| Verified against primary record | |
| First documented outbreak | 19 cases across five United States states as of 21 February 2014, after cosmetic surgery in the Dominican Republic[1] |
|---|---|
| Procedures involved (2013 to 2014) | Liposuction 74 per cent, abdominoplasty 58 per cent, breast implantation 32 per cent[1] |
| Organisms (2013 to 2014) | Mycobacterium abscessus in 13 of 16 confirmed cases, M. fortuitum in two[1] |
| Hospitalisation (2013 to 2014) | 14 of 19 patients, 74 per cent, hospitalised in the United States; no deaths reported[1] |
| Second documented outbreak | 52 patients from nine states as of 8 November 2017, of whom 38 met the confirmed case definition[2] |
| Facilities implicated (2017) | 14 surgeons at seven surgical centres; 26 of 32 confirmed cases with information, 81 per cent, had surgery at one clinic[2] |
| Outcome (2017) | 14 of 15 cases with information required therapeutic surgery after returning to the United States; one death was reported[2] |
| Regulatory action | One clinic temporarily closed by Dominican authorities in the first outbreak; the 2017 clinic temporarily closed on 8 July 2017, with a CDC travel notice issued 18 July 2017[1][2] |
| Surveillance gap | Extrapulmonary nontuberculous mycobacteria infections are not nationally notifiable in the United States[2] |
| Independently reported | |
| Caribbean in United States health travel | 44 per cent of inbound source markets and 19 per cent of outbound destinations in 2011[4] |
| Bands apply only to the rows beneath them. These are counts of detected cases among patients who returned to the United States and whose clinicians recognised and reported the infection, not counts of everyone harmed, and the second investigation states that the relevant infections are not nationally notifiable. No Dominican count of foreign patients, no revenue figure and no national accreditation register was located. No typical cost range is given. | |
Medical tourism in the Dominican Republic is the best-documented case of harm in this series, and the documentation comes from epidemiology rather than from tourism statistics. Two United States outbreak investigations, four years apart, traced clusters of mycobacterial surgical site infections among women who had cosmetic surgery on the island. The second involved 52 patients across nine states and reported one death.
The 2013 to 2014 cluster
Reporting in Morbidity and Mortality Weekly Report on 7 March 2014, a CDC-led team recorded 19 cases of rapidly growing nontuberculous mycobacterium wound infection as of 21 February 2014 among medical tourists who had undergone cosmetic surgery in the Dominican Republic. Sixteen were confirmed and three probable. All patients were female, aged 18 to 59. Cases arose in five states: 11 in New York, three in Massachusetts, two in Connecticut, two in Maryland and one in Pennsylvania. Procedures took place between March and November 2013 and illness onsets between April and November 2013.[1]
The procedures were liposuction in 74 per cent of cases, abdominoplasty in 58 per cent and breast implantation in 32 per cent, the overlap reflecting patients who had more than one. Twelve patients, 63 per cent, had surgery at a single clinic designated clinic A, which Dominican authorities temporarily closed; the remaining seven had surgery at seven other Dominican surgical clinics, giving eight implicated clinics in total.[1]
Of the 16 confirmed cases, 13 were Mycobacterium abscessus and two M. fortuitum, with one pending final speciation. The two index patients, identified in Maryland in August 2013, had both had surgery at clinic A the previous month and within seven days of returning to the United States sought care for wound abscesses, clear fluid drainage, pain and fever. Initial antibiotic therapy was ineffective. Fourteen patients, 74 per cent, were hospitalised in the United States and required multiple therapeutic and corrective surgical procedures along with long courses of antibiotics. No deaths were reported.[1]
One finding deserves separate attention. Of 18 patients interviewed, 13, or 72 per cent, were born in the Dominican Republic. This was not a cluster of tourists in the ordinary sense but largely of Dominican-born women living in the United States returning to their country of origin for surgery, which is a distinct phenomenon from price-driven medical tourism and is often overlooked when destination statistics are compiled.[1]
The 2017 cluster
A second report, published in Morbidity and Mortality Weekly Report on 30 March 2018, recorded that as of 8 November 2017 the CDC had been notified of 52 patients from nine states with a surgical site infection after cosmetic surgery in the Dominican Republic. Thirty-eight, 73 per cent, met the confirmed case definition, the remaining 14 lacking laboratory evidence of nontuberculous mycobacteria. All confirmed cases were in women who had surgery between 4 January and 14 July 2017.[2]
Confirmed cases identified 14 surgeons at seven surgical centres. Of 32 confirmed cases with available information, 26, or 81 per cent, had surgery at one clinic named in the report as CIPLA, which was temporarily closed on 8 July 2017; the CDC issued a travel notice on 18 July 2017 advising United States residents of the risks of any surgery there.[2]
Whole genome sequencing of isolates from 22 cases identified three distinct genetic cluster variants, none of which matched a single clinic or surgeon. The authors note that nontuberculous mycobacteria are ubiquitous in nature and commonly colonise water systems. Of 11 cases with treatment information all received more than one antibiotic, 14 of 15 cases required therapeutic surgical procedures after returning to the United States, and one death was reported.[2]
That the genetic clusters did not map onto individual clinics or surgeons is an important technical result. It argues against a single contaminated instrument or one careless operator and towards an environmental source such as water used in the surgical setting, which is a facility-wide and potentially sector-wide problem rather than an individual one.
Why the counts understate the problem
The 2018 report is explicit that outbreak detection among medical tourists depends on clinical recognition and reporting, and that patients who attended one clinic abroad may be sparsely spread across the United States. It records that extrapulmonary nontuberculous mycobacteria infections are not nationally notifiable, which makes cluster identification harder, and notes that the Council of State and Territorial Epidemiologists subsequently approved a standard case definition for them.[2]
So 19 and 52 are floors, not totals. They count patients whose infection failed to respond to standard treatment, who returned to a United States jurisdiction, and whose clinician both recognised an unusual mycobacterial infection and reported it to a health department. Patients who recovered without that chain of events, who were treated outside the United States, or whose infection was never speciated do not appear. The true number harmed in either period is unknown and unknowable from these sources.
Both reports converge on the same clinical advice: clinicians should consider rapidly growing nontuberculous mycobacteria in a patient with a history of cosmetic surgery abroad whose surgical site infection does not respond to standard therapy, and should maintain a high index of suspicion early in the evaluation. The first report advises prospective travellers to verify before surgery that the provider and facility are licensed and accredited by an internationally recognised accreditation organisation, and the second says the investigation underscores the need for education of prospective medical tourists about risks.[1][2]
The general guidance notes separately that accreditation does not guarantee a good outcome, and records nontuberculous mycobacteria surgical site infections after cosmetic surgery in the Dominican Republic among the standing documented risks of medical tourism, alongside fungal meningitis and carbapenem-resistant infections associated with procedures in Mexico.[3]
The sector these events occurred in
A 2015 briefing by an economist in the United States International Trade Commission’s Office of Industries, published as the author’s own views and not the Commission’s, records the Caribbean as 44 per cent of source markets for inbound United States health travellers in 2011 and 19 per cent of destinations for outbound ones, with Central America at 18 per cent and South America at 26 per cent of outbound destinations.[4]
No Dominican government count of foreign patients, no revenue figure, no hospital or clinic register and no national accreditation list was located for this article. The country’s sector is therefore documented in the public record principally through its failures, which is an artefact of where the investigative effort was applied rather than a complete picture of Dominican healthcare.
Limits of the evidence
The two investigations describe detected clusters in specific periods and do not support any statement about current conditions at any named or unnamed facility, nine and twelve years on. The first report does not record findings on water sources or instrument sterilisation, and its recommended onsite infection control assessment results are not reported in it. The second report’s figure caption gives 37 where its text gives 38 confirmed cases, and that discrepancy is left as the source leaves it. Neither report gives a Dominican denominator, so no infection rate can be calculated. Nothing has been estimated.
See also
- Cosmetic surgery tourism, the activity both clusters involved
- Diaspora medical travel, which 72 per cent of the first cluster represents
- Complication rates in medical tourism, and why these counts are floors
- Clinical outcomes in medical tourism, documented here through epidemiology
- Medical tourism in Panama, a regional destination with no comparable record either way
References
- Schnabel, D. et al. Notes from the Field: Rapidly Growing Nontuberculous Mycobacterium Wound Infections Among Medical Tourists Undergoing Cosmetic Surgeries in the Dominican Republic, Multiple States, March 2013 to February 2014. Morbidity and Mortality Weekly Report, volume 63, issue 9, page 201, 7 March 2014. Verified against primary record: the report was opened and the total of 19 cases as of 21 February 2014 with 16 confirmed and three probable, the state distribution of 11 in New York, three in Massachusetts, two in Connecticut, two in Maryland and one in Pennsylvania, the demographic finding that all patients were female aged 18 to 59, the procedure period of March to November 2013 and onset period of April to November 2013, the case definitions for probable and confirmed cases, the procedure shares of liposuction 74 per cent, abdominoplasty 58 per cent and breast implantation 32 per cent, the finding that 12 patients or 63 per cent had surgery at clinic A with seven at seven other clinics giving eight implicated clinics, the temporary closure of clinic A by Dominican authorities, the species breakdown of 13 Mycobacterium abscessus, two M. fortuitum and one pending speciation among 16 confirmed cases, the antibiotic resistance noted in the Maryland index isolates, the clinical course of the two Maryland index patients presenting within seven days of return with wound abscesses, clear fluid drainage, pain and fever, the ineffectiveness of initial antibiotic therapy, the hospitalisation of 14 patients or 74 per cent requiring multiple therapeutic and corrective surgical procedures and long antibiotic courses, the absence of reported deaths, the finding that 13 of 18 patients interviewed or 72 per cent were born in the Dominican Republic, the recommendation that clinicians consider these organisms in non-responsive surgical site infections after cosmetic surgery in the Dominican Republic, and the advice to travellers to verify provider and facility licensing and accreditation by an internationally recognised organisation were read directly. The report does not record findings on water sources or instrument sterilisation. Retrieved 23 October 2026.
- Gaines, J. et al. Notes from the Field: Nontuberculous Mycobacteria Infections in U.S. Medical Tourists Associated with Plastic Surgery, Dominican Republic, 2017. Morbidity and Mortality Weekly Report, volume 67, issue 12, pages 369 to 370, 30 March 2018, DOI 10.15585/mmwr.mm6712a5. Verified against primary record: the report was opened and the notification of 52 patients from nine states as of 8 November 2017, the 38 or 73 per cent meeting the confirmed case definition with 14 lacking laboratory evidence, the finding that all confirmed cases were in women who had surgery between 4 January and 14 July 2017, the identification of 14 surgeons at seven surgical centres, the finding that 26 of 32 confirmed cases with available information or 81 per cent had surgery at CIPLA, the whole genome sequencing of isolates from 22 cases identifying three distinct genetic cluster variants none matching a single clinic or surgeon, the note that nontuberculous mycobacteria are ubiquitous in nature and commonly colonise water systems, the finding that all 11 cases with treatment information received more than one antibiotic, that 14 of 15 cases required therapeutic surgical procedures after returning to the United States, and that one death was reported, the temporary closure of CIPLA on 8 July 2017 and the CDC travel notice of 18 July 2017, the conclusion that outbreak detection depends on clinical recognition and reporting and that patients from one clinic may be sparsely spread across the United States, the statement that extrapulmonary nontuberculous mycobacteria infections are not nationally notifiable, the subsequent approval of a standard case definition by the Council of State and Territorial Epidemiologists, the recommendation that clinicians maintain a high index of suspicion early in evaluating such infections, the statement that the investigation underscores the need for education of prospective medical tourists, and the reference to the earlier 2013 to 2014 Dominican outbreak were read directly. The report’s figure caption gives 37 where its text gives 38 confirmed cases. Retrieved 23 October 2026.
- Stoney, R. J. and Leidel, L. Medical Tourism. CDC Yellow Book: Health Information for International Travel, 2026 edition, United States Centers for Disease Control and Prevention. Page dated 23 April 2025. Independently reported: the chapter was opened and the listing of nontuberculous mycobacteria surgical site infections after cosmetic surgery in the Dominican Republic among the documented risks of medical tourism alongside fungal meningitis after epidural anaesthesia in Mexico and carbapenem-resistant Enterobacterales infections after invasive procedures in Mexico, the statement that accreditation does not guarantee a good outcome, and the identification of cosmetic surgery procedures most often sought including abdominoplasty, breast augmentation, buttock augmentation, liposuction and rhinoplasty were read directly. Retrieved 23 October 2026.
- Chambers, A. Trends in U.S. Health Travel Services Trade. Office of Industries, United States International Trade Commission, Executive Briefing on Trade, August 2015. Independently reported: the briefing was opened and the 2011 figures placing the Caribbean at 44 per cent of inbound United States health travel source markets and 19 per cent of outbound destinations, with Central America at 18 per cent and South America at 26 per cent of outbound destinations, were read directly. The briefing states that the views expressed are those of the author and not those of the Commission. Retrieved 23 October 2026.
Sourcing note: the case counts here are presented as floors rather than totals, because both investigations make clear that detection depended on home-country clinicians recognising and reporting an unusual infection, and the second states that these infections are not nationally notifiable. The entry draws no conclusion about current conditions at any facility, since the investigations are nine and twelve years old. The 37 against 38 discrepancy inside the second report is reproduced rather than resolved. No infection rate is calculated, because no denominator exists in either source.