East and West, Home Is Best? A Questionnaire‐Based Survey on Mortality of Dutch Travelers Abroad

Arina C. Groenheide MHS, Perry J.J. van Genderen MD, PhD, David Overbosch MD, PhD
DOI: http://dx.doi.org/10.1111/j.1708-8305.2010.00479.x 141-144 First published online: 1 March 2011


A questionnaire‐based survey on the mortality of Dutch travelers abroad revealed that travel outside of Europe carried an increased mortality risk predominantly caused by fatal cardiovascular events and traffic accidents rather than fatal infections. Discussion of these items should receive a prominent place in our travel health consultation.

Up to 50% of the people who travel from the industrialized world to developing countries may experience some kind of ailment. Although most illnesses reported by travelers are mild, 1% to 5% of travelers become ill enough to seek medical attention during or after traveling and 0.01% to 0.1% require medical evacuation. 1,2 Fortunately, the death rate is low. A number of studies have examined the death rate of their citizens abroad, mostly using national foreign affairs data 3–18 or observational studies. 19 Unlike many Western countries, there are no data available on the numbers and causes of death of Dutch citizens abroad, even though countless of Dutch travelers visit destinations outside the Netherlands each year. This lack of information is mostly a result of the absence of a mandatory registration system of Dutch citizens who died abroad.

Although the death rate of citizens abroad remains an important indicator of a country's safety profile, it can—from an alternative point of view—also be considered as the end point of accumulation of personal risk factors, including traveler's personal health and behavior, which may be preventable to a certain extent. Detailed knowledge on these causes of death of travelers abroad is needed to accurately estimate these health risks. Moreover, this information may also be used as an important feedback tool to improve the quality and focus of our current travel health consultation and preparation. The aim of this study is to provide more insight in the number and causes of death of Dutch citizens abroad in relation to their travel destination.


In 2009, we performed a questionnaire‐based survey among all Dutch general physicians. The questionnaire dealt with the following six items: (1) Do you give pretravel advice and to how many persons? (2) How many of your clients in your practice died abroad in the years 2007 and 2008? (3) What was the country of death? (4) What was the cause of death? (5) What was the age and gender of the deceased? and (6) Do you have any additional information on the cause of death?

All countries were classified in regions, according to the designated six World Health Organization (WHO) regions (available at http://www.who.int/about/regions/en/). These six regions were the European region including Turkey, Russia, and Greenland; the region of the Americas, both North America and South America; the African region, the whole continent apart from Morocco, Tunisia, Sudan, Somalia, and Egypt; the Eastern Mediterranean region including the Middle East and Morocco, Tunisia, Sudan, Somalia, and Egypt; the Southeast Asian region with also India, Indonesia, Thailand, and Sri Lanka; and the Western Pacific region including countries like China, Japan, Malaysia, New Zealand, and Australia.

Demographic data, numbers and causes of deaths, and the countries of death were statistically analyzed using SPSS (v.15.0) software (SPSS Inc., Chicago, IL, USA). The number of Dutch travelers to all countries and regions in the world was obtained from the World Tourist Organization (available at http://www.e-unwto.org/home/main.mpx). Mortality rates were expressed in an odds ratio (OR) with a 95% confidence interval (CI) of a specific WHO region in comparison to the risk of mortality in Europe. Chi‐square test was used for statistical comparison of OR between various designated WHO regions. p Values <0.05 were considered to represent a statistically significant difference.


Of a total of 6,395 questionnaires that were sent, 1,818 were returned giving a response rate of 28.4%. A total of 235 deaths were reported while traveling abroad for the years 2007 and 2008. The majority of deaths occurred in the European region (n = 132; 56.2%), followed by the Eastern Mediterranean region (n = 40; 17.0%), the region of the Americas (n = 20; 8.5%), the African region (n = 16; 6.8%), the Southeast Asian region (n = 15; 6.4%), and the Western Pacific region (n = 12; 5.1%). The median age of death was 58 years (range 7 wk to 92 y). The absolute number of deaths increased with age. The number of deaths was the highest in the age category >59 years with a total of 83 deaths (35.3% of all deaths). In all age categories a male preponderance was noted. The predominant causes of death of Dutch travelers were cardiovascular events (n = 131; 55.7%), followed by fatal accidents (n = 33; 14.0%) and fatal infections (n = 16; 6.8%), as shown in Table 1. Traumatic injuries leading to death were usually reported to be a consequence of local driving conditions and unfamiliarity with the roads. Other reported causes of fatalities were related to interaction with marine wildlife and adventure activities. Fatal infections were usually caused by a bacterial disease (pneumonia in five cases, meningitis in three cases, salmonella infection in two cases, and streptococcal disease in one case), followed by parasitic infections (malaria in three cases), whereas viral diseases were rare (rabies in one case). The group of “other causes of death” constituted of various causes including terminal oncological disease and psychological conditions like suicide.

View this table:
Table 1

Number and causes of death of Dutch travelers abroad in 2007 and 2008

WHO regionCardiovascular causeFatal accidentsFatal infectionsOther causesNumber of travelers*Death rate per 100,000 travelers
European region861352848,524,0910.27
Eastern Mediterranean region159214775,5895.15
Region of the Americas94162,005,7900.99
African region6442382,3794.18
Southeast Asian region7224614,4072.44
Western Pacific region8121690,7721.74
Total131 (55.7%)33 (14.0%)16 (6.8%)55 (23.4%)52,993,028

When the various death causes were related to the actual number of travelers to a certain WHO region, travel outside the European WHO region was associated with a significantly increased risk for mortality compared to traveling within Europe, as is shown in Figure 1 and Table 2. The findings of the risk profile of traveling to the African region are certainly noteworthy, as this was associated with a 25‐fold increased mortality risk due to a cardiovascular event, a 40‐fold increased risk for a fatal accident and a more than 100‐fold increased risk for a fatal infection as compared with travel within Europe, respectively. Travel to the Eastern Mediterranean region was also associated with a more than 40‐fold increased risk for a fatal accident and a more than 25‐fold increased risk for a fatal infection, whereas travel to the Southeast Asian region was particularly characterized by an increased risk for death due to a fatal infection, respectively.

Figure 1

Odds ratios (ORs) for death associated with travel to various World Health Organization regions in comparison to travel within Europe. Various graphs show the ORs for death by all causes (top left), cardiovascular deaths (top right), fatal accidents (bottom left), and fatal infections (bottom right), respectively. ORs are given as mean and 95% confidence intervals.

View this table:
Table 2

Comparison of OR for all‐cause mortality in a designated WHO‐defined region as compared with the OR for mortality in the European region

WHO regionEuropean regionRegion of AmericasAfrican regionEastern Mediterranean regionSoutheast Asian regionWestern Pacific region
European regionNA33.25 (p < 0.001)190.40 (p < 0.001)494.58 (p < 0.001)94.62 (p < 0.001)49.49 (p < 0.001)
Region of Americas33.25 (p < 0.001)NA21.64 (p < 0.001)42.85 (p < 0.001)7.35 (p = 0.007)2.37 (p = NS)
African region190.40 (p < 0.001)21.64 (p < 0.001)NA0.38 (p = NS)2.30 (p = NS)5.65 (p = 0.017)
Eastern Mediterranean region494.58 (p < 0.001)42.85 (p < 0.001)0.38 (p = NS)NA5.90 (p = 0.015)11.38 (p = 0.001)
Southeast Asian region94.62 (p < 0.001)7.35 (p = 0.007)2.30 (p = NS)5.90 (p = 0.015)NA0.78 (p = NS)
Western Pacific region49.49 (p < 0.001)2.37 (p = NS)5.65 (p = 0.017)11.38 (p = 0.001)0.78 (p = NS)NA
  • Data are given as chi‐square (p value). A p value <0.05 was considered to represent a statistical significant difference.

  • OR = odds ratio; NS = not significant; NA = not applicable; WHO = World Health Organization.


The findings of our questionnaire‐based survey suggest that travel outside Europe carries a higher mortality risk for Dutch travelers, and the majority of these deaths are related to cardiovascular disease and accidents rather than fatal infections. In absolute terms, cardiovascular events were reported as the most frequent cause of death among Dutch citizens abroad and they occurred mainly in the European region where the majority of Dutch citizens spent their vacations. As might be expected for cardiovascular deaths, the mortality rate increased with age and occurred more frequently in males. It is certainly interesting to note that travel to destinations outside Europe was associated with an even higher mortality risk when the absolute number of travelers to a designated WHO region was taken into account. This finding was particularly prominent for travelers to Africa. These observations suggest that environmental changes like a tropical climate and changes in physical activity associated with vacation pose a serious challenge to the cardiovascular system of the traveler. These findings are in line with reports of fatalities among American, 3,7,8 New Zealand, 4,5 Scottish, 12 Canadian, 10,11 and Australian 14 citizens, who also consistently show that cardiovascular problems are the leading causes of natural deaths abroad.

In addition, travel to Africa also carries a higher mortality risk due to a fatal injury or accident. A plausible explanation might be that severe traffic accidents are more common in these regions, given a recent WHO global status report on road safety (available at http://www.who.int/violence_injury_prevention/road_safety_status/2009/en/index.html). For illustration, over 90% of the world's fatalities on the roads occur in low‐income and middle‐income countries, which have less than half of the world's vehicles. In our study, local driving conditions and unfamiliarity with roads were frequently reported as precipitating factors contributing to fatal traffic accidents. Other precipitating conditions that related to injury death were interaction with marine wildlife and adventure activities. These findings are in line with the findings of a study of United Nations Transition Assistance Group mission in Namibia in which a fatality rate of 0.21 per million km driven was found, which was more than 10‐fold higher as the fatality rate recorded in military population in industrialized countries. 19 Interestingly, the high fatality rate in Namibia occurred despite the absence of dense traffic.

Infectious diseases, although a common cause of illness among travelers, are usually not reported as a frequent cause of death. Nevertheless, travel to Africa and Southeast Asia was associated with a significantly increased risk of death due to a fatal infection as compared with travel within Europe. As in most countries, the prevention of these infections is subject of discussion in our current travel health advice and the success of this approach may be exemplified by the reassuringly low number of fatal infections in our survey and in those of others. However, the results of our study also suggest that our travel health advice should not be limited to discussion of the prevention of infectious diseases. In our opinion, the risk assessment should also include the discussion of the impact of (subclinical) cardiovascular disease as well as the means and safety of transport abroad. This may be particularly relevant for the elderly Dutch traveler who plans to travel to destinations outside of Europe. However, before we come to a definite conclusion, it should also be noted that our study may have had significant methodological limitations like a suboptimal response rate and possibly a recall and response bias, which may limit the generalization of our findings and raise a need for properly designed, confirmative studies.


This study was financially supported by a grant of the Port of Rotterdam. The mailing of the questionnaires was made possible by an unconditional grant of GlaxoSmithKline. Ms K. Spong is acknowledged for English text editing.

Declaration of Interests

D. O. and P. J. J. v. G. received speaker's fee from GlaxoSmithKline as well as reimbursements for attending symposia. A. C. G. states that she has no conflicts of interest to declare.


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