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Chapter 4 Select Destinations The Americas & The Caribbean


Margarita E. Villarino, Sonia H. Montiel, Stephen H. Waterman


Mexico, the second most populous country in Latin America, has a population of >120 million, with 78% living in urban areas. The United States’ third-largest trading partner overall and second-largest agricultural trading partner, Mexico is now considered a middle-income country with the world’s 14th-largest economy. Mexico has a rich history and proud culture that reflect its pre-Columbian civilizations and Hispanic heritage. With one-fifth the area of the United States (about 3 times the size of Texas), Mexico has diverse geographic features within the 31 states and 1 federal district. The Sonoran desert is in the northwest, beautiful beaches are available on both coasts, and forested mountain ranges traverse the western and eastern mainland. Impressive volcanic peaks rise up to 18,000 feet above the high central plateau. The Yucatán Peninsula and southern regions are tropical. The Copper Canyon in the northwestern state of Chihuahua is larger than the US Grand Canyon.

Mexico City is one of the world’s largest cities, with a population >20 million. Despite increasing national prosperity, Mexico’s large cities contain much poverty. Extensive migration has taken place from the poor rural south to the northern border for jobs in bustling border cities, such as Ciudad Juárez and Tijuana.

Mexico has the most foreign visitors of any Latin American country and is the country most frequently visited by US tourists. Travel to beach resorts such as Acapulco, Ixtapa, Cancún, Cozumel, Puerto Vallarta, Nuevo Vallarta, and Cabo San Lucas, along with cruise ship tours, makes up a large portion of tourist travel to Mexico. Also common are day trips to northern border cities and longer cultural trips to historical and World Heritage sites. Popular pre-Columbian anthropologic destinations include Teotihuacan outside Mexico City, Great Pyramid of Cholula in Puebla, El Tajin in Veracruz, Chichen Itzá in Yucatán, Monte Alban in Oaxaca, and Palenque in Chiapas. Baja California offers whale watching on the Pacific Coast and sports fishing in the Gulf of California.

Mexico ranks second only to Thailand as the destination for American patients to receive health services outside the United States (medical tourism). The main services sought are dental services, eye care, and cosmetic surgery in the border cities. Increasingly, a complete range of services and specialized procedures are offered in cities with large medical services infrastructure, such as Mexico City, Monterrey, Merida, Cancún, and Guadalajara (see Chapter 2, Medical Tourism).

Map 4-07. Mexico destination map

Map 4-07. Mexico destination map

PDF Version (printable)



All travelers should be up-to-date with their routine immunizations. Hepatitis A is endemic in Mexico, and all travelers should be immunized with at least the first dose of hepatitis A vaccine before travel to Mexico. Hepatitis B vaccine should be considered for all travelers and is also recommended especially for those with expected long-term stays (≥6 months), those who plan to use medical services, or who are planning activities in Mexico that may expose them to blood or blood products. Other vaccines, such as typhoid and rabies, may be considered, especially for those visitors (such as field biologists, nature adventure tourists) who will be traveling to less-developed, remote areas of the country.

Travelers’ Diarrhea and Other Foodborne and Waterborne Infections

Travelers’ diarrhea is common among visitors to Mexico. In addition to practicing food and water precautions, travelers should consider bringing an antibiotic for self-treatment of diarrhea (see the Food & Water Precautions and Travelers’ Diarrhea sections in Chapter 2). Travelers should avoid consuming raw dairy products, undercooked meat or fish, and raw vegetables. Foodborne infections that are a risk in Mexico include amebiasis, cysticercosis, brucellosis, listeriosis, and infections with Mycobacterium bovis.

An outbreak of 181 cholera cases was reported from the Huasteca Region of the state of Hidalgo, Mexico, in 2013. The outbreak was quickly controlled, and the infecting strain was serogroup O1, serotype Ogawa, toxigenic, biotype El Tor, the same strain that caused outbreaks in Haiti, the Dominican Republic, and Cuba. Although cholera is considered a low risk in Mexico, travelers should adhere to food and water precautions.


Dengue is endemic throughout Mexico, except for the state of Baja California Norte and at higher elevations (for example, it is not present in Mexico City at 7,350 ft [2,240 m]). Large outbreaks of dengue have been reported in recent years, and dengue virus transmission should be considered a risk year-round. To prevent dengue, travelers to Mexico should take measures against mosquito bites (see Chapter 2, Protection against Mosquitoes, Ticks, & Other Arthropods).


Aedes aegypti and A. albopictus mosquitoes that can transmit chikungunya and dengue viruses are found in Mexico. Introduction into Mexico is a possibility given the outbreaks in the Caribbean Islands. Travelers to Mexico should be advised to reduce the possibility of mosquito bites (see Chapter 2, Protection against Mosquitoes, Ticks, & Other Arthropods).


Malaria incidence has decreased dramatically in recent decades in Mexico, and only a few cases of infection with Plasmodium vivax are reported among US travelers each year. Major resorts are free of malaria, as is the US–Mexico border region. Malaria prophylaxis is recommended for travelers to Chihuahua, Chiapas, Durango, Nayarit, and Sinaloa. Mosquito avoidance but not chemoprophylaxis is recommended for travelers to Campeche, Jalisco, Oaxaca, Sonora, Tabasco, and the Othón P. Blanco municipality of Quintana Roo.

Other Infections

Respiratory Diseases

Influenza virus strains similar to those in the United States circulate in Mexico, as was demonstrated by the emergence of pandemic influenza A (H1N1) in North America in the spring of 2009. Coccidioidomycosis, a fungal respiratory disease caused by inhaling spores in the soil, is endemic in northwestern Mexico. Several outbreaks of coccidioidomycosis have been reported among missionary groups from the United States doing construction projects in this region. Histoplasmosis, another fungal respiratory disease agent found in soil, is endemic in other regions of Mexico, mainly the central and southeast regions. Occasional clusters of legionellosis have been reported in association with hotel stays in Mexico. Legionellosis should be considered in elderly and immunocompromised travelers who develop pneumonia, within 14 days of travel.

Parasitic Infections

Cutaneous leishmaniasis, transmitted by sand flies, is found in focal areas of coastal and southern Mexico. The risk is higher for ecotourists, field biologists, and long-term travelers. Travelers should practice preventive measures against fly bites, including avoiding outdoor activities at night. Travelers to beach areas may be at risk for cutaneous larva migrans (CLM), a creeping skin eruption most commonly associated with dog hookworm infection. CLM is preventable by wearing shoes and avoiding direct skin contact with sand. Chagas disease is endemic throughout Mexico (see Chapter 3, Trypanosomiasis, American (Chagas Disease)).


Travelers should be educated on how to prevent animal bites to reduce the risk of rabies. In Mexico, the most common animal species that carry rabies are unvaccinated dogs or cats and wild animals such as raccoons, skunks, coyotes, bats, and foxes. Preexposure rabies vaccination should be considered for travelers who are likely to come into contact with these animals or those who will be traveling to areas with limited access to medical care.

Rickettsial Disease

In Mexico, rickettsial diseases, febrile rash illnesses transmitted by ticks or fleas, include Rocky Mountain spotted fever, which is potentially fatal unless treated promptly with antibiotics, and fleaborne typhus, which usually causes symptoms that are similar to dengue. Travelers should take precautions to avoid flea and tick bites both indoors and outside. Rocky Mountain spotted fever associated with Rhipicephalus sanguineus, the brown dog tick, has been identified recently in northern Mexico in urban and rural areas with large stray dog populations.

Tuberculosis (TB)

Mexico’s TB incidence is lower than rates in Asia, Africa, and Eastern Europe but is 5 times that of the United States. The potential risk of exposure and infection with tuberculosis should be discussed with travelers planning long-term stays (≥6 months), or those who may be exposed to patients with untreated TB (such as those working in health care settings, homeless shelters, or prisons).

Other Health and Safety Risks

Good health care is available in most Mexican cities, and hotels in tourist resorts usually have well-trained physicians available. Injuries, rather than infectious diseases, appear to pose the largest risk of death among healthy travelers to Mexico. In one review, the leading cause of death to all US travelers to Mexico was injuries (51%), and 18% of deaths resulted from motor vehicle crashes.

Mexico’s highway system and roads have become increasingly modernized over the years. Toll highways are often of high quality. Nevertheless, driving in traffic in cities and at night through the countryside can be dangerous. Although travel in Mexico is generally safe, drug-related violence has continued to increase in parts of the country. Department of State advisories should be monitored for alerts in areas where tourists are planning to visit.

Air pollution in Mexico City, while decreased in recent years, can be particularly severe during the dry winter months and can exacerbate asthma and chronic lung and heart conditions. Both healthy travelers from lower elevations and people with lung and heart conditions should cautiously acclimate to Mexico City’s altitude.

Most injuries and deaths caused by poisonous scorpions are reported from states in the Pacific Coast (from Sonora to Oaxaca) and in the center states of Morelos, State of Mexico, Guanajuato, and Durango. Travelers should exercise caution when visiting Mexico’s rural areas and when participating in outdoor activities, especially during spring and summer.


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