International travel has become increasingly common, accessible, and affordable.1,2 In 2010, there were 711 million international outbound trips worldwide, a 7% increase from 2009.3 The number of international visitors to the United States rose to a record 60 million in 2010.4 This growth has provided more opportunities for pathogens to spread beyond geographic and political borders and has increased interest in preventing morbidity and mortality among international travelers. Previous studies of United States, Canadian, Scottish, and Australian civilians who died abroad have analyzed expatriate

death reports at consulates, embassies, and government agencies.5–17 Few studies have addressed passenger mortality during commercial travel on aircraft and cruise BMN 673 cell line ships.18–25 The U.S. Department of State (DOS) Web site lists data on some U.S. citizens who die in a foreign country because of non-natural causes (eg, injuries).26 However, this Web site does not include PD0325901 mouse all deaths of U.S. military or government officials abroad, and DOS may not be notified about deaths of U.S. citizens who reside abroad. The Centers for Disease Control & Prevention’s (CDC) Division of Global Migration and Quarantine (DGMQ)

has statutory authority to make and enforce regulations to prevent the introduction or transmission of communicable diseases into the United States.27 The 20 CDC DGMQ quarantine stations have jurisdiction over all U.S. land border ports, seaports, and airports.28 The U.S. Code of Federal Regulations mandates that the pilot or captain of an international aircraft or ship reports illnesses

and deaths occurring aboard the vessel to the nearest CDC quarantine station.29 This reporting requirement does not apply to U.S. land borders, private physicians, hospitals, or clinics. U.S. Customs & Border Protection (CBP), domestic health departments, and others voluntarily report illnesses and deaths among international travelers to CDC quarantine stations.27 RAS p21 protein activator 1 Our objective was to analyze data on public health investigations of death in international travelers arriving in the United States, and to describe the epidemiology of travelers’ deaths reported to CDC quarantine stations. We examined data from the CDC Quarantine Activity and Reporting System (QARS), a secure online database developed by CDC in 2005 to track illnesses and deaths among inbound international travelers of any citizenship entering the United States and that are reported to CDC quarantine stations. These QARS reports include individual traveler demographic data, clinical summaries, and travel itineraries. For reported deaths, quarantine station staff also collect information on the presumptive cause of death, chronic medical conditions, and when available, the official cause of death. This investigation was approved by CDC with a non-research determination.