Staying Healthy In Nepal
Trekking in Nepal and Himalaya is great but sickness is sometimes a problem. Here are some guidelines on staying healthy; if you do get a sick consult with your leader. This is written for our Nepal treks but applies almost equally to our India/Tibet and Bhutan treks also.
Arrival: Changing time zones knocks people, add the stress of winding up at work and many people arrive feeling slammed, needing a holiday. This is the time you are most likely to get sick; try to take it easy, and definitely take multi-vitamin tablets.
Drinking water: In developed countries, people take for granted clean drinking water, toilets that flush waste away never to be seen again and hygienically packaged food. While trekking in Nepal and Himalaya, these luxuries don’t exist however there is clean and nice toilet most of the Teahouse on the trek. Mineral water, boiled water or water with Iodine is safe to drink while you are in Himalaya. Naturally, we are serious about hygiene on our every trip so don’t worry about it.
Purifying Water: All the water in the streams and rivers of Nepal and Himalaya is contaminated to some degree and therefore not safe to drink without purifying precautions. This unfortunately even includes all water at high altitudes. Only water made from clean snow is safe. Water that has been brought to the boil, even at 5000m/16,404ft is safe – it only needs to be pasteurised which is heating to 75ºC/162ºF, not sterilised (boiling for 10 minutes). At 5800m/19,000ft water boils at around 81ºC/177ºF so all tea, coffee and hot lemon etc. is safe to drink. There are many different methods to purify water; in the lodges, boiled water is normally available, while camping our crew provides thermos of boiled water. Sometimes you may want to purify water yourself; the most convenient method is Iodine tablets. If you have a water filter, ask us if it is worthwhile bringing it.
Diarrhoea: This is a common problem in developing countries, especially India & Nepal. In normal circumstances when you get diarrhoea, you visit a doctor and they conduct some tests. This is the best way to make an accurate diagnosis. However while trekking obviously this is impossible so you may have to be your own doctor if there is no real doctor close by. First, diarrhoea will not normally kill you so urgent treatment is not necessary nor always recommended. Many people over-react and start taking drugs at the first loose stool. Instead, wait a few days and see what happens. Unless it is particularly severe, for example, food poisoning, there is no need to stop trekking, just drink lots of water and listen to your body: if you feel hungry, eat, and if you don’t then take lots of soup and light foods. If the diarrhoea is still definitely troublesome after a few days and you are fairly sure of what type it is then you may want to treat it, but this is still not entirely necessary. If you have a pre-existing condition such as stomach ulcers, gallbladder problems, previously perforated intestine etc, be especially careful with self-diagnosis and treatment.
Giardia: Common in Nepal and Himalaya. It is usually from infected water, especially from Kathmandu and high mountain streams near where yaks graze. It generally takes 7-10 days to develop and does not come on suddenly. The classic symptoms are very sulphurous (rotten egg) smelling farts and burps. The other symptoms that make it easier to distinguish from other types of diarrhoea are: a rumbling, churning upset stomach, sometimes cramping and bloating, and normally there is no fever or chills or nausea. In the last couple of years, giardia has also presented different symptoms, such as;
- watery diarrhea: Giardia can also be virtually symptomless, just occasional soft stools or constipation even and a vaguely upset stomach. Some forms your body will clear given a month or so and a number of people have had it without realising however if it is obvious and a problem there are two drugs that are effective. Tiniba – this can be bought at all Nepalese pharmacies (without a prescription). The name of the active chemical is Tinidazole. The dose is 2 grams, ie 4 x 500 mg (milligrams)) all at once then 24 hours later, the same dose, and 24 hours later, a third dose. It is perhaps better taken in the evening because the usual side effects, a strong metallic taste in your mouth and nausea may be slept off. This dose is about 90% effective – it is possible that it may re-occur later. Do not mix with alcohol. Alternatively, take Flagyl/Metronidazole. The dose is 250mg three times a day for 5 to 7 days. DO NOT mix with alcohol. Note! DONT take Flagyl and Tiniba at the same time.
- Amoebic Dysentery: Occasionally its onset is sudden and weakens a person severely, sometimes to the point of barely being able to lift oneself off the toilet. However it usually comes on slowly, a mild diarrhoea that comes and goes, something that can almost, but not quite, is ignored. This is when it is most dangerous because the symptoms can eventually clear up, but your body is still infested and being slowly damaged. If you suspect you have this then upon return to Kathmandu have a stool test. According to Dr David Schlim of CIWEC clinic, Kathmandu, It causes perhaps 1% or less of all diarrhoea cases in Nepal.
- Travellers / Bacterial Diarrhoea: The onset is often accompanied or even preceded by a fever and/or chills and nausea, next is fairly sudden frequent watery diarrhoea and often cramps. It is caused by slightly different strains of bacteria that your body is normally used to. This type of infection is normally the first to attack fresh from home arrivals to Nepal. There are two methods of treatment. Your body generally copes with foreign bacteria quite well so it should clear up given plenty of time, however, the usual Nepalese version is stronger than many so very effective is to begin a short course of Norfloxacin, under the name Normaflox or Norbactin in Nepal. The dose is 400mg every 12 hours for 3 days. An often recommended drug is Bactrim / Bactrim DS or Septra. There are now resistant strains so these are not nearly as effective, and similarly, there is increasing resistance to Cipro and so another drug is becoming the standard treatment. See a doctor in Kathmandu.
Food Poisoning: This comes on suddenly and severely, usually from both ends – vomiting and diarrhoea. It happens about 4 to 8 hours after eating the contaminated food. Luckily it usually lasts less than 24 hours and recovery is quick, although you may feel weakened. There are no drugs that can help – the body just has to eject all the contaminated food and rid itself of the poison. Rest and, once the first severe bout or two is over, drink plenty of fluids. Oral rehydration solutions are helpful.
Other Medical Problem
Dehydration: While trekking lower down in the valleys it is hot and you sweat a lot so it is important to replace the fluids you lose. At altitude the problem is worse, you are still sweating and the air is dry and thin meaning you must breathe a lot harder. With every breath, you breathe out water vapor. It is very important then to drink a lot. Dehydration makes you feel tired and lethargic and can give you a headache. The symptoms are similar to AMS so the easiest way to avoid confusion is to always keep hydrated.
The basic rules are; drink as much and as often as you like, (that does not include alcohol!) even if it seems like a lot. This can include soups and lots of tea, but even with a lot of liquid food, you should drink a lot of water too. Many people find that with dinner they often drink more than a litre of water, catching up on what they should have drunk during the day. A great guideline is an expression: A happy mountaineer always pees clear!
The easiest way to check that you are not becoming dehydrated is to look at your urine; if it is very yellow or orange you should drink more, but if it is almost clear then you have been looking after yourself well. Using this as a guideline some trekkers find that, although they don’t feel thirsty, their urine is definitely yellow. This means drink more, even if you have to consciously think about it.
The Khumbu Cough: If trekking for a prolonged period at altitude, especially in the Everest region: If you escape the Khumbu Cough you did very well. This is the perpetually running nose and a usually mild productive cough. It is caused by breathing excess quantities of dry cold air – so much that you partially injure your bronchi. A cold or infection is the normal cause of this but in this case, the irritant is only air however your body reacts almost identically – quantities of clear or white goo. Get rid of it when you can, there is plenty more waiting to well up. Since there is no infection it is pointless taking antibiotics. Throat lozenges help so take plenty.
Bronchitis: An inflammation of the bronchi from an infection, ie identical to the Khumbu coughs but instead caused by an infection. Differentiating this from the Khumbu Cough is difficult, but you perhaps experienced a fever and/or some chills. A cough may be more productive. Since it can be a viral or a bacterial infection, taking antibiotics will not always help and is not particularly recommended. Best is some rest and a return to a lower altitude, eg Namche and see a doctor if it is particularly bad.
Pneumonia: This is an infection that causes fluid to build up in the lungs. It is rare but once HAPE was miss-diagnosed as pneumonia and since the treatment was antibiotics, rather than descent, most people died.
Cold/snow injuries
Snow Blindness: This is sunburn of the cornea. It is particularly painful, like hot sand in your eyes. It is entirely preventable by wearing sunglasses that block UV light. This precaution is most important while around snow, even on cloudy days, but altitude alone increases the concentration of UV light so while at higher altitudes also wear sunglasses. Porters often get snow blindness. If sunglasses are not available then cardboard shields shaped like glasses with two narrow slits for vision are easily made and are quite effective.
Frostbite: When flesh freezes solid the results are very serious and often amputation is necessary. Frostbite takes time to develop unless flesh is exposed to a vicious cold wind. First, your fingers or toes feel numb, clumsy and lose power. If you can still vaguely wiggle them then warm them up now, they are on the verge of freezing. Rewarming is painful. When real deep freezing has occurred the flesh turns white or even blue and fingers or toes become wooden, incapable of movement. At this stage, don’t begin rewarming until in a position when refreezing cannot occur (even more damaging). Warm slowly and evenly. Blood temperature to 42ºC is the optimum warming temperature and once defrosted promotes blood circulation. Blisters will probably form. See a doctor as soon as possible.
Bugs, blisters and skin problems
Fleas, bedbugs and scabies: These problem bugs are almost unknown on our treks. The trekking regions of Nepal are considerably cleaner than years ago.
Leeches: The monsoon terrorizer. You have to admire their skill in being able to put a sizeable hole in you completely painlessly. In the damp forest, they wave around waiting for you and are adept at penetrating socks and even boot eyelets. They should be removed by applying a lighted match or cigarette to the end still sticking out.
Blisters: Since you spend most of your time walking, blisters are really worth avoiding. First, use boots that have been worn in if possible. Test your boots by carrying a pack up and down hills – along level ground there is far less stress on your feet. Normally you can feel a blister developing – some rubbing, or a hot spot, or a localised pain. Stop and investigate, even if it occurs during the first 5 minutes, or just in sight of the top of the hill; immediate action is best. The trick is to detect the symptoms before the blister develops. Put tape on or investigate what may be causing the problem.
Blister Treatment – If you develop a blister then there are several approaches. If it is not painful then perhaps surround it (not cover it) with some light padding, eg moleskin, and see how it feels. If it is painful and causing problems then pierce it – clean the skin and sterilise the needle; holding the needle slightly above a candle or match flame for a second or two is effective. Do not cut away the blistered skin until after a few days when it is dried out and no more use for protecting the delicate skin underneath. You can put protective tape over the top with some cotton wool to protect the blister, and some people even put the tape straight over the blister, with no protection. If you have had a previous history of blisters or think that you are likely to get them take preventative action first! Use moleskin, a strong waterproof zinc-oxide tape or similar, and tape up troublesome areas first. Tape before you take your first step and be religious about checking, and replacing, the tape. Vaginal infections If you have experienced these before then it is very worthwhile taking along the medication just in case.
Precautions and Inoculations discussion
This information is given in good faith but with NO responsibility. This was written for our Nepal treks but applies almost equally to our Tibet/Bhutan and India treks.
Precautions: Anyone with heart, lung and blood pressure abnormalities or a continuing medical condition should have a check-up and get a medical opinion before setting off.
Older people: Many recently-retired people have made it to the top of Kala Pattar (5554m/18,222ft) so age need not be a barrier. The older you are, the more important prior fitness preparation is.
Younger children: Caution should be exercised when taking children trekking. Younger people can be slower to adapt to altitude, and very young children have difficulty in communicating exactly how they feel. No studies have been undertaken so cautious doctors recommend the safe maximum for pre-teenage children is 3000m/9843ft. However, a number of young children have made it to the top of Kala Pattar – 5560m. Trekking with children can be very rewarding and bring you closer to the locals. You share a common bond for there are few people without children in Nepal. Little legs are easily carried by a porter when tired, and Sherpanis are good babysitters.
Teenagers: There is no evidence to suggest that teenagers adapt slower to altitude than adults. However, they do appear to be more at risk. This is likely to be because of competitiveness and a will not to give in, and also because some school groups treat the trek as an outward bound exercise, with everyone carrying their own backpack. School groups should allow an extra day or two over the most conservative itineraries and be particularly watchful.
Asthma: This is no reason to avoid trekking. Except in polluted Kathmandu, there are fewer irritants in the air so most asthmatics actually feel better while trekking. Look after your medication – wear your inhaler on a chain around your neck or keep it in a pocket. There is still the normal risk of a serious attack so brief your companions on what to do.
Diabetes: If it is well-controlled diabetes is no reason to avoid trekking. You cannot afford to lose the medication so keep it with you at all times and warn your friends on the procedures in case there is an emergency. Your increased energy expenditure will change carbohydrate and insulin levels so it is very important to monitor your glucose levels frequently and carefully and to keep blood sugar levels well controlled.
High blood pressure (hypertension): Blood pressure will fluctuate more and be higher than usual while on a trek. You should seek the advice of a doctor who is aware of the history of your condition.
Previous heart attacks: Studies have yet to be conducted but it is likely that the level of exertion required on a trek is more significant than the altitude factor. Seek the advice of your doctor.
Epilepsy: There is a moderately increased risk of a seizure at altitude, but is not a reason to stop your trekking. Your companions must be briefed on all the relevant procedures.
Pregnancy: Complications are common, especially in the first pregnancy. Sometimes sophisticated care is needed so it is probably not a good idea to go trekking while pregnant. The effects of reduced oxygen at high altitude on the foetus have not yet been studied.
Past history of chest infections: If you are prone to these bring the medicine you are normally prescribed (usually Augmentin or Roxi-something), and at least 2 full courses of it. If you are ascending to high altitude for only a short time in the Everest region you may want to take it prophylactically, since your chances of picking one up are high.
Immunisations: The most accurate immunisation advice for visiting Nepal can be found on the Web – CIWEC Clinics page. They are Kathmandu most professional medical clinic. It is worth reading very carefully and printing this advice out, plus what follows, before getting your shots. American doctors (perhaps to avoid getting sued) tend to jab far more needles than is useful. The best people to consult about the vaccinations currently recommended are clinics specialising in travel medicine. They will have access to more up-to-date information than a normal general practitioner.
Hepatitis A: Usually passed on in contaminated water; immunisation is considered a must by most doctors unless you have had hepatitis A before. The vaccine is Havrix and a full course will give up to ten years protection.
Hepatitis B: This disease is avoidable since, like AIDS, it is passed by unsafe sex or contaminated blood products. A vaccine is available.
Meningitis: Occasional cases of meningococcal meningitis occur in Nepal. It is an often fatal disease but the vaccine is safe and effective and should be obtained.
Cholera: The World Health Organisation no longer recommend this vaccination. It is only partially effective and often causes a reaction. The risk of travellers acquiring cholera in Nepal is extremely low.
Typhoid: is prevalent in Nepal. There are now a variety of vaccines and one should be obtained.
Tetanus-Diptheria: This vaccine is recommended if you have not had a booster in the last 10 years. Many doctors advise a tetanus booster every time you intend to travel for any length of time.
Polio: If you escaped immunisation as a child a series of vaccinations is recommended. If you have not had a booster as an adult, one may be required. Check with your doctor.
Measles, mumps and rubella: If you did not have these diseases (or the vaccinations) as a child you may need a vaccination.
Japanese Encephalitis B: This disease is transmitted by mosquitoes and there have been sporadic outbreaks in the Terai (lowland Nepal) and India. Western doctors based in Kathmandu suggest the vaccination only for people working in the Terai for extended periods. In other words, you don’t need this vaccination.
Rabies: This deadly virus is transmitted by the bite of an infected animal, usually a monkey or dog. The risk of being bitten is minimal but it has happened. A vaccination is available but even if you’ve had it you will then need a follow-up course of two further injections. If you have not been vaccinated and are unlucky enough to be bitten, a series of injections is available only from the CIWEC clinic in Kathmandu and should be started within a week or so of being bitten.
Malaria: Carried only by the lowland Anopheles mosquito, malaria exists in the Terai in Nepal (ie below 1000m/3281ft), and across much of the rest of rural Asia. There is no risk in Kathmandu or while trekking and the risk in Pokhara appear to be theoretical only. If visiting Chitwan April to October then you can consider taking tablets to protect against malaria. The actual risk, especially since you are there for a short time, is minimal, and the side effects of some drugs less than minimal. Whether you are or are not taking antimalarials, the first line of protection is to avoid being bitten. The Anopheles mosquito is active only between early evening and dawn so you should cover up well between these times and use mosquito repellent on any exposed skin. All the better lodges at Chitwan spray the whole compound regularly with mosquito-killing chemicals. I am always staggered by the number of people taking anti-malarial medication who shouldn’t be. The side effects of some of the stronger drugs can be quite nasty, so especially if you are going climbing or trekking, you shouldn’t be taking them. Ask your doctor about this.
If you are behind on any of the immunizations listed above, they can be safely obtained at clinics in Kathmandu.
Medical insurance: A combined travel/medical insurance policy is a sensible choice for any traveller and a requirement for most tours, please take this insurance in your home country.