Pre-travel Preparation for Cusco, Peru: A Comparison Between European and North American Travelers
Part of the data included in this article was presented as a poster at the ninth Conference of the International Society of Travel Medicine, Lisbon, Portugal, May 1 to 5, 2005.
Miguel M. Cabada, MD, Division of Infectious Diseases, Department of Internal Medicine, University of Texas Medical Branch, 6315 Central City Blvd Apt 116, Galveston, TX 77551, USA.
Background. Demographics, preferences on health care, and regional differences in pre-travel advice guidelines may influence the preparation of travelers to developing countries.
Methods. A secondary data analysis of the database of a travelers' health survey conducted in Cusco in 2002 was performed. Data from those whose place of residence was North America or Western Europe were selected. Illness rates, vaccinations, prophylactic medication use, and general recommendations on disease prevention were compared between the two groups.
Results. Data from 1,612 North Americans (NAM) and 3,590 Western Europeans (EUR) were analyzed. NAM were older, stayed longer in Cusco, and had less experience traveling to developing countries (p < 0.01). They reported being ill more often than EUR (58% vs 42%, p < 0.01). Diarrhea was more frequent among EUR (55.6% vs 46.7%, p < 0.01), and acute mountain sickness (AMS) was more frequent among NAM (52.8% vs 35.2%, p < 0.01). EUR sought advice from health care professionals (67.1% vs 52.0%, p < 0.01) and travel medicine practitioners (45.8% vs 37%, p < 0.01) more often. NAM used prophylactic medications more often (53% vs 48.6%, p = 0.00) and received a lower mean number of vaccines (1.97 ± 1.68 vs 2.63 ± 1.49; t-test 14.02, p < 0.01). Advice on safe sex and alcohol consumption was low in both groups, especially among NAM.
Conclusions. Pre-travel preparation and travel-related illnesses varied between NAM and EUR. Improving consistency of pre-travel preparation based on the best evidence should become a priority among different national bodies providing travel medicine recommendations.
Cusco is located in the south Andes of Peru at an altitude of 3,400 m. It is one of the main tourist destinations in South America with over 1 million foreign tourist arrivals in 2008. Travelers from the United States, Canada, and more than a dozen Western European countries comprised 70% of foreign visitors.1 Cusco is a melting pot where tourists with different cultural backgrounds, health care preferences, and understanding of health risks mix. Studies describing these issues in Cusco and in the region are lacking.
Data collected from travelers to Cusco show a significant burden of health problems. Half of the tourists visiting Cusco report health problems during their stay. Traveler's diarrhea and high-altitude sickness each affect one quarter of visitors.2 Casual sexual activity is common and entails very high risk.3 Local groups sexually interacting with travelers have a high prevalence of sexually transmitted infections and low condom use rates.4–6 Alcohol consumption significantly affects risk-taking behavior in travelers to Cusco with some important gender differences (M. M. Cabada, unpublished data). These suggest the need for efficiently using the scarce pre-travel visit time to counsel on specific risks tailored to the individual and the destination.
Travelers to Cusco lack reliable and consistent destination-specific oriented health advice. Cabada and colleagues reported that 60% of travelers to Cusco received pre-travel health information from a medical source, with rates depending in part on country of origin. Notably, while only 16% of travelers received prophylaxis for high-altitude sickness, more than 25% were taking malaria prophylaxis.7 Similarly, Bauer8 reported that travelers to Cusco were able to spontaneously recall information on malaria prevention more often than information on travelers' diarrhea and high-altitude illness. In another study, only half of the participants knew about the risk for AMS and fewer than 10% knew about acetazolamide.9 Factors affecting pre-travel preparation of travelers at specific destinations are unknown. It has been suggested that differences in travel health practices and education among travelers are influenced by country of origin.7,10
Few studies in host countries address differences in pre-travel preparation in mixed traveler populations. The purpose of this study is to describe the differences in pre-travel advice and interventions provided to travelers from North America and Europe.
A secondary analysis of data collected in a travelers' health survey was performed. A full description of the primary study design and results has been published elsewhere.2,7,11 In brief, the study was performed in the departure area of Cusco's International airport between August and November 2002. Foreign travelers between 15 and 65 years of age were asked to fill out an anonymous questionnaire. Data on demographics, travel itinerary, pre-travel advice, compliance with recommendations, and illnesses were collected.
For this study travelers whose place of residence was reported as North America (United States and Canada) or Western Europe12 were selected. Data on pre-travel interventions and illnesses developed during travel were compared between the two groups. Interventions were divided into three categories: vaccinations, prophylactic medications, and general recommendations on disease prevention.
The characteristics of North American travelers (NAM) and European travelers (EUR) were compared using chi-square test, t-test, and odds ratios calculation with 95% confidence intervals. The study protocol was approved by the Research Office from the Medical School of the Universidad Nacional de San Antonio Abad del Cusco.
During the study period, 6,798 international travelers were approached; 5,988 (88%) agreed to participate and completed the questionnaire. Information from 1,612 NAM and 3,590 EUR was retrieved from the database. Questionnaires excluded from the analysis (786 questionnaires) belonged mainly to travelers residing in developing countries in the Americas.
The mean age of NAM was 38.1 years (SD 12.88); 52.2% (836 of 1,601) were females; 47.9% (767 of 1,601) were single; 88.4% (1,424 of 1,611) visited Cusco mainly for tourism; and 89.4% (1,437 of 1,607) traveled with companions. The mean age of EUR was 34.2 years (SD 10.41); 50.7% (1,808 of 3,566) were females; 53.2% (1,897 of 3,567) were single; 92.2% (3,308 of 3,589) visited Cusco mainly for tourism; and 91.2% (3,258 of 3,572) traveled with companions. The demographic characteristics of both groups are compared in Table 1.
Table 1. Demographic characteristics of NAM and EUR travelers
|Age more than 35 y||762/1,573||1,187/3,540||1.86 (1.65 < OR < 2.11)|
|Gender (female)||836/1,601||1,808/3,566||1.06 (0.94 < OR < 1.20)|
|Marital status (single)||767/1,601||1,897/3,567||0.81 (0.72 < OR < 0.91)|
|Tourism as the main reason to travel||1,424/1,611||3,308/3,589||0.65 (0.53 < OR < 0.79)|
|Traveled with companions||1,437/1,607||3,258/3,572||0.81 (0.67 < OR < 1.00)|
|Stayed more than 7 d in Cusco||439/1,612||855/3,590||1.20 (1.04 < OR < 1.37)|
|Did not visit other Peruvian cities before arriving to Cusco||313/1,609||246/3,585||3.28 (2.74 < OR < 3.92)|
|Did not visit other countries in the 6 mo prior to the study||813/1,610||1,028/3,588||2.54 (2.25 < OR < 2.87)|
NAM reported being ill during their stay in Cusco more frequently than EUR [58.5% (943 of 1,612) vs 42% (1,510 of 3,590), p < 0.01]. They also reported more than one illness more often [23.6% (380 of 1,612) vs 14.1% (505 of 3,590), respectively, p < 0.01]. Among those who admitted being ill in Cusco, NAM reported diarrhea less often [46.7% (440 of 943) vs 55.6% (839 of 1,510), p < 0.01] and AMS more frequently [52.8% (497 of 941) vs 35.2% (531 of 1,509), p < 0.01] than EUR. No significant differences were found regarding the prevalence of sun burns, isolated fever, upper respiratory tract symptoms, sexually transmitted diseases, and traffic accidents.
There were small differences between NAM and EUR regarding the reception of information on travel-related health issues [93.1% (1,494 of 1,604) vs 96.9% (3,454 of 3,566), p < 0.01] and the likelihood of consulting more than one source of information [51.5% (768 of 1,491) vs 56.9% (1,963 of 3,449), p < 0.01]. EUR received information from a health care professional more often [67.1% (2,318 of 3,453) vs 52% (776 of 1,491), p < 0.01]. Specifically, they received information from a travel medicine practitioner [45.8% (1,583 of 3,453) vs 37% (552 of 1,491), p < 0.01] or a general practice physician [28.2% (975 of 3,453) vs 19.5% (291 of 1,491), p < 0.01] more often. The sources of pre-travel health information are compared in Table 2.
Table 2. Sources of information about travel-related diseases used by NAM and EUR travelers
|Travel medicine clinic||552/1,491||1,583/3,453||0.69 (0.61 < OR < 0.79)|
|General practice physician||291/1,491||975/3,453||0.62 (0.53 < OR < 0.72)|
|Pharmacist||55/1,491||271/3,453||0.45 (0.33 < OR < 0.61)|
|Internet||481/1,491||758/3,451||1.69 (1.48 < OR < 1.94)|
|Books||582/1,491||1,667/3,452||0.69 (0.61 < OR < 0.78)|
|Travel agency||250/1,491||536/3,452||1.10 (0.93 < OR < 1.29)|
|Friends||337/1,491||639/3,453||1.29 (1.10 < OR < 1.49)|
The frequency of vaccination was significantly lower among NAM [67.3% (1,079 of 1,603) vs 85.5% (3,053 of 3,570), p < 0.01] as was the mean number of vaccines received by each subject (1.97 SD 1.68 vs 2.63 SD 1.49; t-test 14.02, p < 0.01). When comparing the rates of the most commonly recommended vaccines, NAM received vaccination against yellow fever [46.7% (749 of 1,603) vs 71.7% (2,558 of 3,570), p < 0.01], hepatitis A [58.6% (939 of 1,603) vs 68.6% (2,450 of 3,570), p < 0.01], and typhoid fever [45.3% (726 of 1,603) vs 63.1% (2,252 of 3,570), p < 0.01] less often than EUR.
The use of prophylactic medication was reported by NAM more often [53.1% (851 of 1,603) vs 48.6% (1,733 of 3,569), p = 0.00]; they were also more likely to report receiving more than one kind of prophylactic medication [16.3% (261 of 1,603) vs 10.4% (370 of 3,569), p < 0.01]. The pre-travel health interventions among NAM and EUR are compared in Table 3.
Table 3. Specific pre-travel health interventions among NAM and EUR
| Yellow fever||749/1,603||2,558/3,570||0.35 (0.31 < OR < 0.39)|
| Hepatitis A||939/1,603||2,450/3,570||0.65 (0.57 < OR < 0.73)|
| Typhoid fever||726/1,603||2,252/3,570||0.48 (0.43 < OR < 0.55)|
| Hepatitis B||624/1,603||1,580/3,570||0.80 (0.71 < OR < 0.90)|
| Cholera||133/1,603||531/3,570||0.52 (0.42 < OR < 0.63)|
|Prophylactic medication use|
| For diarrhea||297/1,603||494/3,567||1.41 (1.21 < OR < 1.66)|
| For malaria||389/1,602||1,113/3,569||0.71 (0.62 < OR < 0.81)|
| For altitude sickness||408/1,602||462/3,568||2.30 (1.98 < OR < 2.67)|
|General preventive measures advice|
| Safe food and water||1,415/1,599||3,167/3,563||0.96 (0.80 < OR < 1.16)|
| Insect repellent/bed nets||1,029/1,599||2,561/3,563||0.71 (0.62 < OR < 0.80)|
| Condom use||283/1,599||899/3,563||0.64 (0.55 < OR < 0.74)|
| Sun burn protection||1,013/1,599||2,506/3,563||0.73 (0.64 < OR < 0.83)|
| Alcohol consumption||469/1,597||938/3,559||1.16 (1.02 < OR < 1.32)|
The purpose of this study was to compare the differences in pre-travel advice and interventions between North American and Western European travelers at a single destination. Our results should be interpreted considering the limitations of a secondary data analysis of a previous cross-sectional study. Despite these, we believe that the data provide valuable information regarding the pre-travel preparation of travelers to Cusco. Most studies on knowledge, attitudes, and practice focus on travelers from a single country going to multiple destinations. In contrast, our study explores the differences in pre-travel preparation between travelers from different countries of origin going to a single destination in Peru. This design allows collection of country-specific information that in turn may point out areas where further research is needed or consensus is lacking. Additionally, it provides information to physicians working at the destination site regarding travelers at special risk and in need of different health services.
Important differences in source of pre-travel advice, illness rates, and vaccination rates were found. These issues are discussed below and hypotheses explaining the differences are proposed. NAM were less likely than EUR to receive pre-travel counseling from a health care professional. Our results contrast with those of Jentes and colleagues13 showing that NAM traveling to China sought travel advice from health care professionals more often than EUR. Few studies compare the preferences for pre-travel services between these groups and maybe factors such as destination and perceived risk help explain these variations.
The differences in the quality of pre-travel advice received may be related to the higher illness rates reported by NAM. Studies by Piyaphanee and colleagues and Ropers and colleagues showed that travelers who received advice from a health care professional were more knowledgeable about the risk of malaria.14,15 Farquharson and colleagues16 suggested that discussing travel-related health risks with a health care professional increases adherence with preventive recommendations. Furthermore, the quality of advice received by NAM may affect why they reported more altitude sickness and less diarrhea than EUR. Pre-travel advice and knowledge about high-altitude sickness have shown to decrease rates of high-altitude-related complications,17–19 while studies on travelers' diarrhea have consistently failed to show a benefit from pre-travel advice, and in some of these, those receiving advice from a health care professional had increased rates of diarrhea.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” 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 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 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. Despite malaria prophylaxis and yellow fever vaccine not being indicated to travel to Cusco, the lack of detailed itinerary information in the primary database precludes any assessment of appropriateness. EUR were more likely to visit other destinations during their trip that might have required the use of malaria prophylaxis and yellow fever vaccine, but evaluating this is not possible.
In conclusion, important differences between pre-travel preparation and travel-related illnesses were noted between the group of NAM and EUR travelers studied. Although no definitive conclusions can be drawn about these differences, our data highlight the need for further research on the factors associated with differences in pre-travel preparation and their consequences among travelers from different countries visiting a specific destination. The need to improve access to quality pre-travel health services and to provide consistent destination-specific advice is suggested among international travel medicine providers. Studies by the authors regarding prophylactic medications and high-altitude illness among travelers to Cusco are currently underway to improve our understanding of this problem.
The authors would like to thank the kind assistance in the development of this survey provided by the personnel at Velasco Astete International Airport in Cusco city. We would also like to thank Dr A. Clinton White Jr for critically reviewing the article.
Declaration of Interests
The authors state they have no conflicts of interest to declare.