11,20,21 Also, differences in the characteristics of trip duration and destinations between NAM and EUR may help explain why NAM had higher rates of self-reported

altitude sickness than EUR but lower rates of travelers’ diarrhea. EUR were more likely to travel to other destinations in Peru, probably including other cities at high altitude, and thus acclimatized before arriving in Cusco. At the same time, traveling for longer periods of time probably increased EUR risk of exposure to unsafe food and water. EUR were significantly more likely to report vaccinations against hepatitis A, hepatitis B, typhoid, and yellow fever. Two studies, one among travelers to the Beijing Olympics13 and another among “ecotourists”

PLX4032 order to Malaysia,22 showed similar results. Factors that may help explain reduced vaccine update among NAM include: (1) less availability of publicly funded vaccines in the United States and Canada, (2) fewer clinics dedicated to travel medicine with less access to travel vaccines such as yellow fever or typhoid, (3) greater regulations of required vaccines limiting distribution among clinics, and (4) less reimbursement opportunities through public or private health care insurance plans. These hypotheses would require further study. The appropriateness of the vaccines PD0332991 price prescribed for destination-specific risk of exposure is more important than the number of vaccines given.

EUR were more likely than NAM to visit other cities in Peru and to travel to other countries in the region in the 6 months prior to the study. Therefore, it would seem reasonable that more EUR would receive yellow Resveratrol fever vaccine than NAM as they might have visited risk areas for yellow fever. Travel to Cusco presents particular health risks for travelers. Although food- and waterborne infections and altitude sickness are common, mosquito-borne infections are uncommon at 3,400 m. Thus, besides updating routine vaccinations, only travel vaccines against hepatitis A and typhoid fever are recommended for the Cusco area. Due to the hepatitis B prevalence in the area and potential sexual or health care–associated exposures, hepatitis B vaccine should also be considered. Additionally, prophylaxis for altitude sickness should be discussed with those ascending rapidly. Although neither group was optimally prepared to visit Cusco, shortcomings in pre-travel preparation were different for each group. On the one hand, NAM were less likely than EUR to receive vaccinations against hepatitis A, hepatitis B, and typhoid fever. On the other, EUR were less likely than NAM to take altitude sickness prophylaxis.