Health & safety
Lonely Planet’s Healthy Travel – Asia & India is a handy pocket-size book that is packed with useful information including pretrip planning, emergency first aid, immunisation and disease information and what to do if you get sick on the road. Other recommended references include Traveller’s Health by Dr Richard Dawood and Travelling Well by Dr Deborah Mills – check out the website www.travellingwell.com.au.
Even if you are fit and healthy, don’t travel without health insurance – accidents do happen. Declare any existing medical conditions you have – the insurance company will check if your problem is pre-existing and will not cover you if it is undeclared. You may require extra cover for adventure activities such as rock climbing. If your health insurance doesn’t cover you for medical expenses abroad, consider getting extra insurance – check Lonely Planet’s website for more information. If you’re uninsured, emergency evacuation is expensive; bills of over US$100, 000 are not uncommon.
Find out in advance if your insurance plan will make payments directly to providers or reimburse you later for overseas health expenditures. (In many countries doctors expect payment in cash.) You may prefer a policy that pays doctors or hospitals directly rather than you having to pay on the spot and claim later. If you have to claim later, make sure you keep all documentation. Some policies ask you to call back (reverse charges) to a centre in your home country, where an immediate assessment of your problem is made.
Powered by: recommended by Lonely Planet
There is a wealth of travel health advice on the internet. The World Health Organization (WHO; www.who.int/ith/) publishes a superb book called International Travel & Health, which is revised annually and is available free online. Another website of general interest is MD Travel Health (www.mdtravelhealth.com), which provides complete travel health recommendations for every country and is updated daily. The Centers for Disease Control and Prevention (CDC; www.cdc.gov) website also has good general information.
Recommended items for a personal medical kit:
Antifungal cream, eg Clotrimazole
Antibacterial cream, eg Muciprocin
Antibiotic for skin infections, eg Amoxicillin/Clavulanate or Cephalexin
Antibiotics for diarrhoea include Norfloxacin or Ciprofloxacin; for bacterial diarrhoea Azithromycin; for giardiasis or amoebic dysentery Tinidazole
Antihistamine – there are many options, eg Cetrizine for daytime and Promethazine for night
Antiseptic, eg Betadine
Antispasmodic for stomach cramps, eg Buscopa
Decongestant, eg Pseudoephedrine
DEET-based insect repellent
Diarrhoea – consider an oral rehydration solution (eg Gastrolyte), diarrhoea ‘stopper’ (eg Loperamide) and antinausea medication (eg Prochlorperazine)
First-aid items such as scissors, Elastoplasts, bandages, gauze, thermometer (but not mercury), sterile needles and syringes, safety pins and tweezers
Ibuprofen or another anti-inflammatory
Indigestion medication, eg Quick-Eze or Mylanta
Iodine tablets (unless you are pregnant or have a thyroid problem) to purify water
Laxative, eg Coloxyl
Migraine sufferer – take your personal medicine
Permethrin to impregnate clothing and mosquito nets
Steroid cream for allergic/itchy rashes, eg 1% to 2% hydrocortisone
Sunscreen and hat
Thrush (vaginal yeast infection) treatment, eg Clotrimazole pessaries or Diflucan tablet
Ural or equivalent if you’re prone to urine infections
Pack medications in their original, clearly labelled containers. A signed and dated letter from your physician describing your medical conditions and medications, including generic names, is also a good idea. If carrying syringes or needles, be sure to have a physician’s letter documenting their medical necessity. If you have a heart condition, bring a copy of your ECG taken just prior to travelling.
If you take any regular medication, bring double your needs in case of loss or theft. You can’t rely on many medications being available from pharmacies in Bhutan.
Specialised travel-medicine clinics are your best source of information; they stock all available vaccines and will be able to give specific recommendations for you and your trip. The doctors will take into account factors such as past vaccination history, the length of your trip, activities you may be undertaking and underlying medical conditions, such as pregnancy.
Most vaccines don’t produce immunity until at least two weeks after they’re given, so visit a doctor four to eight weeks before departure. Ask your doctor for an International Certificate of Vaccination (otherwise known as the yellow booklet), which will list all the vaccinations you’ve received.
The World Health Organization recommends the following vaccinations for travellers to Bhutan (as well as being up to date with measles, mumps and rubella vaccinations) :
Adult diphtheria and tetanus Single booster recommended if none in the previous 10 years. Side effects include sore arm and fever.
Hepatitis A Provides almost 100% protection for up to a year, a booster after 12 months provides at least another 20 years’ protection. Mild side effects such as headache and sore arm occur in 5% to 10% of people.
Hepatitis B Now considered routine for most travellers. Given as three shots over six months. A rapid schedule is also available, as is a combined vaccination with Hepatitis A. Side effects are mild and uncommon, usually headache and sore arm. Lifetime protection occurs in 95% of people.
Polio Bhutan’s last case of polio was reported in 1986, but it has been reported more recently in nearby Nepal and India. Only one booster required as an adult for lifetime protection. Inactivated polio vaccine is safe during pregnancy.
Typhoid The vaccine offers around 70% protection, lasts for two to three years and comes as a single shot. Tablets are also available; however, the injection is usually recommended as it has fewer side effects. Sore arm and fever may occur.
Varicella If you haven’t had chickenpox, discuss this vaccination with your doctor.
These immunisations may be recommended for long-term travellers (more than one month) or those at special risk:
Japanese B Encephalitis Three injections in all. Booster recommended after two years. Sore arm and headache are the most common side effects. Rarely, an allergic reaction comprising hives and swelling can occur up to 10 days after any of the three doses.
Meningitis Single injection. There are two types of vaccination: the quadrivalent vaccine gives two to three years’ protection; meningitis group C vaccine gives around 10 years’ protection. Recommended for long-term backpackers aged under 25.
Rabies Three injections in all. A booster after one year will then provide 10 years’ protection. Side effects are rare – occasionally headache and sore arm.
Tuberculosis A complex issue. Adult long-term travellers are usually recommended to have a TB skin test before and after travel, rather than vaccination. Only one vaccine given in a lifetime.
The only vaccine required by international regulations is yellow fever. Proof of vaccination will only be required if you have visited a country in the yellow-fever zone within the six days prior to entering Bhutan. If you are travelling to Bhutan from Africa or South America you should check to see if you require proof of vaccination.
Fortunately, travel in Bhutan is still largely immune to the major banes of travel in Asia – theft and begging. It does, however, have some irritations of its own.
Deep vein thrombosis (dvt)
Deep vein thrombosis (DVT) occurs when blood clots form in the legs during plane flights, chiefly because of prolonged immobility. The longer the flight, the greater the risk. Though most blood clots are reabsorbed uneventfully, some may break off and travel through the blood vessels to the lungs, where they may cause life-threatening complications.
The chief symptom of DVT is swelling or pain of the foot, ankle or calf, usually but not always on just one side. If a blood clot travels to the lungs it may cause chest pain and difficulty in breathing. Travellers with any of these symptoms should immediately seek medical attention.
To prevent the development of DVT on long flights you should walk about the cabin, perform isometric compressions of the leg muscles (ie contract the leg muscles while sitting), drink plenty of fluids and avoid alcohol.
Jet lag & motion sickness
Jet lag is common when crossing more than five time zones; it results in insomnia, fatigue, malaise or nausea. To avoid jet lag try drinking plenty of fluids (nonalcoholic) and eating light meals. Upon arrival, seek exposure to natural sunlight and readjust your schedule (for meals, sleep etc) as soon as possible.
Antihistamines such as dimenhydrinate (Dramamine) and meclizine (Antivert, Bonine) are usually the first choice for treating motion sickness. Their main side effect is drowsiness. A herbal alternative is ginger, which works like a charm for some people.
Eating in restaurants is the biggest risk factor for contracting traveller’s diarrhoea. Ways to avoid it include eating only freshly cooked food, and avoiding shellfish and food that has been sitting around in buffets. Peel all fruit, cook vegetables and soak salads in iodine water for at least 20 minutes. Eat in busy restaurants with a high turnover of customers.
If you are going to altitudes above 3000m you should get information on preventing, recognising and treating Acute Mountain Sickness (AMS). AMS is a notoriously fickle affliction and can also affect trekkers and walkers accustomed to walking at high altitudes. AMS has been fatal at 3000m, although 3500m to 4500m is the usual range.
With an increase in altitude, the human body needs time to develop physiological mechanisms to cope with the decreased oxygen. This process of acclimatisation is still not fully understood, but is known to involve modifications in breathing patterns and heart rate induced by the autonomic nervous system, and an increase in the blood’s oxygen-carrying capabilities. These compensatory mechanisms usually take about one to three days to develop at a particular altitude. Once you are acclimatised to a given height you are unlikely to get AMS at that height, but you can still get ill when you travel higher. If the ascent is too high and too fast, these compensatory reactions may not kick into gear fast enough.
Mild symptoms of AMS are very common in travellers visiting high altitudes, and usually develop during the first 24 hours at altitude. Most visitors to Tibet will suffer from some symptoms; these will generally disappear through acclimatisation in several hours to several days.
Symptoms tend to be worse at night and include headache, dizziness, lethargy, loss of appetite, nausea, breathlessness and irritability. Difficulty sleeping is another common symptom.
AMS may become more serious without warning and can be fatal. Symptoms are caused by the accumulation of fluid in the lungs and brain, and include breathlessness at rest, a dry irritative cough (which may progress to the production of pink, frothy sputum), severe headache, lack of coordination (typically leading to a ‘drunken walk’), confusion, irrational behaviour, vomiting and eventually unconsciousness.
The symptoms of AMS, however mild, are a warning – be sure to take them seriously! Trekkers should keep an eye on each other as those experiencing symptoms, especially severe symptoms, may not be in a position to recognise them. One thing to note is that while the symptoms of mild AMS often precede those of severe AMS, this is not always the case. Severe AMS can strike with little or no warning.
To prevent acute mountain sickness:
Ascend slowly. Have frequent rest days, spending two to three nights at each rise of 1000m. If you reach a high altitude by trekking, acclimatisation takes place gradually and you are less likely to be affected than if you fly directly to high altitude.
Trekkers should bear in mind the climber’s adage ‘Climb high, sleep low’. It is always wise to sleep at a lower altitude than the greatest height reached during the day. High day climbs followed by a descent back to lower altitudes for the night are good preparation for trekking at high altitude. Also, once above 3000m, care should be taken not to increase the sleeping altitude by more than 400m per day. If the terrain won’t allow for less than 400m of elevation gain, be ready to take an extra day off before tackling the climb.
Drink extra fluids. The mountain air is dry and cold, and moisture is lost as you breathe. Evaporation of sweat may occur unnoticed and result in dehydration.
Eat light, high-carbohydrate meals for more energy.
Avoid alcohol as it may increase the risk of dehydration, and don’t smoke.
When trekking, take a day off to rest and acclimatise if feeling over-tired. If you or anyone else in your party is having a tough time, make allowances for unscheduled stops.
Don’t push yourself when climbing up to passes; rather, take plenty of breaks. You can usually get over the pass as easily tomorrow as you can today. Try to plan your itinerary so that long ascents can be divided into two or more days. Given the complexity and unknown variables involved with AMS and acclimatisation, trekkers should always err on the side of caution and ascend mountains slowly.
Treat mild symptoms by resting at the same altitude until recovery, usually a day or two. Take paracetamol or aspirin for headaches. If symptoms persist or become worse, however, immediate descent is necessary – even 500m can help.
The most effective treatment for severe AMS is to get down to a lower altitude as quickly as possible. In less severe cases the victim will be able to stagger down with some support; in other cases they may need to be carried down. Whatever the case, do not delay, as any delay could be fatal.
AMS victims may need to be flown out of Bhutan as quickly as possible – make sure you have adequate travel insurance.
The drugs acetazolamide (Diamox) and dexamethasone are recommended by some doctors for the prevention of AMS. However, you should be aware that their use is controversial. They can reduce the symptoms, but they may also mask warning signs; severe and fatal AMS has occurred in people taking these drugs. Drug treatments should never be used to avoid descent or to enable further ascent.
Insect bites & stings
Bedbugs don’t carry disease but their bites are very itchy. They live in the cracks of furniture and walls and then migrate to the bed at night to feed on you. You can treat the itch with an antihistamine. Lice inhabit various parts of your body but most commonly your head and pubic area. Transmission is via close contact with an infected person. They can be difficult to treat and you may need numerous applications of an antilice shampoo such as Permethrin. Pubic lice are usually contracted from sexual contact.
Ticks are contracted after walking in rural areas. Ticks are commonly found behind the ears, on the belly and in armpits. If you have had a tick bite and experience symptoms such as a rash at the site of the bite or elsewhere, fever, or muscle aches you should see a doctor. Doxycycline prevents tick-borne diseases.
Leeches are found in humid rainforest areas. They do not transmit any disease but their bites are often intensely itchy for weeks afterwards and can easily become infected. Apply an iodine-based antiseptic to any leech bite to help prevent infection.
Bee and wasp stings mainly cause problems for people who are allergic to them. Anyone with a serious bee or wasp allergy should carry an injection of adrenaline (eg an Epipen) for emergency treatment. For others pain is the main problem – apply ice to the sting and take painkillers.
Fungal rashes are common in humid climates. There are two common fungal rashes that affect travellers. The first occurs in moist areas that get less air such as the groin, armpits and between the toes. It starts as a red patch that slowly spreads and is usually itchy. Treatment involves keeping the skin dry, avoiding chafing and using an antifungal cream such as Clotrimazole or Lamisil. Tinea versicolor is also common – this fungus causes small, light-coloured patches, most commonly on the back, chest and shoulders. Consult a doctor.
Cuts and scratches become easily infected in humid climates. Take meticulous care of any cuts and scratches to prevent complications such as abscesses. Immediately wash all wounds in clean water and apply antiseptic. If you develop signs of infection (increasing pain and redness), see a doctor.
Even on a cloudy day sunburn can occur rapidly. Always use a strong sunscreen (at least factor 30), and always wear a wide-brimmed hat and sunglasses outdoors. Avoid lying in the sun during the hottest part of the day (10am to 2pm). If you become sunburnt stay out of the sun until you have recovered, apply cool compresses and take painkillers for the discomfort. One per cent hydrocortisone cream applied twice daily is also helpful.
Coughs, colds & chest infections
Respiratory infections usually start as a virus and are exacerbated by environmental conditions such as urban pollution, or cold and altitude in the mountains. Commonly a secondary bacterial infection will intervene – marked by fever, chest pain and coughing up discoloured or blood-tinged sputum. If you have the symptoms of an infection seek medical advice or commence a general antibiotic.
This mosquito-borne disease is becomingly increasingly problematic throughout the tropical world, especially in the cities. As there is no vaccine available it can only be prevented by avoiding mosquito bites. The mosquito that carries dengue bites day and night, so use insect avoidance measures at all times. Symptoms include high fever, severe headache and body ache (dengue was previously known as ‘breakbone fever’). Some people develop a rash and experience diarrhoea. There is no specific treatment, just rest and paracetamol – do not take aspirin as it increases the likelihood of haemorrhaging. See a doctor to be diagnosed and monitored.
A problem throughout the region, this food- and water-borne virus infects the liver, causing jaundice (yellow skin and eyes), nausea and lethargy. There is no specific treatment for hepatitis A, you just need to allow time for the liver to heal. All travellers to Bhutan should be vaccinated against hepatitis A.
The only sexually transmitted disease that can be prevented by vaccination, hepatitis B is spread by body fluids, including in sexual contact. The long-term consequences can include liver cancer and cirrhosis.
Hepatitis E is transmitted through contaminated food and water and has similar symptoms to hepatitis A, but is far less common. It is a severe problem in pregnant women and can result in the death of both mother and baby. There is currently no vaccine, and prevention is by following safe eating and drinking guidelines.
HIV is spread via contaminated body fluids. Avoid unsafe sex, unsterile needles (including in medical facilities) and procedures such as tattoos.
Present year-round in the tropics, influenza (flu) symptoms include high fever, muscle aches, runny nose, cough and sore throat. It can be very severe in people over the age of 65 or in those with underlying medical conditions such as heart disease or diabetes; vaccination is recommended for these individuals. There is no specific treatment, just rest and paracetamol.
Japanese b encephalitis
This viral disease is transmitted by mosquitoes and is rare in travellers. Like most mosquito-borne diseases it is becoming a more common problem in affected countries. Most cases occur in rural areas and vaccination is recommended for travellers spending more than one month outside cities. There is no treatment, and a third of infected people will die, while another third will suffer permanent brain damage.
For such a serious and potentially deadly disease, there is an enormous amount of misinformation concerning malaria. You must get expert advice as to whether your trip actually puts you at risk. For most rural areas, the risk of contracting malaria far outweighs the risk of any tablet side effects. Before you travel, seek medical advice on the right medication and dosage for you.
Malaria is caused by a parasite transmitted by the bite of an infected mosquito. The most important symptom of malaria is fever, but general symptoms such as headache, diarrhoea, cough or chills may also occur. Diagnosis can only be made by taking a blood sample.
Two strategies should be combined to prevent malaria – mosquito avoidance and antimalaria medications. Most people who catch malaria are taking inadequate or no antimalarial medication.
Travellers are advised to prevent mosquito bites by taking these steps:
Use a DEET-containing insect repellent on exposed skin. Wash this off at night, as long as you are sleeping under a mosquito net. Natural repellents such as citronella can be effective, but must be applied more frequently than products containing DEET.
Sleep under a mosquito net impregnated with pyrethrin
Choose accommodation with screens and fans (if not air-conditioned)
Impregnate clothing with pyrethrin in high-risk areas
Wear long sleeves and trousers in light colours
Use mosquito coils
Spray your room with insect repellent before going out for your evening meal
There are a variety of medications available. The effectiveness of the Chloroquine and Paludrine combination is now limited in many parts of south Asia. Common side effects include nausea (40% of people) and mouth ulcers.
The daily tablet Doxycycline is a broad-spectrum antibiotic that has the added benefit of helping to prevent a variety of tropical diseases, including leptospirosis, tick-borne disease and typhus. The potential side effects include photosensitivity (a tendency to sunburn), thrush (in women), indigestion, heartburn, nausea and interference with the contraceptive pill. More serious side effects include ulceration of the oesophagus – you can help prevent this by taking your tablet with a meal and a large glass of water, and never lying down within half an hour of taking it. It must be taken for four weeks after leaving the risk area.
Lariam (Mefloquine) has received much bad press, some of it justified, some not. This weekly tablet suits many people. Serious side effects are rare but include depression, anxiety, psychosis and having fits. Anyone with a history of depression, anxiety, another psychological disorder, or epilepsy should not take Lariam. It is considered safe in the second and third trimesters of pregnancy. Tablets must be taken for four weeks after leaving the risk area.
The new drug Malarone is a combination of Atovaquone and Proguanil. Side effects are uncommon and mild, most commonly nausea and headache. It is the best tablet for those on short trips to high-risk areas. It must be taken for one week after leaving the risk area.
Rabies is considered to be highly endemic in Bhutan. This uniformly fatal disease is spread by the bite or lick of an infected animal – most commonly a dog or monkey. You should seek medical advice immediately after any animal bite and commence post-exposure treatment. Having pre-travel vaccination means the post-bite treatment is greatly simplified. If an animal bites you, gently wash the wound with soap and water, and apply iodine based antiseptic. If you are not pre-vaccinated you will need to receive rabies immunoglobulin as soon as possible.
Sexually transmitted diseases most common in south Asia include herpes, warts, syphilis, gonorrhoea and chlamydia. People carrying these diseases often have no signs of infection. Condoms will prevent gonorrhoea and chlamydia but not warts or herpes. If after a sexual encounter you develop any rash, lumps, discharge or pain when passing urine, seek immediate medical attention. If you have been sexually active during your travels, have an STD check on your return home.
While rare in travellers, medical and aid workers, and long-term travellers who have significant contact with the local population should take precautions. Vaccination is usually given only to children under the age of five, but adults at risk are recommended pre- and post-travel tuberculosis testing. The main symptoms are fever, cough, weight loss, night sweats and tiredness.
This serious bacterial infection is also spread via food and water. It gives a high and slowly progressive fever, headache and may be accompanied by a dry cough and stomach pain. It is diagnosed by blood tests and treated with antibiotics. Vaccination is recommended for all travellers spending more than a week in Bhutan. Be aware that vaccination is not 100% effective so you must still be careful with what you eat and drink.
Giardia lamblia is a parasite that is relatively common in travellers. Symptoms include nausea, bloating, excess gas, fatigue and intermittent diarrhoea. ‘Eggy’ burps are often attributed solely to giardiasis, but work in Nepal has shown that they are not specific to this infection. The parasite will eventually go away if left untreated but this can take months. The treatment of choice is Tinidazole, with Metronidazole being a second-line option.
Availability of health care
There are no private health clinics or physicians in Bhutan, but all district headquarters towns have a hospital, and will accept travellers in need of medical attention. The best facility is the Jigme Dorji Wangchuk National Referral Hospital in Thimphu. It has general physicians and several specialists, labs and operating rooms. Treatment is free, even for tourists. If you are seriously ill or injured you should consider evacuation to the excellent medical facilities in Bangkok. It is difficult to find reliable medical care in rural areas. Your embassy and insurance company are good contacts.
Self-treatment may be appropriate if your problem is minor (eg traveller’s diarrhoea), you are carrying the appropriate medication and you cannot attend a recommended clinic. If you think you may have a serious disease, especially malaria, do not waste time – travel to the nearest quality facility to receive attention. It is always better to be assessed by a doctor than to rely on self-treatment.
In most large towns there are shops that sell medicines. Many of these are available without a prescription in these medicine shops.
Traveller’s diarrhoea is by far the most common problem affecting travellers – between 30% and 50% of people will suffer from it within two weeks of starting their trip. In over 80% of cases, traveller’s diarrhoea is caused by a bacteria (there are numerous potential culprits), and therefore responds promptly to treatment with antibiotics. Treatment with antibiotics will depend on your situation – how sick you are, how quickly you need to get better, where you are etc.
Traveller’s diarrhoea is defined as the passage of more than three watery bowel-actions within 24 hours, plus at least one other symptom such as fever, cramps, nausea, vomiting or feeling generally unwell.
Treatment reequires staying well-hydrated; rehydration solutions like Gastrolyte are the best for this. Antibiotics such as Norfloxacin, Ciprofloxacin or Azithromycin will kill the bacteria quickly.
Loperamide is just a ‘stopper’ and doesn’t get to the cause of the problem. It can be helpful, for example if you have to go on a long bus ride. Don’t take Loperamide if you have a fever, or blood in your stools. Seek medical attention quickly if you do not respond to an appropriate antibiotic.
Amoebic dysentery is very rare in travellers but is often misdiagnosed by poor quality labs. Symptoms are similar to bacterial diarrhoea, ie fever, bloody diarrhoea and generally feeling unwell. You should always seek reliable medical care if you have blood in your diarrhoea. Treatment involves two drugs: Tinidazole or Metronidazole to kill the parasite in your gut and then a second drug to kill the cysts. If it’s left untreated, complications such as liver or gut abscesses can occur.
Pregnant women should receive specialised advice before travelling. The ideal time to travel is in the second trimester (between 16 and 28 weeks), when the risk of pregnancy-related problems are at their lowest and pregnant women generally feel at their best. During the first trimester there is a risk of miscarriage and in the third trimester complications such as premature labour and high blood pressure are possible. It’s wise to travel with a companion. Always carry a list of quality medical facilities available at your destination and ensure you continue your standard antenatal care at these facilities. Avoid rural travel in areas with poor transportation and medical facilities. Most of all, ensure travel insurance covers all pregnancy-related possibilities, including premature labour.
Malaria is a high-risk disease in pregnancy. WHO recommends that pregnant women do not travel to areas with Chloroquine-resistant malaria. None of the more effective antimalarial drugs is completely safe in pregnancy.
Traveller’s diarrhoea can quickly lead to dehydration and result in inadequate blood flow to the placenta. Many of the drugs used to treat various diarrhoea bugs are not recommended in pregnancy. Azithromycin is considered safe.
Although not much is known about the possible adverse effects of altitude on a developing foetus, many authorities recommend not travelling above 4000m while pregnant.
In the urban areas of Bhutan, supplies of sanitary products are readily available. Birth-control options may be limited so bring adequate supplies of your own form of contraception. Heat, humidity and antibiotics can all contribute to thrush. Treatment is with antifungal creams and pessaries such as Clotrimazole. A practical alternative is a single tablet of Fluconazole (Diflucan). Urinary tract infections can be precipitated by dehydration or long bus journeys without toilet stops; bring suitable antibiotics.