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FOCUS ON NEPAL: A few hints for safe and healthy travel.
Tuesday, 12 December, 2000

Dr Trish Batchelor
The Travel Doctor Auckland NZ
Email: [email protected]

After seven trekking trips to Nepal, I have come to the conclusion that the greatest health risk is becoming addicted to this wonderful country. My husband and I have trekked in other parts of the world…Ladakh, Tibet, northern India, Africa and Peru, yet it is Nepal that keeps drawing us back. The combination of awesome scenery, wonderful people and long, challenging treks is hard to match anywhere.

Trekking in Nepal

Trekking has two distinct styles, teahouse-trekking on the popular tourist routes and organized group treks that tend to go to areas that require you to be self sufficient in terms of food, fuel and accommodation. The style of trek you choose will depend on your budget, experience and preferences. Either way, you are likely to travel into remote areas far from medical care, where you may be exposed to extremes of climate, altitude and physical effort. Adequate preparation for your trip to Nepal means you are far more likely to have a healthy, and therefore enjoyable trip. A method to purify your water and a medical kit to treat diarrhoea, giardia, respiratory infections and minor injuries is essential, as is a visit to a specialized Travel Medicine Doctor to discuss vaccinations, altitude sickness, medical kits, rabies and any personal health issues you may have.

Preparation should be physical and psychological. Get as fit and healthy as you can before you leave and learn something about the culture and people of Nepal. The first time you arrive in Kathmandu you are likely to be slightly overwhelmed by the colours, sounds and smells of this busy and vibrant city, not to mention the erratic driving! Unfortunately, lack of pollution control has resulted in a severe air quality problem in the city. On arrival you may feel this is a far cry from the clear mountain air you were expecting! Minor respiratory problems are common in Kathmandu. Runny noses, sore throats and dry coughs can be managed with basic over the counter medications such as throat lozenges and decongestants. If you are prone to asthma, sinus or chest infections, you should let your travel doctor know. None the less, Kathmandu does have its charms that you are sure to discover! The greatest risk to travellers health in Kathmandu is undoubtedly diarrhoea. It is worth being vigilant with what you eat and drink when you first arrive in Kathmandu. There is nothing worse than starting your trek with a bout of travellers diarrhoea. Buses in Nepal do not come equipped with toilets! Once out on the trekking trail, altitude sickness (AMS) is common in those going above 3000 meters in altitude.

Your vaccinations

Whilst vaccinations are important for preventing serious illnesses, they are only the beginning of your health preparation for a trip to Nepal. You should ensure that you visit someone experienced in travel medicine to get advice about altitude sickness, diarrhoea (how to avoid it and how to treat it), rabies, managing respiratory infections etc.

The vaccinations that are recommended to you will depend upon your style of travel, the length of your trip and your personal vaccination and medical history. The following is a guide only.

Everyone should be up to date with their childhood vaccinations - these include polio, tetanus, diphtheria, measles, mumps and rubella. These childhood diseases are still common in Nepal.
Food and water borne diseases, such as Hepatitis A and Typhoid Fever, are also common in Nepal We would recommend vaccination to prevent them.
For some travellers we would recommend protection against Meningitis, Rabies, Hepatitis B and Japanese Encephalitis. These issues would be discussed on an individual basis.

Altitude sickness (acute mountain sickness or AMS)

Altitude sickness is a common problem for trekkers going above 3000 metres. One study of trekkers in the Everest region showed that around 50% of people had some symptoms of altitude sickness at Namche Bazaar (altitude 3300m). Altitude sickness is still not clearly understood. There is no way to predict who will suffer from it. Age, fitness levels and gender do not make any difference. Young, fit males are most at risk of AMS as they have a tendency to walk faster and not report early symptoms. The most common symptoms of AMS are headache, nausea and a general feeling of tiredness. AMS can progress rapidly to life-threatening forms of altitude sickness. HAPE (high altitude pulmonary oedema), means the lungs have been predominantly affected, and HACE (high altitude cerebral oedema), means the brain is involved Both of these conditions are medical emergencies. These more serious forms of AMS can generally be avoided by sensible acclimatization programmes; being aware of the symptoms of AMS and listening to what your body is trying to tell you!

The best way to avoid AMS is by what we call graded ascent. This involves following a program that allows your body to gradually acclimatize to altitude increases and the lowered oxygen pressure that they bring. The general recommendation is as follows:

Once above 3000 metres in altitude, gain only 300 - 400 meters in altitude daily.
Have a rest day after every 1000 meters in altitude gain.
Try and walk higher each day than the altitude at which you are sleeping.

Most people will find that following this schedule will allow them to avoid AMS, but some of us acclimatize faster and some slower. After your first trip you can modify your schedule to suit your personal profile but it is always best to be conservative on your first trip. Remember that Nepal is addictive and hopefully you will return.
There are medications that can help with acclimatization such as Diamox. These should be discussed with an experienced travel medicine practitioner. Interesting new work is being done on the role of Gingko Biloba in preventing altitude sickness, but it is only in the early stages of research.
Many large trekking companies now carry Gamow bags for trips going above 4500 meters. These are portable altitude chambers that can be used in life-threatening situations. Placing the victim in the Gamow bag we can simulate descent to a lower altitude and can save lives if the weather closes in and descent is impossible. When the conditions have improved, the trekker can then be transported down to a lower altitude.
The treatment for altitude sickness is descending to a lower altitude. This is life-saving and, no matter what the time of day or night, if a trekker is experiencing worsening AMS they should go down.

Helicopter evacuation is becoming big business in Nepal. People should not, however, assume that this is always an option, in the worlds highest mountain range where weather is unpredictable. You should ensure your insurance details have been registered with your embassy (or the Consul General for New Zealanders) if you are not trekking with a well known trekking company. Helicopter evacuation companies will only rescue you if they have been guaranteed payment before leaving Kathmandu.

For those interested in this topic, some useful web sites are:

www.nepalonline.net/hra
www.bena.com/ciwec

Diarrhoea.

Without a doubt, diarrhoea is the most common health problem experienced by travellers to Nepal. The variety of restaurants and food available in Kathmandu is huge and the temptations to break the basic rules are constant. Even the most careful traveller can end up with a stomach bug. Dr David Shlim has written and excellent article on travellers diarrhoea which can be found on the CIWEC clinic website (www.bena.com/ciwec). It is worth following the standard diarrhoea avoidance rules…cook it, boil it, peel it or leave it. Try to eat foods that are freshly cooked. Even the bottled water is suspect. I usually purify all my water with iodine or use a water filter. Well-boiled drinks such as tea should be safe. Diarrhoea is more common in the spring season (from April to June), but is easily contracted at any time in Kathmandu. Food on the trekking trails is generally cooked just prior to serving and is less likely to cause diarrhoea.. This is certainly the case for group-trekking but not necessarily for those using tea houses. Giardia is commonly picked up from the water. I recommend using double the normal dose of iodine to purify your water whilst trekking.

All travellers to Nepal should carry an appropriate medical kit with medications to self-treat for diarrhoea. With good instructions and the correct medication, it is usually easy to quickly cure this uncomfortable ailment. If you have diarrhoea that isnt responding to your medication, you should visit the CIWEC clinic. Their doctors see thousands of patients each year, most of them with diarrhoea. They are very experienced and know exactly what is happening in Kathmandu at the current time.
There are other reasons to be careful with your food and water in Nepal, especially if you are there during the months of June - September. There are two illnesses for which we currently have no treatment which are common during this season - Hepatitis E and Cryptosporidium. There is another bug that causes chronic diarrhoea called Cyclospora that is also common during this time of year. Unfortunately iodine doesnt kill either Cyclospora or Cryptosporidium, and so travellers visiting Nepal during the monsoon should either boil all of their water or use a top-level filter (such as PUR Voyageur).

ETHICAL TREKKING

There are some environmental and social issues that are worth mentioning.

Deforestation is an increasing problem on the major trekking routes. Lodge owners have to buy firewood to cook food and heat water for showers. Showers are an unnecessary luxury. Save some fuel by washing in the river or using a small bowl of warm water.
Plastic bottles do not get disposed of thoughtfully, especially on the trekking routes. It is better to take your own water bottle and use iodine for purifying the water.
The Nepalese people are offended by public displays of affection, and bare skin. Women should always wear long pants or a skirt, men should not go bare chested and should wear baggy shorts.
Think about your porters if you have them. The International Porter Protection Group (IPPG) has been formed to raise trekkers awareness of the issues of porter welfare. If you are going with an organized group, choose one that has been endorsed by the IPPG (see their website at www.ippg.net ). If you are trekking on your own, make sure your porter/s are prepared for conditions at high altitude.
Make sure all of your waste is either burned or carried out.

Have a great time!

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