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Falling ill while on vacation has got to be one of the biggest concerns of Americans flying abroad, especially now in this post-pandemic context we’re living in.

Spending your hard-earned yearly break sick in a hospital bed, in a foreign country where you’re unsure whether doctors can be trusted, and you may not be able to speak the language and communicate your symptoms clearly is a nightmare scenario any traveler will do their best to avoid.

Whether it’s pesky bug bites, food poisoning, or sudden viral infections, these unfortunate occurrences know no borders, though, in some countries, the risks can be substantially higher due to poor sanitary controls or other factors.

Thanks to Forbes, now we know which destinations warrant a greater degree of caution and require travelers to adopt certain preventive measures to remain in good health:

How Has Forbes Identified The Top 5 Worst Destinations For Vacation Illness?

Forbes UK has carried out extensive new research with the aim of establishing what are the riskiest destinations for travelers globally regarding episodes of sickness while on vacation.

Experts looked at data from 2.4 million Tripadvisor posts featuring the keywords ‘salmonella’, ‘gastroenteritis’, ‘e-coli’, and ‘food poisoning’, as well as what were some of the recurring countries to which these terms were attributed.

The results were then cross-referenced against ‘pertinent’ data published by official entities, such as countries the British National Health Service (NHS) has issued specific immunizations for, or regions where drinking tap water is strongly discouraged by the American Centers For Disease Control And Prevention (CDC).

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The scores were compiled as the Forbes Advisor Travel Bug Index; the higher the score, the more common are bouts of illness.

The top five destinations where tourists are most affected by sickness were the following:

5. Cabo San Lucas, Mexico

Cabo San Lucas represents 1/2 of Mexico’s fast-growing dual destination of Los Cabos, highly sought-after for its natural element and developed wellness culture.

Despite being the country’s safest vacation spot for 2023, at least when it comes to low crime levels, Cabo performs poorly sanitation-wise.

In total, 4,987 posts mentioning sickness were gathered, with a prevalence of travelers falling ill at 8.09%. Additionally, the tap water in Cabo is not drinkable, and up to five vaccines must be ‘considered’ by foreigners ahead of visiting, though none are mandatory.

Taking these into account, Cabo has attained an overall score of 63.3, making it the fifth riskiest destination for vacation illness.

4. Playa del Carmen, Mexico

Yet another city in Mexico has made it to the top five, with Playa del Carmen charting at number four with a score of 63.8.

In total, the Riviera Maya location has garnered 8,402 Tripadvisor posts mentioning sickness, with an estimated 6.82% of reviewers claiming to have fallen ill.

Similarly to Los Cabos, the super trendy Playa del Carmen is deemed a relatively safe destination for Americans when limited gang activity in tourist zones is taken into account, but food and water standards may not be as high outside leisure centers.

3. Sal, Cape Verde

The Cape Verdean island of Sal has been attributed a significant score of 70.6, earning it a spot in the top three.

A small archipelago located off the coast of East Africa, Cape Verde is best known for its luxurious beachfront resorts and low criminality rates, which make it one of the 16 safest nations in the continent.

Regrettably, food safety regulations may not be as strictly enforced by local restaurant owners as they would elsewhere, with reports of undercooked meat being served, guests hit by gastric illnesses, and dirty water being common in the media.

The island of Sal has had 390 mentions of sickness on Tripadvisor; far fewer than Mexico’s Cabo or Playa del Carmen, though we must consider it normally hosts less than a million visitors per year, against the Riviera Maya’s 30+ million; hence, the adjusted proportion is higher.

Based on reviews, 11.20% of vacationers are stricken with some sort of malady in Cape Verde.

2. Sharm El Sheikh, Egypt

Second on the list, Egypt’s luxurious Red Sea coastal hub of Sharm El Sheikh has 6,578 complaints on Tripadvisor, with as many as 10.76% of reviewers who have visited reporting holiday sickness at some point during their stay.

The overall score is 83.5, and the rampancy of certain infectious diseases across Egypt as a whole is so worrying health authorities in the Western World recommend visitors to get immunized with at least six different vaccines, two of those being strongly advised.

1. Punta Cana, Dominican Republic

Punta Cana may be second only to Cancun in terms of international holiday bookings in the Western Hemisphere, drawing in millions of sun-seekers irrespective of season, but it’s now been exposed in the Forbes Holiday Sickness ranking as the worst destination worldwide for food poisonings.

Up to 13,463 Tripadvisor ‘sickness’ posts were counted, and while the percentage of sick vacationers is marginally lower than Egypt’s Sharm El Sheikh at 9.61%, Punta Cana still races ahead in the overall chart with a score of 90.4.

The paradise location has been battling bad publicity as early as 2019, when an investigation led by Britain-based Sick Holidays and food tolerance company YorkTest named it the second worst for locally-acquired gastrointestinal disorders globally, with 211 cases recorded between 2017 and 2018.

In this research, it is beaten only by Hurghada in Egypt. Sadly, it seems not much has changed since then.

Should Americans Avoid These Destinations?

These results help us identify which destinations require a higher degree of caution, whether it’s when consuming local food, drinking tap water, or getting immunized, but that doesn’t mean they should be avoided or that you will most certainly fall ill vacationing in Mexico, Cape Verde, Egypt or the Dominican Republic.

A majority, if not all, resorts in these countries are reputed for the high-quality service they offer, their five-star amenities, and world-class buffet service.

When it comes to food poisoning, nothing can ever be ruled out, but it is safe to say that resort guests dining and drinking on the premises have a much lower risk of contracting diseases than those taking their chances with street food or dodgy restaurants in non-touristy zones.

Even then, only a small minority of travelers will eventually get sick, though they often feel better on their own in a couple of days, and an even smaller number will require care or serious medical interventions.

There is one simple rule to follow here:

When visiting any foreign country, make sure you check safety advisories that have been issued for that destination beforehand, and ensure your risks of getting poisoned, or infected by diseases spread locally, are greatly reduced.

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This article originally appeared on TravelOffPath.com