The main health concerns in Bhutan are similar to those in other south Asian destinations: there is a relatively high risk of acquiring traveller's diarrhoea, a respiratory infection, or a more exotic infection. The infectious diseases can interrupt your trip and make you feel miserable, but they are rarely fatal. If you go trekking, there are also risks associated with accidents and altitude sickness. Falling off trails, or having a rock fall on you as you trek, is rare but can happen.
The following advice is a general guide only and does not replace the advice of a doctor trained in travel medicine.
Checking insurance quotes…
Before You Go
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.
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 also 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 – for more information, check Lonely Planet (www.lonelyplanet.com). 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 insurance companies ask you to call them (they suggest reversing the charges, an impossibility from Bhutan) at a centre in your home country, where an immediate assessment of your problem is made.
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. 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, which will list all the vaccinations you've received.
The only vaccine required by international regulations is for 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.
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):
- Diphtheria and tetanus (for adults) Single booster recommended if none taken 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, it is 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 is required for 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.
The following 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.
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, eg Norfloxacin or Ciprofloxacin for bacterial diarrhoea; Tinidazole for giardiasis or amoebic dysentery
- Antihistamine, eg Cetrizine for daytime and Promethazine for night
- Antiseptic, eg Betadine
- Antispasmodic for stomach cramps, eg Buscopan
- Decongestant, eg Pseudoephedrine
- DEET-based insect repellent
- Diarrhoea treatment – an oral rehydration solution (eg Gastrolyte), diarrhoea 'stopper' (eg Loperamide), and antinausea medication (eg Prochlorperazine)
- First-aid items such as scissors, bandages, gauze, thermometer, sterile needles and syringes, safety pins and tweezers
- Ibuprofen or other anti-inflammatory
- Iodine tablets (unless you are pregnant or have a thyroid problem) to purify water
- Laxative, eg Coloxyl
- Permethrin to impregnate clothing and mosquito nets
- Steroid cream for allergic/itchy rashes, eg 1% to 2% hydrocortisone
- Throat lozenges
- Thrush (vaginal yeast infection) treatment, eg Clotrimazole pessaries
- Ural or equivalent if you're prone to urine infections
There is a wealth of travel health advice on the internet. For further information, Lonely Planet (www.lonelyplanet.com) is a good place to start. The World Health Organization (WHO; www.who.int/ith) publishes a superb book called International Travel & Health, which is available free online. Other useful websites are:
- MD Travel Health (www.mdtravelhealth.com) Provides complete travel health recommendations for every country and is updated daily.
- Centers for Disease Control and Prevention (www.cdc.gov) Good general information on travel health issues.
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.
Availability & Cost 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 Wangchuck 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 closest 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. Most of the medical supplies mentioned in this section are available without a prescription.
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, and therefore responds promptly to treatment with antibiotics, such as Norfloxacin. Keep in mind, though, that a couple of loose stools are little cause for concern.
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 car trip. Don't take Loperamide if you have a fever, or blood in your stools, and seek medical attention quickly if you do not respond to an appropriate antibiotic.
Amoebic dysentery is very rare in travellers but is often misdiagnosed. Symptoms are similar to bacterial diarrhoea: 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, followed by a second drug to kill the cysts.
Giardia lamblia is a parasite that is relatively common in travellers. Symptoms include nausea, bloating, excess gas, fatigue and intermittent diarrhoea. The parasite will eventually go away if left untreated but this can take months. The treatment of choice is Tinidazole.
Coughs, Colds & Chest Infections
Respiratory infections usually start as a virus and are exacerbated by 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. Some people develop a rash and experience diarrhoea. There is no specific treatment, just rest and paracetamol – do not take aspirin though, 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 for pregnant women and can result in the death of both mother and baby. There is currently no readily available vaccine, and prevention is following safe eating and drinking guidelines.
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, thrush, 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 never lying down within 30 minutes of taking it. It must continue to be taken for four weeks after leaving the risk area.
Lariam (Mefloquine) is a weekly tablet. 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.
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 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 a 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.
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 to have pre- and post-travel tuberculosis testing. The main symptoms are fever, cough, weight loss, night sweats and tiredness.
This serious bacterial infection is 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.
Even on a cloudy day sunburn can occur, especially at altitude where the atmosphere is thinner. Minimise the risk by applying sunscreen and wearing sunglasses and a hat outdoors.
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.
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.
Mild symptoms of AMS are very common in travellers visiting high altitudes, and usually develop during the first 24 hours at altitude. 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.
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, 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.
To prevent Acute Mountain Sickness:
- Ascend slowly. Have frequent rest days, spending two to three nights at each rise of 1000m.
- 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 and sweat, which may 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.
- Avoid sedatives.
- When trekking, take a day off to rest and acclimatise if feeling overtired. 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. Given the complexity and unknown variables involved with AMS and acclimatisation, trekkers should always err on the side of caution and ascend slowly.
Treat mild symptoms by resting at the same or lower altitude until recovery, usually in 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 and fleas don't carry disease but their bites are very itchy. You can treat the itch with an antihistamine.
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.
- Never drink tap water
- Bottled water is generally safe – check the seal is intact at purchase
- Avoid ice
- Avoid fresh juices – they may have been watered down
- Boil water – this is the most efficient method of purifying it; let it boil a bit longer at higher altitudes
- Purify water – the best chemical purifier is iodine but this should not be used by pregnant women or those with thyroid problems
- Use water filters – should also filter out viruses; ensure your filter has a chemical barrier such as iodine and a small pore size, eg less than four microns
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 road journeys without toilet stops; bring suitable antibiotics.
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 also 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 transport and medical facilities. Most of all, ensure travel insurance covers all pregnancy-related possibilities, including premature labour.
Malaria is a high-risk disease during pregnancy. WHO recommends that pregnant women do not travel to areas that have Chloroquine-resistant malaria. None of the more effective antimalarial drugs is completely safe during 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.