New research reveals that, while fewer Americans are dying abroad overall, the risk of fatal accidents is on the rise, underscoring the need for smarter travel choices and updated safety advice.
Study: Analysis of the Non-Natural Deaths of US Citizens While Abroad. Image Credit: Bilanol / Shutterstock
In a recent study published in the Journal of Travel Medicine, a group of researchers measured how proportional mortality ratios (PMRs) and passenger-adjusted death rates for injury-related fatalities among United States (US) citizens overseas changed by region between 2003 and 2012, and 2013 and 2022.
The study focused on whether relative risks for injury-related deaths among US citizens abroad have changed over time, and how these risks vary by world region and income classification.
Background
Every day, almost 200,000 US citizens leave the country, but headlines still favor exotic pathogens over injuries. Historical analyses show that road crashes, assaults, and drownings kill more travelers than infections, and PMRs often exceed one, indicating greater relative risk abroad.
Existing literature suggests that travelers may have higher fatal injury risks than the local population, particularly for road crashes and certain violent incidents. Although factors such as increasing travel and potentially riskier traveler behaviors have been discussed in previous research, the original article does not directly attribute risk shifts to "rapid growth in budget airlines, social-media–driven adventure tourism, and revenge travel since COVID-19," so these explanations should be considered speculative rather than definitive findings of the study.
Further research is needed to clarify whether and where injury threats are increasing, so that advisories and insurance policies remain relevant for contemporary travelers and planners.
About the study
Researchers extracted records of non-natural deaths of US citizens from the US Department of State- Bureau of Consular Affairs database (October 2002-December 2022) and harmonized country names with World Bank income-region codes.
They then merged these data with cause-specific mortality counts from the World Health Organization (WHO) Mortality Database and outbound passenger numbers from the US Department of Transportation (DOT) International Passenger Flow file. Causes of death in the two sources were reconciled into twelve categories, aligning with prior travel medicine work.
A model built in the Power Business Intelligence platform linked year, region-income group, and cause, enabling calculation of PMRs and deaths per 100,000 outbound passengers. Statistics were generated for two equal ten-year blocks: 2003-2012 and 2013-2022.
Analysis of Variance (ANOVA) was used to examine whether period, region, or their interaction explained variance in PMRs or passenger-adjusted death rates. 95% Confidence Intervals (CIs) for PMRs followed Monson’s exact method, all scripts ran in Stata 15, and cleaning routines used the R programming language.
Deaths missing a specified country were retained only for global counts, not for regional analyses, to avoid geographic misclassification. The study was based solely on publicly available data and did not require ethics approval.
The authors note that the dataset had limitations, including possible underreporting of deaths, missing country assignments for some cases, and a lack of demographic details. Additionally, 2,565 deaths remained unclassified by region due to inconsistencies in the data.
Study results
Across the twenty-year window, 15,549 US citizens died abroad from non-natural causes. Four events, mainly vehicular crashes, homicides, non-vehicular accidents, and suicide, accounted for 81% of cases. Deaths peaked at 1,065 in 2010, fell steadily to a pre-COVID-19 low of 650 in 2019, then rebounded in 2022. Passenger numbers, by contrast, soared to 122 million in 2019, contracting only briefly during the pandemic.
When fatalities were divided by passenger flow, the overall risk of death dropped, but not uniformly: Sub-Saharan Africa’s Europe and Central Asia high-income destinations recorded 44 times more fatal road crashes than their resident populations (PMR 44.2, 95% CI 11.0-178.2), whereas the PMR in Europe and Central Asia high-income countries was 1.7.
Comparing decades revealed that PMRs for vehicular and other accidents climbed significantly (ANOVA period coefficient positive, p < 0.01), while ratios for homicide and suicide remained unchanged. The uptick coincided with domestic declines in comparable injury categories, suggesting that safety gains at home have not been reflected in traveler behavior overseas.
Notably, this post-2020 divergence, where US citizen deaths from vehicular and non-vehicular accidents increased while comparable deaths among local populations continued to decline and contributed to rising PMRs.
Region also mattered as Middle East and North Africa low-income countries showed the highest homicide PMR (4.0, 95 % CI 2.6-6.4), yet Latin America and Caribbean upper-middle-income nations generated the greatest absolute number of homicides (1,839), illustrating how large visitor volumes can dilute PMRs even when raw counts are high.
Despite high absolute homicide counts in Latin America and the Caribbean upper-middle-income countries, their PMR remained below 1 (0.9), indicating that US citizens were at lower risk than the local population.
Suicide PMRs exceeded two in the East Asia and Pacific regions, where cultural or language barriers may impede mental-health outreach to expatriates.
Non-vehicular accidents, mostly falls and recreational mishaps, remained below parity worldwide, apart from high-income settings in Sub-Saharan Africa, which the authors suggest may reflect the impact of higher safety standards or better supervision in those environments, although this is not directly tested.
The supplementary death-per-100-passengers metric did not vary significantly by time or region (ANOVA p > 0.10), limiting its utility as a standalone indicator. Nevertheless, absolute values highlighted how uncommon death in transit truly is: even in the riskiest region, fewer than one traveler per 100,000 died.
Still, the positive shift in accident PMRs means that if passenger volumes return to pre-pandemic highs, additional families each year could face the logistical and financial strains of repatriation. However, the study does not quantify this risk as "hundreds."
These findings justify a renewed emphasis on seat-belt use, sober driving, and the selection of safe excursion providers in government advisories and travel insurance underwriting. While the study used Power BI for modeling and analysis, it did not produce or report interactive maps pinpointing high-risk road corridors near resort towns; this was not an explicit finding of the research.
The original article also highlights that some regions had low direct passenger flows from the US, which may affect risk estimates for those regions.
The authors suggest that future work could explore real-time or dashboard-based data solutions to support traveler safety, but such features were not part of this analysis.
Conclusions
To summarize, over two decades, injury-related deaths of US citizens abroad became relatively more likely to stem from vehicular and other accidents despite falling absolute numbers. Growth in budget travel and adventure tourism may have widened the gap between travelers and local residents, especially on roads in lower-income regions, but the study does not establish these as direct causes of the trend.
Homicide and suicide risks remained geographically skewed but stable, suggesting different underlying dynamics. Because the PMR amplifies changes in both visitor behavior and host-country safety gains, it provides an early warning signal that should inform advisories, rental-car policies, and destination-specific insurance premiums.
The authors also emphasize that substantial data limitations, including underreporting, the presence of unclassified deaths, and missing demographic details, must be taken into account when interpreting these results. Coordinated action could make future journeys safer.