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HEALTH AND SAFETY

Most people look forward to a trek in Nepal as the adventure of a lifetime. However, the very term ‘adventure’ suggests some inherent uncertainty, isolation and risk. There is a higher risk of getting ill in Nepal than if you stayed home, there may be uncertainty as to what illness you have and what to do for it, and the illness may occur in an isolated set­ting, far from medical care. The main health concern in Nepal is the relatively high risk of acquiring either travellers’ diarrhoea, a respiratory infection or a more exotic trop­ical infection. There are also risks associated with accidents while trekking, and altitude sickness. Infectious diseases can interrupt your trip and make you feel miserable, but they are rarely fatal. Falling off trails, or having a rock fall on you as you trek, has been the number one cause of death among trekkers, but the overall death rate is low: one death for every 6500 trekkers.

The risk of becoming ill, or the length of time your trek is interrupted, can be signifi­cantly reduced by obtaining the proper immunizations, following preventive advice, and using this chapter to help diagnose and treat yourself in the event you become ill in the absence of medical care.

PREDEPARTURE PLANNING

Medical Exam & Prescriptions

Trekking is just walking around in the mountains, but due to the altitude, strenuous terrain and isolation, it is a good idea to make sure you are as healthy as possible be­fore starting out. It is worthwhile investigat­ing nagging problems or any unexplained recurrent symptoms before you go, because problems have a way of escalating under the stresses of travel.

If you take regular medications for chronic problems, such as high blood pressure, make sure you stay on the medications for the trek, and carry them with you when you fly, rather than carrying them in your luggage. If you have chronic medical problems, or a history of something complicated that could flare up on a trip, carry a brief outline of your problem with you, possibly written by your physician. This can be extremely useful in the event you are forced to seek care from another physician while you are traveling.

A thorough dental examination is highly recommended because reliable dental care is difficult to obtain in Nepal. Preventable dental problems have ruined a number of treks over the years. People who wear contact lenses can have trouble with grit and dust both in Kathmandu and in the mountains. Make sure you have backup prescription glasses and sunglasses in case you can’t wear your lenses at some point. Bring all the contact lens washing solution you will need. People who have had radial keratotomy (an operation on the cornea to correct vision permanently) may experience visual booster is given to build antibody levels to a point that should offer protection for the rest of your life. There is growing evidence that the first shot offers adequate protection even if given shortly before the trip.

Hepatitis A

This vaccine is given less than four weeks before the trip begins. However, most travel medicine authorities are comfortable with giving just the hepatitis A vaccine, without adding the immune serum globulin. Hepatitis A vaccine offers almost 100% protection against getting hepatitis.

In some countries, a combined hepatitis A and hepatitis B vaccine is available. The regimen requires one shot to begin, and boosters at one month and six months. The combined vaccine is not cheaper, but it does allow you to protect yourself against both hepatitis A and B with only three injections instead of five.

Hepatitis B

This can be a much worse in­fection than hepatitis A, leading to chronic liver disease, cirrhosis and death in some cases. It is acquired through contact with blood or through sexual contact. There is little chance of casually acquiring this in­fection without exposure to contaminated needles, receiving a transfusion or having unprotected sex. For long-term travelers visiting many different countries, or for ex­patriates who plan to be abroad for several years, the hepatitis B vaccine is safe and ef­fective with few side effects and is recom­mended. If you anticipate doing medical work, or that you will be sexually active with local people, this vaccine is highly recom­mended. The regimen for hepatitis B immunization is a series of three shots over a six-month period. An accelerated schedule is available offering protection to those travelers who don’t have six months to complete their injections. The schedule in­volves giving three injections over a three- week period, with a booster required after one year for long-term protection.

Typhoid Fever

This disease is more of a risk in Nepal and India than in any other country in the world. Although almost never fatal when proper treatment is available, it makes people severely ill, and recovery may take several weeks. The original typhoid vaccine, consisting of killed typhoid bac­teria, is becoming obsolete, having been re­placed by two vaccines that have a similar level of protection with fewer side effects. The oral typhoid vaccine (Vivotif) involves swallowing either three or four capsules (one every other day). The level of protection may not be as high as with the new capsular polysaccharide vaccine (Typhim Vi), which consists of a single injection. Neither vaccine offers 100% protection, but they can reduce your risk of getting typhoid fever by around 60% to 90%.

Meningococcal Meningitis

An epidemic of meningococcal meningitis occurred in the Kathmandu valley in 1983; during the next two years six foreigners contracted the disease and two died. In March 1985, the US Center for Disease Control issued an alert to travelers to be vaccinated against men­ingococcal meningitis before traveling to Nepal. Occasional cases occurred in the subsequent years, but there have been no further epidemics in the country, and no cases in foreigners documented in the past seven years. This led the Center for Disease Control to rescind its travel alert and men­ingococcal vaccine is no longer recommend for travelers to Nepal. The situation is monitored constantly, and any increase in meningococcal disease might lead to a change in this recommendation.

Polio

The current generation in the West is no longer afraid of polio because vaccination has made it rare. However, polio has not been eradicated from Nepal, and a booster for people who have been previously immunized is recommended before traveling to Nepal. Childhood polio immunizations wear off over time because there is no longer any boosting effect from exposure to wild polio-virus. If you have been immunized in childhood, one booster as an adult should be obtained before you travel to Asia. The inject able polio vaccine has replaced the oral vaccine due to a slightly increased safety profile.

Rabies

This is a virus that causes a severe brain infection that is invariably fatal. Thus, every effort must be made to avoid infection. Around 96% of human rabies cases are caused by dog bites. However, any mammal can potentially be infected and transmit the virus. Rabies is highly endemic among the street dog population in Nepal, and is a risk from the wild monkeys that live near tem­ples. Rabies is different from other infec­tious diseases in that a person can be immunized after having been exposed. This post-exposure treatment requires the avail­ability of an expensive and hard-to-obtain substance called human rabies immune glob­ulin (HRIG). This substance is available in Nepal only at the CIWEC Clinic Travel Medicine Center. In addition to the HRIQ five injections of rabies vaccine is needed over a one-month period. Because of the difficulty of obtaining HRIG and the awk­wardness of scheduling five injections dur­ing the subsequent month, some people choose to take three shots before they travel. Travelers who take the per-immunization series only need two rabies shots, three days apart, if they are bitten by a possibly rabid animal. Make sure you are aware of the risk of rabies in Nepal, even if you choose not to have the per-exposure rabies vaccine. More than one traveler has died of rabies acquired in Nepal.

Tetanus & Diphtheria

The vast majority of people from Western countries receive these vaccines in childhood. The tetanus and diphtheria germs are worldwide, and preparing for travel abroad is a good chance to boost your immunity. You should take a booster if it has been longer than 10 years since your last one. It is especially important to ask for a tetanus booster if you are over 50 years old, as studies have shown this. population is more likely to have let its tetanus boosters lapse.

Choler

Cholera vaccination is no longer required to enter any country in the world. Although the disease can be devastating to local populations at times, the risk of acquiring cholera as a traveler to Nepal is close to zero, and the few cases that have been documented were indistinguishable from ordinary travelers’ diarrhoea. There­fore, cholera vaccine, whether the old in­jectable vaccine or the new oral vaccine, is not necessary in Nepal.

Malaria

There is currently no vaccine against malaria. Travelers to areas where malaria is a risk must rely on trying to pre­vent mosquito bites and taking prophylactic medication to try to avoid malaria infections! In Nepal, malaria transmission is limited to the lowland Terai area. There is no risk of malaria in Kathmandu, Pokhara, or any of the main trekking areas.

The risk in the Terai is very low, and travelers traversing the area for one or two days (on the way to a trekking destination) do not need malaria prophylaxis. Travelers who visit a jungle lodge in Nepal are at theoret­ical risk, but there have been only two cases of malaria acquired by foreigners in the Terai in the past 17 years.

Japanese Encephalitis

Caused by a virus transmitted by mosquitoes, Japanese en­cephalitis has a maximum risk during the monsoon and just afterwards. The disease exists in Nepal, mainly in the Terai, and mainly during the period from August to October. However, no foreigners have ever acquired this disease in Nepal, so it is hard to calculate the actual risk. This vaccine is not currently necessary for trekkers or for casual visitors to the Terai.

Japanese encephalitis has been docu­mented to occur in very few people in the Kathmandu valley, all of whom were farmers living on the outskirts of the city. Some for­eigners who live in Kathmandu have chosen to be immunised against Japanese enceph­alitis (a series of three injections over a three to four week period).

Yellow Fever

It is a legal requirement in Nepal to have this vaccination if you are coming from an infected area, eg, Africa or ‘ South America, even though vaccination records are not usually checked. The disease does not exist in Nepal.

Tuberculosis

Tuberculosis (TB) is highly endemic in Nepal. However, because infec­tion requires continuous close contact with an infected person, tuberculosis cases are extremely rare among travellers to Nepal. We have documented only two new cases of TB among foreign residents in Nepal, and none among travellers. Thus, although there is a perception of risk, the actual risk is very low. Those who are concerned about acquir­ing TB while travelling should have a skin test before travel; if the test is negative for TB antibodies, a person can be tested after travel to see if they have been exposed to TB. Although a vaccine exists that offers some protection against TB, it gives incom­plete protection, and changes the skin test to positive, making it difficult to tell if a person has actually been exposed to TB or not. We do not recommend TB vaccine for travellers to Nepal.