There are day trips that drive 3 hours to an airport (not Nasca) and start the overflight there, about $500.

I thought you were trying to do this on the cheaper side. If you get yourself down to Nazca, then it's about $100 for the flight itself, plus the cost for the bus.

Have you checked to see what time you need to arrive in Iquitos if you are travelling by boat to a lodge? Typically they do not like to travel in the afternoon. If you are flying from Arequipa, I think you have to connect in Lima.

I'm still considering options. I am not trying to do it on the cheap necessarily, just travel like a middle class Peruvian would do it, so about 1/3 the cost of a tour. I am not trying to replicate a backpacking younger person trip with bedbugs and diarrhea. I was able to add a day so will look into things more in depth, taking a break now, a vacation from vacation planning. Passport apps mailed today!

Middle-class Peruvians are definitely taking the bus to Nazca instead of paying $600/pp to fly!! And quite often you will find even upper-middle (and a few nuns) in the lie-flat overnight buses.

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Me too! I have put my planning for our Mexico trip into hibernation. I used to be good at planning but just cant seem to get into the groove for this trip!

Laughing but it is more than a little pathetic:

I finally called my local clinic's travel section and got the breakdown on the yellow fever vaccine:

$408 for the jab
$200-$400 additional for a "consultation" that is required

Of course none of this is covered by insurance, travel care is strictly called out as not covered care.

So I guess buying a blank WHO yellow vaccine booklet from Amazon, then getting the jab at the Lima airport or Lima clinic, or at a public hospital in a pinch.

That is beyond ridiculous! Here in the UK it is one of the vaccinations not available on the NHS so we have to pay privately. The going rate here in London for a YF jab is £69 ($88). Someone is making vast profits over there!

Too bad you don't have Kaiser. Because they are a regional vaccine center they have the facilities to store live vaccines. It was free for me (did it before I turned 60) after that it isn't recommended. Also turns out they now say you only need it once, so in that case I didn't need it at all (Got one as a child when we moved to the Caribbean. As an aside, my mother came down with malaria there.) There are probably bigger risks such as dengue or zika vs YF unless you can determine that there is an active outbreak of YF when and where you are going (unlikely).

Doesn't the Lima clinic issue the yellow book when you get jabbed? And since you don't need proof why bother with the yellow book anyways? Unless your main goal is sourcing a cheap one for future travel where proof may be asked for.

I'd be willing to bet no one asks to see your yellow book in Peru. Honestly, since you are not going to have time for the vaccine to take effect anyways, and you risk side effects, I would just skip getting it. But you won't find any doctor willing to tell you that. Also now that you are going at the end of dry season, chances are even lower, but I would still always use insect repellent as your main line of prevention.

PS you can find a 4+ to 5 star hotel in Paracas for around $200 a night. Perhaps the spouse would enjoy a night at Hotel Paracas while you continue on to Nazca (see Expedia now for some pretty amazing pricing for oceanfront rooms). I did enjoy both the Ballestas boat trip and the trip out to the Paracas reserve, as well. I'm sure the hotel would book the excursion if you didn't want to DIY.

Cruz del Sur is a recommended bus line that stops in Paracas, Maybe $50 return all the way to Nazca, half that to Paracas. I've usually bought the tix at a kiosk in Lima a few days ahead, but I think you can also reserve online.

I must admit that since yellow fever can be fatal, and because there are a variety of medical conditions that affect the likelihood of severe reactions to exposure and to the vaccine, I would think the best advice would be to pay the cost of the consult and advance innoculation. JMO.

Yes YF is fatal and hence anyone who is under 60 and without other medical conditions should get one. We don't know how old tom is, but for older people, the risk of a severe reaction is probably higher than the risk of contracting YF in Peru in the dry season. Unlikely that anyone at a commercial clinic will do those calculations for you, however as Kaiser has their own travel medicine clinic and supply, they did have a recommended cutoff of 60 YO. I believe that age even qualifies you for an official "contraindication" finding on your yellow card.

First line of defense...avoid getting bitten by mosquitoes!!

They recommend Ultrathon as a longer-lasting repellent. Walmart should be able to get it for you if it isn't in stock elsewhere.

I'm not a physician, but would note that the YF vaccine is a live (if attenuated) virus. Even those who are under age 60 can be at risk for serious side effects -- which can include death -- depending on other health factors. Such reactions are rare, but that's why consultation is often advised -- so a person's unique risk factors can be taken into consideration. My travel physician (at Georgetown University Medical Center) went through the specific risk probabilities I would face in each of the locations I planned to visit before my trip to Peru, and I felt every penny of that consultation worthwhile.

I endorse mlgb"s recommendation to do everything possible to avoid mosquito bites.

Statistically , the risk of major side effects is very low. There is a significant increase in risk for people over 60 but it still remains low. See below an extract for the UK NHS website ;the link https://www.fitfortravel.nhs.uk/advi...20administered

Of course nothing magically changes on your 60th birthday. I think I had a second jab just before my 60th , had it been a year later, I doubt much would have changed....

"Rare side effects

Rarely, serious complications can occur after receiving the yellow fever vaccine. These are more common in those over 60 years of age. These include:

• Yellow fever vaccine associated neurological disease (YEL-AND) is a condition affecting the brain and nervous system, leading to symptoms such as confusion and problems with movement and co-ordination. The risk of YEL-AND occurring is estimated as follows:
  • over 60 years of age = 2.2 cases per 100,000 doses of vaccine administered
  • less than 60 years of age = 0.8 cases per 100,000 doses of vaccine administered

• Yellow fever vaccine associated viscerotropic disease (YEL-AVD) produces a condition similar to yellow fever itself, with multi organ failure and death in approximately 48% of cases. The risk of YEL-AVD occurring is estimated as follows:
  • over 60 years of age = 1.2 cases per 100,000 doses of vaccine administered
  • less than 60 years of age = 0.3 cases per 100,000 doses of vaccine administered

If you have recently received the yellow fever vaccine and feel unwell please contact your GP or the 111 service if your GP practice is closed. You should let them know that you have recently received yellow fever vaccine.

In a medical emergency, when someone is seriously ill and their life is at risk, dial 999.

Vaccination in Those Older Than 60 Years of Age

If you are 60 years of age or older, it is possible for you to receive yellow fever vaccine, but only if you are fit and well, fully understand the risks of vaccination, and have a real risk of getting yellow fever infection at your destination (rather than requiring the vaccine just for certificate purposes). A healthcare practitioner will discuss your risk of disease at your destination and the potential risks of the vaccine, to help you to make an informed decision regarding whether or not to get vaccinated."
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If I were paying $200-400 for a consultation I would expect more than my doctor reading from a website which is likely to be the case. A doctor is not the best person to analyse the relative risk of vaccination -v- getting yellow fever, one would need an actuary for that, though he will clearly be in possession of info re pre existing conditions which may have a bearing. Another factor is that the YF data available in a country like Peru is likely to be very sketchy and so realistically, it would be very difficult to compare the relative risks, especially when visiting different areas at different elevations, with any degree of accuracy.

Yes, this is the main goal, and since both Amazon and the Peru clinics charge about $10 for the booklet, it isn't worth the risk that they are out of booklets.

The CDC site is circumspect about the YF vaccine and age 60, saying something like "only to be used for those visiting high risk areas." Of course, who else would be getting it? Are there recreational vaxxers out there, just doing vaccines for kicks?

I suspect the international travel consultation is with a nurse practitioner, and not an MD. My state law allows nurse practitioners to prescribe drugs. Sometimes these people are called physician's assistants, depends I think on the state.

I did get my YF vaccine for free, decades ago, before insurance tightened up on all that.

So a Lima question:

I was trying to avoid 3 stays, but it isn't easy, and now that I am going clockwise it's harder. Looking at something like this, with 3 stays in Lima:

First 2 nights in Lima, to sort out the currency supply and get vaccine and meds, and get 2 nights rest in the same bed. Fly to Cusco early enough to get a taxi tour going to Ollantay.... and get there before dark.

Then coming back from Nasca (assuming now CdS to the San Isidro bus station) should the long Lima stay come here or at the end of the trip before early flight out?

In a sense the 3 or 4 night stay makes sense here, then leave for airport to fly to Iquitos, return from Iquitos then the evening before early flight out for home, is that too tight? Are those reliable flights, appear to have 6 or more a day IQT>>LIM. Could also put the long stay here at the end of the trip, then coming from Nasca go right from the bus station to an airport hotel to fly out the next morning.

Sorry I missed way up in post #33 the YF vax is for your wife. And mainly for a future trip to East Africa because with her/your insurance it would be very expensive in the US.

Probably good to have a conversation with Ceiba Tops (if that's your final Amazon basin choice) about transfers. When I stayed in a lodge farther down the Amazon (off of a tributary) there was constant rescheduling of the return flight, although it gave me a chance to have an interesting conversation with another semi-stranded passenger at the Iquitos airport. I don't know if September changes things up (I went in high water season). Also, I believe some of the aircraft flying that route have been upgraded. Bearing in mind that there are a variety of reasons that flights can be delayed, not just weather. Labor issues, moving planes around due to other cancellations, etc...

• If you are taking a bus from Nazca back to Lima, that is a LOT more reliable than flying from Iquitos to Lima.

As you have booked your return flight early, It will be less traffic that time of day. Even in all of my trips to Peru, the only time I ever stayed near the airport was when I was on a (free) connecting flight to Arequipa the next morning. I never did that on the final leg, always allowed at least two nights in Lima (to have a day's cushion, or full day for shopping and a final nice dinner). In the early morning hours the trip back to the airport is less stressful, so you don't really have to spend the night there.

Another shout out to my favorite Lima hotel (3B) and neighborhood (Barranco). They would likely be very helpful if you have trouble finding that YF jab, also. Much more than a big chain.

OK, so looking at 2 initial nights in Lima, then 1 night later when in transit from Nasca to Iquitos, then 3 or 4 nights at the end before flying out. It’s a lot of Lima.

Ceiba Tops: now considering no nights in Iquitos, then 3 nights at explorama which is farther from Iquitos and up a tributary, and a sister lodge of CT. Arriving and departing times for boats from Iquitos are on the website.

And seriously -- it's those individual risk factors that could prove of greatest import!

But honestly, I don't understand why anyone would assume that a competent travel physician -- an infectious disease specialist -- would simply read aloud from the CDC website. Or why anyone would assume that such specialists would not be informed by recent research that has not yet been incorporated into the CDC or other broadly available websites. Or why one would assume that the assessment of relative risk is dependent solely upon Peruvian YF data rather than, say, other data about risk factors, the distribution of YF-vector mosquitos, etc.

I do understand that not all travel clinics are staffed by travel physicians. At least in the US, one should be able to determine the credentials of the treating professional upon scheduling and before actually attending an appointment. Which is not to say that I doubt the value of physician extenders -- AFAIK, many are highly competent professionals.

Obviously, only the person contemplating the vaccine can actually weigh the personal risks and benefits, but I, for one, am glad to be able to call upon a qualified infectious disease expert to obtain the information I can't get by simply perusing the internet.

I don't automatically assume that the commercial travel clinics giving consults are going to assign a physician for that task. Most likely it will be a "Travel Nurse", NP, etc..

Because yellow fever is not endemic to the US, not "medically necessary" few places actually have it. In California most people get punted to the commercial clinics (Passport Health). They use NURSES who just read off of the CDC website. That's it. And they want you to bring your own list of inoculations and medical history, they only have what you give them and don't have access to your medical record. A few Public Health Departments and Universities provide travel vaccines, but often just for residents and students. Even fewer will have yellow fever. It's worth checking as the cost will be less than the commercial clinics. I'm also not assuming that you will see anyone but a nurse there, not a "physician".

Thanks for that information, mlgb. Thank goodness I don't live in California! I hope other parts of the US offer travel clinic experiences more like mine in DC.

Hi KJA.

I based my comments not by assuming anything but on two factors. Firstly significant experience of getting vaccination and travel medical advice from GPs and travel clinics in many different parts of the world and, secondly upon discussions with my son who, after training here in London, is is a consultant and director of training in a major hospital in Australia.

If you actually got to see a "an infectious disease specialist" then I suspect you are in a very tiny minority, The vast majority of people wont have access to such a facility. The vast majority of people looking to receive medical advice and vaccinations will access such advice through nurse practitioners in travel clinics or GP surgeries. Going to you own physician has the benefit that they will have access to your medical history whereas at a travel clinic the patient will be expected to provide that. Either way those individuals providing the care on the front line will rely on data and information from a CDC or NHS or similar website.

Not disputing that you got to see an infectious disease specialist but I would have thought the vast majority of these will be busy working in hospitals or primary research centres rather than in travel clinics.

I had no idea how fortunate I've been!

As mentioned above, I go to the Travel Medicine Clinic at Georgetown University Medical Center in DC. A part of the Infectious Diseases division of that university's / hospital's Department of Medicine, several physicians provide travel medicine services through that clinic. The physician I see (an M.D. with board certification in both internal medicine and infectious disease and an M.S. in clinical epidemiology) focuses on tropical disease and is actively involved in research, education, and treatment. She even did part of her advanced training in Peru. I've seen her several times and have always been impressed by her command of both individual and locality based risks and her ability to help me think through the risks and benefits of various possible interventions. She typically uses the CDC website as a "teaching tool" while providing substantially more -- and more specific -- information than is available on that website.

BTW, she mentioned that the number of residents training in travel medicine or tropical diseases has been relatively low in recent years -- not surprisingly, those who have specialized in infectious diseases have been a bit busy with COVID in the last few years. I have no idea how many physicians with advanced, specialized training provide travel medicine services in the US., but if it's hard to find an expert infectious disease physician for travel consultations now, I can only imagine that it will be harder in the next few years.

Fortunate indeed kja! Of course the vast majority of travellers will have no real need for that level of expertise. Indeed, I don't imagine it will be too long before such matters are all handled by Artificial Intelligence ......

Here's hopefully the final itinerary:

Lima 2 nights (yellow fever vax, meds, currency)
Ollantaytambo 3 nights (arrive via taxi tour)
Machu Picchu 1 night (arrive via train)
Cusco 5 nights (arrive via train then shuttle)
Puno 2 nights (arrive via Inka Express tour bus)
Colca Canyon 2 nights (arrive via shuttle arranged by lodge)
Arequipa 3 nights (arrive via shuttle arranged by lodge)
Nasca 1 night (arrive via day bus CdS)
Lima 1 night (arrive via day bus CdS, to get into position for morning flight the next day)
Iquitos 1 night (arrive via flight late morning, to be sure to be in position for boat to lodge which is not refundable, cheap insurance, tour the fixed up Amazon boat)
Amazon Lodge 3 nights (transport to/from Iquitos by the lodge)
Lima 3 nights

Looks good to me! A nice reasonably paced trip. So many people try to rush through these places.

The only slight change I would consider would be to get the train back to Ollantaytambo from AC and then take the taxi tour of the Sacred Valley on the way back to Cusco. The reason being that one of the stops at Chinchero involves an uphill walk from a car park to the plaza of some 20 mins at an altitude of some 3800m ( higher than Cusco) . Some people who have just arrived from sea level find it quite tough.

Understood about Chinchero, but here is what is going on. When MP used to have the am or pm ticketing, things cleared out in the late afternoon and people were able to get some peace at MP then, in addition to early morning. Now with hourly tickets admitting new people till 3pm, they say it's jammed until closing and the only peaceful time is early am, requiring a night's stay nearby. So early rise that day, then spending much of the day at MP and not rushing, and getting the train out late afternoon, therefore no time to sightsee on the journey to Cusco. That altitude is similar to Trail Ridge Road @ Rocky Mtn NP so I know what you mean about being winded, will have to make do. Another option is a day trip from Cusco to Chinchero and a walk down the Inca trail to Urquillos, if it is a pretty walk.

Second leg, after Lima you will fly into Cusco, will you be doing the Diamox regime ahead of time? If not I would simply transfer directly to Ollantaytambo and not do anything requiring exertion at all. It really is best to just rest up on that first day to help acclimate. So just "arrive via taxi" and don't do any "touring". Maybe a later afternoon walk in Ollantaytambo around to the old Inca village streets? (Night 1 don't have a big dinner, something like a soup is good, helps with hydration). Next day possibly see the Ollantaytambo ruins. Night 2. There really isn't much else that is very close by to Ollantaytambo, the other sights are really closer to Cusco. Since you want to get into Machu Picchu early, might it be better to take an afternoon train INTO Aguas Calientes and spend Night 3 there? It's a scenic ride and nice to do during daylight.. (Aguas Calientes and Machu Picchu are BOTH lower in elevation than Ollantaytambo).

You can leave most of your luggage at your Ollantaytambo lodging, then spend the night AFTER Machu Picchu there. Then you will be able to do the half-day "taxi tour" on the way from Ollantaytambo to Cusco, stopping at the Moray Circles and Salineras, and Chinchero. (all three at higher elevations) on the way to Cusco and be deposited directly at your Cusco hotel (instead of the annoying and probably more expensive train/shuttle combo). You don't really need an English speaking tour for this, suggest you get a quote from taxidatum, alternatively your hotel can help arrange this on the spot. This also gives you another chance to see Ollantaytambo ruins if you didn't feel up to it early on or if there were some travel delays. Drop a night off of Cusco. You still have plenty of time to see Pisac as a day trip, the other nearby sites such as Sacsayhuaman and the city of Cusco.

I finally paid for MP train and admission tickets. IncaRail was cheaper so went with that, leaving Ollantaytambo at 6:40 am arriving MP Town supposedly at 8:01am. I got Inca Bridge tickets for 10-11am so I think that's plenty of cushion. And if everything goes well with the train/bus, with the bridge tickets we can access the citadel at 9am, an hour earlier, at least that is what I read online (the tickets don't actually say that any more if they ever did).

A tip for others: Don't try to buy MP tickets at work, the security systems in place may not allow the "joinus" app to function. Was able to do it at home.

As you can see, deleted the night in MP town, it just seemed a lot more running around than it was worth. I got a late train back to Olla, 8:20 pm, so plenty of time to eat and check things out in the town, and a cushion if weather holds us up at the citadel for an hour or 2, won't worry about having to make a train.

I think that that was the right decision, a single visit to MP on a day trip from Ollantaytambo, we'll see.

Also: Inquiring that it is true that the Machu Picchu tickets don't actually say "Machu Picchu" on them anywhere??? They say "Entry to Inka Bridge" with a time, name and passport number, and have the Culture Ministry and Joinus logos, and a square bar code on the left side.

I found a sample online, and no, the new tickets do not say "Machu Picchu" on them, just the name of the chosen route.

https://abexpeditions.com/machu-picchu-tickets/

Comment: For Americans, buying domestic tickets on LATAM is a bit fraught. They want you to use the latamairlines.com site, which charges $20-$50 more per ticket than the https://www.latamairlines.com/pe/es site does. Using a reddit for advice, the Latam NZ site offers the lower Peru site fares but navigates in English and charges in US dollars, https://www.latamairlines.com/nz/en Also following the reddit used a Mastercard, bought 2 of my 3 flights that way. Not sure if the card makes any difference. Noting that if one plans to check a bag might as well buy the full economy fare for about the same price and which also offers free seat selection and a refundable fare. Note also that on the Airbus 320, the first row of exit row seats (extra leg room but not reclineable) is selectable at no additional charge when flying full economy.

A little LATAM drama: Although the advice earlier to purchase flights when you know the dates since the prices just rise as the seats sell was solid, what was missing in that advice was that new flights can be added later that offer their first seats at a lower price, sometimes only minutes different departure time (LIM>>CUZ) from other flights. Since buying a class that has a checked bag and reserved seat nets a refundable fare, I went ahead to initiate a refund online for the old flight and queued up a purchase for a $45 savings for each ticket for a flight leaving 20 minutes later. The refund appeared to process online, but then after a few minutes issued a "fail" notice, which remains online in my account. At this point I just decided to leave things as they were.

Fast forward to this morning, my email has 2 notifications for new international card purchases, indicating that I was re-charged the same amount for the tickets again! Fortunately opening my credit card app it instead shows refunds pending. If I look in my LATAM account it still says "refund failed" but I have lost the seat assignments. I guess I can go ahead and rebook now for $45 less on the other flight leaving 20 minutes later now with credits pending. If it is all refundable it's all good I guess. Would prefer a path to refunds online a little more solid than that. Also worried a bit about all these new flights Lima to Cuzco, on this and other airlines. Is there really the traffic to support 1000 people/hour going to Cusco by air? Wondering if many of these flights will get canceled anyway, by LATAM and others.

"Wondering if many of these flights will get canceled anyway, by LATAM and others." I am afraid there is every chance they. South American Airlines, including Latam do not have a great track record for sticking to schedules if it does not make economic sense. Latam reinstated LHR- LIM flights last year only to cancel when the didn't get enough passengers. They also dont have great customer service when it comes to refunding "refundable' flights. I have afraid still waiting for her refund from LATAM months later. I hope the $45 saving works out and is worth the angst. Frankly, when I buy tickets, I stop looking at fares. It just isn't worth second guessing yourself.

Air France did the same thing to me last year, pulled out of Minneapolis and putting me on a Delta flight (which was fine) but 3 days later. I thought Europeans had protection against that kind of thing, had bought the ticket with Virgin points, called 7 or 8 times, always refused accommodation back to my original departure date. Accepted a refund.

Anyway, the refunds for the earlier flight have processed (from pending to posted on my credit card) so re-booked 20 minutes later on LATAM, $94.50 savings for 2. I was kicking myself for not booking when the date was set and the fare was low and I didn't purchase, so not so much second guessing as undoing a mistake.

Adding a yellow fever vaccination choice:

I’d forgotten about checking Canadian pricing, and the cost there is about $230 CAN so 1/4 that of the US. So if American and close to Canada, the approximately $600 US difference offers possibilities.

Adding Malarone (generic) pricing.

30 pills on Amazon Prime go for $43. That’s about 1/4 the cost at the local pharmacy.

I plan to use my insurance company’s online medical system to visit a doctor without a copay, and without the mandatory travel clinic fee w/o insurance coverage.

Failure on using telemedicine to obtain malarone. They refused to provide “travel” services, just like my general physician. A last option to avoid the $200-400 consultation (which is the only obvious option that’s not a lot of work), is runwayhealth.com, which charges a $30 consultation, then $129 for a 2 week malarone course, $25 for each additional week. Sure wish we could get the $44 for thirty pills of malarone available on Amazon prime, but need a prescription for that.

Ended up using runwayhealth.com which is a pill mill in Florida. $180 for the consultation and 32 pills delivered, so enough for 2. Not the most desirable outcome but it was cheaper than any other obvious solution.

Noting that the $1240 fee for Explorama Lodge hits Sunday and is non refundable. Can’t find any online reviews written within the past 5 years (!).