Chapter 4 Select Destinations The Americas & the Caribbean

Clive M. Brown

DESTINATION OVERVIEW

The Caribbean is an arc-shaped group of islands that separates the Gulf of Mexico and the Caribbean Sea from the Atlantic Ocean. Historically, politically, culturally, and geographically, the Caribbean region can be divided as follows:

• Greater Antilles: Cuba, Jamaica (for a detailed look at health risks in Jamaica, visit Chapter 4, Jamaica), Cayman Islands, Hispaniola (Haiti and Dominican Republic), and Puerto Rico
• Lesser Antilles: Virgin Islands, Anguilla, Saint Kitts and Nevis, Dominica, Barbuda, Montserrat, Guadeloupe, Martinique, Saint Lucia, Saint Vincent and the Grenadines, Barbados, and Grenada
• Atlantic Ocean islands: Bermuda, The Bahamas, and the Turks and Caicos Islands
• South American shelf islands: Trinidad and Tobago, Aruba, Curaçao, and Bonaire

In addition, coastal areas of the mainland countries of Belize in Central America and Guyana, Suriname, and French Guiana in South America are often considered part of the Caribbean.

The islands and mainland countries vary in geography, from volcanic, lush rainforests to sandy and dry islands with fantastic beaches. The dazzling beaches on the islands and mainland coasts of the Caribbean Sea, the Gulf of Mexico, and the Atlantic Ocean are destinations where a traveler can find accommodations ranging from the very basic to luxury, excitement, tranquility, and relaxation.

Coral reefs are among the most diverse and beautiful of all marine habitats, and the Caribbean has about 7% of the world’s coral reefs. With reefs surrounding virtually the entire border of the Cuban marine shelf, the Belize barrier reef complex is the largest continuous reef system in the western Atlantic. The Bahamas offers >1,000 dives, including specialty dives such as shark close-ups and diving with dolphins. The Caribbean is one of the world’s top diving destinations: travelers can dive year round, and water temperatures average 74°F–81°F (23°C–27°C).

The Caribbean climate is tropical, with daytime temperatures in most of the region in the low- to mid-80s°F (26°C–30°C) during North America’s winter months and in the upper 80s to low 90s°F (lower 30s°C) in the summer months. Nighttime temperatures are around 10°F (5°C) cooler. Bermuda has similar summertime temperatures, but in the cooler months the nighttime low is in the upper 50s°F (12°C–15°C). Temperatures fluctuate depending on altitude, especially in the mountainous countries of Cuba (Pico Real del Turquino: 6,476 ft; 1,974 m), Haiti (Morne de la Selle: 8,907 ft; 2,715 m), and the Dominican Republic (Pico Duarte: 10,164 ft; 3,098 m). The Caribbean is a major winter vacation destination, and tourism is an extremely important economic activity for the region. Tourist arrivals were recorded by the Caribbean Tourism Organization as slightly >23.8 million in 2011 for their member countries that reported. In 2010, the United States accounted for almost 12 million tourist arrivals.

HEALTH ISSUES

Immunizations

 In addition to updated routine vaccinations, hepatitis A and B vaccination is recommended for all unvaccinated travelers. Typhoid vaccine is recommended for some travelers, especially if they are staying long-term, staying with friends or relatives, or visiting smaller cities, villages, or rural areas. In rare instances for selected travelers, preexposure rabies vaccination may be recommended.

Malaria

Malaria caused by chloroquine-sensitive Plasmodium falciparum is endemic in Haiti, and the risk of getting malaria for US travelers is estimated to be moderate. Highest transmission rates are reported to occur after the rainy seasons from March to May and October to November. Travelers to Haiti should take chemoprophylactic and preventive measures to minimize the risk of acquiring malaria. Malaria also occurs in the Dominican Republic. Except for rare cases, there have not been ongoing reports of malaria in travelers to Great Exuma, Bahamas, since 2006. CDC has no specific recommendations for travel to The Bahamas, although measures to avoid mosquitoes are recommended to prevent dengue. Endemic malaria occurs in the mainland countries of Guyana, Suriname, and Belize, and malaria chemoprophylaxis is recommended when visiting these countries (see Chapter 3, Travel Vaccines & Malaria Information, by Country).

Other Vectorborne Diseases

Dengue

The Caribbean is among the most common regions from which US travelers acquire dengue. Dengue is endemic in essentially all Caribbean countries because the vector, the Aedes mosquito, is ubiquitous. Outbreaks are being reported more frequently, and the numbers of reported cases of severe dengue are increasing. Travelers to the Caribbean should take measures to protect themselves from daytime mosquito bites to prevent dengue (see Chapter 2, Protection against Mosquitoes, Ticks, & Other Insects & Arthropods).

Yellow Fever

Yellow fever is a risk in parts of Trinidad and Tobago and the mainland countries of French Guiana, Guyana, and Suriname. Vaccine is recommended for travelers aged ≥9 months to the 3 mainland countries and the island of Trinidad. However, it is generally not recommended for travel limited to the urban areas of Port of Spain, and it is not recommended for the island of Tobago.

Chikungunya Fever

In December 2013, the World Health Organization reported local transmission of chikungunya in Saint Martin. This was the first time that local transmission of chikungunya had been reported in the Americas. The virus quickly spread to other islands in the Caribbean and is expected to continue to spread to new areas where the vectors, Aedes aegypti and Ae. albopictus mosquitoes, exist. Chikungunya, like dengue, is transmitted by day-biting mosquitoes. Symptoms are similar to those of dengue and malaria, although often with severe and persistent arthralgia. (Updated May 2, 2014)

Other Diseases

Travelers’ Diarrhea, Foodborne and Waterborne Diseases

Caribbean cuisine is a fusion of spices and cooking styles from African, Amerindian, British, Spanish, French, Dutch, Indian, and Chinese cultures. Whether jerked chicken or ackee and salt fish in Jamaica, cracked (deep fried) conch or conch fritters in The Bahamas, or roti with curried meat or vegetables in Trinidad and Tobago, travelers will want to experience the culinary excitement of Caribbean cuisine. However, travelers should stick to legitimate eating establishments and avoid itinerant vendors. Travelers’ diarrhea is one of the most common travel-related illnesses, and some countries in the Caribbean fall into the intermediate-risk group, with attack rates of 8%–20%. Central America falls into the high-risk group, with attack rates of 20%–50%. Outbreaks of ciguatera poisoning, which results from eating toxin-containing reef fish, have also occurred on many islands (see Chapter 2, Food Poisoning from Marine Toxins).

Epidemic cholera emerged in Haiti in October 2010, and cases are occasionally reported in travelers to Haiti returning to the United States. As of September 1, 2012, a total of 589,970 cases, 320,029 hospitalizations, and 7,539 deaths had been reported in Haiti. The Vibrio cholerae strain that caused the Haiti epidemic was characterized as toxigenic V. cholerae, serogroup O1, serotype Ogawa, biotype El Tor. In November 2010, the outbreak of cholera spread to the Dominican Republic and has been ongoing there but decreased during 2011 and 2012. In 2012 an outbreak of cholera was documented in Cuba.

Histoplasmosis

Outbreaks of histoplasmosis have occurred in travelers to some Caribbean islands and to mainland French Guinea. In 2011, three French cavers developed pulmonary histoplasmosis after a trip to Cuba. Spelunking and trekking may put travelers at higher risk for exposure.

Rabies

In recent years, rabies has been reported in Cuba, the Dominican Republic, Haiti, Grenada, and Puerto Rico.

Physical Concerns for the Traveler

Crime and Drugs

The crime rate is high in some countries of the Caribbean. A 2007 report from the World Bank estimated that the overall murder rate in the Caribbean was 30 per 100,000 inhabitants, 4 times that in North America. Visitors are rarely the victims of violent crime, but are most often victims of property crimes and may be targeted in locations frequented by tourists. Statistics suggest lower crime rates in the Caribbean countries of Montserrat, the Cayman Islands, Saint-Barthélemy, the British Virgin Islands, Bonaire, and Dominica. Travelers from the United States who are visiting friends and relatives in the Caribbean will most likely enter communities that the average tourist will not. These travelers should be reminded that they are not immune to crime and injury in these communities.

Travelers should be aware that while illegal drug use is prevalent in some tourist areas, possession or use of marijuana and other illicit drugs is illegal.

Traffic

Traffic crashes are the leading cause of injury death among US citizens in foreign countries. Tourists will encounter road conditions that differ substantially from those in the United States. In some countries, roads may vary from 2-lane paved roads to dirt tracks, and some may lack markings or reflectors. Although many Caribbean countries have areas with well-paved roads and even highways, many countries and many areas within countries have long, curvy roads with steep stretches where parts of the road are in disrepair. This is especially true in rural and mountainous areas. In a few of the smaller Caribbean islands, such as Bermuda, motor vehicle rentals may be limited to motorbikes, since cars are not often available. Unlike in the United States, drivers drive on the left in the English-speaking Caribbean countries.

Natural Disasters

The Atlantic hurricane season runs from June through November and peaks between August and October. Many of the Caribbean islands are in the path of Atlantic hurricanes through the Atlantic Ocean, the Caribbean Sea, and the Gulf of Mexico. The southernmost islands (Aruba, Barbados, Curaçao, Bonaire, Grenada, and Trinidad and Tobago) are rarely hit by hurricanes.

The Caribbean is also an area of major earthquake activity (magnitude ≥7.0) with the potential for generating tsunamis. On January 12, 2010, Haiti was hit by a magnitude 7.0 earthquake, resulting in >200,000 estimated deaths.

Beaches, Rafting, Diving, and Snorkeling

Even in the cooler months of the year, travelers are at risk for sunburn, which can be more severe with alcohol use. Travelers should use adequate sun protection and keep hydrated. Drowning is the third leading cause of injury death among US citizens in foreign countries, so travelers should ensure that they are fit and healthy before engaging in water-related activities and always have company when doing them. Wearing life jackets while boating or during other water recreation activities can reduce the risk of drowning. Dives should not be done within 24 hours before a flight or before mountain hikes to avoid the risk of decompression sickness.

Cutaneous larva migrans is a risk for travelers on some beaches in the Caribbean. Leptospirosis is common in many areas and poses a risk to travelers engaged in freshwater activities, such as whitewater rafting, kayaking, adventure racing, or hiking.

BIBLIOGRAPHY

1. Caribbean Epidemiology Center and Pan American Health Organization. CAREC surveillance report. CSR [Internet]. 2010 [cited 2012 Sep 26];30(2). Available from: http://new.paho.org/carec/dmdocuments/CSR_August_2010.pdf.
2. Caribbean Tourism Organization. Caribbean tourism—state of the industry. Caribbean Tourism Organization; 2011 [cited 2012 Sep 26]. Available from: http://www.onecaribbean.org/content/files/CaribbeanTourismStateIndustryFeb272011.pdf.
3. CDC. Notes from the field: Identification of Vibrio cholerae serogroup O1, serotype Inaba, biotype El Tor strain—Haiti, March 2012. MMWR Morb Mortal Wkly Rep. 2012 May 4;61(17):309.
4. de Luna Martinez J. Workers' remittances to developing countries: a survey with central banks on selected public policy issues. Washington, DC: The World Bank; 2005. Available from: http://econ.worldbank.org/external/default/main?pagePK=64165259&theSitePK=469372&piPK=64165421&menuPK=64166093&entityID=000012009_20050608121914.
5. Freedman DO, Weld LH, Kozarsky PE, Fisk T, Robins R, von Sonnenburg F, et al. Spectrum of disease and relation to place of exposure among ill returned travelers. N Engl J Med. 2006 Jan 12;354(2):119–30.
6. Greenwood Z, Black J, Weld L, O'Brien D, Leder K, Von Sonnenburg F, et al. Gastrointestinal infection among international travelers globally. J Travel Med. 2008 Jul–Aug;15(4):221–8.
7. Mohammed HP, Ramos MM, Rivera A, Johansson M, Munoz-Jordan JL, Sun W, et al. Travel-associated dengue infections in the United States, 1996 to 2005. J Travel Med. 2010 Jan–Feb;17(1):8–14.
8. Pan American Health Organization. Dengue. Washington, DC: Pan American Health Organization; 2012 [cited 2012 Sep 26]. Available from: http://new.paho.org/hq/index.php?option=com_content&view=article&id=264&Itemid=363&lang=en.
9. Rawlins SC, Hinds A, Rawlins JM. Malaria and its vectors in the Caribbean: the continuing challenge of the disease forty-five years after eradication from the Islands. West Indian Med J. 2008 Nov;57(5):462–9.
10. ScienceDaily. Major Caribbean earthquakes and tsunamis a real risk. ScienceDaily; 2005 [cited 2012 Sep 26]. Available from: http://www.sciencedaily.com/releases/2005/02/050205102502.htm.
11. Swaminathan A, Torresi J, Schlagenhauf P, Thursky K, Wilder-Smith A, Connor BA, et al. A global study of pathogens and host risk factors associated with infectious gastrointestinal disease in returned international travellers. J Infect. 2009 Jul;59(1):19–27.
12. United Nations and the World Bank. Crime, violence, and development: trends, costs, and policy options in the Caribbean. Report no. 37820. Geneva: United Nations and the World Bank; 2007 [cited 2012 Sep 26]. Available from: http://www.unodc.org/pdf/research/Cr_and_Vio_Car_E.pdf.
13. USA TODAY. Dying on foreign roads: where American travelers were killed. USA TODAY [Internet]. 2010 [cited 2012 Sep 26]. Available from: http://www.usatoday.com/travel/news/most-dangerous-driving-countries-chart.htm.