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Peru Travel Requirements & Vaccinations

Peru is a country on the northwest coast of South America, officially known as the Republic of Peru. Spanish is the primary language and is spoken by more than 80 percent of the population. In some popular tourist destinations, English is also widely spoken.

The terrain of Peru is widely varied and ranges from hot, dry plains in the Pacific coastal region to tropical rainforests and jungles that extend to the east and occupy almost 60 percent of the country’s land mass. True to its name, the rainforest and jungle regions are characterized by frequent, heavy rainfall and hot temperatures. Portions of the country farther to the south have cooler winters and more seasonal rainfall.

Because of its varied geography and climate, Peru is home to over 1,800 species of birds, over 300 species of reptiles and 500 species of mammals, including the puma, jaguar and spectacled bear.

Some of the many tourist attractions and activities offered in Peru include:

• Ancient ruins, including the 15th century Inca citadel, Machu Picchu
• Hiking, climbing and mountain biking through picturesque mountainous regions
• Manu National Park with its stunning variety of wildlife
• Town markets offering locally made handicrafts
• Sandy coastlines and beaches
• Wide variety of cultural events featuring local art, cuisine and music

Recommended Vaccinations for Peru Travel

• Hepatitis A
• Yellow Fever

*Rabies vaccination is typically only recommended for very high risk travelers given that it is completely preventable if medical attention is received within 7 – 10 days of an animal bite.Travelers may also be advised to ensure they have received the routine vaccinations listed below. Some adults may need to receive a booster for some of these diseases:

• Measles, mumps and rubella (MMR)
• Tdap (tetanus, diphtheria and pertussis)

Older adults or those with certain medical conditions may also want to ask about being vaccinated for shingles and/or pneumonia.

This information is not intended to replace the advice of a travel medicine professional. Not all of the vaccines listed here will be necessary for every individual.

Talk to the experts at UH Roe Green Center for Travel Medicine & Global Health to determine how each member of your family can obtain maximum protection against illness, disease and injury while traveling, based on age, health, medical history and travel itinerary.

Update April 12, 2024

Information for u.s. citizens in the middle east.

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Travel Advisory November 15, 2023

Peru - level 2: exercise increased caution.

Last Update: Reissued with updates to crime information.

Exercise increased caution due to  crime, civil unrest, and the possibility of kidnapping . Some areas have increased risk. Read the entire Travel Advisory.

Do not travel to:

• The Colombian-Peruvian border area in the Loreto Region due to  crime .
• The Valley of the Apurímac, Ene, and Mantaro Rivers (VRAEM), including areas within the Departments of Ayacucho, Cusco, Huancavelica, and Junin, due to  crime  and  terrorism .

Country Summary : Crime, including petty theft, carjackings, muggings, assaults, and other violent crime, is common in Peru and can occur during daylight hours despite the presence of many witnesses. Kidnapping is rare, but does occur. The risk of crime increases at night. Organized criminal groups have been known to use roadblocks to rob victims in areas outside of the capital city of Lima.

Demonstrations occur regularly throughout the country. Public demonstrations can take place for a variety of political and economic issues. Demonstrations can cause the shutdown of local roads, trains, and major highways, often without prior notice or estimated reopening timelines. Road closures may significantly reduce access to public transportation and airports and may disrupt travel both within and between cities.

U.S. travelers participating in Ayahuasca and Kambo ceremonies should be aware that numerous persons, including U.S. citizens, have reported that while under the influence of these substances, they have witnessed or been victims of sexual assault, rape, theft, serious health problems and injuries, and even death.

Currently, U.S. government personnel cannot travel freely throughout Peru for security reasons . Read the  country information page  for additional information on travel to Peru.

If you decide to travel to Peru:

• Be aware of your surroundings.
• Monitor local media for breaking events and adjust your plans as needed.
• Enroll in the  Smart Traveler Enrollment Program  ( STEP ) to receive Alerts and make it easier to locate you in an emergency.
• Follow the Department of State on  Facebook  and  Twitter .
• Follow the U.S. Embassy on  Facebook  and  Twitter .
• Review the U.S. Embassy  webpage .
• Review the  Country Security Report  for Peru.
• Prepare a contingency plan for emergency situations. Review the  Traveler’s Checklist .
• Visit the CDC page for the latest  Travel Health Information  related to your travel.

Colombian-Peruvian border area in the Loreto Region – Level 4: Do Not Travel

Drug trafficking and other criminal activity, combined with poor infrastructure, limits the capability and effectiveness of Peruvian law enforcement in this area.

The U.S. government has limited ability to provide emergency services to U.S. citizens as U.S. government personnel are restricted from traveling within 20 kilometers of the border with Colombia in the Loreto region, except on the Amazon River itself, without permission. This includes travel on the Putumayo River, which forms most of the Peru-Colombia border.

U.S. government personnel must receive advance permission for any travel to the Peruvian-Colombian border.

Valley of the Apurímac, Ene, and Mantaro Rivers (VRAEM) includes areas within the Departments of Ayacucho, Cusco, Huancavelica, and Junin – Level 4: Do Not Travel

Remnants of the Shining Path terrorist group are active in the VRAEM. The group may attack with little or no warning, targeting Peruvian government installations and personnel.

Drug trafficking and other criminal activity, combined with poor infrastructure, limit the capability and effectiveness of Peruvian law enforcement in this area.

U.S. government personnel are restricted from traveling in the VRAEM except for certain areas during daylight hours. U.S. government personnel must receive advance permission for any travel to the VRAEM. The U.S. government has limited ability to provide emergency services to U.S. citizens due to these travel restrictions.

Visit our website for  Travel to High-Risk Areas .

Embassy Messages

View Alerts and Messages Archive

Quick Facts

Must have six months validity at time of entry.

One page required for entry stamp.

Free, issued at the port of entry.

None Required.

$30,000 USD. More than $10,000 USD must be declared upon entry.

Same as entry.

Embassies and Consulates

U.S. Embassy Lima Avenida La Encalada cdra. 17 s/n Surco, Lima 33 Peru Telephone: + (51)(1) 618-2000 Emergency After-Hours Telephone: + (51)(1) 618-2000 Fax: + (51) (1) 618-2724 Email: [email protected]

U.S. Consular Agency - Cusco Av. El Sol 449, Suite #201 Cusco, Peru Telephone: + (51)(84) 231-474 Emergency After-Hours Telephone:  + (51)(1) 618-2000 Fax: + (51)(84) 245-102

Email: [email protected]

Destination Description

See the Department of State’s Fact Sheet on Peru for information on U.S.-Peru relations.

Entry, Exit and Visa Requirements

COVID-19 Requirements

• There are no COVID-related entry requirements for U.S. citizens.

Requirements for Entry :

• A passport with six months validity is required to enter Peru. Migraciones (Immigration) authorities may also require evidence of return/onward travel.
• Be sure your date and place of entry is officially documented by Migraciones, whether you arrive at a port, airport, or land border.
• Your length of approved stay will be determined by border officials at the time of entry, and can range from 30 to 183 days. Extensions for tourists are usually not approved, and overstays result in fines.
• The Embassy is unable to assist if you are denied entry. Peruvian immigration requires airlines to return travelers who are denied entry to their point of origin.

Requirements for Exit :

• If you do not have an entry record, you will not be allowed to exit the country until immigration authorities confirm the time and place of your entry into the country. This can be a difficult process, costing considerable time and money to resolve.
• Make sure Migraciones (Immigration) records your entry, and then save the record for your exit. An entry record is required even at remote border crossings, where often the proper officials are not present.
• Immediately report lost/stolen passports to local police and keep the report. You must apply for a new passport at the Embassy and obtain a replacement entry record from Migraciones using your police report prior to exiting Peru.

Travel with Minors : Regardless of nationality, all children who are traveling with both birth parents are required to have a valid passport and the necessary visa or citizenship of the country where they are traveling. Peruvian immigration procedures are complex for minors traveling without one or both parents/legal guardians.

For entry/exit from Peru, U.S. citizen minors under the age of 18, traveling alone (or with only one parent), generally do not require additional documentation if entering as a tourist for less than 183 days. However, if the stay lasts more than 183 days, then a Permiso Notarial de Viaje is required (see below).

U.S. citizen minors who are dual national Peruvians, traveling alone (or with only one parent), require a Permiso Notarial de Viaje. Furthermore, step-parents or guardians accompanying a dual U.S.-Peruvian citizen minor must provide a Permiso Notarial de Viaje from the non-traveling minor’s parents (as listed on the birth certificate). Finally, if an accompanying parent has sole custody, legal documentation is required (such as a foreign court-approved custody document stating sole custody, a death certificate, a Peruvian court-approved document for travel, or a birth certificate listing only one parent).

A Permiso Notarial de Viaje is a written, notarized authorization from the non-traveling parent(s). Peruvian immigration will not accept a document notarized by the U.S. Embassy or a document notarized by a U.S. notary in lieu of a Permiso Notarial de Viaje. Please be aware that these authorizations are valid for 30 days and one trip only.

How to get a Permiso Notarial de Viaje:

• In the United States, at the nearest Peruvian Consulate. There are multiple locations .
• In Peru, at most Peruvian notaries. An apostilled U.S. birth certificate is required for issuance.

The U.S. Embassy is unable to assist travelers who are prevented from traveling for lack of a Permiso Notarial de Viaje.

HIV Restrictions : The U.S. Department of State is unaware of any HIV/AIDS entry restrictions for visitors to, or foreign residents of, Peru.

Find information on dual nationality , prevention of international child abduction , and customs regulations on our websites.

Safety and Security

Terrorism:   Terrorist groups and those inspired by such organizations are intent on attacking U.S. citizens abroad. Terrorists are increasingly using less sophisticated methods of attack – including knives, firearms, and vehicles – to more effectively target crowds. Frequently, their aim is unprotected or vulnerable targets, such as: 

• High-profile public events (sporting contests, political rallies, demonstrations, holiday events, celebratory gatherings, etc.) 
• Hotels, clubs, and restaurants frequented by tourists 
• Places of worship 
• Schools 
• Parks 
• Shopping malls and markets 
• Public transportation systems (including subways, buses, trains, and scheduled commercial flights)  

U.S. Embassy Lima enforces a Restricted Travel Policy for Embassy personnel, which is based on its assessment of conditions and developments throughout the country. See the Overseas Security and Advisory Council’s Country Security Report for Peru. See the latest Travel Advisory for Peru .

The VRAEM (Valley of the Apurímac, Ene, and Mantaro Rivers) is particularly remote and a known safe haven for narcotraffickers and the last operational remnants of the Shining Path terrorist group.

For more information, see our  Terrorism  page.  

Crime : Crime is a widespread problem in Peru.

• Sexual assaults and rapes can occur, even in tourist areas. Travel in groups, do not leave food or drinks unattended, and use caution if a stranger offers you food or drink.
• Intoxicated travelers, including U.S. citizens, also have been sexually assaulted, injured, or robbed while under the influence of drugs and alcohol.
• Pick-pocketing, robbery, and hotel room theft are the most common crimes. Armed robberies have occurred throughout the city, including popular tourist destinations. Armed assailants usually target victims for their smartphones, wallets, or purses. If confronted by someone with a weapon, it is best not to resist.
• Incapacitating drugs, such as rohypnol and scopolamine, have been used to facilitate robberies and sexual assaults. Seek medical attention if you begin to feel ill.
• On routes to and from the airport in Lima, robberies have occurred where the assailant uses a tool to break a window while the vehicle is stopped in traffic.  Keep your belongings in the trunk or out of sight. Authorized taxi booths are present at the airport in Lima that will charge a flat rate according to the destination.
• Use hotel safes, if available. Avoid wearing obviously expensive jewelry or clothing, and carry only the cash or credit cards that you need.
• Stay alert in crowds and on public transportation. Be aware that thieves might create distractions to target you.
• Avoid isolated areas when on foot, especially after dark.
• Be alert for robberies in which criminals enter a taxi and force victims to withdraw money from ATMs.
• Use an app-based taxi service, order a taxi by phone, or use a service affiliated with a major hotel, as it is usually safer than hailing an unknown taxi on the street.
• Use ATMs in well-protected indoor areas such as banks or shopping malls. Avoid withdrawing large amounts of cash at one time.
• Do not let your credit card out of your sight in order to avoid credit card “skimming.” You should expect the vendor to use a credit card reader in your presence. The vendor will ask for your passport or ID number on the receipt.
• To avoid carjacking or theft from your car while you are stopped at intersections, drive with your doors locked and windows rolled up. Do not leave valuables in plain view.

There is little government presence in many remote areas of the Andes and Amazon basin. Illicit activities, such as illegal mining, logging, and coca production, are common.

Drug trafficking and other criminal activity, combined with poor infrastructure, limit the capability and effectiveness of Peruvian law enforcement in these areas.

The U.S. government has limited ability to provide emergency services to U.S. citizens along the Colombian border and in the VRAEM, as U.S. government personnel are restricted from traveling in these regions.

Demonstrations  occur frequently. They may take place in response to political or economic issues, on politically significant holidays, and during international events. 

• Demonstrations can be unpredictable; avoid areas around protests and demonstrations.
• Past demonstrations have turned violent.
• Check local media for updates and traffic advisories. 

International Financial Scams:  See the  Department of State  and the  FBI pages for information.

Financial scams are prevalent in Peru. Scams are often initiated through Internet postings/profiles or by unsolicited emails and letters. Scammers almost always pose as U.S. citizens who have no one else to turn to for help. Common scams include:

• Money transfers 
• Grandparent/Relative targeting 

Victims of Crime :  U.S. citizen victims of sexual assault are encouraged to contact the U.S. Embassy for assistance. Report crimes to the local police and contact the U.S. Embassy in Lima. Remember that local authorities are responsible for investigating and prosecuting crime.

• U.S. Embassy: +51-1-618-2000 (phone is answered 24 hours a day, seven days a week)
• Local police: 105 (National Police)
• Tourist Police: 0800-22221
• IPeru: 01-574-8000 (a tourist information service that has English-speaking personnel)

See our webpage on help for U.S. victims of crime overseas .

• Help you find appropriate medical care.
• Assist you with reporting a crime to the police.
• Contact relatives or friends with your written consent.
• Provide general information regarding the victim’s role during the local investigation and following its conclusion.
• Provide a list of local attorneys.
• Provide information on victims’ compensation programs in the United States .
• Provide information on assistance programs for victims of crime in Peru .
• Provide an emergency loan for repatriation to the United States and/or limited medical support in cases of destitution.
• Help you find accommodation and arrange flights home.
• Replace a stolen or lost passport.

Domestic Violence :  U.S. citizen victims of domestic violence are encouraged to contact the Embassy for assistance. Telephone (answered 24 hours): +51-1-618-2000

Tourism : The tourism industry, including adventure activities (e.g. paragliding, sandboarding, etc.), is unevenly regulated, and safety inspections for equipment and facilities do not commonly occur. Hazardous areas/activities are not always identified with appropriate signage, and staff may not be trained or certified either by the host government or by recognized authorities in the field. U.S. citizens are encouraged to pay attention to waiver and liability policies of tour companies, as they may vary or not exist. In the event of an injury, appropriate medical treatment is typically available only in/near major cities. First responders are generally unable to access areas outside of major cities and to provide urgent medical treatment. U.S. citizens are encouraged to purchase medical evacuation insurance . 

Local Laws & Special Circumstances

Criminal Penalties : You are subject to local laws. If you violate local laws, even unknowingly, you may be expelled, arrested, or imprisoned. Individuals establishing a business or practicing a profession that requires additional permits or licensing should seek information from the competent local authorities prior to practicing or operating a business.

Ayahuasca/Kambo/Hallucinogens:  Traditional hallucinogens, often referred to as ayahuasca or kambo, are often marketed to travelers as “ceremonies” or “spiritual cleansing,” and typically contain dimethyltryptamine (DMT), a strong hallucinogen that is illegal in the United States and many other countries.

• Intoxicated travelers, including U.S. citizens, have been sexually assaulted, injured, or robbed while under the influence of these substances.
• Health risks associated with ayahuasca are not well understood, and, on occasion, U.S. citizens have suffered serious illness or death after taking these drugs.
• These incidents often occur in remote areas and far away from modern medical facilities, making the risks even greater.
• Penalties for possessing, using, or trafficking in illegal drugs in Peru are severe.
• Offenders can expect long pre-trial detention and lengthy prison sentences under harsh conditions with significant expense for themselves and/or their families.
• Never agree to carry a suitcase or package through customs for anyone.
• Peru uses strict screening procedures for detecting narcotics smuggling at its international airports.

Customs Currency Regulations :

• $30,000 USD or its equivalent in cash or negotiable items is the maximum allowed for entry or exit.
• Any amount in excess of $10,000 USD must be declared and the legal source proven.

Artifacts :

• Peruvian law forbids the export of pre-Columbian objects and other artifacts protected by cultural patrimony statutes.
• U.S. customs officials are required to seize pre-Columbian objects and certain colonial religious artwork brought into the United States.

Animal Products/Plants :

• Avoid products made of wild plants and animals, as many are of illegal origin and may involve protected or endangered species, whose sale and export are illegal.
• Peruvian authorities will seize any protected species that is sold or transported, either live or transformed into food, medicinal beverages, leather, handcrafts, garments, etc.
• Some products, including live animals, require special permits when leaving Peru.
• Knowingly importing into the United States wildlife or plants that were taken from the wild or sold in violation of the laws of Peru (or any other country) is a violation of the Lacey Act (16 USC § 3371).

Furthermore, some laws are also prosecutable in the United States, regardless of local law. For examples, see our website on crimes against minors abroad and the Department of Justice website.

Arrest Notification : If you are arrested or detained, ask police or prison officials to notify the U.S. Embassy immediately. See our webpage for further information.

Special Circumstances : Many popular destinations in Peru are remote. These areas have few facilities that are able to provide advanced or emergency medical care.

• Local rescue capabilities are severely limited. Many mountain areas are too high for helicopters to reach safely. Accidents or injuries while hiking or climbing are common; crisis responders may take hours or even days to reach you if they are traveling over great distances and/or rough terrain.
• When using tourist company services, travelers are encouraged to use qualified and licensed operators. Many do not meet international safety standards. Inquire about safety standards prior to engaging in adventure activities. The Ministerio de Comercio Exterior y Turismo (Tourism Ministry) website provides information on tourism companies.
• Always check with local authorities before traveling about local geographic, climatic, health, and security conditions that may impact your safety.
• Be aware that you may not have access to phone or internet for days at a time. Check in with family prior to going to remote areas and leave detailed written plans and timetables. Use of a personal GPS beacon is encouraged.

Seismic Activity :  Earthquakes are common throughout Peru. On May 26, 2019, a magnitude 8.0 earthquake struck the Loreto region of Peru. One fatality in the Cajamarca region and 11 injuries as well as isolated power outages and some infrastructure damage were reported.

• Visit Peru’s National Emergency Operations Center (COEN) for more information.
• In the event of a natural disaster, monitor local media and government agencies, including IPeru , the Commission to Promote Peru for Exports and Tourism (PROMPERU) , and Peru’s National Meteorology and Hydrology Service (SENAMHI) for updates.
• WhatsApp: IPeru +51-944-492-314
• Twitter: @Promperu @COENPeru @SENAMHIPeru @Sismos_Peru_IGP
• Visit the U.S. Centers for Disease Control and Prevention website for information on emergency preparedness and response.

Legal Issues in Peru :

• The legal system in Peru may require victims or their families to hire lawyers to advance their cases through the legal system, even for victims of serious crimes.
• U.S. citizens have reported unethical practices by lawyers and others, resulting in costly losses and little hope of remedy through the local judicial system.
• Peruvian laws are subject to change with little notice . The Peruvian government publishes little information in English. The U.S. Embassy cannot give detailed advice about Peruvian law.

Counterfeit and Pirated Goods : Although counterfeit and pirated goods are prevalent in many countries, they may still be illegal according to local laws. You may also pay fines or have to give them up if you bring them back to the United States. See the U.S. Department of Justice website for more information.

Faith-Based Travelers : See the following webpages for details:

• Faith-Based Travel Information
• International Religious Freedom Report – see country reports
• Human Rights Report – see country reports

LGBTQI+ Travelers : There are no legal restrictions on same-sex sexual relations or the organization of LGBTI events in Peru.

See our LGBTQI+ Travel Information page and section 6 of our Human Rights report for further details.

Travelers with Disabilities:  Peruvian law prohibits discrimination against persons with physical and mental disabilities, and the law is enforced.  Social acceptance of persons with disabilities in public is as prevalent as in the United States. The most common types of accessibility may include ramps, special cashiers for those with disabilities, and elevators. Expect accessibility to be limited in public transportation, and common in lodging, communication/information, and general infrastructure. There is a significant difference between Lima (and other large cities) and the rest of the country.

• Rental, repair, and replacement services are available for aids/equipment/devices.
• The Ministry of Foreign Affairs has a list of translators .

Students : See our Students Abroad page and FBI travel tips .

Women Travelers : See our travel tips for Women Travelers .

COVID-19 Testing:

• PCR and/or antigen tests are available for U.S. citizens in Peru, and test results are reliably available within one calendar day.
• Peru is able to test for COVID-19 in country. Private hospitals and laboratories as well as the Peruvian Ministry of Health (MINSA) are administering tests.
• U.S. citizens are responsible for their own COVID-19 testing costs.

COVID-19 Vaccines:

The COVID-19 vaccine is available for U.S. citizens to receive in Peru. Visit the FDA's website to  learn more about FDA-approved vaccines  in the United States.  

• Pfizer-BioNTech, Moderna, AstraZeneca, and Sinopharm vaccines are available in Peru.
• For more information about the Peruvian Ministry of Health’s (MINSA) national vaccine strategy, see (in Spanish)  MINSA's website .

Medical Care :

• Specialized medical care can cost tens of thousands of dollars, and you are expected to pay in full at the time of discharge.
• Pharmacies are widely available. However, some medications might not be offered, and brand names will differ from products in the United States.
• Exercise caution if you explore herbal and folk remedies.

For emergency services in Peru, dial 113 .

Ambulance services are not present throughout the country or are unreliable in most areas except Lima and other major cities. Training and availability of emergency responders may be below U.S. standards. Injured or seriously ill travelers may prefer to take a taxi or private vehicle to the nearest major hospital rather than wait for an ambulance.

We do not pay medical bills . Be aware that U.S. Medicare/Medicaid does not apply overseas. Most hospitals and doctors overseas do not accept U.S. health insurance.

Medical Insurance : Make sure your health insurance plan provides coverage overseas. Most care providers overseas only accept cash payments. See our webpage for more information on insurance overseas. Visit the U.S. Centers for Disease Control and Prevention for more information on type of insurance you should consider before you travel overseas.

We strongly recommend supplemental insurance to cover medical evacuation.

Always carry your prescription medication in original packaging, along with your doctor’s prescription. Check with the Government of Peru to ensure the medication is legal in Peru.

Vaccinations : Be up-to-date on all vaccinations recommended by the U.S. Centers for Disease Control and Prevention.

Further health information :

• World Health Organization
• U.S. Centers for Disease Control and Prevention (CDC)

Air Quality : Visit  AirNow Department of State  for information on air quality at U.S. Embassies and Consulates.

The U.S. Embassy maintains a list of doctors and hospitals . We do not endorse or recommend any specific medical provider or clinic.

Health Facilities in General:

• Adequate health facilities are available in Lima and other major cities, but health care in rural areas may be below U.S. standards.
• Public medical clinics lack basic resources and supplies.
• Hospitals and doctors often require payment “up front” prior to service or admission. Credit card payment is usually available. Some hospitals and medical professionals require cash payment.
• Private and public hospitals usually require advance payment or proof of adequate insurance before admitting a patient.
• Travelers should make efforts to obtain complete information on billing, pricing, and proposed medical procedures before agreeing to any medical care.
• Medical staff may speak little or no English.
• Generally, in public hospitals only minimal staff is available overnight in non-emergency wards.
• Patients bear all costs for transfer to or between hospitals if they do not have insurance.
• Psychological and psychiatric services are limited, even in the larger cities, with hospital-based care only available through government institutions.

Medical Tourism and Elective Surgery :

• U.S. citizens have suffered serious complications or died during or after having cosmetic or other elective surgery.
• Medical tourism is a rapidly growing industry. People seeking health care overseas should understand that medical systems operate differently from those in the United States and are not subject to the same rules and regulations. Anyone interested in traveling for medical purposes should consult with their local physician before traveling and visit the U.S. Centers for Disease Control and Prevention website for information on Medical Tourism, the risks of medical tourism, and what you can do to prepare before traveling to Peru.
• We strongly recommend supplemental insurance to cover medical evacuation in the event of unforeseen medical complications.
• Your legal options in case of malpractice are very limited in Peru.
• Although Peru has many elective/cosmetic surgery facilities that are on par with those found in the United States, the quality of care varies widely. If you plan to undergo surgery in Peru, make sure that emergency medical facilities are available and professionals are accredited and qualified.

Pharmaceuticals:

• Exercise caution when purchasing medication overseas. Pharmaceuticals, both over the counter and requiring prescription in the United States, are often readily available for purchase with little controls. Counterfeit medication is common and may prove to be ineffective, the wrong strength, or contain dangerous ingredients. Medication should be purchased in consultation with a medical professional and from reputable establishments.
• U.S. Customs and Border Protection and the Food and Drug Administration are responsible for rules governing the transport of medication back to the United States. Medication purchased abroad must meet their requirements to be legally brought back into the United States. Medication should be for personal use and must be approved for usage in the United States. Please visit the  U.S. Customs and Border Protection  and the  Food and Drug Administration  websites for more information.   

Please review Peru's rules on medication .  

Non-Traditional Medicine:

• U.S. citizens have suffered serious complications or died while seeking medical care from non-traditional “healers” and practitioners in Peru. Ensure you have access to licensed emergency medical facilities in such cases.

Assisted Reproductive Technology and Surrogacy :

• If you are considering traveling to Peru to have a child through use of assisted reproductive technology, please see our ART and Surrogacy Abroad page .
• Surrogacy is illegal for foreigners in Peru, subject to complex local regulation.
• If you decide to pursue parenthood in Peru via assisted reproductive technology (ART) with a gestational mother, be prepared for long and unexpected delays in documenting your child’s citizenship. Be aware that individuals who attempt to circumvent local law risk criminal prosecution.

Water Quality:

• In many areas, tap water is not potable. Bottled water and beverages are generally safe, although you should be aware that many restaurants and hotels serve tap water unless bottled water is specifically requested. Be aware that ice for drinks may be made using tap water. 
• Many cities in Peru, such as Puno, Cusco, Arequipa, Ayacucho, and Huaraz, are at high altitude. Be aware of the symptoms of altitude sickness, and take precautions before you travel. Visit the U.S. Centers for Disease Control and Prevention website for more information about  Travel to High Altitudes .

Adventure Travel:

• Visit the U.S. Centers for Disease Control and Prevention website for more information about  Adventure Travel . 

General Health :

The following diseases are prevalent:

• Travelers’ Diarrhea
• Guillain-Barré Syndrome
• Hepatitis A and B
• Leishmaniasis
• Tuberculosis
• Yellow fever

Use the U.S. Centers for Disease Control and Prevention recommended mosquito repellents and sleep under insecticide-impregnated mosquito nets. Chemoprophylaxis is recommended for all travelers even for short stays.  

HIV/AIDS: For more information visit MINSA’s website (in Spanish): https://www.dge.gob.pe/vih/ .

Visit the U.S. Centers for Disease Control and Prevention website for more information about  Resources for Travelers  regarding specific issues in Peru.

Air Quality:

• Air pollution is a significant problem in several major cities in Peru. Consider the impact seasonal smog and heavy particulate pollution may have on you and consult your doctor before traveling if necessary.  
• Infants, children, and teen.
• People over 65 years of age.
• People with lung disease such as asthma and chronic obstructive pulmonary disease (COPD), which includes chronic bronchitis and emphysema.
• People with heart disease or diabetes.
• People who work or are active outdoors. 

Travel and Transportation

Road Conditions and Safety :  Driving conditions in Peru are very different from those found in the United States, and can be considerably more dangerous. Visitors are strongly encouraged to familiarize themselves with local law and driving customs before attempting to operate vehicles.

• Roads are often poorly maintained and may lack crash barriers, guard rails, signs, and streetlights.
• Fog is common on coastal and mountain highways, making conditions more treacherous.
• Slow-moving buses and trucks frequently stop in the middle of the road unexpectedly.
• Road travel at night is particularly hazardous. Due to safety concerns, U.S. Embassy personnel are prohibited from traveling on mountainous roads at night.
• Traveling in a group is preferable to solo travel. Spare tires, parts, and fuel are needed when traveling in remote areas, where distances between service areas are long.

Traffic Laws:  Traffic laws are often ignored and rarely enforced, creating dangerous conditions for drivers and pedestrians.

• Seat belts are mandatory for driver and front-seat passengers in a private vehicle.
• It is against the law to talk on a cellular phone while driving, and violators may be fined.
• When driving in urban areas, taxis and buses often block lanes impeding traffic.
• Directional signals are often not used, and vehicles frequently turn from the middle through traffic lanes.
• While driving outside major cities and on the Pan-American Highway, you must drive with your lights on.
• Traffic officers must wear uniforms and identification cards that include their last name on their chest.
• Traffic officers are not allowed to retain your personal identification or vehicle documents.
• Under no circumstances should you offer or agree to pay money to traffic officers.
• If you are involved in an accident, you MUST contact local police and remain at the scene without moving your vehicle until the authorities arrive. This rule is strictly enforced, and moving a vehicle or leaving the scene of an accident may constitute an admission of guilt under Peruvian law.
• If your car is a rental, call the agency or representative of the insurance company provided by the rental agency.
• Always carry your driver's license, a copy of your passport, and the rental agreement when you drive a rental car.
• International driver's licenses are valid for one year, while driver's licenses from other countries are generally valid for 30 days.

Public Transportation : Many buses are overcrowded, poorly maintained, and lack safety features such as seat belts.

• Bus accidents resulting in multiple deaths and injuries are common due to routes along narrow, winding roads without a shoulder and steep drop-offs.
• Accidents are frequently attributed to excessive speed, poor bus maintenance, poor road conditions, and driver fatigue.
• Individuals should use private taxi companies or car-share applications when traveling as opposed to hailing taxis on the side of the road for safety.

See our Road Safety page for more information. Visit the website of Peru’s  national tourist office  and national authority responsible for road safety. 

Aviation Safety Oversight : The U.S. Federal Aviation Administration (FAA) has assessed the government of Peru’s Civil Aviation Authority as being in compliance with International Civil Aviation Organization (ICAO) aviation safety standards for oversight of Peru’s air carrier operations. Further information may be found on the FAA’s safety assessment page .

Maritime Travel : Mariners planning travel to Peru should check for U.S. maritime advisories and alerts . Information may also be posted to the U.S. Coast Guard homeport website , and the NGA broadcast warnings .

For additional travel information

• Enroll in the  Smart Traveler Enrollment Program (STEP)  to receive security messages and make it easier to locate you in an emergency.
• Call us in Washington, D.C. at 1-888-407-4747 (toll-free in the United States and Canada) or 1-202-501-4444 (from all other countries) from 8:00 a.m. to 8:00 p.m., Eastern Standard Time, Monday through Friday (except U.S. federal holidays).
• See the  State Department’s travel website  for the  Worldwide Caution  and  Travel Advisories .
• Follow us on  Twitter  and  Facebook .
• See  traveling safely abroad  for useful travel tips.

Peru was cited in the State Department’s 2022 Annual Report to Congress on International Child Abduction for demonstrating a pattern of non-compliance with respect to international parental child abduction. Review information about International Parental Child Abduction in  Peru . For additional IPCA-related information, please see the  International Child Abduction Prevention and Return Act ( ICAPRA )  report.

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• Section 1 - Perspectives : Why Guidelines Differ

Disease Patterns in Travelers

Cdc yellow book 2024.

Author(s): Allison Walker, Regina LaRocque

Travelers are an important population because of their mobility, their potential for exposure to infectious diseases outside their home country, and the possibility that they could bring those diseases from one country to another. The coronavirus disease 2019 (COVID-19) pandemic is the most recent example of the role travelers can play in the global spread of infectious diseases. Ebola virus, Zika virus, and antimicrobial-resistant pathogens are other examples of health threats whose geographic distribution has been facilitated by international travelers over the past several years. Travelers consequently should be included in general and targeted epidemiologic surveillance—including the use of molecular genomic approaches—to better understand both the exposure risk and impact of current and novel prevention recommendations.

The ability to provide appropriate pretravel guidance—and, when necessary, optimal posttravel evaluation and treatment—is predicated on understanding the epidemiologic features (disease patterns) among different traveling populations. Accounting for behaviors that can influence and potentially increase risk for travel-associated infections and diseases (e.g., attendance at a mass gathering, long-term or adventure travel, visiting friends and family) helps the astute clinician make directed travel health recommendations and focus their attention on the more likely diagnoses from among the lengthy list of travel-associated infections and diseases. An understanding of the epidemiology of the diseases themselves, including modes of transmission, incubation periods, signs and symptoms, duration of infectiousness, and accuracy of diagnostic testing, is also crucial. Including international travelers in epidemiologic surveillance provides additional information about the presence, frequency, seasonality, and geographic distribution of diseases, which might shift over time due to outbreaks, changes in climate and vector habitat, emergence or reemergence in new areas or populations, successful public health interventions, or other factors.

The risk for travel-related infection can, however, be difficult to ascertain precisely for several reasons. Existing information regarding disease risk for travelers is limited because of the difficulty in obtaining accurate numerators (i.e., number of cases of infection among travelers) and denominators (i.e., number of overall travelers or number of travelers to a specific destination who are susceptible to infection). In cases of mild illness, travelers might never seek health care, or clinicians might not perform diagnostic tests to identify the cause. Travelers often visit multiple destinations, complicating identification of the location of exposure. Data on disease incidence in local populations might be available, but the relevance of such data to travelers—who have different risk behaviors, eating habits, accommodations, knowledge of and access to preventive measures, and activities—might be limited. In addition, epidemiologic investigations involving travelers use various methodologic designs, each with their own strengths and weaknesses, making findings difficult to compare or combine. Many single-clinic or single-destination investigations draw conclusions that might not be generalizable to travelers from different local, national, or cultural backgrounds.

Two existing networks provide epidemiologic data on international travelers from the United States and acquisition of travel-related illness. The GeoSentinel Global Surveillance Network is a worldwide data collection and communication network composed of International Society of Travel Medicine–associated travel and tropical medicine clinics that collect posttravel illness surveillance data. GeoSentinel scientists analyze these data to describe travel-related illness in specific populations of travelers.

Global TravEpiNet (GTEN) is a consortium of health clinics across the United States that deliver pretravel health consultations. Data from GTEN provide a snapshot of travelers seeking pretravel health care, and longitudinal cohort data on risk for and acquisition of travel-associated conditions, including for a subset of travelers who self-collect biological samples for microbiologic and genomic testing.

These travel medicine networks, and travel medicine researchers, increasingly are implementing next-generation sequencing tools to delineate the epidemiology of travel-associated infections and the role of travelers in the global spread of infectious diseases. Advances in the field of genomic sequencing enable high-resolution surveillance that can identify previously unrecognized geographic and epidemiologic associations. These molecular tools are becoming essential to understanding the spread of disease, the emergence of new pathogens or variants of existing ones, and the evolution of antimicrobial resistance. Combining these molecular techniques with traditional surveillance, epidemiologic approaches, and community-based participatory research represents a promising approach to expanding the evidence base underpinning the guidance and recommendations in the field of travel medicine. A broader evidence base will enable better-informed pretravel preparation for the individual traveler, and development of new approaches to mitigating the impact of travel on the global spread of disease.

HealthMap uses online informal sources and real-time surveillance to provide information on emerging public health threats for diverse audiences.

Bibliography

Gardy JL, Loman NJ. Towards a genomics- informed, real-time, global pathogen surveillance system. Nat Rev Genet. 2018;19(1):9– 20.

LaRocque RC, Rao SR, Lee J, Ansdell V, Yates JA, Schwartz BS, et al. Global TravEpiNet: a national consortium of clinics providing care to international travelers—analysis of demographic characteristics, travel destinations, and pretravel healthcare of high- risk US interna-tional travelers, 2009– 2011. Clin Infect Dis. 2012;54(4):455– 62.

Sotir M, Freedman D. Basic epidemiology of infectious diseases, including surveillance and reporting. In: Zuckerman J, Brunette G, Leggat P, editors. Essential Travel Medicine. Chichester (UK): John Wiley & Sons; 2015:1– 7.

Walz EJ, Wanduragala D, Adedimeji AA, Volkman HR, Gaines J, Angelo KM, Boumi AE, et al. Community-based participatory research in travel medicine to identify barriers to preventing malaria in VFR travellers. J Trav Med. 2019;26(1):tay148.

Wilder- Smith A, Boggild AK. Sentinel surveillance in travel medicine: 20 years of GeoSentinel publications (1999– 2018). J Trav Med. 2018;25(1):tay139.

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Malaria and Travelers for U.S. Residents

Quick links.

• Prophylaxis Guidelines for Malaria in “Off-the-Radar” Areas
• Travel to West Africa? Don’t Neglect Malaria Prevention
• Mosquito Repellent Fact Sheet
• Prescribing Information for Malaria Prevention Drugs
• Yellow Book Malaria Section New!
• Blog: CDC Malaria Hotline—When the Caller is Ill Abroad

This information is intended for travelers who reside in the United States. Travelers from other countries may find this information helpful; however, because malaria prevention recommendations and the availability of antimalarial drugs vary, travelers from other countries should consult health care providers in their respective countries. For more health recommendations for international travel, visit the CDC Yellow Book .

Every year, millions of US residents travel to countries where malaria is present. About 2,000 cases of malaria are diagnosed in the United States annually, mostly in returned travelers.

Travelers to sub-Saharan Africa have the greatest risk of both getting malaria and dying from their infection. However, all travelers to countries where malaria is present may be at risk for infection.

Obtain a detailed itinerary including all possible destinations that may be encountered during the trip and check to see if malaria transmission occurs in these locations. The Malaria Information by Country Table  provides detailed information about the specific parts of countries where malaria transmission does or does not occur. It also provides additional information including the species of malaria that occur there, the presence of drug resistance, and the specific medicines that CDC recommends for use for malaria prevention in each country where malaria transmission occurs on CDC’s Malaria maps.

Prevention of malaria involves a balance between ensuring that all people who will be at risk of infection use the appropriate prevention measures, while preventing adverse effects of those interventions among people using them unnecessarily. An individual risk assessment should be conducted for every traveler, taking into account not only the destination country, but also the detailed itinerary, including specific cities, types of accommodation, season, and style of travel. In addition, conditions such as pregnancy or the presence of antimalarial drug resistance at the destination may modify the risk assessment.

More on: Malaria Risk Assessment for Travelers

Based on the risk assessment, specific malaria prevention interventions should be used by the traveler. Often this includes avoiding mosquito bites through the use of repellents or insecticide treated bed nets, and specific medicines to prevent malaria.

More on: Preventing Mosquito Bites While Traveling

If malaria prevention medicines will be needed for the traveler, the  Malaria Information by Country Table lists the CDC-recommended options. For many destinations, there are multiple options available. Factors to consider are the patient’s other medical conditions, medications being taken (to assess potential drug-drug interactions), the cost of the medicines, and the potential side effects.

More on: Tips on Choosing the Right Drug for an Individual Traveler

The Drugs for Malaria Prevention table  provides prescription dosing information for both adults and children.

In some countries (including those with malaria risk), drugs may be sold that are counterfeit (“fake”) or substandard (not made according to United States standards). Such drugs may not be effective. Antimalarial drugs should always be purchased before traveling overseas!

For details and specific warnings, see Counterfeit and Substandard Antimalarial Drugs

This picture shows some things that travelers can use to protect themselves against malaria: malaria pills; insect repellent; long-sleeved clothing; bednet; and flying insect spray. (Not shown, but also protective: air conditioned or screened quarters.)

The interventions used to prevent malaria can be very effective when used properly, but none of them are 100% effective.

Malaria is always a serious disease and may be a deadly illness. Travelers who become ill with a fever or flu-like illness either while traveling in a malaria-risk area or after returning home (for up to 1 year) should seek immediate medical attention and should tell the physician their travel history.

Travelers who are assessed at being at high risk of developing malaria while traveling should consider carrying a full treatment course of malaria medicines with them. Providing this reliable supply of medicine (formerly referred to as standby or emergency self-treatment) will ensure that travelers have immediate access to an appropriate and high quality medicine if they are diagnosed with malaria while abroad. Depending on the medicine they are using for prevention, this could either be atovaquone/proguanil or artemether/lumefantrine.

More on: Malaria Treatment (United States)

Travelers are often surprised to learn that even if they adhered to all of the prevention advice and did not become sick with malaria, recent travel to a place where malaria transmission occurs is an exclusion criterion for blood donation.

More on: Prevention of Blood Transfusion-Associated Malaria

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New! Locally Acquired Cases of Malaria in Florida, Texas, Maryland, and Arkansas

New! Update to Guidance for use of Artemether-Lumefantrine (Coartem®) in Pregnancy for Uncomplicated Malaria New! Discontinuation of CDC’s Distribution of Intravenous Artesunate as Commercial Drug Guidance for Malaria Diagnosis in Patients Suspected of Ebola Infection in the United States -->

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• New! Malaria is a Serious Disease
• New!   La malaria (paludismo) es una enfermedad grave
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• Choosing a Drug to Prevent Malaria
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• CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website.

Yellow Fever

• Requirements: None
• Recommendations:
• Recommended for all travelers ≥9 months of age going to areas at elevations <2,300 m (7,546 ft) in the regions of Amazonas, Loreto, Madre de Dios, San Martin, Ucayali, Puno, Cusco, Junín, Pasco, and Huánuco, and designated areas (Map 2-23 ) 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.
• Generally not recommended for travelers whose itineraries are limited to the following areas west of the Andes: regions of Lambayeque and Tumbes and the designated areas (Map 2-23 ) of western Piura and south, west, and central Cajamarca.
• Not recommended for travelers whose itineraries are limited to the following areas: all areas >2,300 m (7,546 ft) in elevation, areas west of the Andes not listed above, the city of Cusco, the capital city of Lima, Machu Picchu, and the Inca Trail (Map 2-23 ).
• Areas with malaria: All departments <2,000 m (6,562 ft), including the cities of Iquitos and Puerto Maldonado and only the remote eastern regions of La Libertad and Lambayeque. None in the following areas: Lima Province; the cities of Arequipa, Ica, Moquegua, Nazca, Puno, and Tacna; the highland tourist areas (Cusco, Machu Picchu, and Lake Titicaca); and along the Pacific Coast (Map 2-24 ).
• Drug resistance 3 : Chloroquine.
• Malaria species: P. vivax 85%, P. falciparum 15%.
• Recommended chemoprophylaxis: Atovaquone-proguanil, doxycycline, mefloquine, or tafenoquine. 4

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• v.60(12); 2014 Dec

Travel medicine

To define the practice of travel medicine, provide the basics of a comprehensive pretravel consultation for international travelers, and assist in identifying patients who might require referral to travel medicine professionals.

Sources of information

Guidelines and recommendations on travel medicine and travel-related illnesses by national and international travel health authorities were reviewed. MEDLINE and EMBASE searches for related literature were also performed.

Main message

Travel medicine is a highly dynamic specialty that focuses on pretravel preventive care. A comprehensive risk assessment for each individual traveler is essential in order to accurately evaluate traveler-, itinerary-, and destination-specific risks, and to advise on the most appropriate risk management interventions to promote health and prevent adverse health outcomes during travel. Vaccinations might also be required and should be personalized according to the individual traveler’s immunization history, travel itinerary, and the amount of time available before departure.

A traveler’s health and safety depends on a practitioner’s level of expertise in providing pretravel counseling and vaccinations, if required. Those who advise travelers are encouraged to be aware of the extent of this responsibility and to refer all high-risk travelers to travel medicine professionals whenever possible.

Rates of international travel continue to grow substantially, with an unprecedented 1 billion travelers worldwide crossing international boundaries in 2012. 1 This increasing globalization in travel increases the risk of travel-related illnesses and other health exposures; therefore, health care professionals need to accurately advise travelers about these potential risks. However, evidence suggests that the pretravel care provided to Canadian travelers, particularly immigrant travelers visiting friends and relatives (VFR), is likely suboptimal. 2 , 3 Only a small number of travelers seek pretravel health advice 4 – 6 given that there is a general lack of awareness of travel health issues and that travel health services are not insured under government health plans. Furthermore, travelers who do typically seek advice do so from practitioners who are not specifically trained to counsel patients on travel-related health risks. 7

The objective of this review is to define the practice of travel medicine, provide health care professionals with the basics of a comprehensive pretravel consultation for patients traveling internationally, and assist these clinicians in identifying patients who might require referral to travel medicine professionals.

Mr D. and his family will be traveling to both rural and urban areas in northern Uttar Pradesh, India, in 3.5 weeks (during the summer months) to visit friends and family. Mr D. and his wife, aged 38 and 35 years, respectively, were born in India, and their children, aged 7 and 4 years, were born in Canada. This will be the children’s first trip to India. The expected duration of travel is 1 month.

Guidelines and recommendations on travel medicine and travel-related illnesses from key travel health authorities including the International Society of Travel Medicine, the Committee to Advise on Tropical Medicine and Travel, the World Health Organization, the Centers for Disease Control and Prevention, and the Infectious Diseases Society of America were reviewed. MEDLINE and EMBASE searches (from 2001 to January 2013) for English-language articles using the terms travel medicine, guidelines, pretravel consultation, vaccine-preventable diseases, and vaccinations were also performed. In addition, reference lists of identified guidelines and studies were examined, and a group of experts in travel medicine from across Canada was convened to further identify key literature and topics.

Definition of travel medicine

Travel medicine can be defined as follows:

[T]he field of medicine concerned with the promotion of health … for the peoples, cultures and environment of regions being visited in addition to the prevention of disease or other adverse health outcomes in the international traveller .... [I]t focuses primarily on pretravel preventive care. 7

Travel medicine is a rapidly evolving, highly dynamic, multidisciplinary specialty that requires expertise on various travel-related illnesses, as well as up-to-date knowledge on the global epidemiology of infectious and noninfectious health risks, health regulations and immunization requirements in various countries, and the changing patterns of drug-resistant infections ( Table 1 ). 8 It is highly recommended that pretravel care be rendered by practitioners who hold a certificate of knowledge in the field (eg, such as that provided by the International Society of Travel Medicine) and who have regular experience in advising travelers with varying and complex health conditions, destinations, and itineraries. 7 , 9

Body of knowledge for the practice of travel medicine as defined by the ISTM

ISTM—International Society of Travel Medicine, STI—sexually transmitted infection.

Data from ISTM. 8

Pretravel consultation basics

The goal of the pretravel consultation is to reduce the traveler’s risk of illness and injury during travel through preventive counseling and education ( Table 2 ), medications ( Table 3 ), and immunizations ( Tables 4 and ​ and5), 5 ), as required. 9 – 24 A comprehensive risk assessment is the foundation of this consultation and allows the practitioner to individualize care based on the traveler-, country-, and itinerary-specific risks. 7 – 10 , 25 A questionnaire designed to collect such data is an essential tool for supporting this process and for determining if more specialized care by a travel medicine professional is required. A sample of a pretravel risk assessment questionnaire is available from CFPlus . * Figure 1 provides a triage algorithm that can assist clinicians in determining the extent of pretravel health advice required and when referral to a travel medicine professional is advised.

Travel medicine triage algorithm

* A sample of a pretravel risk assessment questionnaire is available at www.cfp.ca . Go to the full text of the article online and click on CFPlus in the menu at the top right-hand side of the page.

† Chronic illnesses or conditions that are considered high risk include diabetes mellitus; chronic cardiac or pulmonary conditions; renal disease; mental health or psychiatric illnesses; thymus disorders; cancer; epilepsy or history of chronic convulsions or seizures; and blood or clotting disorders.

‡ Yellow fever vaccine is only available at health care sites that have been designated as Yellow Fever Vaccination Centres by the Public Health Agency of Canada. Visit www.travelhealth.gc.ca for a list of centres.

Preventive counseling required for international travelers

DEET—diethyltoluamide, IV—intravenous, STI—sexually transmitted infection.

Data from Hill et al, 9 Centers for Disease Control and Prevention, 10 Committee to Advise on Tropical Medicine and Travel, 11 – 14 and World Health Organization. 15

Treatment strategies for high-risk travelers

Types of vaccinations for travelers

BCG—bacillus Calmette-Guérin, IHRs—international health regulations, JE—Japanese encephalitis, TBE—tick-borne encephalitis.

Data from Centers for Disease Control and Prevention. 10

Vaccinations that might be recommended or required in international travelers

BCG—bacillus Calmette-Guérin, CATMAT—Committee to Advise on Tropical Medicine and Travel, CHF—congestive heart failure, DCO—human diploid-cell culture, DM—diabetes mellitus, ETEC— enterotoxigenic Escherichia coli , IBD—inflammatory bowel disease, IHRs—international health regulations, PHAC—Public Health Agency of Canada, rDNA—recombinant DNA, TB—tuberculosis, VFR—visiting friends and relatives, WHO—World Health Organization.

Data from Centers for Disease Control and Prevention, 10 CATMAT, 14 WHO, 15 PHAC, 16 CATMAT, 17 – 23 and Greenaway et al. 24

Traveler-specific risks:

A thorough evaluation of the traveler’s health status and medical history is required. 7 – 10 , 25 Certain travelers are considered high risk and should be evaluated by a travel medicine professional, such as immunocompromised patients, pregnant or breastfeeding women, young children, the elderly, patients with pre-existing medical conditions or chronic illnesses (eg, diabetes mellitus, chronic cardiac or pulmonary conditions, renal disease, mental health or psychiatric illness, thymus disorders, cancer, epilepsy or history of chronic convulsions or seizures, blood or clotting disorders), and those VFR (travelers that have migrated from a developing country to an industrialized region, and who are now returning to their country of birth). Compared with other groups of international travelers, those VFR (particularly children) experience a higher incidence of travel-related infectious diseases owing to their travel to higher-risk destinations, duration of travel, lack of awareness of risk and misconceptions regarding immunity, financial barriers, lack of access to pretravel health care, and cultural and language barriers. 3 , 26 , 27

Destination-specific risks:

Determining destination- specific risks during the pretravel consultation is also essential and requires a basic understanding of the common illnesses specific to the region of travel. Practitioners should be aware of the most recent information on the disease endemicity of the destination, current outbreaks, and any recommended or required immunizations. Table 6 lists resources for up-to-date information on the geographic distribution of various travel-related illnesses.

Travel medicine resources

CATMAT—Committee to Advise on Tropical Medicine and Travel, CDC—Centers for Disease Control and Prevention, EuroTravNet—European Travel Medicine Network, IAMAT—International Association for Medical Assistance to Travellers, IDSA—Infectious Diseases Society of America, INSPQ—Institut national de santé publique du Québec, ISID—International Society for Infectious Diseases, ISTM—International Society of Travel Medicine, PHAC—Public Health Agency of Canada, WHO—World Health Organization.

Itinerary-specific risks:

Assessment of the patient’s itinerary should include data on countries and regions to be visited; visits to urban versus rural areas; dates and length of travel in each area; purpose of travel; types of accommodations; and modes of transportation. It is also important to assess for possible high-risk activities during travel (eg, hiking, rafting, spelunking, scuba diving) or animal contact. Travelers participating in recreational water activities, such as white-water rafting, might be at increased risk of leptospirosis, particularly if these activities occur after heavy rainfall or flooding. 28 Cavers are at an increased risk of diseases such as rabies and histoplasmosis. 29 – 33 Schistosomiasis is common in the developing world, and swimming in fresh water, even for a short duration, in areas where schistosomiasis is prevalent can lead to transmission of this parasitic infection. 34 Travel to destinations more than 2500 to 3500 m above sea level (eg, Cusco, Machu Picchu, Peru; La Paz, Bolivia; Lhasa, Tibet; Everest base camp in Nepal) carries the risk of altitude illness, which, if not appropriately managed, can progress to ataxia, coma, and even death. 9 , 35

Risk management

Following the risk assessment, counseling on risk management is imperative: suggest personal protective measures against insect-borne diseases and strategies for reducing water and food-borne illnesses; advise on itinerary-specific risks; counsel on sun or climate effects, the psychological effects of travel (eg, culture shock), and personal behaviour risks (eg, sexually transmitted diseases, illegal drug use); provide self-management strategies for diarrhea; discuss the preparation of a travel health kit ( Box 1 10 ); and advise on obtaining travel insurance and accessing medical care abroad. Prescriptions for the prophylaxis of malaria and altitude sickness, as well as antibiotics for the self-treatment of traveler’s diarrhea, might also be required. When considering antimalarials, clinicians require up-to-date knowledge on antimalarial drug effectiveness and resistance patterns, and should also be aware of the potential liabilities associated with the provision of inappropriate antimalarials. Table 2 suggests the basic preventive and prophylactic strategies that should be provided to travelers based on their individual travel-associated risks. 9 – 15

Preparation of a travel health kit

Vaccinations must be personalized according to the individual traveler’s immunization history, the countries to be visited, the type and duration of travel, and the amount of time available before departure. Ideally, the health care provider should be consulted 2 to 3 months in advance of travel in order to allow sufficient time for optimal immunization schedules to be completed.

Vaccines for travelers can be divided into 3 categories: routine, required, and recommended ( Table 4 ). 10 The pretravel consultation provides an excellent opportunity to ensure that travelers are up-to-date on their routine immunizations according to the Canadian Immunization Guide. 16 Currently, yellow fever is the only vaccine required as a condition of entry into certain countries in Africa and South America under the World Health Organization’s international health regulations. 17 In Canada, the vaccine is available only at designated Yellow Fever Vaccination Centres. (Visit www.travelhealth.gc.ca for a list of centres.) The quadrivalent meningococcal vaccine (conjugate preferred) is also required by the government of Saudi Arabia for all pilgrims visiting Mecca for the Hajj (annual pilgrimage) or Umrah. 15 , 18 Table 5 10 – 24 lists other vaccines that might be considered based on travelers’ risks; these might include hepatitis A and B vaccines, typhoid immunization (particularly for those VFR traveling to the Indian subcontinent), 36 , 37 and immunization against Japanese encephalitis or tick-borne encephalitis, among others.

Practitioners administering vaccinations must follow accepted immunization practices as outlined in the Canadian Immunization Guide , 16 and should also be able to prioritize risks for travelers who might only be able to afford limited vaccinations or schedules. The latter requires a strong knowledge base on immunizations and the current epidemiology of travel-related illnesses and, therefore, referral to a travel medicine professional is recommended.

Roles and responsibilities of family physicians and community pharmacists

Because family physicians and community pharmacists are often the first point of contact for patients who will be traveling abroad, they play a pivotal role in identifying at-risk travelers and emphasizing the importance of obtaining a pretravel consultation. At a minimum, all presenting patients should be routinely asked whether they plan to travel internationally, particularly to a developing country. Before deciding whether or not to provide a pretravel consultation, practitioners should determine their level of competency and comfort in performing this consultation. Both the Committee to Advise on Tropical Medicine and Travel and the International Society of Travel Medicine recommend that all high-risk travelers be referred to travel medicine professionals with expertise in providing individualized care and addressing the unique needs of these travelers. 7 , 9

Case discussion

Mr D. and his family are high-risk travelers owing to the presence of multiple risk factors: VFR, being last-minute travelers (< 2 months), involving children, and going to a high-risk destination ( Figure 1 ). Unless their health care provider is competent in travel medicine, they should be referred to a travel medicine professional. Routine vaccinations need to be updated for all parties. The clinician needs to be aware of the risks associated with travel to India, including food and water risks (eg, hepatitis A, typhoid fever, traveler’s diarrhea), as well as mosquito-borne (eg, dengue fever, malaria, Chikungunya, Japanese encephalitis) and other diseases (eg, hepatitis B, rabies). The choice of specific interventions will depend on the details of the itinerary and travelers’ demographic profiles. Proper counseling on food and water hygiene, insect protection, safety, medical insurance, and evacuation strategies also need to be provided. Selection of an appropriate antimalarial for chloroquine-resistant Plasmodium falciparum malaria is essential, as is comfort in antimalarial dosing for both children and adults. Owing to the high rate of fluoroquinolone-resistant bacteria causing traveler’s diarrhea in India, an appropriate antibiotic, such as azithromycin, should also be offered, with an awareness of pediatric and adult dosing and indications for use. The oral vaccine for traveler’s diarrhea should also be discussed. This vaccine provides short-term protection only (approximately 3 months) against enterotoxigenic Escherichia coli (ETEC) diarrhea. However, it is important to note that vaccine protection against ETEC diarrhea is approximately 50%. Also, less than 50% of cases of traveler’s diarrhea are caused by ETEC bacteria. Given that the family is planning to depart in less than 1 month, accelerated vaccine options (eg, hepatitis B and rabies in this case) need to be offered where applicable. If hepatitis B coverage is advised, accelerated combination hepatitis A and B options for the children and parents should be considered. The monovalent hepatitis A vaccine would also be an option in patients who had previously completed the hepatitis B vaccine series. In adults born in countries endemic for hepatitis A (such as India), serologic testing for natural hepatitis A immunity might be helpful in guiding vaccine choices; if, for example, the patient is immune, then hepatitis B immunization alone (in an accelerated format) would be an option.

Travel medicine is a challenging specialty that requires up-to-date knowledge on the global epidemiology of infectious and non-infectious health risks, the changing distribution of drug-resistant infections, and both international and local health regulations and immunization requirements. Because travel medicine is primarily focused on preventive health care, the traveler’s health and safety will depend on the practitioner’s level of expertise and proficiency in providing pretravel counseling, as well as the required or recommended vaccinations. Practitioners should be skilled in performing a detailed risk assessment for each individual traveler in order to accurately evaluate traveler-, itinerary-, and destination-specific risks, and to advise on the most appropriate interventions to promote health and prevent adverse health outcomes during travel. Those who advise travelers are encouraged to be aware of the extent of this responsibility and to refer all high-risk travelers to a travel medicine professional whenever possible.

EDITOR’S KEY POINTS

• Travel medicine is a multidisciplinary specialty that requires expertise in travel-related illnesses, as well as up-to-date knowledge of the global epidemiology of infectious and noninfectious health risks, health regulations and immunization requirements in various countries, and the changing patterns of drug-resistant infections.
• During pretravel consultations, practitioners can assess travel-related risks and advise patients on appropriate interventions to promote health and prevent adverse health outcomes during travel. However, if practitioners are not competent in travel medicine, high-risk travelers (eg, patients with chronic illness, those visiting high-risk destinations) should be referred to travel medicine professionals.
• A traveler’s health and safety will often depend on a practitioner’s level of expertise and proficiency in providing pretravel counseling and the required or recommended vaccinations.

This article is eligible for Mainpro-M1 credits. To earn credits, go to www.cfp.ca and click on the Mainpro link.

This article has been peer reviewed.

La traduction en français de cet article se trouve à www.cfp.ca dans la table des matières du numéro de décembre 2014 à la page e571 .

Contributors

All authors have contributed substantially to the conception and design of this paper, have revised it critically for important intellectual content, and have provided approval of the final version submitted for publication.

Competing interests

Dr Aw has received research grants, travel fees, chairman fees, and honoraria for continuing medical education (CME) and media events from Sanofi Pasteur; honoraria for CME events from Merck and GlaxoSmithKline; fees for media educational events from Crucell Vaccines Canada (Janssen); and honoraria for chairing CME events and reviewing Mainpro talks from Pfizer. Dr Boraston has received a grant from Sanofi Pasteur. Dr Botten has participated in advisory boards for Sanofi Pasteur and has provided travel health consultancy services to Sobeys Pharmacy Ltd. Dr Cherniwchan has received honoraria from Sanofi Pasteur for his contributions to the Canadian Travel Medicine Working Group. Dr Kelton has received honoraria from Sanofi Pasteur for his contributions to the Canadian Travel Medicine Working Group and has participated in speaking engagements and received honoraria from Sanofi Pasteur, Crucell Vaccines Canada, Pfizer Canada, and the Ontario Pharmacists Association. He is also Medical Director of the Complete Traveler’s Clinic, which provides comprehensive pretravel advice and offers a variety of immunizations; these vaccines are purchased from various pharmaceutical companies and offered to travelers when appropriate as part of the pretravel consultation. He has received rebates or discounts on vaccine orders from Sanofi Pasteur, Merck, GlaxoSmithKline, Novartis, and Crucell Vaccines Canada. Dr Libman has received consulting fees from Sanofi Pasteur and CME course sponsorship from GlaxoSmithKline. Dr Saldanha has received honoraria from Sanofi Pasteur for his contributions to the Canadian Travel Medicine Working Group; honoraria for CME events and rebates or discounts on vaccine orders from Sanofi Pasteur, Merck, and Crucell Vaccines Canada. Dr Scappatura has received non-financial support from Sanofi Pasteur for patient handouts and vaccination materials. Mr Stowe has received honoraria from Sanofi Pasteur for his contributions to the Canadian Travel Medicine Working Group.

LEW DICK, M.D., M.P.H.

Am Fam Physician. 1998;58(2):383-398

A more recent article on pretravel consultation is available .

See related patient information handout on tips for staying healthy during travel , written by the author of this article.

One third of persons who travel abroad experience a travel-related illness, usually diarrhea or an upper respiratory infection. The risk of travelers' diarrhea can be reduced by eating only freshly prepared, hot foods. Combination therapy with a single dose of ofloxacin plus loperamide usually provides relief from travelers' diarrhea within 24 hours. Using a diethyltoluamide (deet)–containing insect repellent and wearing permethrin-coated clothing can reduce the risk of malaria, yellow fever and other diseases contracted from insects. Routine immunizations such as tetanus, measles, mumps and rubella, and influenza should be updated if necessary before the patient embarks on the trip. Hepatitis A immunization should be administered to persons traveling to places other than Canada, Australia, New Zealand, Japan and western European countries. Typhoid vaccination should be considered for travelers going to developing countries. Yellow fever immunization is indicated for travelers going to endemic areas of South America and Africa. Malaria prophylaxis with chloroquine is indicated for travelers going to Mexico and Central America. Mefloquine is recommended for those traveling to areas where malaria is resistant to prophylactic treatment with chloroquine. Medical advice for patients planning trips abroad must be individualized and based on the most current expert recommendations.

Each year as many as 45 million Americans travel abroad, with about 20 million of them spending time in rural areas or developing countries, locations where the risks of contracting an illness are great. 1 A study of travelers to developing countries and eastern Europe revealed that more than one third had some type of illness during their trip. 2 Diarrhea and the common cold were the most common illnesses. On a typical two-week trip, travelers “lost” an average of three days because of illness. Almost 20 percent of them remained ill after their return home, and 10 percent sought medical care for their illnesses.

Although infectious diarrhea and upper respiratory tract infections account for most travel-related morbidity, cardiovascular disease is the most common cause of mortality in travelers. A study of overseas fatalities among Americans revealed that cardiovascular disease was the cause of more than one half of the deaths; injuries accounted for almost one quarter of the deaths. 3 According to data from Condé Nast Traveler , each year 25,000 Americans are injured during travel abroad, and 750 Americans are killed in motor vehicle accidents abroad.

Physicians knowledgeable in the field of travel medicine can help their patients prepare for trips abroad by providing advice on ways to prevent or mitigate travel-related illnesses.

Assessment Before Travel Abroad

Ideally, the initial consultation about travel abroad should occur at least six weeks before the patient's departure to allow time for booster immunizations and assessment of any adverse reactions. The pretravel history includes documentation of all of the places the patient plans to visit, the time of year for the trip, the purpose of the visit and the duration of stay. In addition, the patient's allergy history should be reviewed, as well as the vaccination history and past medical history. Current diseases, medications and allergies influence vaccine indications and contraindications. Each piece of information assists in determining the relative risks and benefits of vaccines and medicines for the trip.

Information should be obtained about all destinations, including “stopovers” and side excursions. For example, a business traveler to Lima, Peru, might also take a leisure trip to the Amazon jungle or the high-altitude city of Cusco, Peru. Both of these locations require other preparations in addition to those required for the Lima stay. The time of year may affect the risk of acquiring infections because many infectious diseases have cycles associated with the rainy season or rising ambient temperatures.

The duration of the trip also influences the risk of acquiring a given disease. For example, Japanese B encephalitis vaccine is not routinely recommended for persons staying fewer than 30 days in endemic areas.

Finally, the patient should be asked to find out if any medicolegal certificates, such as documentation of yellow fever immunization or human immunodeficiency virus (HIV) status, are required for entry into the country of destination.

General Issues

Routine immunizations such as tetanus and influenza should be updated and patients should be advised about preventing and treating minor illnesses, travelers' diarrhea and environmental exposures that carry a risk of infection. The five-step approach illustrated in Figure 1 may be used to determine immunization and chemoprophylaxis requirements for patients traveling abroad. 4 Because some vaccines may not be covered by a patient's health insurance, the costs of vaccines and the relative risks of travel-related illness must be kept in mind when prioritizing travel-related health recommendations 1 ( Figure 2 ) .

Routine dental and medical care should be updated before the trip. In addition, patients should be sure to have a sufficient supply of routinely taken medications. Patients must know what their medical insurance covers, including medical evacuation if they become sick or are injured overseas. Routine concerns for most travelers include ways to prevent sunburns and insect bites, and which health-related items to include in a travel kit.

A variety of resources are available for information about travel medicine, either for the patient or for the physician ( Table 1 ) . In addition to a discussion of the patient's concerns, educational materials such as a written handout or a video may be useful. It may be helpful to have the patient talk with a nurse educator.

Common Travel-Related Conditions

Travelers' diarrhea.

Travelers' diarrhea is so common that it has inspired vernacular such as “Turkey trots,” “Delhi belly” and “Montezuma's revenge.” In one study, travelers were found to be 6.5 times more likely to have diarrhea while traveling abroad than during a similar time span at home. 5 The risk of acquiring travelers' diarrhea ranges from 20 to 30 percent among short-term travelers worldwide 2 , 6 to as high as 83 percent among long-stay tourists in Nepal. 7 Many pathogens cause travelers' diarrhea, but the most common organism is enterotoxigenic Escherichia coli . 8

The risk of travelers' diarrhea is reported to be reduced by prophylaxis with bismuth subsalicylate. 8 Although the standard precaution of “boil it, cook it, peel it or forget it” seems logical, adopting this practice during travel abroad has not been proved to reduce the incidence of travelers' diarrhea. A study of travelers to Nepal demonstrated that both low- and high-budget travelers contracted diarrhea and that compliance with standard advice for prevention did not significantly reduce the incidence. 7

Foods most commonly associated with travelers' diarrhea are quiches and casseroles prepared earlier in the day and reheated before serving. 7 Experience with the occurrence of travelers' diarrhea among guests on cruise ships 9 and among travelers in Nepal 7 suggests that freshly prepared foods served steaming hot are less likely than other foods to be tainted with infectious agents and to cause diarrhea. Contaminated water may be a risk in various forms, including ice cubes. Commercial filtering devices and halogenation kits (chlorine or iodine) are available. The Web sites for TravMed and Magellan's ( Table 1 ) contain information on obtaining filtering devices and halogenation kits.

Pretravel advice can improve travelers' ability to treat themselves and thus avoid the need to obtain local medical consultation or to return home because of illness. 5 Ciprofloxacin (Cipro) or ofloxacin (Floxin) can reduce the duration of travelers' diarrhea from four to five days to only one day when the antibiotic is initiated at the onset of diarrhea. 10

Various regimens may be used to prevent and treat travelers' diarrhea ( Table 2 ) . Combination therapy with a single dose of ofloxacin plus two tablets of loperamide (Imodium) has been shown to be comparable to or better than longer regimens, with 91 percent of the treated patients in one study feeling well by the end of 24 hours. 10 Discussions about travelers' diarrhea should include an emphasis on the need for rehydration if diarrhea develops during a trip. Rehydration is especially important in very young and infirm patients. In general, patients should be advised to seek medical care if they have bloody diarrhea, a fever higher than 38.0°C (100.4°F) or severe symptoms.

Protection Against Insects

Many travel-related illnesses, such as malaria, yellow fever, tick-borne encephalitis and dengue fever, have insect vectors. Diethyltoluamide (deet)–containing insect repellents are the most effective deterrents. The deet concentration alone may not predict toxicity, but a standard maximum concentration of 10 percent for children and 30 percent for adults usually provides hours of safe protection without toxicity. 11 Insect repellents should be applied only to exposed skin and, to reduce side effects, should be washed off as soon as possible after exposure to insects ceases. Permethrin-coated clothing and bed nets provide additional protection against insects. Applying a sunscreen 30 minutes before the insect repellent is applied maintains sun-screen effectiveness.

Transportation Risks

Careful selection of transportation reduces the risk of trauma and death. Overcrowded vehicles and lack of safety devices make foreign travel riskier than travel in the United States. Avoiding night driving and avoiding flying on unscheduled airlines or on airlines with poor safety records may increase safety abroad. Cruise ship hygiene records and airline safety data are now available online ( Table 1 ) .

Sexually Transmitted Diseases

Counseling about preventing sexually transmitted diseases and their risks may be advisable in patients who may pursue riskier sexual behaviors while they are traveling. Despite the global rise of HIV infection, studies suggest a low rate of condom use among travelers and general ignorance of the risk of HIV infection in foreign countries. One survey documented a 15 percent rate of sexually transmitted diseases in travelers on their return home. 12

Immunizations and Chemoprophylaxis

Unfortunately, immunizations against childhood diseases remain inadequate in non-Western countries. Furthermore, levels of immunity are variable among persons who have received routine immunizations. A survey of travelers revealed that 20 percent had incomplete immunity against poliomyelitis, 13 percent had inadequate levels of tetanus protection and 60 percent had inadequate levels of diphtheria antitoxin. 13

Table 3 summarizes the routine vaccinations that should be updated in patients planning travel abroad. Details of indications, contraindications, routes of administration, side effects, accelerated schedules and special circumstances are found in several key references. 14 , 15 Country-specific risks are outlined in the “Yellow Book” published by the Centers for Disease Control and Prevention and on its Web page, and in commercial travel medicine packages ( Table 1 ) .

Measles Vaccine

Persons born after 1957 who have not received two documented doses of measles vaccine, who have not had measles diagnosed by a physician or who do not have serologic evidence of measles immunity are candidates for one booster dose of measles vaccine. Documented doses must be live-virus vaccine given at or after 12 months of age, at least one month apart and at least three months after any dose of inactivated vaccine.

Rubella Vaccine

The mumps, measles, rubella (MMR) vaccine is the preferred rubella booster for augmenting rubella immunity in persons older than 12 months. Rubella vaccine is important in women of childbearing age who do not have documented rubella immunity.

Poliovirus Vaccine

Poliomyelitis remains endemic in developing countries of Africa, Asia, eastern Europe and the Middle East. Areas currently deemed free of endemic poliovirus include the countries in the Western Hemisphere and central and western Europe, New Zealand, Australia and Japan. In general, travelers to endemic areas who have received the three-dose series and a booster should be given one additional lifetime booster. The inactivated poliovirus vaccine (enhancedpotency IPV [e-IPV]) is preferred in unimmunized persons to reduce the risk of iatrogenic poliomyelitis.

Tetanus-Diphtheria Vaccine

Outbreaks of diphtheria have occurred in Algeria, Ecuador and areas of the former Soviet Union during the past decade, 14 and tetanus remains endemic worldwide. Previously immunized adults and children aged seven years and older should receive a booster tetanus and diphtheria toxoid every 10 years. Persons who plan to travel to remote places where tetanus boosters may be unavailable should consider receiving a booster dose if it has been five years or more since their last tetanusdiphtheria immunization. 15

Varicella Vaccine

Varicella is highly infectious and present worldwide. The disease is more severe in persons 13 years and older. International travelers without varicella immunity are candidates for varicella immunization, especially if they anticipate close contact with local populations. 15

Influenza and Pneumococcal Vaccines

Influenza occurs at any time of the year in the tropics and from April to September in the Southern Hemisphere. Patients who are candidates for the vaccine in the winter season in the United States should receive the most current influenza vaccine available before traveling abroad. 15

Persons eligible for the influenza vaccine are often candidates for pneumococcal vaccination as well ( Table 3 ) .

Hepatitis A Vaccine and Immune Globulin

Hepatitis A is the most common travel-related disease that can be prevented by vaccination ( Figure 3 ) . Estimates are that five of every 1,000 short-term travelers and two of every 100 long-term travelers (staying more than two months) contract hepatitis A. 16 The CDC recommends hepatitis A vaccination for all international travelers except those going to Canada, Australia, New Zealand, Japan and western Europe ( Table 4 ) . The two vaccines, Havrix and Vaqta, produce greater than 99 percent seroconversion. 15

It takes four weeks to reach optimal antibody production following hepatitis A immunization. If travel is imminent and the interval between immunization and the trip is less than four weeks, the vaccine may be administered at the same time as immune globulin (administration should be at separate sites and with different syringes). While the total antibody production is lower following coadministration of the vaccine and immune globulin, it is adequate for protection. 15

Immune globulin provides 60 to 70 percent protection against hepatitis A for short-term travelers. However, hepatitis A vaccination is preferred over immune globulin because it affords greater and longer protection. Immune globulin is primarily indicated for use in persons who cannot receive the hepatitis A vaccine, are under two years of age or will be embarking on their trip in less than four weeks ( Table 5 ) .

Typhoid Vaccine

The risk of typhoid ranges from 0.1 cases per 1 million travelers in northern Europe to more than 100 cases per 1 million travelers in India, Pakistan, Peru, Chile and Mexico. 17 Many cases occur in persons who are visiting their country of origin. Protection from typhoid with the vaccine ranges from 50 to 80 percent depending on the vaccine and prior exposure to typhoid organisms. 17

The CDC recommends typhoid vaccination in persons traveling in endemic areas for longer than three weeks ( Table 6 ) . The injectable typhoid vaccine (Typhim Vi) has greater side effects and no better efficacy than the oral typhoid vaccine (Ty21a). While a meta-analysis of the three typhoid vaccines led to the conclusion that whole-cell vaccine is more efficacious than Ty21a and Typhim Vi vaccines, the whole-cell vaccine has a higher side effect profile. 18 The meta-analysis only included examination of a three-dose series of Ty21a. In the United States, Ty21a is a four-dose series. Nonetheless, until head-to-head trials are performed, Typhim Vi injectable and Ty21a oral vaccines may have the edge over the whole-cell vaccine when efficacy is weighed against the risk of side effects.

Yellow Fever Vaccine

The incidence of yellow fever has surged in the past decade, with the highest number of cases reported to the World Health Organization since 1948. 19 Yellow fever carries a nearly 60 percent case-fatality rate in nonimmune adults. 15 Vaccination against yellow fever may be required for entry into some countries and is recommended as prophylaxis against yellow fever in endemic zones ( Figures 4 and 5 ) .

To provide protection against yellow fever, the vaccine must be given at least 10 days before the date of entry into the endemic area ( Table 7 ) . Vaccination provides almost total protection for 10 years. The vaccine should not be administered to persons with sensitivity to eggs or egg products. If yellow fever vaccination is required for entry into a country, travelers who cannot receive the vaccine may be given a letter explaining the reason they have not received the vaccine.

Japanese B Encephalitis Vaccine

The risk of Japanese B encephalitis infection is very low for travelers. Eleven cases of Japanese B encephalitis have been reported in Americans in the past 15 years, with eight of those cases occurring in U.S. military personnel. 15 , 17 In high-risk countries with rural areas of rice growing, pig farming or mosquito infestation, the risk of infection is estimated as one case per 20,000 persons per week. 15 , 17

Persons staying in highly endemic areas for longer than 30 days are candidates for vaccination against Japanese B encephalitis 14 ( Table 8 ) . The vaccine should be administered at least two weeks before departure to allow time for monitoring adverse reactions. The risk of allergic reaction to the Japanese B encephalitis vaccine has been reported to be 50 to 104 cases per 10,000 vaccinees. 17 It is estimated that urticaria and angioedema occur at a rate of one case per 260 persons receiving the vaccine. 15

Meningococcal Vaccine

Meningococcal disease serogroup A or C occurs epidemically and frequently across the “meningitis belt” of sub-Saharan Africa, especially during the dry months of December through June ( Figure 6 ) . Recently, epidemics of serogroup A meningococcal disease occurred outside the “belt” countries, in Tanzania, Kenya and Mongolia.

Meningococcal disease in American travelers to endemic areas is rare, but the CDC recommends administration of the meningococcal vaccine in persons traveling to endemic areas during the dry season, especially if extended contact with local persons is anticipated 14 ( Table 9 ) .

Malaria Chemoprophylaxis

Determining the need for and proper prophylaxis of malaria is a dynamic process. The CDC recorded 3,005 cases of Plasmodium falciparum malaria in U.S. civilians from 1980 to 1993. 13 Nearly 30,000 travelers from Europe and North America contract malaria each year. 20

Several options for malaria chemoprophylaxis exist. Controversy surrounds the drug of choice but, in general, prophylaxis regimens can be divided into those for chloroquine-sensitive malaria and those for chloroquine-resistant malaria ( Figure 7 ) . Except in Thailand's border areas, mefloquine (Lariam) is the drug of choice for chloroquine-resistant malaria ( Table 10 ) . Chloroquine or mefloquine chemoprophylaxis must be initiated one to two weeks before departure and continued for four weeks after return to non-malarious areas.

The CDC's Web page ( http://www.cdc.gov/travel/travel.html ) and the CDC's “Yellow Book” are good sources for current information on malaria risk, prophylaxis and treatment. The CDC also maintains a malaria hotline for health care providers (telephone: 404-332-4555; fax: 404-332-4565).

Hepatitis B

Apart from standard risk factors for hepatitis B, travelers have a low risk of acquiring the infection abroad except where the prevalence of hepatitis B is greater than 2 percent 13 , 14 ( Figure 8 ) . In areas with moderate to high prevalence, hepatitis B seems to be transmitted not only prenatally, parenterally and sexually, but also by exposure of open skin lesions to wound exudates of local persons infected with the virus. Studies of missionaries and their families documented a hepatitis B sero-conversion rate of 10.8 percent after an average of nine years of service in endemic areas. 21 The monthly incidence of symptomatic or asymptomatic hepatitis B is estimated to be 80 to 420 infections in 100,000 expatriates working in developing areas with a moderate to high prevalence of hepatitis B. 21

In moderately endemic and highly endemic areas, hepatitis B vaccination is recommended for persons who will be staying in the area for six months or longer. It is also recommended for all health care workers, regardless of the length of stay ( Table 11 ) . Other candidates for hepatitis B vaccination include persons who anticipate receiving local medical or dental care or who expect to have sexual contact with local residents. In the United States, universal hepatitis B vaccination is currently recommended for children. In endemic areas, children can be the source of infection for other family members.

Rabies Prophylaxis

Rabies is pervasive worldwide and highly endemic in many developing countries. Because rabies is almost always fatal, appropriate prophylaxis is critical. The CDC takes a conservative approach by recommending a primary course of rabies prophylaxis in persons traveling in enzootic areas for more than 30 days ( Table 12 ) .

Studies of Peace Corps volunteers and of tourists to Nepal have not shown these recommendations to be cost effective. 22 , 23 A less costly approach would be to vaccinate persons unable to obtain human rabies immune globulin and the safer human diploid cell vaccine (HDCV) or rabies vaccine, adsorbed postexposure series, within eight days of exposure. Most U.S. embassies have information on the availability of appropriate postexposure prophylaxis in the country of interest.

If patients are planning a trip to a locale with a potential for rabies exposure, pre-travel counseling should include advice about the need to thoroughly cleanse wounds with soap and water and to seek appropriate medical attention if a possible rabies exposure occurs. Patients who have received preexposure rabies vaccination must still obtain two additional rabies immunizations if exposure to rabies occurs. The high cost of postexposure prophylaxis reinforces the importance of having adequate insurance to cover health expenses abroad, including evacuation.

Cholera and Plague Vaccines

Vaccines for plague and cholera are available in the United States, but both have low efficacy. The risk of travelers acquiring plague and cholera is low. These vaccines are rarely indicated.

Learning More About Travel Medicine

Travel medicine is emerging as a distinct specialty because of ever-changing global disease patterns and increased world travel. Travel medicine recommendations are modified frequently, so up-to-date sources should always be reviewed before specific travel advice is given to patients planning trips abroad.

Travel medicine offers the family physician a new niche in a diverse specialty. The resources listed in Table 1 provide useful information for physicians who want to develop expertise in travel medicine.

Tornieporth NG, Johnson WD. Infections associated with international travel: recent developments and global trends. Adv Intern Med. 1996;41:119-64.

Bruni M, Steffen R. Impact of travel-related health impairments. J Trav Med. 1997;4:61-4.

Hargarten SW, Baker TD, Guptill K. Overseas fatalities of United States citizen travelers: an analysis of deaths related to international travel. Ann Emerg Med. 1991;20:622-6.

Thanassi WT, Weiss EL. Immunizations and travel. Emerg Med Clin North Am. 1997;15:43-70.

McIntosh IB, Reed JM, Power KG. Travellers' diarrhoea and the effect of pre-travel health advice in general practice. Br J Gen Pract. 1997;47:71-5.

Scoville SL, Bryan JP, Tribble D, Paparello SF, Malone JL, Ohl CA, et al. Epidemiology, preventive services, and illnesses of international travelers. Mil Med. 1997;162:172-8.

Hoge CW, Shlim DR, Echeverria P, Rajah R, Herrmann JE, Cross JH. Epidemiology of diarrhea among expatriate residents living in a highly endemic environment. JAMA. 1996;275:533-8.

Advice for travelers. Med Lett Drugs Ther. 1994;36:41-4 1994;36:72]

Koo D, Maloney K, Tauxe R. Epidemiology of diarrheal disease outbreaks on cruise ships, 1986 through 1993. JAMA. 1996;275:545-7.

Ericsson CD, DuPont HL, Mathewson JJ. Single dose ofloxacin plus loperamide compared with single dose or three days of ofloxacin in the treatment of travelers diarrhea. J Trav Med. 1997;4:3-7.

Osimitz TG, Murphy JV. Neurological effects associated with use of the insect repellent N,N-diethyl-m-toluamide (DEET). J Toxicol Clin Toxicol. 1997;35:435-41.

Mulhall BP. Sexually transmissible diseases and travel. Br Med Bull. 1993;49:394-411.

Cossar JH, Reid D, Fallon RJ, Bell EJ, Riding MH, Follett EA, et al. A cumulative review of studies on travellers, their experience of illness and the implications of these findings. J Infect. 1990;21:27-42.

Health information for international travel, 1996–97. Atlanta, Ga.: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Infectious Disease, 1997; HHS publication no. (CDC) 95-8280.

Thompson RF. Travel and routine immunizations. Milwaukee, Wis.: Shoreland Medical Marketing, 1993.

Steffen R, Kane MA, Shapiro CN, Billo N, Schoellhorn KJ, van Damme P. Epidemiology and prevention of hepatitis A in travelers. JAMA. 1994;272:885-9.

Kozarsky PE. Maximum immunization for travel: con. J Travel Med. 1995;2:186-91.

Engels EA, Falagas ME, Lau J, Bennish ML. Typhoid fever vaccines: a meta-analysis of studies on efficacy and toxicity. BMJ. 1998;316:110-6.

Robertson SE, Hull BP, Tomori O, Bele O, LeDuc JW, Esteves K. Yellow fever: a decade of reemergence. JAMA. 1996;276:1157-62.

Lobel HO, Kozorsky PE. Update on prevention of malaria for travelers. JAMA. 1997;278:1767-71.

Steffen R. Risks of hepatitis B for travelers. Vaccine. 1990;8:531-832.

Shlim DR, Schwartz E, Houston R. Rabies immunoprophylaxis strategy in travelers. J Wilderness Med. 1991;2:15-21.

Bernard KW, Fishbein DB. Pre-exposure rabies prophylaxis for travellers: are the benefits worth the cost?. Vaccine. 1991;9:833-6.

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Travel Vaccines and Advice for Peru

With a wide array of natural beauty to explore, Peru is a popular destination.

A place of great history, Peru has something to offer everyone. A day can be spent hiking dunes, sunning on seaside or walking through ancient ruins.

Contained within Peru are parts of the Andes mountain range and the Amazon jungle.

There is plenty to see and do in the urban areas and rural villages as well. From fantastic music to culinary delights, large cities like Lima, Cusco and Piura have much to offer.

Do I Need Vaccines for Peru?

See the bullets below to learn more about some of these key immunisations:

• Hepatitis A – Food & Water – Recommended for most travellers to the region, especially if unvaccinated.
• Hepatitis B – Blood & Body Fluids – Recommended for travellers to most regions.
• Tetanus – Wounds or Breaks in Skin – Recommended for travellers to most regions, especially if not previously vaccinated.
• Typhoid – Food & Water – Recommended for travellers to most regions.
• Yellow Fever – Mosquito – Recommended for all travellers over 9 months of age going to areas at elevations under 2,200 metres in the regions of Amazonas, Loreto, Madre de Dios, San Martin and Ucayali, Puno, Cusco, Junín, Pasco, Huánuco, far north of Apurimac, far northern Huancavelica, far northeastern Ancash, eastern La Libertad, northern and eastern Cajamarca, northern and northeastern Ayacucho, and eastern Piura.
• Rabies – Saliva of Infected Animals – High risk country. Vaccine recommended for long-stay travellers and those who may come in contact with animals.

See the tables below for more information:

Antimalarials or recommended for travel to some jungle regions. Consult with a travel health specialist to learn if you will need them for your trip.

There is also a risk of contracting Zika virus whilst in Peru. Because of the birth defects caused by the virus, it is recommended that pregnant women do not travel to Peru.

Dengue is another threat to travellers. The mosquito-borne disease can be fatal if it becomes hemorrhagic fever. Protection from all three diseases is possible through using insect repellents and mosquito netting.

See our vaccinations page to learn more about these infections and vaccines. Ready to protect yourself? Book your travel health appointment today by calling or schedule online now .

Do I Need a Visa or Passport for Peru?

No visa is required for stays under 183 days in Peru. Passports must be valid for at least six months beyond the date of entry.

Sources: Embassy of Peru and GOV.UK

What is the Climate Like in Peru?

The equator runs through Peru making the climate very warm. The average annual temperature is in the mid-20’s. Nights can get chilly with temperatures reaching the low-10’s.

There is a rainy season from March to May and from October to November. In November and December there is light rain.

How Safe is Peru?

Peru’s safety situation is like other Latin American countries. Travellers should avoid leaving their residences after dark without a local guide. Be sure to stick to well-lit areas and public thoroughfares with heavy foot traffic.

When in public, be aware of your surroundings, especially in urban areas. Pickpocketing and other forms of petty theft are common in Peru.

Do not travel with debit or credit cards. Leave them at your hotel or hostel for the day unless they are necessary.

Some drugs that are illegal in the United States are widely available in Peru. Be cautious in what you buy do not return with any substances that are illegal in the UK.

Trekking in Peru

One of the most popular tourist activities in Peru is trekking. There are many routes for visitors to hike, with the most famous being the Inca Trail that leads to Machu Picchu. These trips are a great way to soak in natural beauty and experience historical sites.

There are many companies to choose from when planning a trek, and prices can vary. Ensure to research the group you are going with to assure safety and financial security.

There is also a range of extreme sports such as skydiving and rafting that are open to the public.

What Should I Take To Peru?

Here are some essential items to consider for your trip to Peru:

• Medical Supplies – These can be expensive in Peru, so it is important to bring one’s own. Ensure to include anti-diarrhoeal, antimalarials and basic over-the-counter aides.
• Breathable Clothing – The climate of Peru in the central lowlands and the coast can be quite hot. Wear clothing that is not too thick, and that you wouldn’t mind sweating in.
• Warm Clothing – Take these with you if travelling to an area near or within the Andes mountain range.
• Documents – Be sure to bring a passport and another form of identification.
• Cash – It is safest to operate on a cash-only basis.

Embassy of the United Kingdom in Peru

If you are in Peru and have an emergency (for example, been attacked, arrested or someone has died) contact the nearest consular services. Contact the embassy before arrival if you have additional questions on entry requirements, safety concerns or are in need of assistance.

British Embassy Lima Torre Parque Mar (22nd Floor) Avenida José Larco 1301 Miraflores Lima Peru Telephone: +51 1 617 3000 Emergency Phone: 00 51 1 617 3000 Fax: +51 1 617 3100 Contact Form: Click Here

If you have any questions about travelling to Peru or are wondering which jabs you may need for your trip, schedule an appointment with your local Passport Health travel medicine clinic. Ring us up at or book online today .

On This Page: Do I Need Vaccines for Peru? Do I Need a Visa or Passport for Peru? What is the Climate Like in Peru? How Safe is Peru? Trekking in Peru What Should I Take To Peru? Embassy of the United Kingdom in Peru

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