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While taking part in our out-door travel packages you will be in wilderness areas, at sea or under water, and your trip thus carries a necessary risk factor. It is important to us that our clients are aware of the risks involved and how to avoid them.

Your health and safety is of primary importance to us!! Nature Expeditions offers you the safest way to discover Peru. Read here, how Nature Expeditions guarantees your safety and provides emergency support.

For your safety, we recommend you to make sure that you have appropriate medical coverage in case of emergency.

We also recommend that you refresh your first aid knowledge, and visit your personal physician or a travel health clinic 4-8 weeks before departure to make sure that your vaccinations are up-to-date.

General Advice:

Jet Lag:
Jet lag is common when a traveler crosses more than five time zones. Symptoms may include sleep difficulty, fatigue, malaise, nausea, loss of appetite, and other gastrointestinal symptoms. Levels of performance, both intellectual and physical, may be less than par. Sleeping pills may be helpful in promoting sleep and adjusting to a new time zone after arrival. The chief side-effect of all sleeping pills is drowsiness or dizziness upon awakening.

Get adequate rest before departure
Drink plenty of fluids
Eat light meals
Avoid alcohol
Upon arrival, get exposure to natural sunlight and readjust your schedule for meals, sleep, etc.) as soon as possible

Vaccinations:
Hepatitis A		Recommended for all travelers
Typhoid		Recommended for all travelers
Yellow fever		Obligatory for areas east of the Andes mountains (rainforest). Required for travelers arriving from a yellow-fever-infected area in Africa or the Americas.
Hepatitis B		For travelers who may have intimate contact with local residents, especially if visiting for more than 6 months
Rabies		For travelers who may have direct contact with animals and may not have access to medical care
Routine immunizations		All travelers should be up-to-date on tetanus-diphtheria, measles-mumps-rubella, polio, and varicella immunizations.

Travelers Diarrhea:
Travelers Diarrhea is the most common travel-related ailment. The cornerstone of prevention is food and water precautions, as outlined below. All travelers should bring along an antibiotic and an antidiarrheal drug to be started promptly if significant diarrhea occurs, defined as three or more loose stools in an 8-hour period or five or more loose stools in a 24-hour period, especially if associated with nausea, vomiting, cramps, fever or blood in the stool.

A quinolone antibiotic is usually prescribed: either ciprofloxacin (Cipro) 500 mg twice daily or levofloxacin (Levaquin) 500 mg once daily for a total of three days. Quinolones are generally well-tolerated, but occasionally cause sun sensitivity and should not be given to children, pregnant women, or anyone with a history of quinolone allergy.

Alternative regimens include a three day course of rifaximin (Xifaxan) 200 mg three times daily or azithromycin (Zithromax) 500 mg once daily. Rifaximin should not be used by those with fever or bloody stools and is not approved for pregnant women or those under age 12.

Azithromycin should be avoided in those allergic to erythromycin or related antibiotics.

An antidiarrheal drug such as loperamide (Imodium) or diphenoxylate (Lomotil) should be taken as needed to slow the frequency of stools, but not enough to stop the bowel movements completely. Diphenoxylate (Lomotil) and loperamide (Imodium) should not be given to children under age two.

Most cases of travelers' diarrhea are mild and do not require either antibiotics or antidiarrheal drugs. Adequate fluid intake is essential.

If diarrhea is severe or bloody, or if fever occurs with shaking chills, or if abdominal pain becomes marked, or if diarrhea persists for more than 72 hours, medical attention should be sought.

Though effective, antibiotics are not recommended prophylactically (i.e. to prevent diarrhea before it occurs) because of the risk of adverse effects, though this approach may be warranted in special situations, such as immunocompromised travelers.

Do not drink tap water unless it has been boiled, filtered, or chemically disinfected.
Do not drink unbottled beverages or drinks with ice.
Do not eat fruits or vegetables unless they have been peeled or cooked.
Avoid cooked foods that are no longer piping hot. Cooked foods that have been left at room temperature are particularly hazardous.
Avoid unpasteurized milk and any products that might have been made from unpasteurized milk, such as ice cream.
Avoid food and beverages obtained from street vendors.
Do not eat raw or undercooked meat or fish, including ceviche.

Wear long sleeves, long pants, hats and shoes (rather than sandals).
Apply insect repellents containing 20-35% DEET (N,N-diethyl-3-methylbenzamide) or 20% picaridin (Bayrepel) to exposed skin (but not to the eyes, mouth, or open wounds). DEET may also be applied to clothing.
Products with a lower concentration of either repellent need to be reapplied more frequently. Products with a higher concentration of DEET carry an increased risk of neurological toxicity, especially in children, without any additional benefit.
Do not use either DEET or picaridin on children less than two years of age. For additional protection, apply permethrin-containing compounds to clothing, shoes, and bed nets. Permethrin-treated clothing appears to have little toxicity.
Don't sleep with the window open unless there is a screen.
If sleeping outdoors or in an accommodation that allows entry of mosquitoes, use a bed net, preferably impregnated with insect repellent, with edges tucked in under the mattress. The mesh size should be less than 1.5 mm.
If the sleeping area is not otherwise protected, use a mosquito coil, which fills the room with insecticide through the night.

Make sure your health insurance covers you for medical expenses abroad. If not, supplemental insurance for overseas coverage, including possible evacuation, should be seriously considered. If illness occurs while abroad, medical expenses including evacuation may run to tens of thousands of dollars.

For US citizens:
For a list of travel insurance and air ambulance companies, go to Medical Information for Americans Traveling Abroad on the U.S. State Department website. Bring your insurance card, claim forms, and any other relevant insurance documents. Before departure, determine whether your insurance plan will make payments directly to providers or reimburse you later for overseas health expenditures. The Medicare and Medicaid programs do not pay for medical services outside the United States.

Pack a personal medical kit, customized for your trip. Following are some recommendations for things you may consider to include into your personal medical kit:

Note: some of the newer quinolones, such as levofloxacin (Levaquin), may be effective for all the above. Travelers unable to tolerate quinolones may need to bring along more than one antibiotic.

Antidiarrheal drugs (e.g. loperamide, diphenoxylate, kaolin-pectin)
Drugs for motion sickness (e.g. meclizine)
Sleeping pills (for jet lag)
Acetazolamide (for altitude sickness)
Acetaminophen (Tylenol)
Acetaminophen with codeine
Anti-inflammatory drugs (e.g. ibuprofen)
Antiemetic (e.g. prochlorperazine for nausea)
Antacids or bismuth subsalicylate
Antihistamines (e.g. Benadryl)
Decongestants
Antibacterial ointment for cuts or abrasions (e.g. Bactroban)
Steroid cream (e.g. hydrocortisone 1%)
Vaginal cream for yeast infections (e.g. miconazole or clotrimazole)
Epinephrine injection (e.g. EpiPen) - for those with a history of allergies to insect stings or other severe allergic reactions

Avoid contact with stray dogs and other animals. If an animal bites or scratches you, clean the wound with large amounts of soap and water and contact local health authorities immediately. Wear sun block regularly when needed. Use condoms for all sexual encounters. Ride only in motor vehicles with seat belts. Do not ride on motorcycles.

Traveling at sea:
During summer months from December to March skies are mostly permanently blue and without clouds. Therefore sun-exposure at sea is quite high. We recommend for the entire year using sun-block with the highest level of sun protection possible (45 and higher).

During the winter months from June to August temperatures are still at around 16 degrees of Celsius. The Peruvian coast will be many times covered in fog in the morning that later on clears up and gives way to a grey and sometimes even blue sky at around noon time. All marine travel programs are equally possible under this weather conditions but we recommend bringing warm and waterproof clothing.

When traveling by boat, sea sickness is a common problem. Click here in order to learn how to avoid or treat it.

Generally spoken traveling in Peru is not dangerous. However in the sometimes crowed and overpopulated coastal cities, many of them being ports and suffering high unemployment rates, it is advisable to be cautious when traveling on your own and not in an organized group of Nature Expeditions or any other travel agency. Precaution is the best way to travel safe. We recommend not to wear expensive watches or jewelry, and of course hide your camera and video camera in a bag, when not using it. This way you significantly lower the danger of becoming a victim to theft.

Sea food is a must when traveling along the coast and of course the Peruvian Ceviche (raw fish cooked in lemon juice) is a specialty nobody wants to miss. However, if you are traveling with a tight itinerary and if you don’t want to run a risk of travelers Diarrhea, we strongly recommend to NOT eating Ceviche, no matter if it is a good restaurant or not. Nearly everybody we know that ate Ceviche ended up sooner or later with at least a diarrhea or even worse.

Dengue fever, a flu-like illness sometimes complicated by hemorrhage or shock, is transmitted by Aedes mosquitoes, which bite primarily in the daytime and favor densely populated areas, though they also inhabit rural environments. In Peru, most cases are reported from the northern coast and the northeastern and central jungle region. Dengue was also reported recently near the Ecuadorian border. No vaccine is available at this time. Insect protection measures are essential.

When traveling in the Andes you are moving between 2,500 and 5,000 meters of altitude. Therefore sun-exposure naturally is quite high. We recommend using sun-block with the highest level of sun protection possible (45 and higher).

Acute Mountain Sickness is common at high altitudes. At elevations over 10,000 feet (3,048 meters), 75% of people will have mild symptoms. In order to learn what you can do to prevent Acute Mountain Sickness, click here.

When you want to visit the rainforest you need certain vaccinations, you will not need in the rest of the country

Prophylaxis is recommended for all rainforest areas. Most cases occur in Loreto.

Either mefloquine (Lariam) , atovaquone/proguanil (Malarone)(PDF) , or doxycycline may be given.

Mefloquine is taken once weekly in a dosage of 250 mg, starting one-to-two weeks before arrival and continuing through the trip and for four weeks after departure. Mefloquine may cause mild neuropsychiatric symptoms, including nausea, vomiting, dizziness, insomnia, and nightmares. Rarely, severe reactions occur, including depression, anxiety, psychosis, hallucinations, and seizures. Mefloquine should not be given to anyone with a history of seizures, psychiatric illness, cardiac conduction disorders, or allergy to quinine or quinidine.

Atovaquone/proguanil (Malarone) is a recently approved combination pill taken once daily with food starting two days before arrival and continuing through the trip and for seven days after departure. Side-effects, which are typically mild, may include abdominal pain, nausea, vomiting, headache, diarrhea, or dizziness. Serious adverse reactions are rare. Doxycycline is effective, but may cause an exaggerated sunburn reaction, which limits its usefulness in the tropics.

Long-term travelers who may not have access to medical care should bring along medications for emergency self-treatment should they develop symptoms suggestive of malaria, such as fever, chills, headaches, and muscle aches, and cannot obtain medical care within 24 hours. Symptoms of malaria sometimes do not occur for months or even years after exposure.

Dengue fever, a flu-like illness sometimes complicated by hemorrhage or shock, is transmitted by Aedes mosquitoes, which bite primarily in the daytime and favor densely populated areas, though they also inhabit rural environments. In Peru, most cases are reported from the northern coast and the northeastern and central jungle region. Dengue was also reported recently near the Ecuatorian border. No vaccine is available at this time. Insect protection measures are essential.

Transmitted by the bite of the infected female phlebotomine sandfly, the leishmaniases are a globally widespread group of parasitic diseases. The sand fly vector is usually infected with one species of flagellate protozoa belonging to the genus Leishmania.

The disease is transmitted by sand flies, which are about one-third the size of mosquitoes. Sand flies breed in sites where its larvae will find warmth, moisture, and organic matter, such as leaf litter, loose earth, old tree bark, rubbish heaps, and crevices in human dwellings. Sand flies typically bite from dusk to dawn, but may bite during the daytime if disturbed. There is no vaccine at present. The key to prevention is insect protection measures, which are essentially the same as those outlined for mosquitoes, except that netting must be finer-mesh (at least 18 holes to the linear inch) since sand flies are smaller.

Although people are often bitten by sand flies infected with Leishmania protozoa, most do not develop the disease. However, among persons who are immunosuppressed (e.g. as a result of advanced HIV infections, immunosuppressive treatment for organ transplants, haematological malignancy, auto-immune diseases), cases quickly evolve to a full clinical presentation of severe leishmaniasis.

Cutaneous leishmaniasis (CL) can produce large numbers of skin ulcers--as many as 200 in some cases--on the exposed parts of the body, such as the face, arms and legs, causing serious disability and leaving the patient permanently scarred. Diffuse cutaneous leishmaniasis (DCL) never heals spontaneously and tends to relapse after treatment. The cutaneous forms of leishmaniasis are the most common and represent 50-75% of all new cases. 90% of all cases of CL occur in Afghanistan, Brazil, Iran, Peru, Saudi Arabia and Syria, with 1-1.5 million new cases reported annually worldwide. In case you should recognize an open wound appearing on your skin that does not close well, persists and even grows (this may appear even weeks after your visit to a rainforest area) please contact a clinic specialized in tropical diseases immediately.

Mucocutaneous leishmaniasis (MCL), or espundia, produces lesions which can lead to extensive and disfiguring destruction of mucous membranes of the nose, mouth and throat cavities. 90% of all cases of MCL occur in Bolivia, Brazil and Peru.

Visceral leishmaniasis (VL), also known as kala azar, is the most severe form of the disease, which, if untreated, has a mortality rate of almost 100%. It is characterized by irregular bouts of fever, substantial weight loss, swelling of the spleen and liver, and anemia.