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Health and safety advice for expats in Peru

By South American
Explorers Lima Club

It is important to visit your physician months before you plan to visit or move to Peru. Only you and your physician know what medications you need on a daily, monthly or annual basis. It is important to purchase any prescriptions you may need while away. It is also a good idea to get a check up before you leave in order to avoid having to do it here. Be sure to bring any health items that you use on a regular basis at home, such as Advil or Tylenol, Peptobismal, or birth control.

Once here, it is only a matter of time before you will need to find a primary physician, gynecologist, and dentist. Much like at home, it is best to find these doctors through personal referrals.

Although each individual has specific health issues to address, there are several precautionary measures everyone must take before arriving to. The following information provides an outline of illnesses common to Peru and what precautionary measures can be taken to prevent them.

Health Care
International travelers are strongly advised to take out full health insurance and should be prepared to pay up front for medical services even if carrying health insurance.

Inoculation
A survey of foreign and Peruvian doctors yielded the following recommendations (check with your own physician about inoculations you will need):

  • Update measles, diphtheria and polio. Tetanus or tetanus booster.
  • Yellow fever is recommended for travel in high and low jungle areas. It is a required inoculation if traveling to the Tambopata Reserve or into Brazil. (Not effective first ten days after inoculation; not recommended for pregnant women.)
  • Anti-malarial protection if traveling in jungle areas. Be sure your physician knows that Peru has chloroquine-resistant strains. Remember you will need to start medication for a specified time before entering infected areas and continue a certain time after leaving. Before and after times depend on your medication. Read the instructions carefully. You only need to take malaria tablets for jungle areas. For the latest updates on potential risk areas see: www.cdc.gov
  • Gamma globulin for protection against hepatitis A. Cannot be given at the same time as live virus vaccinations, e.g. yellow fever. Talk with your physician about the immunological effects of taking gamma globulin, especially in the long term.
  • Typhoid is recommended although it will not provide total protection; sensible food and drink precautions are your best defense. Given in two shots, four weeks apart or in oral form.

About Cholera

In February 1991, Peru had an outbreak of cholera that reached epidemic proportions. Cholera is a water-borne disease that is spread through poor hygiene and contaminated foods. Improper waste treatment and the dumping of raw sewage offshore reinforce the cycle. The bacteria causes major and immediate dehydration in the body, but for those in good health and receiving immediate care, cholera is seldom fatal. The disease mostly affects those living in poor conditions where fresh water and money for proper food is lacking. The epidemic was under control within a year. For the Peru traveler, cholera is not a major concern. Avoid drinking untreated water and be sure that all food is well cooked. Fresh fruits and vegetables should be soaked in a solution of iodine for 30 minutes or carefully peeled.

Malaria & Yellow Fever
World health organization

http://www.who.int/en/

  1. A yellow fever vaccination certificate is required of travelers over six months of age arriving from infected areas. Travelers arriving from non-endemic zones should note that vaccination is strongly recommended for travel to areas within the Amazon Basin, even if an outbreak has not been reported and they would normally not require a vaccination certificate to enter the country.
  2. Following WHO guidelines issued in 1973, a cholera vaccination certificate is no longer a condition of entry to Peru. However, autochthonous cases of cholera were reported in 1996. Up-to-date advice should be sought before deciding whether these precautions should include vaccination as medical opinion is divided over its effectiveness.
  3. Immunization against typhoid is advised, as the incidence of typhoid in Peru is very high.
  4. Falciparum malaria exists in all areas below 1500m and in the areas of Jaen, Lambayeque, Loreto, Luciano Castillo, Piura, San Martin, Tumbes and Ucayali. All health centers, which are controlled by the Peruvian Government Ministry of Health, will provide free information and medication to anyone entering a high-risk area.

Malaria Medications
Here is a brief overview of popular antimalaria prophylactic tables.

Mefloquin(Larium)-Begin taking it two-and-a-half weeks (3 doses) before departure. Stop taking medication immediately if side effects such as nightmares, mood swings, restlessness, dizziness, or gastro-intestinal symptoms.

Malaron(Proguanil with Atovaquone)-Begin taking it one to two days before travel. Good for malaria region of up to 28days, through it is probably safe for 2.5 months. Best taken with food or milk. Cannot be purchased in Peru. Must be purchased from the United States or Europe.

Doxycycline- Begin taking it one to two days before travel. Side effects include sensitivity to sun exposure and loss of appetite.

Chloroquine & Proguanil (Nivaquine, Aralen or Resochin & Paluadrine)- Begin taking one week before travel. Proguanil/or Paludrine in the U.K. is not available in the USA. Chloroquine & Proguanil combinations are the only anti-malaria medications available in the UK without a physician's prescription. It is the only pediatric antimalaria medication, although it is so bitter that few children can tolerate it, even when taken with food.

Info & Useful Websites
We have compiled a list of websites that deal with malaria and yellow fever. However, the best source for this kind of information is a physician, preferably your own.

CDC
www.cdc.gov/travel/tropsam.htm
This site provides medical information for US citizens traveling abroad to South America.

Healthlink
http://healthlink.mcw.edu/travel-links.html
International society of health professionals who work with travelers. Also includes information about travel clinics in different countries.

NHS Direct
www.nhsdirect.nhs.uk
A UK site with general information. Link above is to the malaria page.

Netdoctor
www.netdoctor.co.uk/travel/malaria_prevention/latin_america.htm
Guidelines for malaria prevention in Latin America and the Caribbean

MDTravelHealth
www.mdtravelhealth.com/destinations/samerica
Complete travel health information updated daily for physicians and travelers.

Expedia
www.expedia.co.uk/daily/wg/P42822.asp
Information sorted by country.

Food & Drink
Drink only bottled or boiled (at least 5min) water. Pasteurized milk is widely available. Avoid dairy products that are likely to contain un-boiled milk, unless you have an iron stomach. Make sure all dairy products have been pasteurized to avoid tuberculosis and other infectious diseases. It is best to assume that all "country cheeses" have not been pasteurized. Ceviche, a popular marinated raw fish dish, can be infected with tapeworm cysts capable of infecting humans. Avoid street food vendors and the cheaper restaurants. Eat only well-cooked meat and fish, preferably served hot. Pork, salad and mayonnaise may carry increased risk. Vegetables should be cooked and fruit peeled. Always check the expiration date of processed food.

There is a useful saying that applies to Peru: "Peel it, boil it, cook it or forget it."

As your system adjusts to a change in diet, it is not unusual to experience a bout of diarrhea. Give your stomach a break for 24 hours; eat lightly if at all; drink lots of fluids, and slowly build up your tolerance. Medicines for diarrhea can be purchased in pharmacies, but be sure to check expiration dates. Diarrhea causes dehydration. Drink lots of hot fluids and replace electrolytes with re-hydration salts.

Do not drink tap water anywhere in Peru unless it has been boiled for 5 minutes or treated with iodine. (Note: boiling water at high altitude is less effective since water boils at a lower temperature at altitude.) Iodine kills all known pathogens, including giardia. You can neutralize bacteria, viruses and protozoa with tincture of iodine (5 drops to one quart). Iodine crystals are available in many camping stores in the United States and Europe. You can mask the iodine taste with lemonade mix or an iodine taste neutralizer that is sometimes provided. Add oral re-hydration salts or drink Gatorade to replace minerals. Travelers should bring sufficient water treatment tablets/iodine crystals, a water filter or be prepared to boil water whilst in Peru. Alternatively, bottled water is available in one or two liter bottles. Other bottled beverages are also safe to drink.

Water Purification
This information is intended to be educational in nature and should not be construed as medical advice. You should consult your physician or local outfitter regarding any specific medical conditions or questions and before taking any medications. This information has been taken from the High Altitude Medicine Guide (http://www.high-altitude-medicine.com/) and further information is available from this site.

Water can play a major role in the transmission of enteric infections, and virtually all of the agents that cause travelers' diarrhea may be present in contaminated water. Anywhere that trekkers are able to travel these days, people live or travel higher up; consider all ground water to be contaminated. Travelers wishing to avoid diarrhea should not consume untreated water. Various water treatment methods are reviewed below.

Bottled Water is only as safe as the source. There are recorded instances of contaminated bottled water contributing to cholera epidemics. Carbonated water is acidic enough (due to the dissolved carbon dioxide) to kill contaminating bacteria. Bottled water has the disadvantage of being an additional expense, and is not always available. We also discourage trekkers from relying on bottled water for the simple reason that all of these plastic bottles are carried into the mountains, and few are carried out, producing a tremendous and completely unnecessary waste disposal problem.

Heat kills microorganisms, and virtually all enteropathogens are readily killed at temperatures well below the boiling point. The process of heating water to a boil makes it hot enough long enough to disinfect it, even at elevations as high as Everest Base Camp. There is no need to boil water for 10 or 20 minutes, as some guidebooks recommend. Bringing water to a boil is adequate for disinfection.

Chemical Disinfection of water relies on the killing of bacteria (Giardia and amoeba cysts) and viruses. Halogens (chlorine and iodine) are the most commonly used. The important point is that the effectiveness of the chemical is dependant on concentration of the chemical, temperature of the water, and contact time. Decreased concentration (better flavor) or decreased temperature (inevitably the case in the mountains) requires a longer contact time for disinfection. Sediment (cloudy water) increases the need for a halogen. Bear in mind that adding flavor crystals to your water will use up the halogen and should only be done AFTER the recommended contact time for disinfection. Remember: "Add Flavor Later."

Chlorine has been used for several centuries for water disinfection. The most common objection to it is the flavor, though there have been some suggestions that it is unreliable in killing Giardia cysts in commonly used concentrations.

Halazone tablets are convenient and inexpensive, but have several disadvantages. Due to their chemical formulation, reliable disinfection in all conditions requires 6 tablets per liter for 1-hour contact, resulting in poor flavor. Additionally, the tablets rapidly lose effectiveness when exposed to warm, humid air.

Supterchlorineation, Decholorination is a two-step method is somewhat inconvenient, and the chemicals needed are destructive to clothing and gear if spilled, but it is highly effective and results in nearly flavorless water. This process works as high concentrations of chlorine are developed, and then in a second step removed by the addition of peroxide.

Iodine has been used to disinfect water for nearly a century. It has advantages over chlorine in convenience and probably efficacy; many travelers find the taste less offensive as well. It appears safe for short and intermediate length use (3-6 months), but questions remain about its safety for long-term use. It should not be used by persons with allergy to iodine, persons with active thyroid disease, or pregnant women.

Iodine is available in numerous forms, which can be confusing to the traveler.

Preparation
Iodine
Amount/Liter
Iodine Topical Solution
2%
8 drops
Iodine Tincture
2%
8 drops
Lugol's Solution
5%
4 drops
Povidone-Iodine (Betadine®)
10%
4 drops
Tetraglycine hydroperiodide(Globaline®, Potable Aqua®, EDWGT®)
8 mg
1 tablet

DISINFECTING CONTACT TIMES

Water Clarity
5 °C
15 °C
Clear
30 min
15 min
Cloudy
60 min
30 min

NOTES:

  • Final drinking concentrations calculated at 8 mg iodine/liter
  • Measure with a tuberculin syringe or dropper: 1 drop = 0.05 ml
  • In general, if you are in a hurry double the chemical dose and halve the contact time. If you want better flavor, halve the dose and double the contact time.
  • If you believe the water may be heavily contaminated, double the chemical dose or double the contact time.
  • Povidone is a non-toxic polymer that binds the iodine to allow higher concentrations in solution. This system provides a sustained-release reservoir of iodine, and makes calculation of the "strength" of the solution difficult.
  • Addition of a small amount of vitamin C (50 mg) to your water after the contact time with the iodine will render the water nearly flavorless!

Filtration works by physically removing infectious agents from the water. The organisms vary tremendously in size, from large parasitic cysts (Giardia and Entamoeba histolytica 5-30 µm), to smaller bacteria (E. coli 0.5 x 3 µm, Campylobacter 0.2 x 2 µm), to the smallest viruses (0.03 µm). Thus, how well filters work depends to a great extent on the physical size of the pores in the filter medium.

Filters provide immediate access to drinking water without adding an unpleasant taste. However, they suffer from several disadvantages: micro cracks or eroded channels within the filter may allow passage of unfiltered water, they can become contaminated, and no filters sold for field use are fine enough to remove virus particles (Hepatitis A, rotavirus, Norwalk virus, poliovirus, and others). In addition, they are expensive and bulky compared to iodine or other treatment methods.

Some filter manufacturers have added an iodine resin layer to the filter in order to kill any agents passing through the filter stage. Data on effectiveness is limited, but some models have still been shown to provide incomplete disinfection of contaminated water.

High altitude
When traveling or living in high altitude cities, such as Cuzco, Huaraz, Puno or Huancayo, beware of altitude sickness (for most people this is no more than a slight headache and shortage of breath for a day or two). Avoid alcohol the day before and a few days after arrival. One of the best ways to minimize the effects of "soroche" (high altitude sickness) is to avoid dehydration. Drink lots of liquids. Rest the first day, but take a short walk in the afternoon. Hard candy helps. Locals recommend coca tea (mate de coca). Eat lightly. Some of the annoying effects of mild "soroche" can be lessened with antacids and aspirin. But for serious problems; descend to a lower altitude. Beware also of the equatorial sun, which can cause a burn in less than half-an-hour even when it's cloudy. Wear a hat, long sleeves and apply plenty of sun block.

Altitude Sickness
Cusco is at about 3,400m or 11,000 feet and the Inca trail passes 4,200m or 14,000 feet. At such altitudes, altitude sickness is a real possibility and precautions should be taken to avoid serious complications.

This information is intended to be educational in nature and should not be construed as medical advice. You should consult your physician regarding any specific medical conditions or questions and before taking any medications or departing on your trip. This information has been taken from the High Altitude Medicine Guide (http://www.high-altitude-medicine.com/) and further information is available from this site.

As one ascends through the atmosphere, barometric pressure decreases (though the air still contains 21% oxygen) and every breath contains fewer and fewer molecules of oxygen. One must work harder to obtain oxygen, primarily by breathing faster. This is particularly noticeable with exertion, such as walking uphill. Being out of breath with exertion is normal, as long as the sensation of shortness of breath resolves rapidly with rest.

Acclimatization is the process of the body adjusting to the decreasing availability of oxygen. It is a slow process, taking place over a period of days. Certain normal physiologic changes occur in every person who goes to altitude:

  • Hyperventilation (breathing fast)
  • Shortness of breath during exertion
  • Increased urination
  • Changed breathing pattern at night
  • Awakening frequently at night
  • Weird dreams

As the amount of oxygen in the lungs decreases, the blood becomes less and less efficient at acquiring and transporting oxygen. This means that no matter how fast one breathes, attaining normal blood levels of oxygen is not possible at high altitude.

As long as you are awake, it is not much trouble to remember to breathe, but at night, an odd breathing pattern develops. Periodic breathing consists of cycles of normal breathing, breath-holding, and accelerated breathing. The breath-holding may last up to 10-15 seconds. This is not correlated with altitude sickness. It may improve slightly with acclimatization, but does not usually resolve until descent. Periodic breathing can cause a lot of anxiety in trekkers. If periodic breathing symptoms are troublesome, a medication called acetazolamide may be helpful.

Acute Mountain Sickness (AMS)
When acclimatization lags significantly behind ascent, various symptoms occur. Acute Mountain Sickness (AMS) represents the body's intolerance of the hypoxic (low oxygen) environment at one's current elevation.

Who can get AMS?
Anyone who goes to a high altitude, there is no increased prevalence based on age, gender, physical fitness, or previous altitude experience. It is primarily related to rate of ascent. It is also impossible to predict who is likely to get sick at altitude.

RECOGNIZE AMS. In the context of a recent ascent, a headache, with any one or more of the following symptoms above 2,500 meters (8,000 feet) qualifies you for the diagnosis of AMS:

  • Loss of appetite, nausea, or vomiting
  • Fatigue or weakness
  • Dizziness or light-headedness
  • Difficulty sleeping
  • Confusion
  • Staggering gait

It is remarkable how many people mistakenly believe that a headache at altitude is "normal" when it is actually AMS. Be willing to admit that you have altitude illness.

How to Avoid AMS
The key to avoiding AMS is a rational ascent that gives your body time to acclimatize. People acclimatize at different rates, so no absolute statements are possible, but in general, the following recommendations will keep most people from getting AMS:

At altitudes above 3,000 meters (10,000 feet), your sleeping elevation should not increase more than 300 meters (1,000 feet) per night, and every 1,000 meters (3,000 feet) you should spend a second night at the same elevation.

What To Do If You Have AMS
DO NOT ASCEND ANY HIGHER. Violating this simple rule has resulted in death. Stay at the same altitude until your symptoms completely go away. Once your symptoms are completely gone, you have acclimatized and it is OK to continue ascending. It is always OK to descend, as you will get better faster.

The Severe Forms of AMS -- High Altitude Cerebral Edema (HACE)
AMS is a spectrum of illness, from mild to life-threatening. At the "severely ill" end of this spectrum is High Altitude Cerebral Edema; this is when the brain swells and ceases to function properly. HACE, once present, can progress rapidly, and can be fatal in a matter of a few hours. Persons with this illness are often confused, and may not recognize that they are ill.

The hallmark of HACE is a change in cognition, or the ability to think. There may be confusion, changes in behavior, or lethargy. However, it is probably easier to recognize a characteristic loss of coordination that is called ataxia. This is a staggering walk that is identical to the way a person walks when very intoxicated. The treatment is immediate descent. This must be done as soon as possible and cannot wait until morning (unfortunately, HACE often strikes at night). Delay may be fatal. How far down? At least to the last elevation at which they woke up in the morning with no symptoms of AMS.

High Altitude Pulmonary Edema (HAPE)
Another form of severe altitude illness is High Altitude Pulmonary Edema, or fluid in the lungs. Though it often occurs with AMS, it is not felt to be related and the classic signs of AMS may be absent. Signs and symptoms of HAPE include any of the following:

  • Extreme fatigue
  • Breathlessness at rest
  • Cough, possibly production of frothy or pink sputum
  • Gurgling or rattling breaths
  • Chest tightness, fullness, or congestion
  • Blue or gray lips or fingernails

The treatment for HAPE is the same as for HACE: immediate descent. As with HACE, it is of the utmost urgency; delay may be fatal. The same rules apply for how far as well: to the last elevation where the victim felt well upon awakening.

Things to Avoid
Respiratory depression (the slowing down of breathing) can be caused by various medications, and may be a problem at altitude. The following medications can do this, and should never be used by someone who has symptoms of altitude illness (these may be safe in non-ill persons, although this remains controversial):

  • Alcohol
  • Sleeping pills (acetazolamide is the sleeping tablet of choice at altitude)
  • Narcotic pain medications in more than modest doses
    We also recommend light, easy to digest meals, with little oil, meat, and without beans, which are more difficult to digest at high altitudes.

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