Chapter 4Select DestinationsThe Americas & the Caribbean
Peru: Cuzco–Machu Picchu
Peru is approximately twice the size of the state of Texas, with a population of almost 30 million people. Thousands of tourists are drawn to Peru every year to enjoy the country’s magnificent geographic, biologic, and cultural diversity. A primary destination for most travelers is the remarkable Incan ruins of Machu Picchu, named a UNESCO World Heritage site in 1983 and voted one of the New Seven Wonders of the World in 2007. Machu Picchu stands in the middle of a tropical mountain forest, in an extraordinarily beautiful setting. It was probably the most amazing urban creation of the Inca Empire at its height; its giant walls, terraces, and ramps seem as if they have been cut naturally in the continuous rock escarpments. The natural setting, on the eastern slopes of the Andes, is in the upper Amazon Basin, with its rich diversity of flora and fauna.
A typical visit to Peru includes arrival at the capital city of Lima, a megacity the size of the state of Rhode Island, with approximately one-third of Peru’s population. Interestingly, many people think Lima is a high-altitude Incan city, but it is actually located on the Pacific coast at sea level. After spending a few days in Lima, one takes an hour-long flight to Cuzco, the gateway to Machu Picchu and a worthwhile destination of its own. Tourists can visit multiple Inca-era ruins and Peruvian mountain villages and markets in the Valle Sagrado (Sacred Valley) before taking the train to Machu Picchu. One of the world’s most popular and best-known treks, the Inca Trail, begins classically at kilometer 82 (7,700 ft; 2,600 m) on the Cuzco–Machu Picchu railway. This moderate 26-mile (43-km) trek is usually done in 4 days and 3 nights, and most fit people should be able to complete the hike. Nevertheless it is quite challenging, with 3 high mountain passes; the highest is Warmiwañusca at 13,829 ft (4,215 m), before ending in the ruins of Machu Picchu (7,970 ft; 2,430 m).
Many people also wish to add a tropical rainforest experience to their Cuzco trip and take the 30-minute flight from Cuzco to Puerto Maldonado, 34 miles (55 km) west of the Bolivian border, on the confluence of the Rio Tambopata with the Madre de Dios River, a major tributary of the Amazon River. Most travelers take a boat up the Rio Tambopata to one of several rustic lodges. Visitors wanting to see the Amazon rainforest may also go to Manu National Park in the south, also reached via Cuzco.
Other popular tourist destinations in Peru include the northern Amazon rainforest in Loreto that can be visited by traveling to the lodges around Iquitos or by journeying on the increasingly popular Amazon River cruises that go both upstream and downstream from Iquitos. As elsewhere, ecotourism is a growing activity in Peru. Also, Peru is home to the Cordillera Blanca, a hundred-mile range of spectacular snow-covered peaks that form the backbone of the Andes Mountains in Peru. The Cordillera Blanca boasts 33 peaks >18,040 feet (5,500 meters) and has an international reputation for its spectacular trekking and world-class mountaineering.
Important pre-travel information for Peru includes advice on preventing high-altitude illness, the risk for cutaneous leishmaniasis in certain jungle areas, use of yellow fever vaccine in some areas, and the risk of malaria for travelers visiting popular jungle lodges.
Altitude and Acute Mountain Sickness
All travelers to Machu Picchu will arrive and transit through Cuzco, 11,150 ft (3,400 m) above sea level. Most will quickly note shortness of breath on gathering luggage and making their way to local hotels on the hilly streets. Many arriving travelers will find the elevation leads to some degree of acute mountain sickness (AMS), with the initial symptoms of headache, nausea, and loss of appetite beginning 4–8 hours after arrival. The hypoxemia of high altitude can also affect the quality of sleep in the first few nights in Cuzco, causing restless sleep, frequent awakening, and periodic breathing (irregular breathing patterns, often alternating periods of deep breathing and shallow breathing), even in those who appear to be doing well during the day. A few travelers may progress to severe forms of altitude illness, including high-altitude pulmonary edema (HAPE) and high-altitude cerebral edema (HACE). The symptoms of AMS can markedly impair the traveler and prevent enjoyment of the sights of Cuzco.
Surveys have shown that most travelers arrive in Cuzco with limited or no knowledge of AMS or the fact that AMS can be prevented to a large degree by prophylactic use of acetazolamide. Every traveler to Cuzco should be counseled about AMS pre-travel and be prepared to prevent or self-treat AMS with acetazolamide. (More information about prevention and treatment of altitude illness can be found in Chapter 2, Altitude Illness.) Locals refer to AMS as soroche and will almost always offer the new arrival a cup of hot coca tea (mate de coca) when checking in to the hotel. Although many believe mate de coca can prevent and treat soroche, no data support its use in the prevention or treatment of AMS. Perhaps of concern to some who may experience random drug screening as a condition of employment, people who drink a single cup of coca tea will test positive for cocaine metabolites in standard drug toxicology screens for several days. However, sitting quietly and resting while enjoying a cup of tea is a most civilized activity and a pleasant memory.
New arrivals may also find it helpful to transit directly from Cuzco to the Valle Sagrado of the Rio Urubamba to spend the first few days and nights at a somewhat lower altitude. This spectacular river valley begins 15 miles (24 km) northeast of Cuzco in the town of Pisac (9,751 ft; 2,972 m), known for its colorful Sunday markets, and continues downstream toward the northwest for another 37 miles (60 km) to reach the town of Ollantaytambo (9,160 ft; 2,792 m). One can board the train to Machu Picchu in Ollantaytambo, at the northwest end of the Valle Sagrado, and the not-to-be-missed visit to Cuzco can be made on return from Machu Picchu, when people are better acclimatized. The train follows the Rio Urubamba north and northwest (downstream) to Aguas Calientes (6,690 ft; 2,040 m). Machu Picchu (7,970 ft; 2,430 m) is located on a ridge above the town.
Many areas in the Pacific valleys of the Andes and the Amazon tropical rainforest are endemic for cutaneous leishmaniasis (CL), a parasitic infection transmitted by bites of sand flies (see Chapter 3, Leishmaniasis, Cutaneous). While this disease is widespread in southeastern Peru, the highest risk for travelers seems to be in the Manu Park area in Madre de Dios. In Manu, CL is most often caused by Leishmania braziliensis, and there is a risk of both localized ulcerative CL and mucosal leishmaniasis. There is no visceral leishmaniasis in Peru. Travelers should be counseled to be meticulous about vector precautions, as there is no vaccine or chemoprophylaxis to prevent leishmaniasis. Any person with a skin lesion persisting more than a few weeks after return from Peru should be evaluated for CL.
Proof of yellow fever vaccination is not required for entry into Peru. Travelers who are limiting travel to the cities of Lima, Cuzco, and Machu Picchu, and the Inca Trail do not need yellow fever vaccination. Peru recommends vaccination for those who intend to visit any jungle areas of the country <2,300 m (7,546 ft). For complete CDC yellow fever vaccination recommendations for Peru, see Chapter 3, Travel Vaccines & Malaria Information, by Country.
In general, the risk of malaria in travelers visiting Peru is low. There are, on average, <5 cases reported in the United States each year that were acquired in Peru. Both Plasmodium vivax malaria and P. falciparum malaria are found in the Peruvian Amazon.
There is no malaria risk for travelers visiting only Lima and vicinity, coastal areas south of Lima, or the popular highland tourist areas (Cuzco, Machu Picchu, and Lake Titicaca). The malaria-endemic areas for most tourists are the neotropical rainforests of the Amazon, with 2 major destinations (see Map 3-38). The city of Iquitos in the northern rainforest is a frequent arrival destination for those traveling to jungle lodges around the city or for boarding river cruise boats for rainforest travel. Malaria transmission occurs in the areas in and around Iquitos. Malaria transmission is seasonal, with peak activity between January and May that correlates with the rainy season and the height of the Amazon River. Chemoprophylaxis is recommended for most travelers.
The city of Puerto Maldonado is a 30-minute flight from Cuzco and a popular arrival destination for those visiting the rainforest lodges on the Rio Tambopata. Newly arrived travelers usually transit directly from the airport to the boats that take them up the river to numerous lodges. Peruvian Ministry of Health data document that malaria transmission occurs in Puerto Maldonado. Most cases reported in the region occur in local loggers and gold miners in the forests. Travelers transiting Puerto Maldonado for a short 2- to 3-day visit to lodges on the Rio Tambopata may not need chemoprophylaxis. For those who are staying longer or who are engaging in higher-risk activities and may benefit from chemoprophylaxis, one could consider using daily primaquine in this area of Peru, as the malaria species present is now exclusively P. vivax.
Risk for the traveler varies with itinerary, style of travel, and location of accommodations. Malaria in the Peruvian Amazon is unpredictable from season to season; P. falciparum epidemics occasionally occur in the Loreto region. When making a decision on whether to recommend chemoprophylaxis or simply mosquito precautions, all these factors and data need to be taken into consideration.
Other Infectious Diseases
Typical travelers’ diarrhea is relatively common. Fluoroquinolone-resistant Campylobacter gastrointestinal infections are common and should be suspected in anyone with a gastrointestinal illness with fever and systemic symptoms and failure to clinically improve in 12–24 hours after initial empiric fluoroquinolone treatment. Azithromycin is recommended in this setting. Cyclosporiasis, an intestinal illness caused by the parasite Cyclospora cayetanensis, is also common in Peru. This diagnosis should be considered in people with watery diarrhea, loss of appetite, weight loss, cramping, and bloating that persist for days to weeks. Treatment is with trimethoprim-sulfamethoxazole.
Dengue is common in the neotropical areas of Peru and the northern coast. Mayaro virus, an alphavirus found in the Amazon Basin and transmitted by mosquitos, causes a denguelike illness. As with other alphaviruses, Mayaro can result in lengthy and debilitating arthralgias. Physicians treating patients with signs and symptoms of a denguelike illness and a recent history of travel to the Amazon should consider Mayaro infection in the differential diagnosis, especially if arthralgia is prominent and prolonged and dominates the clinical picture. Travelers to Peru should take measures to protect themselves from daytime mosquito bites to prevent dengue (see Chapter 2, Protection against Mosquitoes, Ticks, & Other Insects & Arthropods).
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