Travel Tips for Mexico, Updated Intl. Guide – Travel Medicine, Inc.
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Capital: Mexico City

Time Zone: -6 hours. GMT -5 hours during daylight saving time.
Tel. Country Code: 52
USADirect Tel.: 95
Electrical Standards: Electrical current is 120/60 (volts/hz). North American Style Adaptor Plug. Grouding Adaptor Plug A.

Travel Advisory - Mexico

Travelers to Central and South America and the Caribbean need to protect themselves against mosquito-transmitted viruses, such as dengue and Zika, as well as nighttime biting mosquitoes in countries where there is  the threat of malaria. I recommend all travelers use a combination of DEET or Picaridin repellent on their skin and Permethrin fabric insecticide on their clothing for greater than 99% protection against mosquito and tick bites.

Dr. Rose Recommends for Travel to Mexico

Resource Links

World Health Organization
Travel Health Services
Country Insights
Travel Warnings
Consular Information
Foreign Commonweatlh Office


U.S. Embassy
Paseo de la Reforma 305
Mexico City

U,S. Citizens Services

The American Citizens Services section of the U.S. Embassy provides a number of services and resources to help with emergency situations.

Entry Requirements

HIV Test: Not required.

Required Vaccinations: None required.

Passport Information

ENTRY REQUIREMENTS: For the latest entry requirements, also contact the  the Embassy of Mexico, Washington, DC or any Mexican consulate in the United States for the most current information.

Land or sea travelers must have a valid U.S. passport•or U.S. citizenship documents such as a certified copy (not a simple photocopy or facsimile) of a U.S. birth certificate, a Naturalization Certificate, a Consular Report of Birth Abroad, or a Certificate of Citizenship are acceptable along with photo identification, such as a state or military issued ID.

Vaccinations: Recommended and Routine

Hepatitis A: Recommended for all travelers >1 year of age not previously immunized against hepatitis A.

Hepatitis B: Recommended for all travelers who might be exposed to blood or body fluids from unsafe/unprotected sexual contact; from injecting drug use with shared/re-used needles and syringes; from medical treatment with non-sterile (re-used) needles and syringes; exposure to open sores on another person. Recommended for any traveler requesting protection against hepatitis B infection.

Influenza: Vaccination recommended for all travelers >6 months of age who have not received a flu shot in the previous 12 months.

Rabies: Recommended for travelers spending time outdoors in rural areas where there is an increased the risk of animal bites. Transmission may occur following contact with the saliva from an infected wild or domestic animal (including bats), most often via a bite or lick to an open wound. Risk of exposure is increased by type of activity (e.g. running, cycling), and longer duration of stay.
Children are considered at higher risk because they tend to play with animals and may not report bites.
• Pre-exposure vaccination eliminates the need for rabies immune globulin in the event of a high-risk animal bite, but does not eliminate the need for treatment with the vaccine.

Routine Immunizations: Immunizations against tetanus-diphtheria, measles, mumps, rubella (MMR vaccine) and varicella (chickenpox) should be updated, if necessary, before departure. MMR protection is especially important for any female of childbearing age who may become pregnant.
• The new Tdap vaccine, ADACEL, which also boosts immunity against pertussis (whooping cough) should be considered when a tetanus-diphtheria booster is indicated.

Typhoid: Recommended for all travelers with the exception of short-term visitors who restrict their meals to major restaurants and hotels, such as business travelers and cruise passengers.

Yellow Fever: Not required or recommended.

Hospitals / Doctors

All travelers should be up-to-date on their immunizations and are advised to carry a medical kit as well as antibiotics to treat travelers diarrhea or other infections; they should bring drugs for malaria prophylaxis, if needed according to their itinerary. Travelers who are taking regular medications should carry them properly labeled and in sufficient quantity to last for the duration of their trip; they should not expect to obtain prescription or over-the-counter drugs in local stores or pharmacies in this country - the equivalent drugs may not be available.
• Travelers are advised to obtain travel insurance that provides for medical evacuation to a medical facility in the United States in the event of serious illness or injury that cannot be treated locally.

Adequate medical care can be found in major cities. Excellent health facilities are available in Mexico City, but training and availability of emergency responders may be below U.S. standards. Care in more remote areas is limited. Mexico City has two world-class hospitals, both with fully bilingual English-speaking doctors. The ABC (American British Cowdray) Hospital is located in Colonia America, next to the American School, while the Angeles Hospital is located in the Pedregal, in the south of Mexico City. Another good hospital is the Spanish Hospital in Polanco.

Listing of hospitals and medevac servicesis on the U.S. Embassy website.

ABC Medical Center
Col. Las Americas
Mexico City
The ABC Medical Center (American British Cowdray Medical Center) is a private hospital with English-speaking board-certified physicians and state-of-the-art medical technology. Specialties include cardiology, Ob/Gyn, emergency medicine, neurology.

Hospital Angeles Clinica Londres
Durango 64
Col. Roma
Mexico City
The Hospital Angeles Clinica Londres has 5 floors of comfortable rooms, divided in 78 private rooms, 3 suites and 1 master suite. Services include general medical & surgical, Ob/Gyn, ICU, CCU, 24-hour emergency.

Camino A Santa Teresa 1050
Col. Heroes De Padierna
Mexico City

Ameri-Med Puerto Vallarta Hospital
Plaza Neptuno
Marina Vallarta
Puerto Vallarta

Monterrey also has fine hospitals, notably the Hospital San Jose Tec. de Monterrey, the Hospital Santa Engracia, and the Hospital Jose A. Muguerza. Guadalajara has the Americas Hospital, Hospital del Carmen, Hospital Mexico-Americano, Hospital San Javier, Hospital Dr. Angel Leao and the Hospital Santa Maria Chapalita.

Destination Health Info for Travelers

AIDS/HIV: In almost every Latin American country, the highest levels of HIV infection are found amongst men who have sex with men (MSM). This problem is largely hidden, because it is highly stigmatized behavior. The extent of HIV infection among MSM is downplayed in many countries. More than half of Latin Americans living with HIV reside in the region’s four largest countries: Brazil, Columbia, Mexico and Argentina. The most severe epidemics, however, are found in smaller countries such as Honduras and Belize, which have HIV prevalence rates of 1.5% and 2.5% respectively. The majority of countries in the region have prevalence rates of less than 1%, but the prevalence among specific groups, such as men who have sex with men and sex workers, is often much higher. The estimated HIV/AIDS prevalence in adults ages 15 to 49 in Mexico is 0.3%. (Source:
• Transmission of HIV can be prevented by avoiding: sexual contact with a high-risk partner; injecting drug use with shared needles; non-sterile medical injections; unscreened blood transfusions.
• The threat of HIV/AIDS should not be a primary concern for the traveler. However, there may be a concern for a subset of travelers who may be exposed to HIV, the virus that causes AIDS, through contact with the body fluids of another person or their blood. Although travel has contributed in a general way to the global spread of AIDS, fear of traveling because of this disease is not warranted.

Accidents & Medical Insurance: Accidents and injuries are the leading cause of death among travelers under the age of 55 and are most often caused by motor vehicle and motorcycle crashes; drownings, aircraft crashes, homicides, and burns are lesser causes.
• Heart attacks cause most fatalities in older travelers.
• Infections cause only 1% of fatalities in overseas travelers, but, overall, infections are the most common cause of travel-related illness.
• MEDICAL INSURANCE: Travelers are advised to obtain, prior to departure, supplemental travel health insurance with specific overseas coverage. The policy should provide for direct payment to the overseas hospital and/or physician at the time of service and include a medical evacuation benefit. The policy should also provide 24-hour hotline access to a multilingual assistance center that can help arrange and monitor delivery of medical care and determine if medevac or air ambulance services are required.

Altitude Sickness (AMS): High-altitude volcano summits in Mexico that attract climbing expeditions include Pico de Orizaba (18,700ft), Iztaccihuatl (17,332 ft) and La Malinche (14,600 ft).
Acute mountain sickness (AMS), also known as altitude illness, is a common malady above 2,400 m (8,000 ft), especially if you have not had a chance to acclimatize by ascending gradually. The prevalence of AMS varies between 15% and 75%, depending on your speed of ascent, altitude gained, sleeping altitude, and individual susceptibility. Acute mountain sickness can progress to high altitude cerebral edema (HACE) or be associated with high altitude pulmonary edema (HAPE). You should intersperse your ascent with rest days and avoid, if possible, increasing your sleeping altitude by more than 1,000 - 1,500 feet each night. To reduce further your risk of AMS, take acetazolamide (Diamox), starting the day prior to beginning your ascent. Acetazolamide is a respiratory stimulant that speeds acclimatization and is about 75% effective. It may also reduce the risk of HAPE.
• Symptoms of AMS include mild to moderate headache, loss of appetite, nausea, fatigue, dizziness and insomnia. Mild AMS usually resolves with rest plus medication for headache and nausea. You can also take acetazolamide to treat mild AMS.
• Under no circumstances should you continue to ascend (especially to a higher sleeping altitude) if you have any persistent symptoms of altitude illness. In the absence of improvement or with progression of symptoms you should descend (at least 500 m) to a lower altitude.
• Dexamethasone (Decadron) is a steroid drug used for treating AMS and HACE. You should carry stand-by treatment doses. You can take dexamethasone together with acetazolamide to treat mild- to moderate-AMS.
• More severe AMS (increasing headache, vomiting, increasing fatigue or lethargy) may indicate the incipient onset of high-altitude cerebral edema (HACE)—recognized by confusion, difficulty with balance and coordination, staggering gait. Start treatment with dexamethasone and descend immediately.
• Increasing dry cough and breathlessness at rest may indicate high altitude pulmonary edema (HAPE). Nifedipine, sildenafil (Viagra), or tadalafil (Cialis) can be used for both the prevention and treatment of HAPE. Dexamethasone and the asthma drug salmeterol (Serevent) also will prevent HAPE.
• Descent, combined with medication (and oxygen, if available) is the best treatment for more severe AMS, HACE or HAPE. Consider helicopter evacuation if the situation is urgent.

Caution: Prior to departing for a high-altitude trip, consult with a physician about the use of medications for preventing/treating altitude illness.

Further advice:

Base Camp High Altitude Medicine
CDC High Altitude Medicine
The Institute for Altitude Medicine
International Society for Mountain Medicine

Amebiasis: There is a high incidence of amebiasis in Mexico, especially in the southern areas where up to 8.4% of the population is seropositive for E. histolytica antibodies. To avoid amebiasis, travelers should drink only safe water and eat only well-cooked food. All fruit should be peeled before eating. Other parasitic diseases include ascariasis, trichiuriasis, and hookworm. None of these infections are common in travelers.

Animal Hazards: Scorpion bites are a major health problem in many Mexican states, affecting more than a quarter of a million people annually. Each year, 1000-2000 deaths occur from scorpion bites. The sting produces a syndrome that ranges in severity from a simple sting mark to a life-threatening illness. Mild envenomation, which is more common in adults than in children and consists mainly of local pain, resolves without specific treatment over the course of hours or days. Severe envenomation is usually more common in small children. The clinical syndrome includes uncoordinated neuromotor hyperactivity, oculomotor and visual abnormalities and respiratory compromise.
In severe cases that are treated without antivenom, intensive supportive care is necessary for the management of violent neuromotor hyperactivity and respiratory compromise. Intubation and ventilation are occasionally necessary.
• Scorpion antivenoms (Anascorp®, Instituto Bioclon, Mexico City) can successfully resolve the systemic toxicity of scorpion envenomation within 1 to 4 hours after treatment.
Read more: 

Chagas’ Disease: Risk occurs below 1,500 meters elevation in the rural areas of the southern and western states. Most risk is found in those rural-agricultural areas where there are adobe-style huts and houses that potentially harbor the night-biting triatomid (assassin) bugs. Travelers sleeping in such structures should take precautions against nighttime bites, which typically occur on the face of the sleeping victim.
• Other methods of transmission are possible, from: consumption of food or juice (especially sugar cane juice and acai palm juice) contaminated with crushed triatome insects; from blood transfusions; from in-utero transmission.

Cholera: This disease is sporadically active in this country but the threat to tourists is very low. Cholera vaccine is recommended only for relief workers or health care personnel who are working in a high-risk endemic area under less than adequate sanitary conditions, or travelers who work or live in remote, endemic or epidemic areas and who do not have ready access to medical care. Canada, Australia, and countries in the European Union license an oral cholera vaccine. The cholera vaccine is not available in the United States.
• The main symptom of severe cholera is copious watery diarrhea.
• Antibiotic therapy is a useful adjunct to fluid replacement in the treatment of cholera by substantially reducing the duration and volume of diarrhea and thereby lessening fluid requirements and shortening the duration of hospitalization.

 A single 1-g dose of azithromycin is effective treatment for severe cholera in adults. This drug is also effective for treating cholera in children. 

Crime/Security/Civil Unrest: You should avoid all large public gatherings, protests and demonstrations as they may turn violent or be the target of random attacks. Participation in demonstrations by foreigners is prohibited.
The city of Oaxaca has experienced periods of violent civil unrest in the past year. Underlying tensions and a large police presence remain in the city.
Armed rebel and civilian groups are present in the State of Chiapas, particularly in remote areas including jungle areas near the Guatemalan border. If you are considering travel to remote areas of Chiapas, you should remain in well-frequented tourist areas and familiarise yourself with the local security situation.
Crime: We advise you to exercise a high degree of caution in Mexico because of the high level of violent crime. Pay close attention to your personal security at all times and monitor the media for information about possible new safety or security risks. If you are the victim of a crime, particularly if you wish to proceed with a criminal investigation, you should immediately report the crime to the police.
Violent crime, including sexual assault, armed robbery and kidnapping, occurs in popular tourist destinations and beach resorts. Drink and food spiking occurs in bars and restaurants. There have been reports of sexual assault and other serious crimes, including assault and robbery, committed by individuals presenting themselves as police officers. Petty crime, such as pickpocketing and bag snatching, is prevalent at tourist destinations, airports, bus stations and on the metro in Mexico City. Security risks increase after dark.
• The number of so-called express kidnappings, where individuals are forced to withdraw funds from ATMs to secure their release, continues to increase, particularly in urban areas. There has been a recent increase in the number of express kidnappings targeting people travelling on the Metro. The use of ATMs located inside shopping malls during daylight hours may reduce risk.
• The incidence of kidnapping people for longer periods for financial gain is increasing and there have been allegations of complicity by police officers. You should be cautious and discreet about openly discussing your financial or business affairs.
• Thieves often work in cooperation with or pose as taxi drivers. Travellers have been robbed when using taxis hailed from the street. You should only use radio-despatched taxis or taxis based at a designated stand (sitios), particularly in Mexico City. Use only official taxis (yellow/white with an aircraft symbol on the door of the vehicle) from the airport, after pre-paying the fare inside the airport.
Crime levels on inter-city buses and when travelling on highways are high. Avoid unnecessary travel at night and use only first-class bus services. The use of toll (cuota) roads rather than free (libre) roads wherever possible may reduce the risk of crime when driving in Mexico.
• It is increasingly common for extortionists to call prospective victims on the telephone, often posing as law enforcement or other officials, and demand payments in return for the release of an arrested family member. If you receive such calls you should contact local police.
• Organised crime and drug-related violence is prevalent in all cities bordering the United States of America, and in particular, in the states of Michoacan, Sinaloa, Sonora and Guerrero (particularly in the city of Acapulco). In most urban areas of the States of Baja California, Chihuahua, Nuevo Leon, Sinaloa, Sonora, Coahuila and Guerrero, military and federal police forces maintain a visible presence to combat organised crime and to improve security conditions. They patrol the streets, set up roadblocks and conduct random vehicle checks.

Local Travel: Driving on rural roads in Mexico is dangerous due to poor road conditions, the presence of livestock and pedestrians on roads, and inadequate street lighting and signage. For further advice, see the bulletin on Overseas Road Safety from Smartraveller:

Dengue Fever: An outbreak of dengue fever was reported from the southern zone of Tamaulipas in January 2009. The risk of dengue is currently greatest in the southern and central Pacific urban coastal areas and in extreme northeastern Mexico. Increased risk may occur during the rainy season, from July through October. Dengue fever is a mosquito-transmitted, flu-like viral illness widespread in Central America. Symptoms consist of sudden onset of fever, headache, muscle aches, and a rash. A syndrome of hemorrhagic shock can occur in severe cases.
• Dengue is transmitted via the bite of an infected Aedes aegypti mosquito. Aedes mosquitoes feed predominantly during daylight hours. All travelers are at risk and should take measures to prevent daytime mosquito bites. Insect-bite prevention measures include applying a DEET-containing repellent to exposed skin and applying permethrin spray or solution to clothing and gear.
• There is no vaccination or medication to prevent or treat dengue.

A worldwide dengue fever map is here

Environmental Pollution: Acute respiratory infections are a common cause of illness in Mexico, probably aggravated by this country’s legendary air pollution, about the worst in the world. Extreme conditions can occur in Mexico City and Guadalajara, especially from December to May. Travelers with heart disease, emphysema, and asthma may need to limit or avoid travel to regions with poor air quality. Drinking tap water in Mexico City and other areas contains high concentrations of lead. Lead is also found in polluted air, leaded paints, in some canned foods and beverages, and leached into beverages stored in lead-glazed pottery.

Gnathostomiasis: The number of cases gnathostomiasis is increasing as Mexicans are eating more freshwater, as opposed to saltwater, fish. This food-borne disease is acquired through ingesting a parasite found in raw or undercooked freshwater fish (usually eaten in the form of tilapia, or ceviche, a famous Mexican raw fish dish). High-risk areas include the States of Sinaloa, Oaxaca, Veracruz, Tamaulipas, Naryarit, and Guerrero, which includes the city of Acapulco. All travelers to these regions should avoid eating raw freshwater fish.

Helminthic Infections: Hookworm, roundworm, and whipworm infections, and also strongyloidiasis, are highly prevalent in most rural areas. (Hookworm disease infects up to 90% of some rural villagers.) Travelers should wear shoes to prevent the hookworm and strongyloides larvae from penetrating the skin. All food should be thoroughly cooked to destroy roundworm, whipworm, and pork tapeworm eggs. Pork tapeworm disease is common and can be prevented by eating only thoroughly cooked pork.

Hepatitis: Hepatitis A is highly endemic in this country. All travelers not previously immunized against hepatitis A should be vaccinated against this disease. Travelers who are non-immune to hepatitis A (i.e. have never had the disease and have not been vaccinated) should take particular care to avoid potentially contaminated food and water. Travelers who will have access to safe food and water are at lower risk. Those at higher risk include travelers visiting friends and relatives, long-term travelers, and those visiting areas of poor sanitation.
• Hepatitis E is endemic with sporadic cases and outbreaks reported in northern Baja, Guerrero, and Morelos States, as well as in the Mexico City and Tijuana. Transmission of the hepatitis E virus (HEV) occurs primarily through drinking water contaminated by sewage and also through raw or uncooked shellfish. Farm animals, such as swine, and also deer and wild boar, may serve as a viral reservoirs. (HEV is one of the few viruses which has been shown to be transmitted directly from animals through food.) In developing countries, prevention of hepatitis E relies primarily on the provision of clean water supplies and overall improved sanitation and hygiene. There is no vaccine.
• The overall hepatitis B (HBsAg) carrier rate in the general population ranges from 0.3% to 1.6%. Carrier rates up to 4% have been reported from Chiapas State. Hepatitis B is transmitted via infected blood or bodily fluids. Travelers may be exposed by needle sharing and unprotected sex; from non-sterile medical or dental injections, and acupuncture; from unscreened blood transfusions; by direct contact with open skin lesions of an infected person. The average traveler is at low risk for acquiring this infection. Vaccination against hepatitis B is recommended for: persons having casual/unprotected sex with new partners; sexual tourists; injecting drug users; long-term visitors; expatriates, and anybody wanting increased protection against the hepatitis B virus.
• Hepatitis C is endemic at a low level, with a prevalence of 0.7% in the general population. Most hepatitis C virus (HCV) is spread either through intravenous drug use or, in lesser-developed countries, through blood contamination during medical procedures. Over 200 million people around the world are infected with hepatitis C - an overall incidence of around 3.3% of the population of the world. Statistically, as many people are infected with HCV as are with HIV, the virus that causes AIDS.

Influenza: Risk extends from November to March in areas north of the Tropic of Cancer and throughout the year in areas south of that. The flu vaccine is recommended for all travelers over age 6 months.

Influenza A (H1N1-Swine Flu): The Centers for Disease Control has lifted its recommendation to avoid travel to Mexico, because the outbreak in Mexico appears to be slowing in many areas and because the risk of severe disease from H1N1 virus infection now appears to be less than originally thought. The CDC advises that those at high risk for influenza complications should speak with their physicians about the risks of traveling to Mexico and might consider postponing their trips. The high risk groups include pregnant women, those under age 5 or over age 65, those with compromised immune systems, and those with significant underlying medical problems.

Facts about swine flu:
• Swine influenza (swine influenza A H1N1) is a virus that usually affects pigs but occasionally can make people sick.
• Sustained human –to- human transmission of H1N1 flu virus (human swine flu) has not previously been documented.
• Symptoms are similar to seasonal influenza (flu) including headache, chills, cough followed by fever, loss of appetite, muscle aches and fatigue, runny nose, sneezing, watery eyes and throat irritation. Nausea, vomiting and diarrhea may occur in adults as well as in children. In more severe cases, or in people with chronic conditions, complications such as pneumonia may develop.

The World Health Organization and the Centers for Disease Control do not recommend any travel restrictions at this time. To protect yourself from H1N1 influenza, wash your hands regularly and avoid close contact with anyone who is coughing or sneezing. The symptoms of H1N1 influenza include fever, cough, sore throat, body aches, headache, chills and fatigue, similar to seasonal influenza. Any traveler to Mexico who develops flu-like symptoms should immediately seek medical attention. Consider treatment with Tamiflu or Relenza if you develop symptoms. Source: MD Travel Health.

Insects: You should exercise prevention measures against both daytime and nighttime insect bites. For maximum protection, apply a DEET-containing repellent to exposed skin (30% concentration recommended), apply permethrin spray or solution to your clothing and gear, and sleep under a permethrin-treated bednet (if available).
• Until now, DEET-based repellents have been the gold standard of protection against disease-transmitting insect bites. The CDC and WHO now recommend 20% picaridin as an effective DEET alternative. You can achieve nearly 100% protection by using a properly-applied skin repellent and wearing permethrin-treated clothing.

Leishmaniasis: Cutaneous leishmaniasis is endemic in rural areas in the southern territory of Quintana Roo, eastern Yucatan, Campeche, eastern Tabasco, Chiapas, Oaxaca, and eastern Veracruz. Mucocutaneous leishmaniasis (espundia) has occurred in Jalisco State, and visceral leishmaniasis (kala-azar) has occurred in Guerrero and Morelos States. Diffuse cutaneous leishmaniasis occurs in both the northeast and southeast regions. Mucocutaneous leishmaniasis has occurred in Jalisco State. This disease is transmitted by sandflies, which are most active between sunset and dawn. The parasites that cause leishmaniasis are transmitted by the bite of the female phlebotomine sandfly. Sand flies bite in the evening and at night and are usually found in forests, the cracks of stone or mud walls, or animal burrows.

• All travelers should take measures to prevent sandfly bites. Insect-bite prevention measures include applying a DEET-containing repellent to exposed skin, permethrin (spray or solution) to clothing and gear, and sleeping under a permethrin-treated bednet.
• You should suspect this disease if you have slow- or non-healing skin infections after visiting this country.

Read more on leishmaniasis

Malaria: There is a low risk of malaria in some rural areas of southern Mexico under 1,000 meters elevation. The incidence of malaria is highest in the states of Chiapas, Oaxaca, Guerrero, Quintana Roo, and Campeche, and in Sinaloa State on the Pacific Coast. Lesser-risk areas include Michoacan and Tabasco states. Most cases reported from tourist centers occur in the vicinity of Huatulco Bay (Pochutla region of Oaxaca). P. vivax accounts for more than 99% of infections. No cases of chloroquine-resistant malaria have been reported. Falciparum infections appear to be limited to rain forest areas near the borders with Belize and Guatemala.
Malaria has been eliminated from large urban areas and the major international resorts.
• Malaria precautions are recommended for overnight stays in many rural areas at low altitude, especially in southern Mexico. Persons staying overnight at the following archaeological sites should take consider chloroquine prophylaxis: Palenque, Bonampak, Uxmal, Kabah, Labna, Sayil, Edzna, Coba, and Tulum.
• Chloroquine is not recommended when visiting the major resort areas of Acapulco, Ixtapa, Mazatlan, Cancun, Cozumel, and Merida on the Pacific and Gulf coasts. Travelers to these areas should take measures to prevent insect bites. These protective measures will also help prevent dengue fever and leishmaniasis.

A malaria map is located here. There is low to absent risk of malaria in Mexico.

Alternative malaria map

• Malaria is transmitted via the bite of an infected female Anopheles mosquito. Anopheles mosquitoes feed predominantly during the hours from dusk to dawn. All travelers should take measures to prevent evening and nighttime mosquito bites. Insect-bite prevention measures include applying a DEET-containing repellent (such as Ultrathon) to exposed skin, applying permethrin spray or solution to clothing and gear, and sleeping under a permethrin-treated bednet. DEET-based repellents have been the gold standard of protection under circumstances in which it is crucial to be protected against insect bites that may transmit disease. Nearly 100% protection can be achieved when DEET repellents are used in combination with permethrin-treated clothing.
• You should consider the diagnosis of malaria if you develop an unexplained fever during or after being in a malaria-endemic region of this country.

NOTE: Picardin repellents (20% formulation, such as Sawyer Premium or Natrapel 8-hour) are now recommended by the CDC and the World Health Organization as acceptable non-DEET alternatives to protect against malaria-transmitting mosquito bites. Picaridin is also effective and ticks and biting flies.

Marine Hazards: Swimming related hazards include jellyfish, Portuguese Man-O-War, sharp coral, fire coral, poisonous sponges (the red fire sponge and the touch-me-not), bristle worm, sea urchins, scorpionfish, puffer fish, Moray eel, stingrays, barracudas and sharks. There are no sea snakes in the Caribbean Sea.
• To avoid a shark attack, swim or dive with a group. Avoid swimming during hours of darkness or twilight, in fog, or in murky waters. Avoid swimming in the vicinity of sea lions, harbor seals or elephant seals. Avoid swimming near the mouths of rivers where sharks hunt for fish. When diving, minimize time spent at the surface. Wearing a wetsuit and fins or lying on a surfboard creates the silhouette of a seal to a shark below you. Shallow water is not a deterrent to sharks; attacks have occurred in less than 5 ft/1.5 m of water.
• Ciguatera poisoning is prevalent and can result from eating coral reef fish such as grouper, snapper, sea bass, jack, and barracuda. The ciguatoxin is not destroyed by cooking.
• Scuba Diving-Hyperbaric Chamber Referral: Divers Alert Network (DAN) maintains an up-to-date list of all functioning hyperbaric chambers in North America and the Caribbean. DAN does not publish this list, since at any one time a given chamber may be non-functioning, or its operator(s) may be away or otherwise unavailable. Through Duke University, DAN operates a 24-hour emergency phone line for anyone (members and non-members) to call and ask for diving accident assistance. Dive medicine physicians at Duke University Medical Center carry beepers, so someone is always on call to answer questions and, if necessary, make referral to the closest functioning hyperbaric chamber. In a diving emergency, or for the location of the nearest decompression chamber, call 919-684-8111.

Onchocerciasis: This blackfly-transmitted disease is limited to areas along rivers between 600 and 1,500 meters elevation in Chiapas and Oaxaca States. Highest risk is from October through April. Travelers should take measures to prevent insect (blackfly) bites.

Other Diseases/Hazards: Anthrax (small outbreaks reported in Zacatecas, central Mexico)
• Brucellosis (90% of cases associated with contact with goats; greatest risk occurs in the northern and central states; chiefly from the northern districts bordering the United States and the northwestern and west-central districts; outbreak reported in March 2009 from contaminated cheese sold in the Hidalgo Market in Guanajuato)
• Coccidiomycosis (fungal respiratory infection [“valley fever”] endemic in the dry north of Baja California Norte, Sonora and Chihuahua States, and along the Pacific Coast; outbreaks have occurred in church groups from U.S. doing construction work; cough and fever are main symptoms)
• Cysticercosis and neurocysticercosis (caused by the ingestion of pork tapeworm eggs; common, especially in Guanajuato and Michocan States)
• Histoplasmosis (contact with bat guano transmits this fungal disease)
• Leptospirosis
• Lyme disease (presumably occurs)
• Relapsing fever (tick-borne; endemic in northern and central Mexico)
• Typhus (both louse- and flea-borne; reported in Chiapas State)
• Tick-borne rickettsioses (spotted fever group; reported in some rural areas; one case of human monocytic ehrlichiosis was reported in Yucatan).

Rabies: Several dozen or more human cases are reported annually. Ninety percent of cases are acquired from contact with rabid dogs, usually in rural areas. Rabid vampire bats reportedly are a problem in Sinaloa State. Travelers should especially avoid stray dogs and seek immediate treatment of any animal bite. Rabies vaccination is especially indicated following the unprovoked bite of a dog, cat, bat, or monkey.
Rabies vaccine is recommended for: persons anticipating an extended stay; for those whose work or activities may bring them into contact with animals; for people going to rural or remote locations where medical care is not readily available; for travelers desiring extra protection. Children are considered at higher risk because they tend to play with animals and may not report bites.
• Pre-exposure vaccination eliminates the need for rabies immune globulin, but does not eliminate the need for two additional booster doses of vaccine. Prompt medical evaluation and treatment of any animal bite is essential, regardless of vaccination status.

Rickettsial Diseases (Q Fever, Scrub & Murine Typhus, Spotted Fevers) : The Ministry of Public Health of Sonora reported that this year [2010] a total of 44 people have been infected by rickettsiae, 5 of whom died. The southern region of the state [Sonora] is where most cases of the disease have occurred.Most cases are thought to be due by Rickettsia rickettsii, the cause of Rocky Mt. Spotted Fever. (See below)

Rocky Mountain Spotted Fever: The first human case of infection caused by Rickettsia in Yucatan was detected in 1996, and it was determined that the species was R. felis. Since then, epidemiologic surveillance was implemented to search for human cases in the public hospitals of the state, and in 2005, the first human case of Rocky Mountain spotted fever was detected. During the following 2 years, eight new confirmed cases and one probable case were identified. Seven cases involved children younger than 12 years of age, with a fatal outcome in three of the cases. Children are a particularly vulnerable population for this serious emerging infection.

• Rocky Mountain spotted fever is the most lethal and most frequently reported rickettsial illness in the United States. It has been diagnosed throughout the Americas; in Mexico, it is called “fiebre manchada”. The disease is caused by Rickettsia rickettsii, a species of bacterium that is spread to humans by ixodid (hard) ticks. Initial signs and symptoms of the disease include sudden onset of fever, headache, and muscle pain, followed by development of rash (starting on the hands and feet and spreading inwards).
The name “Rocky Mountain spotted fever” is somewhat of a misnomer. Beginning in the 1930s, it became clear that this disease occurred in many areas of the United States other than the Rocky Mountain region. It is now recognized that this disease is broadly distributed throughout the continental United States, and occurs as far north as Canada and as far south as Mexico, Central America, and parts of South America. Between 1981 and 1996, this disease was reported from every U.S. state except Hawaii, Vermont, Maine, and Alaska.

• Travelers, especially those engaging in outdoor activities in rural areas, such as campers and hikers, should take measures to prevent tick bites. Tick-bite prevention measures include applying a DEET-containing repellent to exposed skin and permethrin spray or solution to clothing and gear.

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Seabather's Eruption: Reported in and near Cancun. This condition is caused by sea anemone larvae trapped under the bathing suit. Released toxin causes skin irritation, rash, and fever.

Swine Influenza A (H1N1): According to the World Health Organization, the Government of Mexico has reported three separate outbreaks of influenza-like-illness. In the Federal District of Mexico, 854 cases of pneumonia have been reported. Of those, 59 have died. In San Luis Potosi, located in central Mexico, 24 cases of influenza-like-illness, with three deaths, have been reported. And from Mexicali, near the border with the United States, four cases of influenza-like-illness, with no deaths, have been reported.
• The majority of these cases have occurred in otherwise healthy young adults. Seasonal influenza normally affects the very young and the very old, but these age groups have not been heavily affected in the current outbreak. CDC has confirmed that seven of 14 respiratory specimens sent to the CDC are positive for the swine influenza virus and are similar to the swine influenza viruses recently identified in the US among residents of California and Texas.
CDC and state public and animal health authorities are currently investigating 8 cases of swine flu in humans in California and Texas that may be related to cases in Mexico. At this time there have been no fatalities reported in the U.S.
• To date, there have been no reported cases of influenza-like-illness in the resort areas along the coast of Mexico.
This investigation is still in the early stages. Further updates to this investigation and any related travel recommendations will be posted on when available.

CDC Recommendations:
CDC has NOT recommended that people avoid travel to Mexico at this time. If you are planning travel to Mexico, follow these recommendations to reduce your risk of infection and help you stay healthy.
• See a travel medicine specialist or a doctor familiar with travel medicine at least 4–6 weeks before you leave to answer your questions and make specific recommendations for you.
• Antiviral Medications: People at higher risk for complications from seasonal influenza—such as older people, young children, and people with certain health conditions (such as asthma, diabetes, or heart disease) — may want to ask their doctor for prescription antiviral medications to take on their trip.

CDC recommends two prescription influenza antiviral drugs to treat and/or prevent swine flu. The drugs are:

-Oseltamivir (brand name Tamiflu®) or,
-Zanamivir (brand name Relenza®)

Both are prescription drugs that fight against swine flu by keeping flu viruses from reproducing in your body. These drugs can prevent infection if taken as a preventative. If you get sick, they can make your illness milder and make you feel better faster. They may also prevent serious health problems from developing. For treatment, the drugs work best if started within 2 days of getting sick. Talk to your doctor about correct indications for treatment or prevention.

Seek medical care immediately if you develop flu symptoms: Headache, sore throat, fever, cough, and muscle aches, These symptoms may be severe, and many flu fatalities are caused by secondary bacterial pneumonia.

Be sure you are up-to-date with all your routine vaccinations, including seasonal influenza vaccine if available.

Travelers' Diarrhea: High risk country-wide (outside major resorts and first-class hotels). More illness occurs during the rainy season, May through October. Bacterial organisms, in the following order—enterotoxigenic E. coli, campylobacter, salmonella, and shigella—account for more than 80% of cases of travelers’ diarrhea (TD). A quinolone antibiotic, azithromycin, or rifaximin, combined with loperamide (Imodium), is recommended for the treatment of acute diarrhea. Diarrhea not responging to antibiotics may be due to a parasitic disease such as giardiasis or cryptosporidiosis. Up to 6% of cases of diarrhea may be due cryptospodidiosis.
Note: Compared with bacterial diarrhea, a longer stay in Mexico is a risk factor for cryptosporidiosis. Additionally, Cryptosporidium cases pass greater number of watery stool and suffer more episodes of diarrhea compared with bacterial causes of TD.
(Source: Nair P, Mohamed JA, DuPont HL, et al. Am J Trop Med Hyg. 2008 Aug;79(2):210-4.)
• Nitazoxanide (Alinia) is the treament of choice for cryptosporidiosis. Available as a 20 mg/mL oral suspension.
Adult dose: 500 mg orally twice daily for 3 days in healthy hosts; dose may be safely increased to 1 g twice daily in AIDS patients and the duration of treatment may be prolonged.

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Tuberculosis: This disease is highly endemic, particularly among the native Indian and indigenous populations in southern Mexico and Baja California. Multidrug-resistant strains are common.
• TB is transmitted following inhalation of infectious respiratory droplets. Most travelers are at low risk. Travelers at higher risk include those who are visiting friends and relatives (particularly young children), long-term travelers, and those who have close contact with an infected individual. There is no prophylactic drug to prevent TB. Travelers with significant exposure should have PPD skin testing done a few weeks after returning to evaluate their risk of infection.

Typhoid Fever: This disease is widespread and more cases of typhoid fever are reported in travelers returning from Mexico than from any other Latin American country. There is increased risk of typhoid from June through October, countrywide. Vaccination against typhoid fever is recommended for: travelers venturing outside of tourist areas; long-term travelers; adventure travelers; those wishing maximum disease protection. Because the typhoid vaccines are only 60% to 70% effective, safe food and drink selection remain important.

Viral Encephalitis: Rare cases of St. Louis encephalitis, Venezuelan equine encephalitis, and eastern and western encephalitis are reported. Mosquito-bite prevention is recommended.

Yellow Fever: There is no risk of yellow fever in this country and there are no requirements for a certificate of vaccination.