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he Centers for Disease Control and Prevention is warning Americans about the risks of “medical tourism” after nearly two dozen US residents contracted serious infections related to cosmetic surgery in the Dominican Republic.

The 21 people affected were all women who underwent surgeries including liposuction, tummy tucks, butt implants, and breast reduction at one of five clinics in the Dominican Republic in 2013. In the process, they were infected with rapidly growing mycobacteria, organisms that thrive in dirty water and may enter the body during a procedure in an unsterile environment.

The bacteria caused an oozing skin condition that in some cases did not completely heal even nine months after their surgeries, according to a CDC study released Wednesday.

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Each year, between 75,000 and 750,000 US residents travel abroad to receive medical services. Although little is known about medical tourism, it’s on the rise, primarily because health care is much cheaper in parts of the developing world like Latin America and South Asia.

But regulation of health care facilities abroad is a patchwork at best. “People traveling for medical care need to be informed of its risks,” said Dr. Douglas Esposito, a medical epidemiologist with the CDC’s Travelers’ Health Branch and a lead author of the study. “There are many unknowns overseas … in how they deal with infection.”

Mycobacteria are also notoriously resistant to most antibacterial drugs, making them “complex and complicated” to treat, said Esposito.

Once painful swellings surfaced on their skin, the women were treated with a prolonged course of antibacterial drugs (in some cases, more than five different drugs) and surgical procedures to drain fluid from infected tissue or remove implants.

Thirteen patients had been to the same clinic in the Dominican Republic, which was referred to as “clinic A” in the study. Only one reported full recovery nine months after the surgery. For more than half the patients, getting treatment was also a financial burden — either in direct medical costs or in the inability to work.

Part of the problem is that standards of care are not global. Some international organizations inspect and certify health care facilities outside the US, but none of the cosmetic surgery clinics in the Dominican Republic were accredited by those organizations.

An abdominoplasty — a surgery to remove belly flesh that more than half the women underwent — costs around $1,500 to $2,000 in the Dominican Republic, about one-third what it costs in the US, according to one study.

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For the 21 women, however, saving money was not their sole motivation. Most of them were either born in the Dominican Republic, or had family or friends there who told them about the clinic where they had surgeries.

The infections were first detected when two women in Maryland went to their physician in 2013 with infected abscesses. They revealed that an acquaintance in Massachusetts had “similar problems” after getting cosmetic surgery at the same clinic.

Rapidly growing mycobacteria infection is not a “nationally notifiable” disease, which means that it is not usually reported to a federal body like the CDC. But the concerned physician notified the Maryland Department of Health, triggering a nationwide investigation to find patients who may have contracted similar infections in the Dominican Republic.

The country’s Ministry of Health reported that clinic A, where the majority of the women had surgeries, has since closed.

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