Cusco & Machu Picchu
CDC Yellow Book 2024Popular Itineraries
Peru is the third largest country in South America, with a population of over 30 million, and offers a rich local culture. The highlands are a popular tourist destination, boasting colorful folklore, intricate crafts, and monumental ruins.
A one-hour flight separates Lima (elevation 528 ft; 161 m) on the Pacific coast from Cusco (elevation 11,152 ft; 3,400 m), where most travelers start their journey through southern Peru. A UNESCO World Heritage site, downtown Cusco was built over the capital of the Inca empire and features a mixture of Inca stonework and colonial baroque architecture. In addition to museums and monuments, the city offers accommodations ranging from budget hostels to luxury hotels. The nearby ruins of Sacsayhuamán, Puka Pukara, Tambomachay, and Q’enco are included in some tour itineraries. The Valle Sagrado (Sacred Valley), with the towns and ruins of Písac, Calca, Urubamba, and Ollantaytambo, can be visited with day tours or can serve as the starting point for an adventure to Machu Picchu.
Machu Picchu was named an UNESCO World Heritage site in 1983 and included in the New Seven Wonders of the World in 2007. This mountaintop citadel includes more than 200 structures masterly adapted to the terrain with giant walls, terraces, stairs, and ramps cut or entwined naturally in the rock. To reach Machu Picchu, travelers must take a train to the town of Aguas Calientes at the base of the mountain or hike their way to the ruins. The 41-mile (66 km) train ride from Poroy train station to Aguas Calientes takes about 3 hours; Poroy train station is about 8 miles (13 km) from Cusco. Travelers can also catch trains to Aguas Calientes from Ollantaytambo station, about 2 hours outside of Cusco.
A short flight (<1 hour) connects Cusco to Juliaca, close to Lake Titicaca (elevation 12,507 ft; 3,812 m), but taking a bus (6 hours) or train (10 hours) offers stunning scenery. The Uros, Taquile, and Amantaní islands in Lake Titicaca are inhabited by Quechua and Aymara populations. The Colca Canyon, about 4 hours away from the city of Arequipa, is the second deepest canyon in the world and provides hiking options as well as sites to view the impressive Andean condor.
Infectious Disease Risks
Ensure travelers are up to date on routine vaccinations, including coronavirus disease 2019 (COVID-19) and seasonal influenza. Travelers also should be vaccinated against hepatitis A and typhoid.
Enteric Infections & Diseases
Typical travelers’ diarrhea is common among visitors to Peru (see Sec. 2, Ch. 6, Travelers’ Diarrhea). Norovirus, enterotoxigenic Escherichia coli, Shigella spp., and Campylobacter spp. are the most common causes of diarrhea among travelers to the region. High rates of fluoroquinolone-resistant Campylobacter infections have been documented in Peru and the region. Cryptosporidium spp., Giardia duodenalis, and Cyclospora cayetanensis are also common causes of diarrhea. These agents can cause persistent and recurrent diarrhea unresponsive to typical empiric antibacterial standby treatment for moderate to severe travelers’ diarrhea. Counsel patients about food and drink precautions, proper hydration, and the use of standby treatment, preferably azithromycin.
Bartonellosis (CarriÓn Disease)
Acute Bartonella bacilliformis infection (see Sec. 5, Part 1, Ch. 3, Bartonella Infections ), or Carrión disease, is a bacterial infection transmitted by sand flies that causes hemolysis of infected red blood cells. Outbreaks have been reported in the Urubamba province, which contains Aguas Calientes, Machu Picchu, and the Sacred Valley and sporadic cases continue to occur mainly affecting children in rural communities. Risk for short-term travelers to the region is considered low.
Chagas Disease (American Trypanosomiasis)
Although Chagas disease (see Sec. 5, Part 3, Ch. 25, Trypanosomiasis, American / Chagas Disease) is endemic to semi-urban and rural areas in southern Peru, the risk is negligible for travelers visiting Aguas Calientes, Cusco city, Machu Picchu, and the Sacred Valley.
Chikungunya, Dengue, Mayaro & Zika
Although travelers to Peru may be at risk for several mosquito-borne illnesses, no cases of dengue (see Sec. 5, Part 2, Ch. 4, Dengue) have been reported in the last decade from the district that contains Aguas Calientes and Machu Picchu. Chikungunya (see Sec. 5, Part 2, Ch. 2, Chikungunya), Mayaro, and Zika (see Sec. 5, Part 2, Ch. 27, Zika) have not been reported from Urubamba province.
Leishmaniasis (see Sec. 5, Part 3, Ch. 14, Cutaneous Leishmaniasis) is caused by infection with Leishmania parasites, which are spread by the bite of phlebotomine sand flies. Although transmission of leishmaniasis appears to be limited in Aguas Calientes, Machu Picchu, and the Sacred Valley, the infection is endemic to most areas of Peru. Advise travelers to avoid contact with sand flies and to practice insect bite precautions (see Sec. 4, Ch. 6, Mosquitoes, Ticks & Other Arthropods).
There is no transmission of malaria in the tourist areas of Aguas Calientes, Cusco city, Machu Picchu, or the Sacred Valley. For complete CDC malaria recommendations for Peru, see Sec. 2, Ch. 5, Yellow Fever Vaccine and Malaria Prevention Information, by Country
Proof of yellow fever vaccination is not required for entry into Peru. The risk of yellow fever in Cusco city, Machu Picchu, and the Sacred Valley is negligible, and travelers are not recommended to receive yellow fever vaccination for those itineraries. The town of Aguas Calientes, often a base for those visiting Machu Picchu, is at an elevation of 6,690 ft (2,039 m), just below the threshold where yellow fever vaccination is recommended. Nevertheless, historical data do not support transmission in the area. Discuss the risk of yellow fever with travelers planning to stay in Aguas Calientes and, regardless of whether vaccination is offered, recommend insect bite precautions. For complete CDC yellow fever vaccination recommendations for Peru, see Sec. 5, Part 2, Ch. 26, Yellow Fever and Sec. 2, Ch. 5, Yellow Fever Vaccine & Malaria Prevention Information, by Country.
Environmental Hazards & Risks
Altitude Illness & Acute Mountain Sickness
The flight from Lima to Cusco involves a change in elevation of approximately 11,000 ft (3,350 m) in approximately one hour, an ascent rate that increases the risk for altitude illnesses. Common symptoms include shortness of breath on exertion and poor sleep characterized by frequent awakenings and irregular breathing. Symptoms are often noticed immediately upon arrival to Cusco and may take several days to improve.
Acute mountain sickness (AMS) affects nearly one-half of travelers during the first 48 hours in Cusco but is usually mild, allowing most travelers to continue with planned activities. AMS presents with headache, often with nausea, dizziness, and fatigue. Recognition of these symptoms should delay further ascent until improvement. Although uncommon at Cusco’s elevation, some travelers may progress to severe forms of altitude illness, including high-altitude pulmonary edema and high-altitude cerebral edema. These conditions are life-threatening and require expert medical consultation and immediate descent to a lower elevation. Supplemental oxygen therapy can help alleviate symptoms but should not replace descent in severe cases. People with chronic lung disease, symptomatic heart disease, and sickle cell disease may not do well at high elevations and should see a physician with expertise in travel medicine before planning to visit these destinations (see Sec. 4, Ch. 5, High Elevation Travel & Altitude Illness).
Advise travelers to plan itineraries so that attractions at lower elevations are visited first. Initially staying in the Sacred Valley along the Rio Urubamba can help travelers gradually acclimate to higher elevations. The towns of Písac (9,751 ft; 2,972 m), Calca (9,600 ft; 2,925 m), Urubamba (9,420 ft; 2,870 m), and Ollantaytambo (9,160 ft; 2,791 m) are all at lower elevations than Cusco. The town of Urubamba, 32 mi (52 km) northeast of Cusco, offers the largest variety of lodging and dining accommodations for travelers. Machu Picchu, perched in the Andes Mountains, is counterintuitively at a lower elevation (7,972 ft; 2,430 m) than most of the surrounding tourist bases, including Cusco. Once in the town of Aguas Calientes (6,690 ft; 2,040 m), most travelers take a bus to the mountain ruins.
Hikes along the Inca Trail to Machu Picchu with different difficulty levels are popular and follow ancient Incan roads, treating the hiker to mountain scenery and tropical rainforests, culminating with the spectacular Inti Punku (Sun Gate) at the entrance to the ruins. The hike starts at an elevation of 8,438 ft (2,571 m) and reaches a maximum elevation of 13,828 ft (4,214 m) in the Warmiwañusca pass on the second day. Most routes, however, ensure travelers will not sleep > 2,000 ft above the elevation slept the previous night.
The Classic Inca Trail Route is approximately 27 mi (43 km) long and takes 4 days; shorter and longer hikes can also be booked. Travelers to Peru can explore destinations at higher elevations, including Lake Titicaca (12,507 ft; 3,812 m), Colca Canyon (11,155 ft; 3,400 m), and the Cordillera Blanca (10,138–19,685 ft; 3,090–6,000 m); if possible, these should be visited after Cusco and the Sacred Valley, to allow exposure to lower elevations first.
Counsel travelers before departure about AMS and signs that should prompt local medical consultation. Travelers should never ascend to higher elevations if symptoms are present. Most local physicians are experienced in the management of altitude illness. Consider prescribing acetazolamide for prevention or self-treatment of altitude illness. Coca leaf tea (mate de coca) is often offered to travelers on arrival to Cusco and other high-elevation destinations in Peru. Locals claim that mate de coca prevents and treats acute mountain sickness, but evidence does not support its use. As little as one cup of mate de coca can yield detectable cocaine metabolites in drug screening tests for a few days, a potential issue for athletes and others subjected to drug screens at work.
The Machu Picchu ruins, and part of the Inca Trail, are located within a tropical rain forest wildlife reserve. Both venomous (e.g., Bothrops andeanus) and non-venomous snake species are part of the fauna of the reserved area. Sightings of snakes are not uncommon, but bites are exceedingly rare. Staying within the marked trails, avoiding reaching into crevices in the ruins, and, most importantly, avoiding deliberate contact with snakes can prevent unintended injury (see Sec. 4, Ch.7 Zoonotic Exposures: Bites, Stings, Scratches & Other Hazards).
Other Safety Risks
The Inca ruins in Cusco are built on the mountains and entwine with their contour. Steep stairways, uneven terrain, and cliffs are characteristic of Sacred Valley ruins and Machu Picchu. Using walking sticks can help prevent falls and ankle injuries. Awareness of surroundings, staying within marked boundaries, and using caution when taking group pictures and selfies in ruins can prevent falls from precipices (see Sec. 4, Ch. 12, Injury & Trauma).
Ayahuasca is a concoction of different jungle vines and shrubs that causes hallucinations and is used in traditional rituals of indigenous populations in South America. Some of ayahuasca’s active ingredients may have potent monoamine oxidase activity. Ritual and recreational use of ayahuasca is expanding and travelers are a common target for advertisement in Peru. The safety and regulations for the commercial use of this drug have not been established in Peru. Some establishments offering ceremonies for a fee may not be prepared to treat side effects. Deaths, violent acts, and sexual abuse occurring during drug-induced hallucinations have been reported in the lay literature. Advise travelers to be cautious; review their medication list (both prescription and over-the-counter) to identify any potential drug–drug interactions from ayahuasca ingestion that could result in serious health outcomes (see Yellow Book chapter, Poisonings).
The following authors contributed to the previous version of this chapter: Mark J. Sotir
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