Chapter 10 Popular Itineraries The Americas & the Caribbean
Peru: Cusco, Machu Picchu & Other Regions
Peru is a country almost twice the size of the state of Texas, with a population of 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 are 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. Located in southern Peru, in the middle of a tropical mountain forest on the eastern slopes of the Andes Mountains, Machu Picchu is extraordinarily picturesque. Considered perhaps the most amazing urban creation of the Inca Empire at its height, its giant walls, terraces, and ramps appear to be cut naturally from the continuous rock escarpment.
Lima, the capital city of Peru, is a sprawling megacity home to approximately one-third of Peru’s population. Some mistakenly believe Lima is a high-altitude Incan city; it is actually located at sea level on the Pacific coast (Map 10-10). From Lima, it is an hour-long flight to get to Cusco, the gateway to Machu Picchu and a worthwhile destination of its own. Visitors can see Inca-era ruins in Cusco and surrounding mountain villages, and shop in markets in the Valle Sagrado (Sacred Valley).
A train takes passengers from Cusco to several places where they can ascend to the actual site. From the town of Aguas Calientes, buses travel up the mountain to Machu Picchu. Multiple-day hikes across Andean mountain trails are also popular. One of the world’s best-known treks, the Inca Trail, begins at an elevation of more than 8,000 ft (>2,500 m) on the Cusco-Machu Picchu railway. Most physically fit people should be able to complete this 26-mile (43-km) hike in 4 days and 3 nights. The route is quite challenging, however, traversing 3 high mountain passes—the highest is Warmiwañusca at 13,796 ft (4,205 m)—before it ends at the ruins of Machu Picchu (7,970 ft; 2,430 m).
Many people also choose to add a tropical rainforest experience to their Cusco trip and take the 30-minute flight from Cusco to Puerto Maldonado, 34 miles (55 km) west of the Bolivian border. Puerto Maldonado is at the confluence of the Rio Tambopata and the Madre de Dios River, a major tributary of the Amazon River. Most travelers take a boat up the Rio Tambopata to stay at one of several rustic lodges. Those wanting to see the Amazon rainforest can visit the more remote Manu National Park, also accessible from Cusco. Additional sites of interest in southern Peru include the Nazca Desert—home of the ancient geoglyphs known as the Nazca Lines—and Lake Titicaca, which overlaps Peru’s border with Bolivia. It is called the highest navigable lake in the world.
Other natural wonders of this country include the Loreto Region and the Cordillera Blanca mountain range. Iquitos, the capital of the Loreto Region, can only be reached by boat or by plane; no roads lead to the city. From Iquitos, travelers can explore the northern Amazon rainforest by cruising upstream or downstream the Amazon River. The Cordillera Blanca, a hundred-mile range of spectacular snow-covered peaks, forms the backbone of the Andes Mountains in Peru. The Cordillera Blanca boasts 33 peaks >18,040 ft (5,500 m) and has earned a reputation for world-class trekking and mountaineering.
Map 10-10. Peru destination map
Important pretravel information for travelers going to Peru includes advice on preventing high-altitude illness, reducing risk for cutaneous leishmaniasis and vectorborne illnesses, including malaria, and—depending on the itinerary—the need for vaccination against yellow fever.
Altitude Illness and Acute Mountain Sickness
Travelers to Machu Picchu will arrive and transit through Cusco, 11,200 ft (3,400 m) above sea level. A recent study of travelers to Cusco found that three-quarters flew directly from sea level. On arrival, most tourists will quickly notice they are short of breath when gathering luggage and making their way to local hotels on the hilly streets. Many, maybe as many as half, will find that Cusco’s 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 that accompanies high-elevation travel can also affect the quality of sleep in the first few nights in Cusco, causing restless sleep, frequent awakening, and irregular respiratory patterns (alternating deep and shallow breathing), even in those who appear to be doing well during the day. Some travelers may progress to severe forms of altitude illness, including high-altitude pulmonary edema and high-altitude cerebral edema, life-threatening conditions that mandate immediate descent to a lower elevation. Even more mild symptoms of AMS can markedly impair the traveler and prevent enjoyment of the sights of Cusco. People with underlying lung disease may not be the best candidates for travel to this destination. Expert pretravel medical consultation is advised (see Chapter 3, High-Altitude Travel & Altitude Illness).
Surveys have shown that most travelers arrive in Cusco with limited or no knowledge of AMS or the fact that it can be prevented to a large degree by prophylactic use of acetazolamide. Pretravel counseling should include information about AMS and a prescription for medication to prevent or self-treat the condition. Travelers to other parts of Peru may also require counseling about AMS; common travel destinations at high elevation include the city of Puno on the shore of Lake Titicaca (12,556 ft; 3,830 m), and the Cordillera Blanca (peaks >18,040 ft; 5,500 m).
Locals refer to AMS as soroche and may 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. People who drink a single cup of coca tea will test positive for cocaine metabolites in standard drug toxicology screens for several days, a potential concern to anyone subject to random drug screens at work.
New arrivals may find it helpful to transit directly from Cusco to the Valle Sagrado of the Rio Urubamba to spend the first few days and nights at a somewhat lower elevation. This river valley begins 15 miles (24 km) northeast of Cusco in the town of Pisac (9,751 ft; 2,972 m), known for its colorful Sunday markets, continuing 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 visit Cusco on the return from Machu Picchu, when better acclimatized. The train follows the Rio Urubamba north and northwest (downstream) to Aguas Calientes (6,693 ft; 2,040 m). Machu Picchu (7,972 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 4, Cutaneous Leishmaniasis). 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. Counsel travelers to be meticulous about vector precautions, as there is no vaccine or prophylaxis to prevent this disease. 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, and travelers limiting their itineraries to Lima, Cusco, Machu Picchu, and the Inca Trail do not need yellow fever vaccination. Many travelers, however, choose to acclimate and/or stay in Aguas Calientes before taking the bus to the Inca citadel. But because Aguas Calientes is in a region (Cusco Region) where yellow fever vaccine is recommended, and because it is at an elevation where yellow fever mosquitoes are potentially active (i.e., it is below 2,300 m), travel health providers should advise vaccination for any travel plans involving Aguas Calientes.
CDC recommends vaccination for all travelers ≥9 months of age who intend to visit areas of the country <7,546 ft (2,300 m) in the regions of Amazonas, Loreto, Madre de Dios, San Martin and Ucayali, Puno, Cusco, Junín, Pasco, and Huánuco, and designated areas of the following regions: far north of Apurimac, far northern Huancavelica, far northeastern Ancash, eastern La Libertad, northern and eastern Cajamarca, northern and northeastern Ayacucho, and eastern Piura (see Map 10-10). For complete CDC yellow fever vaccination recommendations for Peru, see Chapter 2, Yellow Fever Vaccine & Malaria Prophylaxis Information, by Country.
Both Plasmodium vivax and P. falciparum malaria are found in the Peruvian Amazon, as well as the central jungle and northern coastal regions. Except for the urban areas of Lima and its environs and the coastal areas south of Lima, malaria is presumed to be present in all departments of Peru <6,562 ft (2,000 m). This includes the cities of Iquitos (in the north) and Puerto Maldonado (in the south) and the remote eastern regions of La Libertad and Lambayeque. CDC recommends malaria prophylaxis when visiting any of these locations. There is no malaria risk for travelers visiting only the popular highland tourist areas of Cusco, Machu Picchu, and Lake Titicaca. For complete CDC malaria recommendations for Peru, see Chapter 2, Yellow Fever Vaccine & Malaria Prophylaxis Information, by Country.
The malaria-endemic areas of concern for most tourists are the neotropical rainforests of the Amazon, north and south (see Map 10-10). Although P. falciparum epidemics sometimes occur in the Loreto Region, routine malaria transmission in and around Iquitos happens throughout the year, with peak activity corresponding to the rainy season between January and May. In the south, Peruvian Ministry of Health data document that malaria transmission occurs in and around the city of Puerto Maldonado, the take-off point for travelers staying in rainforest lodges. Most cases reported in this region occur in local loggers and gold miners in the forests. Nevertheless, prophylaxis for travelers planning a visit to any rainforest areas should be strongly recommended.
Other Infectious Diseases
Typical travelers’ diarrhea is relatively common (see Chapter 2, Travelers’ Diarrhea). Fluoroquinolone-resistant Campylobacter infections should be suspected in anyone with a gastrointestinal illness with fever, systemic symptoms, and failure to improve within 12–24 hours after beginning empiric fluoroquinolone treatment. Azithromycin can be used for people who do not respond to empiric treatment of acute gastroenteritis with a fluoroquinolone.
Cyclosporiasis, an intestinal illness caused by Cyclospora cayetanensis, is also common in Peru (see Chapter 4, Cyclosporiasis). The parasite, named for the Cayetano Heredia University in Lima, where early epidemiologic and taxonomic research was conducted, causes watery diarrhea, anorexia, weight loss, and cramping and bloating that persists for days to weeks. Treatment is trimethoprim-sulfamethoxazole.
In addition to yellow fever and malaria, several other mosquitoborne illnesses are found in Peru, and all travelers should be instructed on how to protect themselves from mosquito bites (see Chapter 3, Mosquitoes, Ticks & Other Arthropods). Dengue is common in the neotropical areas of Peru and the northern coast. Mayaro virus, an alphavirus transmitted by mosquitoes of the Amazon Basin, causes a dengue-like illness followed by, in some cases, long-lasting and debilitating arthralgias. Chikungunya, another alphavirus, has been reported. Most recently, Zika was identified in Peru. Because of the risk of birth defects in infants born to women infected with Zika during pregnancy, women who are pregnant or trying to become pregnant should research the most recent recommendations at www.cdc.gov/zika. Physicians treating patients with signs and symptoms of a dengue-like illness and a recent history of travel to the Amazon should include Mayaro, chikungunya, and Zika as part of their differential diagnosis. For more details, see sections on dengue, chikungunya, and Zika virus in Chapter 4.
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