Chapter 10 Popular Itineraries The Americas & the Caribbean
Mexico, the second most populous country in Latin America, has a population of more than 120 million; 78% live in urban areas. The United States’ second-largest agricultural trading partner and third-largest trading partner overall, Mexico ranks 15th in national wealth based on gross domestic product. The capital, Mexico City, is 1 of the world’s largest cities (population >20 million) and is a frequent site for business and meetings, mass gathering events, and tourism travel.
One-fifth the size of the United States (about 3 times larger than Texas), Mexico has diverse geographic features throughout its 32 states. The Sonoran desert is in the northwest, beautiful beaches line 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 other southern and coastal regions are tropical. The Copper Canyon, in the state of Chihuahua, is larger than the Grand Canyon (see Map 10-09).
Mexico receives more foreign visitors than any other country in Latin America, and it is the country most frequently visited by US tourists. In 2017, there were 188 million border crossings at 25 land ports of entry between United States and Mexico. Beach resort travel (Acapulco, Ixtapa, Cancún, Puerto Peñasco, Playa del Carmen, Cozumel, Puerto Vallarta, Nuevo Vallarta, and Cabo San Lucas) and cruise ship tours make up a large portion of tourism to Mexico. On the Pacific Coast, travelers can go whale watching in Baja California or sport fishing in the Gulf of California.
The country’s rich history and proud culture reflecting its pre-Columbian and Hispanic heritage attract many tourists, as well. Travelers to Mexico can visit World Heritage sites and pre-Columbian anthropologic destinations including Teotihuacan outside Mexico City, the Great Pyramid of Cholula in Puebla, Tulum and Cobá in Quintana Roo, El Tajín in Veracruz, Chichén Itzá in Yucatán, Monte Albán in Oaxaca, and Palenque in Chiapas.
A large number of US residents visit Mexico to receive health services. Only Thailand sees more medical tourists from the United States (see the Thailand section in this chapter). Services sought from providers in the northern border cities primarily include dental and eye care and cosmetic surgery. Increasingly, a complete range of services and specialized procedures for medical tourists are becoming available in Mexico City, Monterrey, Mérida, Cancún, and Guadalajara, cities that feature a more robust infrastructure (see Chapter 9, Medical Tourism).
Map 10-09. Mexico destination map
All travelers should be up-to-date with their routine immunizations. Hepatitis A is endemic to Mexico; visitors should receive at least the first dose of the hepatitis A vaccine series before travel. Hepatitis B vaccine is also recommended, especially for those expecting to stay in Mexico ≥6 months, medical tourists, or anyone who might be exposed to blood or other body fluids (including through sexual contact). Discuss the need for typhoid and rabies vaccination with travelers going to less developed, remote areas of the country (field biologists and nature adventure tourists, for example) or anyone planning an extended visit to see friends or relatives (see Chapter 9, Visiting Friends & Relatives: VFR Travel).
Preexposure rabies prophylaxis is recommended for travelers likely to have contact with wild animals and for those traveling to areas with limited access to medical care (see Chapter 4, Rabies). In Mexico, the wild animal species that carry rabies include bats, coatis (also known as coatimundi, tejón, cholugo, or moncún), coyotes, foxes, and skunks; less commonly, unvaccinated dogs and cats are exposure sources.
Travelers’ Diarrhea and Other Foodborne and Waterborne Infections
Travelers’ diarrhea is common among visitors to Mexico, and education is key. Provide traveler patients with instruction in proper food and water precautions (see Travelers’ Diarrhea and Food & Water Precautions in Chapter 2). Remind travelers that tap water is not potable, to avoid consuming unpasteurized or unaged, artisanal dairy products, and not to eat raw or undercooked meat or fish, leafy greens, or raw vegetables. Foodborne infections in Mexico are due to a variety of pathogens (viral, bacterial, and parasitic) including, but in no particular order: Salmonella enterica, Shigella spp., Escherichia coli, Campylobacter spp., Cyclospora cayetanensis, Entamoeba histolytica, Taenia solium (cysticercosis), Brucella spp., Listeria monocytogenes, and Mycobacterium bovis. Prescribe antibiotics for self-treatment of diarrhea with careful and explicit directions for their use.
DENGUE, CHIKUNGUNYA, AND ZIKA
Travelers should take steps to prevent mosquito bites by using insect repellent, wearing long-sleeved shirts and long pants, and staying in accommodations with screens or air conditioning (see Chapter 3, Mosquitoes, Ticks & Other Arthropods). Dengue is endemic throughout Mexico; virus transmission is a risk year-round, and large outbreaks occur periodically (see Chapter 4, Dengue). Chikungunya has been reported since 2014 (see Chapter 4, Chikungunya). Also, Zika is a risk in Mexico (see Chapter 4, Zika). Because of the risk of birth defects in infants born to women infected with Zika during pregnancy, women who are pregnant or trying to become pregnant should research the most recent recommendations at www.cdc.gov/zika.
Dramatic decreases in malaria incidence in recent decades mean risk of infection to travelers to Mexico is low (see Chapter 4, Malaria). Major resorts are free of the disease, as is the US–Mexico border region. Plasmodium vivax malaria prophylaxis is currently recommended only for travelers going to Chiapas and the southern part of Chihuahua. Mosquito avoidance (but not prophylaxis) is recommended for travelers visiting Campeche, Durango, Jalisco, Nayarit, Quintana Roo, San Luis Potosí, Sinaloa, Sonora, and Tabasco.
In Mexico, rickettsial diseases (see Chapter 4, Rickettsial Diseases) include Rocky Mountain spotted fever (potentially fatal unless treated promptly with antibiotics) and fleaborne typhus (a severe disease with symptoms similar to dengue). The brown dog tick (Rhipicephalus sanguineus), associated with Mexico’s large urban and rural stray dog population, is the vector for Rocky Mountain spotted fever. Provide travelers with information about how to avoid flea and tick bites, both indoors and outside.
Transmitted by sand flies, cutaneous leishmaniasis is found in parts of coastal and southern Mexico (see Chapter 4, Cutaneous Leishmaniasis). The risk for this infection is greatest for ecotourists, field biologists, and long-term travelers. Travelers can reduce risk of sand fly bites by avoiding outdoor activities at night.
Beachgoers 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 (see Chapter 4, Cutaneous Larva Migrans).
Chagas disease, transmitted by triatomine insects infected with Trypanosoma cruzi, is endemic throughout Mexico (see Chapter 4, American Trypanosomiasis).
Influenza virus strains similar to those in the United States circulate in Mexico, making pretravel flu vaccination a prudent health protection measure. Inhaled fungal spores have caused lung infections in returning travelers: Coccidioides is endemic to the soil of northwestern Mexico, and Histoplasma is found mainly in Mexico’s central and southeast regions (see Chapter 4, Coccidioidomycosis and Histoplasmosis).
Legionellosis (Legionnaire’s Disease) should be considered as part of the differential diagnosis in people developing pneumonia within 14 days of travel outside the United States, especially the elderly and immunocompromised (see Chapter 4, Legionellosis). Travel history surveillance periodically identifies associations between the disease and stays at particular hotels and resorts in Mexico.
Although 4 times what it is in the United States, Mexico’s TB incidence is lower than that of Asia, Africa, and Eastern Europe. Providers should help travelers determine their potential for exposure to M. tuberculosis; risk of infection is greatest for those intending to remain in Mexico ≥6 months; travelers working in health care settings, homeless shelters, or prisons where they may be exposed to patients with untreated TB; or people planning an extended visit home to spend time with friends and relatives (see Chapter 4, Tuberculosis).
OTHER HEALTH AND SAFETY RISKS
Good health care is available in most Mexican cities, and tourist hotels and resorts usually have well-trained physicians available. Payment (cash or credit card) may be required before any care is given, and most providers do not accept US health insurance or Medicare/Medicaid plans.
Injuries, not infectious diseases, pose the greatest life threat to healthy travelers in Mexico. In one review, about half (51%) of all US traveler deaths in Mexico were injury related; 18% due to motor vehicle crashes (see Chapter 8, Road & Traffic Safety). Mexico’s highway system and roads are mostly modern, well maintained, and safe. Toll highways are often of high quality. Nevertheless, driving in city traffic and at night through the countryside can be dangerous. Remind travelers to use seat belts when riding in cars and to always wear a helmet when riding bicycles or motorbikes.
Although travel to Mexico is generally considered safe, thefts and robberies do occur, and drug-related violence does exist in some places (see Chapter 3, Safety & Security Overseas). Travelers should consult the US Department of State for relevant safety and security alerts pertaining to their intended destinations within Mexico.
Air pollution in Mexico City, while decreased in recent years, can be particularly severe during the dry winter months and can exacerbate asthma and aggravate chronic lung and heart conditions (see Chapter 3, Air Quality & Ionizing Radiation). Healthy travelers coming from lower elevations and people with lung and heart conditions should use caution while acclimating to Mexico City (elevation 7,382 ft; 2,250 m).
Injuries and deaths caused by poisonous Centruroides genus (bark) scorpions have been reported from states along the Pacific Coast (extending from Sonora down to Oaxaca) and in the center states of Durango, Guanajuato, State of Mexico, and Morelos. Travelers should be aware of scorpions, snakes, and other venomous creatures when visiting Mexico’s rural areas and when participating in outdoor activities, especially during spring and summer (see Chapter 3, Animal Bites & Stings).
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