Kathmandu has the best health facilities in the country, but standards at clinics and hospitals decline the further you get from the capital. In mountainous areas, there may be no health facilities at all. Trekkers who become unwell in the mountains are generally evacuated to Kathmandu, or overseas in the event of something really serious. Always take out travel insurance to cover the costs of hospital treatment and emergency evacuations.
Many of the most popular areas for visitors are remote and inaccessible, so you should read up on the possible health risks. While trekking, it makes sense to carry an emergency medical kit so that you can treat any symptoms until you reach medical care.
Self-diagnosis and treatment can be risky, so you should seek medical help if you become ill. Although drug dosages appear in this text, they’re for emergency treatment only. Correct diagnosis is vital.
Following is a list of items you should consider including in your medical kit – consult your pharmacist for brands available in your country.
* Diamox (Acetazolmide) tablets if trekking above 3500m
Lonely Planet’s Healthy Travel Asia & India is packed with information such as pre-trip planning, emergency first aid, immunisation and disease information, and what to do if you get sick on the road. Travel with Children from Lonely Planet includes advice on travel health for younger children. A useful health-care overview for travel in remote areas is David Werner’s Where There Is No Doctor.
Specific titles covering trekking and health:
Medicine for Mountaineering & Other Wilderness Activities (James A Wilkerson) covers many medical problems typically encountered in Nepal.
Mountain Medicine (Michael Ward) has good background info on cold and high-altitude problems.
Altitude Illness: Prevention & Treatment (Stephen Bezruchka) is essential reading for high-altitude trekking, written by an experienced Nepal trekker.
Wilderness First Aid & Wilderness Medicine (Dr Jim Duff and Peter Gormly) is an excellent portable companion, available in Nepal at the Kathmandu Environmental Education Project (KEEP) or published abroad by Cicerone.
Considering the terrain, potential health risks and high cost of medical evacuation, it is unwise to travel to Nepal without adequate health insurance.
You do not officially require any immunisations to enter the country, unless you have come from an area where yellow fever is present – in which case, you must show proof of immunisation.
It is best to seek medical advice at least six weeks before travelling, since some vaccinations require multiple injections over a period of time.
Note that some vaccinations should not be given during pregnancy or to people with allergies.
Vaccinations you might consider:
Diphtheria and tetanus Vaccinations for these two diseases are usually combined and are recommended for everyone. After an initial course of three injections (usually given in childhood), boosters are necessary every 10 years.
Hepatitis A The vaccine for hepatitis A (eg Avaxim, Havrix 1440 or VAQTA) provides long-term immunity (possibly lifelong) after an initial injection and a booster at six to 12 months.
Hepatitis B Vaccination involves three injections, the quickest course being over three weeks with a booster at 12 months.
Influenza ‘Flu’ is considered by many to be the most common vaccine-preventable illness in travellers. This vaccine is annual.
Japanese encephalitis This is a mosquito-borne viral encephalitis that occurs in the Terai and occasionally in the Kathmandu Valley, particularly during the monsoon (August to early October). The vaccine is given as three injections over three to four weeks and is usually boosted at three years. Recommended only for prolonged stays to the Terai (especially the west) or Kathmandu Valley.
Meningococcal meningitis A single-dose vaccine boosted every three to five years is recommended only for individuals at high risk and for residents.
Polio This serious, easily transmitted disease is still found in Nepal. Everyone should keep up to date with this vaccination, which is normally given in childhood. A booster every 10 years maintains immunity.
Rabies Vaccination should be considered for long-term visitors, particularly if you plan to travel to remote areas. In Nepal the disease is carried by street dogs and monkeys. Vaccination is strongly recommended for children. Pretravel rabies vaccination involves having three injections over 21 to 28 days. If someone who has been vaccinated is bitten or scratched by an animal they will require two vaccine booster injections, while those not vaccinated will require more. The booster for rabies vaccination is usually given after three years.
Tuberculosis (TB) This disease is highly endemic in Nepal, though cases are extremely rare among travellers. Most people in the West are vaccinated during childhood.
Typhoid Drug-resistant typhoid fever is a growing problem in Nepal, particularly in the Terai, and vaccination is recommended. The vaccine is available as a single injection or oral capsules – ask your doctor for advice.
Yellow fever This disease is not endemic in Nepal and a vaccine for yellow fever is required only if you are coming from an infected area. The record of this vaccine should be provided in a World Health Organization (WHO) Yellow Vaccination Booklet and is valid for 10 years.
Visiting Nepal may take you to some very remote areas, so it makes sense to visit the doctor before you travel for a general check-up.
Medex offers a free download of the useful booklet Travel At High Altitude, aimed at laypeople and full of good advice for staying healthy in the mountains. A Nepali translation of the booklet is also available on the website.
While trekking it may be impossible to reach medical treatment, so consider carrying the following drugs for emergencies (the concentrations in which these drugs are sold in Nepal are noted next to the drug):
* azithromycin 250mg – a broad-spectrum antibiotic, useful for traveller’s diarrhoea; take the equivalent of 500mg per day for three consecutive days
* norfloxacin 400mg or ciprofloxacin 500mg – for traveller’s diarrhoea; the usual treatment is two tablets daily for one week
* tinidazole 500mg – the recommended treatment for giardiasis is four pills all at once for two days; for amoebiasis, take four pills at once for three days, then diloxanide furoate 500mg three times a day for 10 days
Kathmandu has several excellent clinics, including the Nepal International Clinic and CIWEC Clinic (which has a branch in Pokhara).
While trekking, your only option may be small, local health posts, and even these are few and far between.
In remote areas, you should carry an appropriate medical kit and be prepared to treat yourself until you can reach a health professional.
There are several different viruses that cause hepatitis (inflammation of the liver). The symptoms are similar in all forms of the illness and include fever, chills, headache, fatigue, feelings of weakness as well as aches and pains, followed by loss of appetite, nausea, vomiting, abdominal pain, dark urine, light-coloured faeces, jaundiced (yellow) skin and yellowing of the whites of the eyes.
Hepatitis A and E are transmitted by contaminated drinking water and food. Hepatitis A is virtually 100% preventable by using any of the current hepatitis A vaccines. Hepatitis E causes an illness very similar to hepatitis A and there is at present no way to immunise against this virus.
Hepatitis B is only spread by blood (unsterilised needles and blood transfusions) or sexual contact. Risky situations include having a shave, tattoo or body piercing with contaminated equipment.
The rabies virus causes a severe brain infection that is almost always fatal. Feral dogs and monkeys are the main carriers of the disease in Nepal.
Rabies is different from other infectious diseases in that a person can be immunised after having been exposed. Human rabies immune globulin (HRIG) is stocked at the CIWEC clinic and the Nepal International Clinic in Kathmandu.
In addition to the HRIG, five injections of rabies vaccine are needed over a one-month period. Travellers who have taken a preimmunisation series only need two rabies shots, three days apart, if they are bitten by a possibly rabid animal.
If you receive a bite or a scratch from an animal in Nepal, wash the wound with soap and water, then a disinfectant, such as povidone-iodine, then seek rabies immunisations. Considering the risk, it makes sense to keep your distance from animals in Nepal, particularly street dogs and monkeys.
Upper respiratory tract infections (such as the common cold) are common ailments in Nepal, especially in polluted Kathmandu. Respiratory infections are aggravated by high altitude, cold weather, pollution, smoking and overcrowded conditions, which increase the opportunities for infection.
Most upper respiratory tract infections go away without treatment, but any infection can lead to complications such as bronchitis, ear infections and pneumonia, which may need to be treated with antibiotics.
HIV and AIDS are growing problems in Nepal, with an estimated 75,000 Nepalis infected with the virus, so insist on brand-new disposable needles and syringes for injections.
Blood used for transfusions is usually screened for HIV/AIDS but this cannot always be done in an emergency. Try to avoid a blood transfusion unless it seems certain you will die without it.
Antimalarial tablets are only recommended if you will be spending long periods in the Terai, particularly during the monsoon. There is no risk in Kathmandu or Pokhara, for short visits to Chitwan, or on typical Himalayan trekking routes.
It makes sense to take measures to avoid being bitten by mosquitoes, as dengue fever, another mosquito-borne illness, has been sporadically documented in the lowlands. Use insect repellent if travelling to the Terai, particularly if staying overnight in jungle areas or in cheap hotels.
Plug-in mosquito killers are more effective than combustible mosquito coils, which can cause respiratory problems.
Even veteran travellers to South Asia seem to come down with the trots in Nepal. It’s just one of those things. The main cause of infection is contaminated water and food, due to low standards of hygiene. However, diarrhoea is usually self-limiting and most people recover within a few days.
Dehydration is the main danger with diarrhoea, particularly in children, pregnant women or the elderly. Soda water, weak black tea with a little sugar, or soft drinks allowed to go flat and half-diluted with clean water will help you replace lost liquids.
In severe cases, take oral rehydration salts made up with boiled or purified water. In an emergency you can make up a solution of six teaspoons of sugar and half a teaspoon of salt to a litre of boiled or bottled water. Stick to a bland diet as you recover.
Loperamide (Imodium) or diphenoxylate (Lomotil) can be used to bring temporary relief from the symptoms, but they do not cure the problem.
In the case of diarrhoea with blood or mucus (dysentery), any diarrhoea with fever, profuse watery diarrhoea and persistent diarrhoea not improving after 48 hours, you should visit a doctor for a stool test. If you cannot reach a doctor, the recommended treatment is norfloxacin 400mg or ciprofloxacin 500mg twice daily for three days.
These drugs are not recommended for children or pregnant women. The preferred treatment for children is azithromycin in a dose of 10mg per kilogram of body weight per day (as a single dose each day for three days).
Caused by the protozoan Entamoeba histolytica, amoebic dysentery is characterised by a gradual onset of low-grade diarrhoea, often with blood and mucus. Infection persists until treated.
If medical treatment is not available, tinidazole or metronidazole are the recommended drugs. Treatment is a 2g single dose of tinidazole daily or 250mg of metronidazole three times daily for five to 10 days. Alcohol should not be consumed while taking these medications.
This waterborne intestinal parasite infects the upper intestine, causing diarrhoea, fatigue and loss of appetite lasting up to 12 weeks. Fortunately, the illness is a risk in Nepal mainly during the monsoon, when few tourists visit. Iodine is not sufficient to kill the parasite but it can be removed by water filters and it is easily killed by boiling.
The treatment for Cyclospora diarrhoea is trimethoprim and sulfamethoxazole (sold commonly as Bactrim) twice a day for seven days. This drug cannot be taken by people who are allergic to sulphur.
Also known as giardia, giardiasis accounts for around 12% of the diarrhoea among travellers in Nepal. The disease is caused by a parasite, Giardia Lamblia, found in water that has been contaminated by waste from animals.
Symptoms include stomach cramps, nausea, a bloated stomach, watery and foul-smelling diarrhoea, and frequent sulphurous burps and farts but no fever.
The best treatment is four 500mg tablets of tinidazole taken as a single dose each day for two consecutive days. Tinidazole cannot be taken with alcohol.
Above 2500m, the concentration of oxygen in the air you breathe starts to drop off markedly, reducing the amount of oxygen that reaches your brain and other organs. Decreasing air pressure at altitude has the additional effect of causing liquid to leak from the capillaries into the lungs and brain, which can be fatal. The human body has the ability to adjust to the changes in pressure and oxygen concentration as you gain altitude, but this is a gradual process.
The health conditions caused by the effects of altitude are known collectively as altitude sickness or acute mountain sickness (AMS). If allowed to develop unchecked, AMS can lead to coma and death. However, you can avoid this potentially deadly condition by limiting your rate of ascent, which will allow your body to adjust to the altitude. There is also a 100% effective treatment if you do experience serious symptoms: descend immediately.
If you go trekking, it is important to read up on the causes, effects and treatment of altitude sickness before you start walking. Attend one of the free lectures on altitude sickness given by the Himalayan Rescue Association in Kathmandu.
The onset of symptoms of AMS is usually gradual, so there is time to adjust your trekking schedule or retreat off the mountain if you start to feel unwell. Most people who suffer severe effects of AMS have ignored obvious warning signs.
The process of acclimatisation is still not fully understood, but it is known to involve modifications in breathing patterns and heart rate and an increase in the oxygen-carrying capacity of the blood. Some people have a faster rate of acclimatisation than others, but almost anyone can trek to high altitudes as long as the rate of ascent does not exceed the rate at which their body can adjust.
AMS is a notoriously fickle affliction and it can affect trekkers and walkers who are accustomed to walking at high altitudes as well as people who have never been to altitude before. AMS has been fatal at 3000m, although 3500m to 4500m is the usual range.
On treks above 4000m, almost everyone experiences some symptoms of mild altitude sickness – breathlessness and fatigue linked to reduced oxygen in the blood being the most common.
Mild symptoms usually pass if you stop ascending and give your body time to ‘catch up’ with the increase in altitude. Once you have acclimatised at the altitude where you first developed symptoms, you should be able to slowly continue your ascent. Serious symptoms are a different matter – if you develop any of the symptoms described here, you should descend immediately.
Mild symptoms of AMS are experienced by many travellers above 2800m. Symptoms tend to be worse at night and include headache, dizziness, lethargy, loss of appetite, nausea, breathlessness, irritability and difficulty sleeping.
Never ignore mild symptoms of AMS – this is your body giving you an alarm call. You may develop more serious symptoms if you continue to ascend without giving your body time to adjust.
AMS can become more serious without warning and it can be fatal. Serious 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 and death.
If you trek above 2500m, observe the following rules:
Ascend slowly Where possible, do not sleep more than 300m higher than the elevation where you spent the previous night. If any stage on a trek exceeds this increase in elevation, take at least one rest day to acclimatise before you start the ascent. If you or anyone else in your party seems to be struggling, take a rest day as a precaution.
Climb high, sleep low It is always wise to sleep at a lower altitude than the greatest height reached during the day. If you need to cross a high pass, take an extra acclimatisation day before you cross. Be aware that descending to the altitude where you slept the previous night may not be enough to compensate for a very large increase in altitude during the day.
Trek healthy You are more likely to develop AMS if you are tired, dehydrated or malnourished. Drink extra fluids while trekking. Avoid sedatives or sleeping pills and don’t smoke – this will further reduce the amount of oxygen reaching your lungs.
If you feel unwell, stop If you start to display mild symptoms of AMS, stop climbing. Take an acclimatisation day and see if things improve. If your symptoms stay the same or get worse, descend immediately. If on an organised trip make sure your tour leader is aware of your conditions. Don't feel pressured to continue ascending just to keep up with your group.
If you show serious symptoms, descend If you show any serious symptoms of AMS, descend immediately to a lower altitude. Ideally this should be below the altitude where you slept the night before you first developed symptoms. Most lodges can arrange an emergency porter to help you descend quickly to a safe altitude.
Treat mild symptoms by resting at the same altitude until recovery. Take paracetamol or aspirin for headaches. Diamox (acetazolamide) can be used to reduce mild symptoms of AMS. However, it is not a cure and it will not stop you from developing serious symptoms. The usual dosage of Diamox is 125mg to 250mg twice daily. The medication is a diuretic so you should drink extra liquid to avoid dehydration. Diamox may also cause disturbances to vision and the sense of taste and it can cause a harmless tingling sensation in the fingers.
If symptoms persist or become worse, descend immediately – even 500m can help. If the victim cannot walk without support, they may need to be carried down. Any delay could be fatal; if you have to descend in the dark, seek local assistance.
In the event of severe symptoms, the victim may need to be flown to a lower altitude by helicopter. Getting the victim to a lower altitude is the priority – get someone else from the group to call for helicopter rescue and start the descent to the pick-up point. Note that a helicopter rescue can cost you US$2500 to US$10,000.
Emergency treatments for serious symptoms of AMS include supplementary oxygen, nifedipine, dexamethasone and repressurisation using a device known as a Gamow bag (this should only be administered by health professionals), but these only reduce the symptoms and they are not a ‘cure’. They should never be used to avoid descent or to enable further ascent.
The only effective treatment for sufferers of severe AMS is to descend rapidly to a lower altitude.
Don’t drink the water in Nepal. Ice should be avoided except in upmarket tourist-oriented restaurants. While trekking, purify your own water rather than buying purified water in polluting plastic bottles.
The easiest way to purify water is to boil it thoroughly. Chlorine tablets (eg Puritabs or Steritabs) kill many pathogens but are not effective against giardia and amoebic cysts. Follow the directions carefully – filter water through a cloth before adding the chemicals and be sure to wet the thread on the lid to your water bottle. Once the water is purified, vitamin C or neutralising tablets can be added to remove the chemical taste.
Trekking filters take out all parasites, bacteria and viruses, and make water safe to drink. However, it is very important to read the specifications so that you know exactly what the filter removes from the water.
Another option is a UV light–based treatment such as a Steripen.
If you have a sustained fever (over 38°C) for more than two days while trekking and you cannot get to a doctor, an emergency treatment is a course of the broad-spectrum antibiotic azithromycin (500mg twice a day for seven days), but you should seek professional medical help as soon as possible.