americas, the United States predominated (57 deaths, 5%), with natural causes being the main cause of death.

View this table:
Table 3

Number of deaths of usual residence overseas by area of birth and cause of death, Australia, 2001 to 2003

Country of birthNatural causesTransportDrowningOtherAll accidents
Australia27npnpnpnp
New Zealand8810npnp20
New Caledonia47npnpnpnp
Papua New Guinea10npnpnpnp
Nauru13npnpnpnp
Fiji25npnpnpnp
Oceania total2101041226
UK19331121154
Ireland104048
France110044
Germany25114520
The Netherlands1012npnp17
Switzerland8npnpnpnp
Italy54059
Europe total262682130119
Indonesia15npnpnpnp
Malaysia22npnpnpnp
Philippines185049
Singapore9np0np5
China14105520
Japan2368418
Korea8npnpnpnp
India2640011
Asia total13532142074
Canada9np0np8
United States4444513
Americas total5394821
South Africa10npnpnpnp
African total10npnpnpnp
Others11025121350
  • np = not published; following Australian Bureau of Statistics protocol, these cells not published due to small cell size and confidentiality.

Discussion

It is important that significant tourist destinations, such as Australia, are able to accurately describe the extent of illness and injury affecting their overseas visitors. This investigation shows that the average number of deaths of overseas visitors to Australia has dropped from 378 per year for the period 1997 to 2000 to 356 per year for the period 2001 to 2003,17 although this may have been in part due to a slight drop in international tourist arrivals from 4.86 m in 2001 to 4.75 m in 2003 following a slight rise from 4.32 m in 1997 to 4.93 m in 2000, possibly due to external events such as terrorism and the emergence of severe acute respiratory syndrome.13

Natural causes continued to account for the majority of deaths, which is consistent with the previous study by Wilks and colleagues17 and a slightly higher rate compared with studies of deaths of travelers abroad, in particular, from Canada,7,8 the United States,4,5 Australia,3 and Scotland.6 Deaths due to cardiovascular disease predominate, however, the 15% of deaths due to malignant neoplasms, while consistent with the previous Australian study,17 is not reported in studies from other countries. Suicides remain a relatively uncommon cause and the homicide rate in this study was low (eight cases over 3 y). Indeed, as noted by Venditto and Mouzos from their investigation of visitor deaths for the Australian Institute of Criminology19 : “it can be said with reasonable conviction that the murder of overseas visitors in Australia is a statistically rare event” (p. 5). In that study, between 1994 and 2003, the murder rate of tourists was 0.9 per million short‐term visitors to Australia.

As predicted, motor vehicle crashes and water‐related incidents were the leading causes of accidental death in this study. Several of the visitor nationalities that had a higher proportion of transport‐related deaths came from Germany, the Netherlands, China, and Japan, some of which were identified as possible “high‐risk” road users in a previous transport study.20 A number of these nationalities were also identified in the 1997 to 2000 study of overseas visitor deaths in Australia.17 These groups generally drive on the opposite (right) side of the road in their home countries. Side of the road/side of the car familiarity has previously been identified as a factor in serious overseas visitor road crashes, along with fatigue, not wearing a seatbelt, language and signage difficulties, and generally driving unfamiliar vehicles in unfamiliar environments.21 Continuing attention to overseas visitor road safety in Australia is very important.

Accidental drowning was the second most frequent type of injury death. A study of surf drowning deaths by Morgan and colleagues found that international tourists had an annual average crude surf beach drowning rate of 2.36 per 100,000 population, corrected for average number of days of travel in Australia, representing almost 25% of the drowning deaths reported.22 Mackie notes that unfamiliar marine environments are a particular hazard for international tourists.23 In 2001 to 2003, 53 tourists from at least 23 countries drowned in Australia (approximately 18 per year), which is a higher rate than that for 1997 to 2000 (15.5 per year).17 In the present study, as a proportion, tourists from Japan, China, and Germany seemed to be at greater risk, although the highest number of overseas tourist deaths due to drowning came from the UK.

Identifying those visitor groups who are potentially “at risk” should assist health and tourism authorities to present appropriate safety information in the language of the target group and to ensure this information is made available to visitors before they leave home and when they arrive.9 In particular, the message must be communicated that those enjoying the expansive coastal beaches of Australia should swim in areas patrolled by the iconic Surf Lifesavers.24 Because Australia is a travel destination that promotes water‐related activities25 and because the water is an unfamiliar environment for tourists from many of our source countries,26 water safety remains a priority area for the pretravel health consultation and worthy of mention in travel advisories. This was supported by a review of coronial inquests in Australia, which concluded that “Static signage and general safety information brochures will only be effective if they are drawn to the attention of visitors, ideally before, or at least on arrival, at the particular destination” (p. 52).27 This parallels the issues in scuba diving where the focus in recent years has been ensuring that an appropriate assessment of medical fitness of divers is conducted before diving.28 Although yet to be formally evaluated, particularly for other at‐risk groups, examples of significant tourist water safety initiatives undertaken by Surf LifeSaving Australia for the Japanese inbound market have been described elsewhere.29 Wider public access to semiautomated external defibrillators in Australia, including among Surf LifeSaving and other first responder groups, such as St John Ambulance Australia, may also assist travelers.

The geographical base of overseas visitor fatalities partly reflects visitor numbers from source markets into Australia. For example, in the year 2005, the main inbound short‐term international visitor arrival groups were from New Zealand (1,075,800), UK (734,200), Japan (651,000), the United States (456,100), and Mainland China (308,500).13 However, it is possible to state with some confidence that Australia appears to be a relatively safe travel destination for a number of reasons: the number of deaths per year is reducing, the proportion of natural deaths among overseas visitors (73%) is higher than that reported elsewhere, and death by homicide appears to be less common.4–8,19,30 The current rate of homicides appears less common when compared with the earlier Australian study.17 Calculating crude death rates was not practical in this research because it was impossible to distinguish short‐term or long‐term visitors to identify overseas visitors who were in Australia for elective medical treatment or who were medically evacuated from another destination. A number of countries, including Ireland, New Zealand, UK, Sweden, Finland, Norway, the Netherlands, Malta, and Italy, have negotiated reciprocal health care agreements for medically necessary emergency treatment in Australia.31 Indeed, this emphasizes once again the importance of inbound travelers having appropriate travel insurance.

This study also has a number of other limitations. It is a cross‐sectional study examining retrospectively collected data taken from death certificates from the period 2001 to 2003. It is also not possible to determine the extent to which preexisting illnesses contributed to these figures, especially for deaths due to natural causes, but it is presumed that it was a major contributor.

Conclusions

Australia remains a relatively safe destination for international travelers, at least in terms of fatalities, which appear to be declining. Most deaths of overseas tourists in Australia are due to natural causes with cardiovascular disease being the predominant cause of death in this group. Accidents remain the most common preventable cause of death of travelers with road and water safety being the major issues. It is important that tourism and travel medicine groups continue to advocate for improved health and safety of international travelers visiting Australia, including appropriate pretravel health and safety advice for inbound tourists.

Declaration of interests

The authors state that they have no conflicts of interest.

Acknowledgments

The authors are most grateful for the kind assistance of the ABS.

References

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