Guatemala & Belize
CDC Yellow Book 2024Popular Itineraries
Bordered by Mexico to the north, Belize and Honduras to the east, and El Salvador to the south, Guatemala is the largest country in Central America, both by population (>18 million) and by area (>42,000 mi2 or >108,000 km2). Often referred to as the “Land of Eternal Spring” for its agreeable year-round temperatures in much of the country, tourists visit Guatemala to explore its Mayan ruins, picturesque colonial towns, and scenic geology, including volcanos and lakes. It is also a popular destination for Spanish language instruction. Guatemala received >2 million visitors annually prior to the coronavirus disease 2019 (COVID-19) pandemic.
Guatemala City, the capital, is highly urbanized and features luxury hotels, a wide variety of cuisines, and available medical services. By contrast, conditions are often markedly different outside of the capital, with fewer consumer products available, more difficult travel conditions, and often inadequate medical services. Guatemala’s 22 departments encompass a diverse ecological range, including highland cloud forests, dense forests, semi-arid deserts, and large tracts of agricultural lands. Rural areas offer significant charm and interesting destinations, but travelers should be prepared for a wider variety of health risks.
Approximately the same size as New Jersey, Belize has an area of 8,867 mi2 (23,000 km2). It shares its western and southern border with Guatemala and its northern border with Mexico’s Quintana Roo state; the Caribbean Sea forms the eastern boundary of the country (see Map 10-17). Northern Belize is characterized by coastal plains with pockets of dense forest, while the west and south are predominantly coastal plains or savannas and low mountains, respectively. Belize’s Caribbean coastline features sandy white beaches, numerous islands, and one of the longest barrier reefs in the world.
Travelers visiting Belize’s inland can participate in a variety of adventure activities, including canoeing, cave tubing, climbing Mayan ruins, hiking, and zip-lining through jungle canopies. Most visitors come to experience the sandy white beaches and the coastal barrier reefs, which boast some of the best scuba diving in the region. The official language of Belize is English, although Belizean Creole, Spanish, Mayan languages, and Plautdietsch (a variety of German spoken by Mennonite settlers) are also spoken.
Map 10-17: Guatemala & Belize
Infectious Disease Risks
Ensure travelers are up to date on their routine immunizations. Routine childhood immunization rates in both Guatemala and Belize declined during the COVID-19 pandemic, potentially increasing the risk for infections among both the local population and visitors. Hepatitis A and typhoid vaccines are recommended for visitors to both countries.
Enteric Infections & Diseases
Giardia is endemic throughout the world. In addition to drinking water precautions, remind travelers to avoid swallowing water from streams, ponds, and lakes (see Sec. 5, Part 3, Ch. 12, Giardiasis).
Taeniasis & Cysticercosis
Guatemala and Belize are considered endemic for multiple parasitic infections, including taeniasis and cysticercosis, which are caused by different life stages of the Taenia solium parasite (see Sec. 5, Part 3, Ch. 22, Taeniasis). Cases occur in all departments of Guatemala; the majority have been reported from Chiquimula, Huehuetenango, Petén, Quetzaltenango, and Zacapa. Taeniasis can present as a mild or asymptomatic intestinal infection following the ingestion of undercooked pork products.
Cysticercosis, a more serious infection of muscle, brain, or other tissues, is caused by ingestion of T. solium eggs shed in the stool of human carriers. Over months to decades, the infection can progress to neurocysticercosis, a rare but potentially disabling or fatal infection (see Sec. 5, Part 3, Ch. 6, Cysticercosis). Consuming food, including raw or undercooked vegetables, contaminated with T. solium eggs can cause cysticercosis.
Travelers’ diarrhea commonly affects visitors to Guatemala and Belize. Advise travelers to follow instructions on safe food and water precautions (see Sec. 2, Ch. 8, Food & Water Precautions). Tap water is not potable in Guatemala or Belize, even in the capital cities. There are many options for treating water, including boiling, filtration (for example, using ceramic water filters), chlorination, and disinfection using ultraviolet light.
Counsel travelers to avoid consuming unpasteurized dairy products (particularly soft or fresh cheeses) and raw or undercooked meat or fish. Leafy green or raw vegetables should be thoroughly washed and disinfected or cooked before consumption. For further information about travelers’ diarrhea, see Sec. 2, Ch. 6, Travelers’ Diarrhea.
Typhoid fever, caused by infection with Salmonella typhi, occurs in both Guatemala and Belize and can be life-threatening, although appropriate and timely management usually prevents serious disease (see Sec. 5, Part 1, Ch. 24, Typhoid & Paratyphoid Fever). Infection with typhoid fever in the United States is associated with international travel, in particular southern Asia, but also among travelers returning from Central America.. Offer typhoid vaccine to all travelers, especially to those visiting smaller cities or rural areas. Vaccinated travelers should still follow food and water precautions to prevent typhoid fever and other enteric infections.
Respiratory Infections & Diseases
Coronavirus Disease 2019
For current information on COVID-19 (see Yellow Book chapter, COVID-19), consult the Guatemala Ministry of Health COVID-19 information page, US Embassies in Guatemala and Belize, and CDC website. All travelers going to Guatemala and Belize should be up to date with their COVID-19 vaccines.
Influenza (see Sec. 5, Part 2, Ch. 13, Influenza) strains typically circulate in Central America in a pattern similar to the United States. Advise travelers to receive the influenza vaccine ≥2 weeks before departure. Low reported rates of influenza at destinations may reflect limited surveillance rather than an absence of transmission.
Guatemala and Belize are considered moderate incidence countries for tuberculosis (TB). Help travelers determine their potential for exposure to Mycobacterium tuberculosis. Risk for infection is greatest among travelers who will be working around individuals with untreated TB (e.g., drug rehabilitation centers, health care settings, prisons, shelters); those staying for an extended time with friends and relatives; and those who eat unpasteurized dairy products, a risk factor for bovine TB (see Sec. 5, Part 1, Ch. 22, Tuberculosis).
Sexually Transmitted Infections & HIV
HIV prevalence in Guatemala is low in the general population (0.2% among adults aged 15 to 49 years). Most cases occur among people at increased risk, including commercial sex workers, those who use injection drugs, men who have sex with men, and the sexual partners of these individuals. HIV prevalence is greater in Belize (1.1% among adults aged 15 to 49 years). Counsel travelers to reduce their risk of HIV and other sexually transmitted infections, including chlamydia, gonorrhea, herpes, and syphilis, by avoiding injection drug use and unprotected sex. High-quality condoms are available for purchase at pharmacies in both countries.
Soil- & Waterborne Infections
Cutaneous Larva Migrans
Cutaneous larva migrans, a creeping skin eruption commonly associated with animal hookworm infection, has been reported in Guatemala and Belize (see Sec. 5, Part 3, Ch. 4, Cutaneous Larva Migrans, and Sec. 11, Ch. 8, Dermatologic Conditions). Cases are associated with walking on beaches or warm soil; advise travelers to use footwear and avoid direct skin contact with soil and sand.
Leptospirosis (see Sec. 5, Part 1, Ch. 11, Leptospirosis), a bacterial disease that can affect humans and animals, is known to occur in Guatemala with most cases reported following flooding related to hurricanes. Cases have been reported from most departments in the country. Leptospirosis has been documented in Belize, although little is known about the frequency or geographic distribution of infection. Advise travelers to avoid swimming or wading in water (particularly flood waters) potentially contaminated with animal urine and to use protective footwear or clothing if they are likely to be exposed during work or recreation. Encourage travelers to seek healthcare if they experience symptoms suggestive of leptospirosis, although a confirmed diagnosis may be challenging in Guatemala and Belize.
Arboviruses: Chikungunya, Dengue & Zika
Chikungunya, dengue, and Zika viruses are all transmitted in both Guatemala and Belize. Annual rates of arbovirus infections vary significantly. Travelers staying primarily in highland areas will have limited exposure to disease-carrying mosquitoes; those visiting coastal or low-lying areas and beaches are at increased risk. Cases of chikungunya (see Sec. 5, Part 2, Ch. 2, Chikungunya) and Zika (see Sec. 5, Part 2, Ch. 27, Zika) have been reported in Guatemala in recent years and, to a lesser extent, in Belize. Because of the risk for birth defects in infants born to mothers infected with Zika virus during pregnancy, instruct people who are pregnant or trying to become pregnant and their sex partners about the most recent CDC recommendations and promote the use of mosquito-avoidance behaviors.
Dengue (see Sec. 5, Part 2, Ch. 4, Dengue) is endemic to coastal and jungle areas, with risk occurring year-round in some places. Large outbreaks occur periodically in both countries, such as in 2019; there are also reports of increasing cases in early 2023. In recent years, the greatest number of dengue cases in Guatemala have been reported in the departments of Baja Verapaz, Escuintla, Petén, Quetzaltenango (lowland areas), Santa Rosa, and Zacapa. Dengue is uncommon in Guatemala City but has been reported.
Encourage travelers to take steps to prevent mosquito bites by using insect repellent, wearing long-sleeved shirts and long pants, and staying in accommodations with window screens or air-conditioning where available (see Sec. 4, Ch. 6, Mosquitoes, Ticks & Other Arthropods).
Guatemala and Belize are classified as endemic for cutaneous leishmaniasis (see Sec. 5, Part 3, Ch. 14, Cutaneous Leishmaniasis). Risk for infection is greater among people with outdoor exposure (e.g., ecology workers, ecotourists, travelers staying in rustic settings). Travelers can reduce their risk for sand fly bites by avoiding outdoor activities at night, wearing protective clothing, applying insect repellent, and sleeping in air-conditioned or well-screened areas. In Guatemala, most cases are reported from the departments of Alta Verapaz, Huehuetenango, and Petén. Detailed data on leishmaniasis in Belize are not routinely published.
Malaria cases have been declining in Guatemala in recent years but risk is still a concern in some areas. Alta Verapaz, Escuintla, Izabal, Petén, and Suchitepéquez account for most cases, and prophylaxis against Plasmodium vivax malaria is recommended only for travelers visiting these departments. Antigua, Guatemala City, and Lake Atitlán are not considered risk areas for malaria (see Sec. 2, Ch. 5, Yellow Fever Vaccine and Malaria Prevention Information, by Country).
In Belize, there are rare locally-transmitted malaria cases and none in Belize City. Except for travel to the aforementioned departments in Guatemala, mosquito avoidance (but not chemoprophylaxis) is recommended for travelers to both countries.
Although there are reports of rickettsial infections throughout Central America, the extent of rickettsial diseases is not well-documented and is almost certainly under-reported. In Guatemala, infections have included Rickettsia prowazekii, Rickettsia rickettsia, and Rickettsia typhi, among others; the first documented human case of Rickettsia felis infection was recently reported, although the risk is not yet well understood (see Sec. 5, Part 1, Ch. 18, Rickettsial Diseases). In Belize, Rickettsia-infected ticks have been found in several districts suggesting infection risk to humans. Provide travelers to both countries with information about how to avoid flea and tick bites, both indoors and outdoors (see Sec. 4, Ch. 6, Mosquitoes, Ticks & Other Arthropods).
Chagas disease (see Sec. 5, Part 3, Ch. 25, American Trypanosomiasis / Chagas Disease), transmitted by triatomine insects infected with Trypanosoma cruzi, is endemic to some areas of Guatemala. Most cases have been reported from the departments of Chiquimula and Jutiapa, with a smaller number from other, primarily lowland, departments.
In 2022, health care providers and public health officials published a report of the first known case of acute Chagas disease diagnosed in Belize. Risk for infection among travelers is believed to be low but is presumably increased for people staying in poor quality housing in endemic regions.
Yellow fever is not a risk in either Guatemala or Belize. The Government of Guatemala, however, requires proof of vaccination against yellow fever from travelers ³1 year old arriving from countries where there is risk of yellow fever virus transmission or who have >12-hour airport layovers or transits through countries with risk of yellow fever transmission. For more details, see Sec. 2, Ch. 5, Yellow Fever Vaccine and Malaria Prevention Information, by Country and Sec. 5, Part 2, Ch. Yellow Fever. Belize currently has no yellow fever vaccine requirements for entering travelers.
Environmental Hazards & Risks
In Guatemala City, with its population of over three million, air pollution can be a concern especially for those with asthma and aggravating conditions. Belize’s urban areas are much less dense, but urban and rural air quality in both countries may be negatively impacted by vehicle emissions, burning of waste, and limited regulatory control of industrial emissions. In Guatemala, periods of intense volcanic activity can cause increased particulate matter in areas within range of a volcano’s fallout (see Sec. 4, Ch. 3, Air Quality & Ionizing Radiation).
At 1,533 m (5,029 ft) above sea level, Guatemala City is at a moderately high elevation. The highest point in Guatemala is just over 3,900 m (13,000 ft). Belize has a more moderate topography (average elevation of 130 m) with its highest point at 1,124 m (3,668 ft). Advise travelers coming from lower elevations, particularly those with heart and lung conditions and those planning to climb high-elevation volcanos, to consider an acclimatization period (see Sec. 4, Ch. 5, High Elevation Travel & Altitude Illness).
Guatemala and Belize are among the few countries in the Americas that still report rabies in dogs. Rabid dogs are reported every year, and all dog bites must be considered as possible exposures to rabies (see Sec. 5, Part 2, Ch. 18, Rabies). Rabies can also be transmitted by other Central American animals, including bats, coatis, coyotes, foxes, and skunks. Educate travelers about recommended postexposure prophylaxis following an animal bite or scratch. Although rabies immune globulin for postexposure prophylaxis is available in some areas of Guatemala, supplies can be uncertain; Belize is not known to have immune globulin available for postexposure prophylaxis.
Recommend preexposure rabies prophylaxis to travelers who will be involved in outdoor activities (e.g., bicycling, camping, or hiking), especially in rural areas; people planning activities that place them at increased risk for exposure to dogs or wildlife (e.g., those who will have occupational exposure to animals); or those who will be visiting less developed, remote areas where access to medical care is limited. Children can be at particular risk due to exposure to dogs. Advise long-term travelers (e.g., humanitarian aid workers, faith-based workers) and their children to receive preexposure rabies prophylaxis.
Scorpions, Snakes & Other Venomous Wildlife
A wide variety of scorpion, snake, and spider species, including venomous varieties, can be found in both Guatemala and Belize.
The striped bark scorpion (Centruroides spp.), pale-yellow in color with two dark stripes on its carapace, is highly venomous and commonly found in both Guatemala and Belize. In Guatemala, scorpions are more prevalent in the eastern jungles and in sites around Lake Atitlán. Guatemala and Belize have 18 species of venomous snakes (e.g., coral snakes, a variety of pit vipers, and the neotropical rattlesnake), with some bites posing a risk for serious injury, including death. The Chilean recluse spider (Loxosceles laeta) and black widow spider (Latrodectus spp.) are venomous spiders found in Guatemala and Belize. Antidotes and antivenoms are available at some locations in Guatemala and Belize; anyone experiencing a bite should quickly seek medical attention.
Beach & Ocean Exposures
Many of the Pacific Ocean black sand beaches in Guatemala are known for dangerous undertow, large waves, and steep drop-offs; multiple drownings happen each year. Even strong swimmers can be at risk, and children should be supervised anywhere near the water’s edge.
Belize is known for its beaches and diving opportunities, but divers should be advised to seek a reputable diving company with a strong safety record. Beginner divers should ensure that their diving plans are commensurate with their level of experience. Sharks are known to be present in the waters off Belize, and swimmers and divers should seek local guidance.
The invasive lionfish is found in waters off Belize; the spines of the lionfish are venomous and can cause intense pain and discomfort for humans who are pricked. Treatment involves hot water, analgesics, and antihistamines, and may require medical attention. Divers should review safety instructions before engaging in lionfish spearing. Lionfish can be eaten safely. There is little information regarding lionfish off the small Caribbean coast of Guatemala.
Ciguatera poisoning occurs when consuming reef fish that have high concentrations of ciguatoxin in their flesh. Ciguatera poisoning has been rarely reported in Belize, with the few reported cases related to consumption of barracuda but not lionfish. There have been investigations of fish with ciguatoxin bioaccumulation on the Caribbean coast of Guatemala but little documentation of human cases. Travelers should be aware of nausea, vomiting, and neurologic symptoms such as tingling fingers, tingling toes, or a sensation of hot-cold temperature reversal. Instruct travelers to seek medical attention if any of these symptoms develop.
Harmful Algal Blooms
Guatemala periodically experiences harmful algal blooms on the Pacific coast (see Yellow Book chapter, Food Poisoning from Marine Toxins). Paralytic shellfish poisoning is a potentially serious risk for people consuming bivalve mollusks (e.g., clams, oysters, mussels, scallops) harvested during these periods. When conditions warrant, Guatemala’s Ministry of Agriculture can impose bans on harvesting and eating shellfish; advise travelers to follow local instructions. Alerts may be published by the Ministry of Health and other government entities and disseminated via local news sources. Recommend travelers to avoid swimming during harmful algal blooms; exposure can cause eye and skin irritation.
Climate & Sun Exposure
The climate in Guatemala and Belize varies significantly by region. Remind travelers of the risk of sun exposure during outdoor activities, even in predominately temperate high-elevation areas (see Sec. 4, Ch. 1, Sun Exposure). In many of the urban or tourist areas, broad-spectrum sunscreen may be available for purchase. Advise travelers going to more rural areas to purchase sunscreen prior to departure and to take it with them in their travel health kit (see Sec. 2, Ch. 10, Travel Health Kits).
Earthquakes & Volcanos
Guatemala is one of the most seismically and volcanically active countries in the world. Past earthquakes define the landscape of colonial ruins in Antigua Guatemala, but frequent high intensity earthquakes have brought significant destruction in areas throughout the country as recently as 2012. Smaller earthquakes occur frequently and occasionally cause fatalities due to landslides and infrastructure damage. Alert travelers to the importance of understanding and adhering to evacuation instructions and to be aware of designated meeting areas near large buildings.
Guatemala has three currently active volcanos (Pacaya [2,552 m; 8,373 ft], Santa María/Santiaguito [3,772 m; 12,375 ft], Volcán de Fuego [3,768 m; 12,362 ft]) and multiple other dormant and extinct volcanoes. In 2018, eruptions from Volcán de Fuego resulted in landslides that killed over 200 people and destroyed many homes. As with earthquakes, counsel travelers to be aware of local news related to volcanic activity; advise them to work only with reputable guides and to practice caution when mountaineering around active volcanoes.
Seasonal Flooding, Hurricanes & Tropical Storms
Guatemala and Belize are affected by Atlantic hurricanes, and Pacific storms can also affect Guatemala, with the season lasting from mid-May to November. Remind travelers to follow weather reports of hurricanes, tropical storms, or heavy rainstorms, which can provoke catastrophic flooding and landslides, even significantly inland. Make sure travelers know to never enter a flooded roadway and to be mindful of the potential for increased incidence of diarrheal illnesses and mosquito-borne diseases after certain weather events.
Safety & Security
Crime & Security
Advise visitors going to Guatemala or Belize to travel in groups and stay on main roads. Theft and robbery are the most common forms of crime in Guatemala, although narcotics-related violence exists in some areas (see Sec. 4, Ch. 11, Safety & Security Overseas). Encourage travelers to consult the US Department of State website for critical safety and security alerts pertaining to their intended destinations within Guatemala, including areas considered as “do not travel” due to elevated risk due to crime.
Although Belize generally poses a lower risk for crime, Belize City warrants caution due to elevated levels of violent crime. Travelers can find specific up-to-date information for this location and others on the US Department of State website.
Protests occur with some regularity in Guatemala, both in urban areas and through nationwide blockades of roadways. These typically well-publicized blockades can complicate transit and cause localized skirmishes. Land disputes in some areas of Guatemala have a history of violence, so encourage travelers to consult reputable local guides before traveling in rural areas or during a blockade period. While less common, political demonstrations can also occur occasionally in Belize, and travelers should follow local media reports and avoid large gatherings.
Remind travelers going to Guatemala or Belize to use a seat belt (and age-appropriate car seat or booster seats for families with children) when riding in a car and to wear a helmet when riding a bicycle or motorbike (see Sec. 8, Ch. 5, Road & Traffic Safety). Travelers with children should be advised to carry car seats with them as they may be difficult to locate in-country. Injuries pose a significant threat to travelers in Guatemala, with road-related mortality steadily rising according to the World Bank. Guatemala’s roadway system is often in poor repair, with steep drop-offs in mountainous areas and washouts in low-lying areas.
Roadway and boating accidents are likewise a concern in Belize. Trauma services outside of (and even within) larger cities are limited. Driving at night through the countryside can be dangerous and should be avoided.
Availability & Quality of Medical Care
Good quality health care is available in Guatemala City through larger private hospitals. Private hospitals with 24-hour service are available in Belize City. The public hospital systems, even in larger cities, face significant resource limitations in both countries. Medical services in rural areas may be extremely limited. Payment (cash or credit card) is likely to be required before care is given. US health insurance is not accepted. Discuss with patients the importance of purchasing travel health insurance and medical evacuation insurance (see Sec. 6, Ch. 1, Travel Insurance, Travel Health Insurance & Medical Evacuation Insurance), as well as packing a first aid kit (see Sec. 2, Ch. 10, Travel Health Kits).
Medical tourism is a growing industry in Guatemala, with many internationally trained physicians providing care, and, to a lesser extent, is seen in Belize. Nonetheless, potential concerns include the ability to manage unforeseen emergencies and infection with antimicrobial-resistant strains of bacteria, some of which are not commonly found in the United States (see Sec. 11, Ch. 5, Antimicrobial Resistance). Make potential medical tourists aware of the additional inherent risks associated with surgery, medical procedures, and traveling while being treated for a medical condition or during recovery (see Sec. 6, Ch. 4, Medical Tourism).
The following authors contributed to the previous version of this chapter: Ava W. Navin, Emily S. Jentes
Belize Fisheries Department (2018). Belize National Lionfish Management Strategy 2019-2023. Available at: https://blueventures.org/wp-content/uploads/2021/03/Belize-National-Lionfish-Strategy-2019.pdf [PDF].
Bermúdez CSE, Troyo A. A review of the genus Rickettsia in Central America. Res Rep Trop Med. 2018;9:103–12.
Borges, A. (2013). Scorpionism and Dangerous Scorpions in Central America and the Caribbean Region. In: Gopalakrishnakone, P. (eds) Scorpion Venoms. Springer, Dordrecht. Available from: https://doi.org/10.1007/978-94-007-6647-1_21-1.
Department of Defense/Colorado State University. Guide to Venomous Snakes for Military personnel in Guatemala. Available from: www.denix.osd.mil/dodparc/parc-resources/education-and-outreach/guide-to-venomous-snakes-on-military-installations-in-guatemala/Snake%20Pamphlet_Guatemala_cleared_508.pdf [PDF].
López B, Jaramillo J, Armstrong PA, López MR, Gleaton AN, Chung IH, et al. First human case of Rickettsia felis reported in Guatemala. Alerta. 2022;5(2):159–60.
Ministry of Public Health and Welfare—Guatemala. Department of Epidemiology. Weekly Epidemiolocal Bulletin No 51. December 2021. Available from: http://epidemiologia.mspas.gob.gt/informacion/salas-situacionales/boletines/boletines-de-semanas-epidemiologicas-2021?download=198:semepi-52-2022.
Ministry of Public Health and Welfare—Guatemala. Department of Epidemiology. Circular No. TLGG-010-2022 Alerta Epidemiolgica por intoxicacion paralitica por moluscos. Available from: http://epidemiologia.mspas.gob.gt/phocadownloadpap/alertas/2022/circular-tllgg-010-2022.pdf [PDF].
Ministry of Public Health and Welfare—Guatemala. Department of Epidemiology. Situación epidemiológica de leptospirosis en Guatemala. January 2018. Available from: http://epidemiologia.mspas.gob.gt/files/Publicaciones%202018/Zonoticas/Vigilancia%20de%20Leptospirosis%202007-%202017%20semana%201-52.pdf [PDF].
Murray KO, Saldaña MA, Gunter SM, Manzanero R, Zielinski-Gutierrez E, Herrera C, et al. Diagnosis of acute Chagas disease in a Belizean child with evidence of a multiclonal Trypanosoma cruzi infection. Am J Trop Med Hyg. 2022;107(5):992–5.
Pan-American Health Organization. Epidemiological Update: Dengue, chikungunya and Zika in the context of COVID-19. December 2021. Available from: https://iris.paho.org/bitstream/handle/10665.2/55639/EpiUpdate23Dec2021_eng.pdf?sequence=1&isAllowed=y [PDF].