The cruise ship passenger death rates declined significantly during each year’s third quarter (p = 0.0025; Figure 2). However, the cruise ship passenger death rates increased significantly, from 0.37 to 0.82 deaths per million passenger-nights from year 1 to year 3 (p = 0.0094). The rate of cardiovascular deaths among cruise ship passengers increased significantly from 0.27 to 0.66 per million passenger-nights over the 3-year period (p = 0.0088) and decreased every third quarter (significant seasonality) (p = 0.0055). In contrast, the rate of non-cardiovascular deaths among cruise ship passengers did

not differ significantly by year for years 1 to 3 (range 0.1–0.18 per million passenger-nights). This analysis represents the first comprehensive TGF-beta inhibitor investigation of causes of death among international travelers arriving in the United States on conveyances. Our investigation showed that cardiovascular conditions were the major cause of death for travelers of both sexes. This finding is consistent with an earlier report that the most common cause of death for U.S. travelers abroad in 1975 and 1984 was cardiovascular Raf inhibitor disease.9 From 2005 to 2007, approximately one third of deaths in the U.S. population were attributed to cardiovascular disease (including

stroke).32–34 In contrast, 70% of the deaths in our investigation were attributed to cardiovascular conditions, which is more than twice the proportion of cardiovascular deaths for the U.S. population. Infectious disease caused 12% of the deaths in our investigation, but only one of these deaths, which occurred in an HIV-positive person with pneumococcal pneumonia, may have been preventable by vaccination.35 The other three persons who died from vaccine-preventable diseases (two meningococcal meningitis and one rabies) did not meet the vaccination criteria of the Advisory Committee on Immunization TCL Practices and CDC’s Health Information for International Travel (Yellow Book) and were unlikely to have received these vaccinations before travel.36–40 The male predominance

of deceased travelers reported to CDC is consistent with previous published reports.5,9–11,14–15,20 An analysis of GeoSentinel data from 1997 to 2007 showed that male travelers had a higher risk of acute hepatitis A, chronic viral hepatitis, and sexually transmitted infections (STI).41 Of the males who died from infectious disease in our investigation, one died of disseminated Neisseria gonorrhoeae, one from viral hepatitis, one from chronic hepatitis C, and three from HIV/AIDS complications; no deaths of females were attributed to STIs, hepatitides, or HIV/AIDS. However, male travelers were not more likely to die of infectious disease than female travelers. Sixty-two percent of deaths in our investigation were associated with maritime travel; of these, 85% were associated with cruise ships.