Travel Health Nepal

Hygiene is not one of Nepal’s strong points. Sanitation is poor, and lots of bugs make the rounds, especially during spring and the monsoon. But by coming prepared and looking after yourself, you’re unlikely to come down with anything worse than a cold or the local version of “Delhi belly”.

This section deals with health matters mainly in the context of Western-style medicine; you could of course also turn to traditional ayurvedic or Tibetan practices.

Before you go

No inoculations are required for Nepal, but hepatitis A, typhoid and meningitis jabs are recommended, and it’s worth being up to date with tetanus, polio, mumps and measles boosters. Malaria tablets, injections for Japanese B encephalitis and rabies are also worth considering. All of these can be obtained in Kathmandu, but it’s better to get injections done beforehand. If you have any medical conditions or concerns about your health, don’t set off without seeing a doctor first. Medicines are sold over the counter everywhere, but it’s best to bring your prescribed medications. Consider having a dental check-up before you go.

If you’re planning on trekking, bear in mind the possibility of altitude sickness and other trekking hazards.

Recommended inoculations

Most travellers decide to inoculate themselves against the following diseases, which are, on the whole, fairly ghastly but not fatal. Deciding which to protect yourself against is a matter of risk management.

Hepatitis A is an infection or inflammation of the liver that causes mild fever, nausea/vomiting, loss of appetite and jaundice. It’s fairly common in Nepal, and while it won’t kill you, it’ll put a swift end to your travels and lay you up for several months. It’s transmitted through contaminated food and water, so sensible hygiene will reduce the risk of catching it, but you can’t count on fastidiousness alone.

Typhoid and paratyphoid are common in Nepal, and are also spread through contaminated food and water. These nearly identical diseases produce a persistent high fever, headaches, abdominal pains and diarrhoea, but are treatable with antibiotics and are rarely fatal. Paratyphoid usually occurs in epidemics and is less severe.

You should have a tetanus booster every ten years, whether you travel or not – and within five years of acquiring a dirty wound. Assuming you were vaccinated for polio in childhood, only one booster is necessary during your adult life. Immunizations against mumps and measles are recommended for anyone who wasn’t vaccinated as a child and hasn’t already had these diseases.

Flu is no more prevalent in Nepal than elsewhere, but you might consider getting a flu jab before you leave just to reduce the risk of spending several days sick during your holiday.

Optional inoculations

The following diseases are all rare, but potentially fatal.

Meningicoccal meningitis, spread by airborne bacteria, is a very serious disease that attacks the lining of the brain, and can cause death in as little as a day. While localized cases are occasionally reported in Nepal, the chances of catching meningitis are remote. That said, the injection is very effective, causes few side effects, and lasts for three to five years.

Rabies is a problem in Nepal, and the best advice is to give dogs and monkeys a wide berth. It can be cured by five post-exposure injections (available in Kathmandu), administered over a month; these are 100 percent effective if given in reasonable time. The pre-exposure vaccine involves three injections over four weeks, which gives some protection for three years; if you get bitten, you’ll still have to get two more boosters. It’s probably not worth it except for long-stays and children.

Japanese B encephalitis, though potentially fatal, is mostly confined to the more jungly portions of the Terai around monsoon time. Visitors to Kathmandu and the Terai who are staying for a long

period between April and October should certainly consider vaccinating against it. Rural areas where pigs are kept are most risky. The inoculation is in the form of three injections given over a month.

Hepatitis B is a more serious version of Hepatitis A, but is passed on through blood and sexual contact. The vaccine is recommended for those working in a medical environment. Long-term travellers are sometimes vaccinated as they might have an accident and need to receive blood.

Don’t bother with the cholera inoculation – few authorities believe it’s worthwhile, and the risk in Nepal is minimal.

Malaria prophylaxis

Most visitors won’t need to take malaria tablets. The disease hasn’t been eradicated in Nepal, but it is unknown above 1000m, and rare outside the monsoon months. The risk to short-term travellers is very low, but it’s well worth taking anti-mosquito measures anyhow, especially during the rainy season.

Prophylaxis (regular doses of tablets) is worth considering if you plan to visit the Terai (which includes Chitwan and Bardia national parks) between June and September. Longer-term visitors and anyone visiting India should seek expert advice, and rafters should remember that valleys in the hills can be lower than 1000m.

Precautions

The lack of sanitation in Nepal is sometimes overhyped – it’s not worth getting too uptight about it or you’ll never enjoy anything, and you’ll run the risk of rebuffing Nepalese hospitality. The best advice is to follow the guidelines below when you can.

Most travellers are careful about drinking dirty water, but food is now thought to be the worst culprit, and it’s usually tourist restaurants and “Western” dishes that bring the most grief: more people get sick in Kathmandu than anywhere else in Nepal. Be particularly wary of anything reheated, and food that’s been sitting where flies can land on it. Nepali food is usually fine and you can probably trust anything that’s been boiled or fried in your presence, although meat has additional risks. Raw, unpeeled fruit and vegetables – including pickles – should always be viewed with suspicion in local places, though all but the cheapest tourist restaurants usually have acceptable salads, fruit juices and lassis these days.

Kathmandu’s polluted air gives many people respiratory infections within a few days of arrival; asthmatics and others with breathing problems are particularly affected. Minimize your exposure by staying off the main streets, and seriously consider bringing a filtering face mask if you’re spending much time in the Kathmandu Valley. You can also help your immune system by keeping warm, dry and well rested. Most importantly, get out of the valley to where the air is fresh as quickly as possible.

You need to be particularly vigilant about personal hygiene while travelling in Nepal. That means, above all, washing your hands often – waterless antibacterial soap comes in handy. Keep any cuts clean and disinfected. If you’re staying in cheap guesthouses, bring a sleeping sheet to keep fleas and lice at bay. Scabies and hookworm can be picked up through bare feet, so it’s best to always wear shoes; flip-flops provide reasonable protection in bathrooms.

When travelling in the Terai, don’t give mosquitoes the opportunity to bite you. They’re hungriest from dusk to dawn, when you need to wear repellent and/or long-sleeved clothes, sleep under netting and use plug-in mosquito killing/deterring devices or smoke coils. Very few mosquitoes carry malaria, so you don’t need to worry over every bite. Try not to scratch bites as infection may result.

Travellers in rural areas of the eastern Terai should protect against sandflies in the same way, as they transmit the disease visceral leishmaniasis, also called kala-azar, which causes fever andpotentially fatal enlargement of the spleen.

Take the usual precautions to avoid sunburn and dehydration. You’ll probably want at least medium protection, and high protection will be essential while trekking.

Water

Untreated water should be avoided when possible and you may not always notice the risk. Plates and glasses are customarily rinsed just before use: if you’re handed wet utensils it’s a good idea to give them a discreet wipe. Use treated or bottled water when brushing your teeth, and keep your mouth closed in the shower. Thamel restaurants generally use clean water for ice, but it’s probably still worth steering clear. Similarly, many guesthouses provide filtered water, but you can’t guarantee it was boiled first, or that the filters are clean. Tea and bottled drinks are generally safe.

Mineral water is available everywhere but purifying your own – either by boiling and filtering, or by using purification tablets – is cheaper and doesn’t produce plastic waste. Iodine tablets are more effective than chlorine (and it’s possible to buy tablets to neutralize the medicinal taste) – be careful to follow the instructions, especially when it comes to giving the tablets enough time to work. Aqueous iodine solution, aka Lugol’s solution, is available in pharmacies across Nepal, together with plastic pipettes; it’s far cheaper than tablets brought from home, and works faster. There are high-tech alternatives; the pocket-sized Steropen, which uses UV light, is portable and popular, but requires a battery.

HIV/AIDS

Almost ninety percent of transmissions in Nepal are thought to be through heterosexual contact, especially in the context of migrant workers and prostitution. Brothels are full of HIV-positive sex workers. Trekking guides can also be considered a relatively high-risk group. Carry condoms with you (locally available but it’s best to bring some) and insist on using them. Condoms also protect you from other sexually transmitted diseases such as hepatitis B.

Male travellers who get a shave from a barber should make sure that the blade used is clean, and nobody should go for ear-piercing, acupuncture or tattooing unless fully satisfied the equipment is sterile. Should you need an injection, make sure new, sterile equipment is used. And if you need a blood transfusion, bear in mind that the Nepalese blood supply isn’t adequately screened.

Common ailments

Chances are that at some point during your travels in Nepal you’ll feel ill. In most cases, it won’t be something you need a doctor for but sod’s law says it will happen somewhere remote and inconvenient. The following information should help with self-diagnosis, although it is not a substitute for professional medical advice. If you’re unable to get to a clinic – a strong possibility when trekking – you might choose to self-medicate, and dosages are given below.

Some of the illnesses and parasites you can pick up in Nepal may not show themselves immediately. If you become ill within a year of returning home, tell the doctor where you’ve been.

Intestinal troubles

Diarrhoea is the most common bane of travellers. If it’s mild and not accompanied by other major symptoms, it should pass of its own accord within a few days without treatment. However, it’s essential to replace the fluids and salts you’re losing – cheap and effective oral rehydration formulas are widely available. Bananas and fizzy drinks are also good for replacing electrolytes. “Starving the bug to death” is an old wives’ tale, though you’re unlikely to be hungry. Tablets like Imodium will plug you up if you have to travel, but won’t cure anything.

If the diarrhoea comes on suddenly and is accompanied by cramps and vomiting, there’s a good chance it’s food poisoning, brought on by toxins secreted by foreign bacteria. There’s nothing you can do other than keep replacing fluids, but it should run its course within around 24 to 48 hours. If you’re feverish, have severe diarrhoea that lasts more than three days or if you see blood or mucus in your stools, seek treatment.

In the eventuality of serious or persistent intestinal problems, you’re strongly advised to have a stool test done at a clinic, where a doctor can make a diagnosis and prescription. Bacterial diarrhoea, which causes 85 percent of identifiable cases, is recognizable by its sudden onset, accompanied by nausea and vomiting, stomach cramps and sometimes fever. The treatment is one 400mg tablet of the antibiotic Norfloxacin/Norbactin every twelve hours for five days, or one 500mg tablet of Ciprofloxacin every twelve hours for three days.

About five percent of diarrhoea cases in Nepal are giardiasis (giardia), which produces three or four loose stools a day, and is often recognizable by copious, foul-smelling belches and farts. The cure is a single dose of 2g of Tinidazole (four 500mg tablets of locally available “tiniba”), which can make you tired and nauseous for 24 hours, and absolutely shouldn’t be mixed with alcohol.

Amoebic dysentery is relatively rare. Setting in gradually, it manifests itself in frequent, small, watery bowel movements, often accompanied by fever. To self-medicate, take one 500mg tablet of Tinidazole four times a day for three days. This must be followed by taking one 500mg Diloxaride Furoate (Furamide) tablet every eight hours for ten days, in order to kill amoebic cysts that can infect the liver.

If the diarrhoea is associated with fatigue and appetite loss over many days, and occurs between April and November, it may be the result of cyclospora (sometimes called blue-green algae). Another water-borne condition, it’s treated with the antibiotic trimethoprim sulfamethoxazole (Bactrim or Septra). Again, be sure to keep rehydrating. Iodine and chlorine do not kill cyclospora, so drink boiled water if you can during the peak months of June and July.

Finally, bear in mind that oral drugs, such as malaria pills or the contraceptive pill, are rendered less effective or completely ineffective if taken while suffering from diarrhoea.

Flu and fever

Flu-like symptoms – fever, headache, runny nose, fatigue, aching muscles – may mean nothing more than the latest virus. Rest and aspirin/paracetamol should do the trick. However, strep throat, bronchial or sinus infections will require an antibiotic course such as Erythromycin or Amoxycillin. Flu symptoms and jaundice point to hepatitis, which is best treated with rest and a plane ticket home.

A serious fever or delirium is cause for real concern. Diagnosis is tricky; the sufferer needs to be taken to a doctor as quickly as possible. To begin with, try bringing the fever down with aspirin/paracetamol. If the fever rises and falls dramatically every few hours, it may be malaria, which, in the absence of medical help, can be zapped with three tablets of pyralfin (Fansidar). If the fever is consistently high for four or more days, it may be typhoid – again, only if no doctor is available, treat with Ciprofloxacin/Norfloxacin or Chloramphenicol.

Minor symptoms

Minor muscle cramps, experienced after exercise or sweating, may indicate you’re low on sodium – a teaspoon of salt will bring rapid relief. Likewise, a simple headache may just mean you’re dehydrated. (However, a severe headache, accompanied by eye pain, neck stiffness and a temperature, could mean meningitis – in which case get to a doctor pronto.)

Itchy skin is often traced to mosquito bites, but can also be fleas, lice or scabies. The latter, a burrowing mite, generally goes for the spaces between fingers and toes. Shampoos and lotions are available in Nepal. Air out your bedding and wash your clothes thoroughly.

Worms may enter your body through the skin (especially the soles of the feet), or through food. An itchy anus is a common symptom, and you may even see them in your stools. They are easy to treat with worming tablets, available locally.

Animal bites and leeches

For animal bites or scratches, immediately wash the wound with soap and water for at least five minutes then rinse with Providone iodine (found in Nepal); if this isn’t available, use 40–70 percent alcohol – local raksi may do the trick. This should kill any rabies virus on the spot but anyone bitten by an animal should hightail it to a Kathmandu clinic for expensive post-exposure rabies shots (see Massage). The disease’s incubation period is ten to ninety days – ideally, you’re supposed to capture the animal alive for observation!

Thickly vegetated country, such as the Terai national parks or low-lying trekking areas, can come alive with leeches during the monsoon. Protect yourself by wearing insect repellent, long clothing and perhaps gaiters. There is a small risk of infection, particularly if you pick them off and the mouth parts get left behind in the wound. It’s best to leave them – they won’t take so much blood that they’ll harm you. Otherwise, the advised way to remove a leech is to break its suction by gently sliding a fingernail around first the thinner, then the thicker end of the animal. Locals tend to use a rapid finger flick and take their risks – and this may be the only practicable solution in thickly infested areas. Using salt, iodine or, worst of all, heat from a lighter or match will make a leech drop off but not before it effectively vomits into the wound.

Getting medical help

In a non-emergency, make for one of the traveller-oriented clinics in Kathmandu. Run to Western standards, these can diagnose most common ailments, write prescriptions and give inoculations. In other cities and towns, local clinics (often attached to pharmacies) can usually provide adequate care. An array of Indian-manufactured medicines are available without prescription in the pharmacies of all major towns (check the sell-by date).

In the event of serious injury or illness, contact your embassy for a list of recommended doctors. The majority are in Kathmandu and speak English. It’s a good idea to register with your embassy or consulate on arrival, especially if you go trekking or rafting.

Hospitals are listed in the Kathmandu and Pokhara sections of the guide; others are located in Dhulikhel, Tansen and the bigger Terai cities. Most are poorly equipped.

Medical resources

cdc.gov/travel The official US government travel health site.

w ciwec-clinic.com This Kathmandu clinic is an authoritative source of information.

w iamat.org The International Association for Medical Assistance to Travellers provides a list of English-speaking doctors in Nepal plus guidance on diseases and inoculations.

w istm.org Website of the International Society for Travel Medicine.

w masta-travel-health.com MASTA (Medical Advisory Service for Travellers Abroad) has a list of UK travel health clinics.

w thehtd.org The Hospital for Tropical Diseases Travel Clinic is the only UK medical facility dedicated to tropical diseases.

w tripprep.comTravel Health Online has a comprehensive database of necessary vaccinations for most destinations.

Antibiotics

Tourists in Nepal tend to rush for antibiotics, but they shouldn’t be taken lightly: most tummy bugs cure themselves in around 48–72 hours, and antibiotics can increase susceptibility to other problems by killing off all organisms in the digestive system (yoghurt can replenish them to some extent, as can acidophilus tablets – also good for thrush and fungal infections). Some may cause allergic reactions or unpleasant side effects, and the more a particular antibiotic is used, the sooner organisms become resistant to it. It’s not a bad idea to travel with a course of the drugs mentioned here (especially as fake, badly stored and out-of-date drugs are not rare in Nepal), but make sure you have the correct dosages explained to you beforehand.