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Australian consular advice: www.smartraveller.gov.au/zw-cgi/view/Advice/Nepal
IN NEPAL & THE HIMALAYAS
Kathmandu and northern Nepal presents many risks to
traveller. All of these can be heightened by the remoteness of the trekker. Contingency
plans in case of illness or accident (inquire from your travel agent) are recommended.
Also check that your travel insurance covers evacuation.
The phrase "Travel broadens the mind and loosens the bowels." is apt. It should
also be remembered that severe or prolonged diarrhoea can be debilitating. It may
completely ruin ones holiday or even be life threatening. It is a common illness in
- Tetanus/Diphtheria, Polio boosters
- hepatitis A, Typhoid, Mencervax
- Japanese Encephalitis vaccine may be worthwhile if spending
1 month or more in rural areas particularly if during wet season (June to Sept.).
- Cholera vaccine not recommended although the new vaccine
could be considered
Most episodes of diarrhoea are short-lived and require no particular treatment The
need to treat diarrhoea depends on either its severity or persistence. Transmission is
mostly via contaminated food or water.
- Food which is freshly and thoroughly cooked is safe.
- Eat fruit or vegetables that you can peel or cut open
yourself, eg. banana, citrus fruits, papaya.
- Dry foods and Breads are generally safe.
- Canned and bottled drinks are safe.
- Avoid milk, and other milk products unless made with
pasteurised (or boiled) milk.
- Avoid uncooked leafy vegetables, eg. salads.
- Avoid untreated "fresh" mountain water.
PURIFICATION OF WATER
Boiling water at altitude will take longer to render it safe.
Safe water for drinking can be prepared by either filtering or using chemicals or both.
Iodine: 8 drops of 1% iodine solution in 1 litre of water and let stand for 30 minutes.
Filters: The trekker travel well supplied by MASTA and many chemist outlets is convenient,
lightweight, effective and recommended. Approx. cost $100 but worth it.
RABIES (illness is 100% fatal to humans)
Source: mostly dogs, cats & monkeys (even minor scratch or lick of graze).
Incubation period 10 days to 10 years. Be wary of all animals whether tame or not.
Malaria is a potentially life-threatening infection
prevalent in most of the tropics. It is a parasitic disease spread by the bite of
Anopheles mosquito which is active between dusk and dawn. The number of cases of malaria
reported in Australia each year is increasing. (Currently around 1000). Malarial symptoms
can occur after 8 days following an infected bite. The classic symptoms are fever,
malaise, headache, chills and sweats.
Kathmandu and northern Nepal have minimal risk and no risk above 1300 meters so
antimalarial drugs are not recommended. However use of insect repellents is recommended as
other diseases spread by biting insects and mosquitoes. (dengue, Japanese encephalitis)
Lowlands and south Nepal drug resistant malaria occurs throughout the year. Doxycycline or Mefloquine together with strict use
of insect repellents is recommended. (eg. Chitwan National Park). However if the
traveller will only be spending a few days in the park and will be back in Australia
within 7 days, then strict measures to avoid mosquito bites alone is reasonable. see also malaria
Minimisation of exposure to mosquitoes
Stringent measures to prevent mosquito contact reduce the risk of contracting
malaria by ten fold.
- Minimise night time outside activities.
- Avoid dark coloured clothing as it attracts
mosquitoes as do perfume, cologne & after-shave.
- Clothing to cover arms and legs in the
evenings. NB. It is common for mosquitoes to attack leg/ankle region.
- Use of mosquito repellents. The most
effective mosquito repellent is (DEET). "Rid" or "Muskol". It is
effective for 3 to 4 hours when applied to clothing or skin. It needs to be spread evenly
and completely over all exposed skin. Repellents containing more than 20% DEET should be
avoided in infants and young children. (see also Children's dosage for antimalarials).
Untreated travellers in proximity to treated ones are more apt to be bitten.
- Mosiguards:- Ankle and wrist bands
impregnated with DEET, mosquito nets impregnated with permethrin are available from TMVC,
MASTA, camping stores and some chemists.
- DEET repellents should be kept well away
from plastics, including cameras, as it will dissolve them
This is considered the most important mosquito spread viral disease in the world today.
Severe headache, bone & muscle pain, high fever and rash usually occur 4-6 days after
an infected bite. The "Dengue" mosquito ( Aedes aegpti ) prefers to feed on
humans and has invaded urban areas.
Acute mountain sickness "AMS" is infrequent below 2500 m. It occurs in
travellers who rapidly ascend to altitudes of 2500 m or more. The risk relates more to the
speed of ascent than the altitude reached. The problem is caused by the reduction in
atmospheric pressure with altitude. Less oxygen reaches the muscles and the brain, and the
heart and lungs must work harder to compensate. Individual susceptibility to acute
mountain sickness is highly variable, and males are more susceptible than females. Youth
and fitness do not prevent AMS.
Mild form of AMS: Symptoms include headache, dizziness, fatigue, loss of appetite,
nausea, and a general feeling of being unwell that is often compared to having the flu or
Severe AMS: It may begin with little or no warning. There are two types of severe
- High altitude pulmonary oedema (fluid in the lungs)
- High altitude cerebral oedema (swelling of the brain).
They may occur independently, but usually both forms occur
together. The symptoms may include severe headache, vomiting, severe lassitude,
drowsiness, giddiness, inability to sit upright cough, frothy white or pink sputum and
breathlessness. It is important to remember that people with AMS are a risk to themselves
as well as others, are more likely to fall or have other injuries and be belligerent.
(See: additional notes)
Medical Kit: Panadol, sunscreens, sunburn cream, antihistamines, antiseptic
(Betadine), antifungal (tinea and thrush), diarrhoea medications (antibiotic, gastrolyte
if taking children), bandages and dressings, condoms.
Heat and Humidity: Plenty of drinks rich in mineral salts (fruit and vegetable
juices, clear soups and even a little table salt) are recommended. Daily showering, loose
cotton clothing and talcum powder will reduce heat rash. Risk of severe sunburn needs
Bathing, Bare Feet & Shoewear: Skin penetrating parasites abound in fresh water
lakes and rivers of south-east Asia. These vary from the harmless but prolonged skin
irritation of cercarial dermatitis (Swimmers Itch) up to the serious infestations of
schistosomiasis and leptospirosis. Other parasites in soil and can penetrate the soft skin
of tourists walking barefoot. ... Shoes and clothing should be examined before use -
particularly in the morning - as snakes and scorpions tend to rest in them. ... Leather
goods made from inadequately treated skins may contain anthrax spores causing life
threatening skin sores.
Accident Prevention: Traffic accidents are a leading cause of accidents among
travellers. Vehicles are often unroadworthy. Unfamiliarity with roads, poor condition of
roads and drunk drivers add to the dangers.
Plane Trip: Drink plenty of fluids, exercise legs, avoid excessive alcohol &
Prolonged Travel: Extra pair of spectacles
Dental Check up advisable - Dental treatment in developing countries could be a health
Travel insurance should cover not only medical & hospital expenses but also
costs due to general accidents, medical evacuation, loss of luggage & money, as well
as delays due to strikes.
Sexually Transmitted Disease: There is a high risk of HIV in developing countries
(NB. 42% of those already infected with HIV being women 1*). Also most travellers
contracting STD had not planned to have sexual contact whilst away. (coerced by the
culture and or alcohol) Local condoms are unreliable . There is no evidence that HIV or
any other sexually transmitted infections are acquired from insect bites.
Management of Diarrhoea
Because diarrhoea is so common it is important to be aware of how to manage it if
Most travellers do not develop dehydrating diarrhoea; almost any beverage coupled
with a source of salt (eg., salted crackers) suffices for hydrating most ill travellers
Bottled or canned beverages, tea, broth, foods such as rice, bananas, papaya (pawpaw),
potatoes and dry biscuits are tolerated best. Children with diarrhoea are of special
concern (see Travelling with children).
- Antimotility drugs ('stoppers'). Since most
diarrhoeal illnesses last only a few days, these drugs may be very helpful in relieving
diarrhoea and cramps. Do not use if high fever or blood in motions. Do not use in children
under 6, and be cautious in children under 12. Adult Dosage: loperamide (Imodium) -2
capsules (each 2 mg) followed by 1 cap after each unformed stool. (maximum 8 caps per
- Antibiotics. Diarrhoea with high fever, distressing
symptoms or blood in motions:
A single dose of two tablets of any of the following drugs
should be effective. If response is not dramatic after 12 hours continue 1 tab twice a day
for a further 3 days. (Norfloxacin 400mg, ciprofloxacin 500mg , doxycycline 100mg,
- Prolonged diarrhoea greater than 10
days and without fever:
A bowel parasite "giardiasis" is the commonest cause. The best treatment is
tinidasole (Fasigyn) - 4 x 500mg tablets (2g) in a single dose. Metronidazole 400mg three
times a day for 5 days is an alternative. If this is not completely effective amoebic
dysentery is a possibility. Tinidazole (Fasigyn) - 4 x 500mg tablets (2g) daily for 3
successive days should be effective.
When diarrhoea is prolonged and with fever seek medical
Prevention of acute mountain sickness
Acclimatisation should be achieved at an altitude between 1500 and 2500 m for 2-4 days
before ascending to a higher elevation. Once above 3000 m particular care should be taken
not to increase the sleeping altitude by more than 300 m per day, and to spend an extra
day for each 1000 m gained.
The body's water losses increase during an active day in the dry cold air at high
altitude, therefore, fluid intake should be increased (you may need as much as 4-7 litres
per day). Drugs to prevent AMS often only
hide the warning symptoms.
Treatment of acute mountain sickness
Most cases will improve with rest, aspirin or paracetamol in normal doses, and avoidance
of alcohol. This often takes only 1 or 2 days. If necessary, descent of a few hundred
meters is usually curative. Insomnia should not be treated with sleeping pills, since they
tend to aggravate a low oxygen level during sleep.
The most effective and important immediate measure is descent or evacuation to a
lower altitude. This should be insisted upon by all means available and with no loss of
time. Frequently a descent of 500-1000 m is sufficient.
Descent becomes increasingly important as the severity of acute mountain sickness
increases. The warning signs mentioned on previous page should be indication for immediate
Additional measures include oxygen, dexamethasone (8 mg initially, then 4 mg every 6 hours
for 1 to 3 days, then tapered over 5 days). . A portable hyperbaric chamber such as the
Gamonbag (a large portable airtight bag with an air pump) may be very useful in diagnosing
and treating AMS.
You should wash the wound immediately with soap and water and then disinfect with iodine
(betadine). Seek medical attention if risk seems high. (unprovoked attack, irritable
animal) and have post-exposure vaccine as soon as possible (preferably within 48 hours).
Otherwise at least seek medical advice on return.
Early diagnosis and treatment of malaria
Any fever developing after 8 days or upon return (particularly within the first 3 months)
may be due to malaria. You should consult a doctor, and ask for a malarial thick blood
film to be done. You should do so within 48 hours of onset of fever, or earlier if you are
more than moderately unwell.
Antimalarial Drugs & Common side effects ... Childrens dosages
Chloroquine: Minor side effects such as stomach upset
and blurred vision occur frequently. These can lessened by taking tablets with food, or
taking half the dose on 2 occasions each week. They are safe in pregnant women and
children in correct doses. Pruritus (itch) in dark skin individuals is common. . If you
have had generalised psoriasis, chloroquine and other chloroquine-like drugs, including
primaquine, quinidine and proguanil should be avoided. Retinal changes including eye
damage and blindness may occur after prolonged use but on the usual 300mg per week dose it
would take 6-7 years.
- a combination of atovaquone and proguanil in a single tablet, is a new
addition for malaria prevention. Its use has been approved for treatment and
prevention of malaria (TGA-Australia) since November 2001. It is particularly useful where malaria is
resistant to chloroquine and mefloquine (Larium). On evidence to date, it appears
to be very safe and effective, but is expensive.
For prevention of malaria, Malarone is taken once a day,
starting 1 day before entering malarial risk area and continuing for 1 week after leaving the
malarious area. It should be taken with food or milk. This regime is simple
and suited to business & frequent travellers. Nb. When Malarone is used for malaria prevention, side
effects are uncommon . However, nausea, vomiting, abdominal pain, and diarrhoea
occur when higher doses of the drug are used for treatment. Convulsions and rash
have rarely been reported.
Doxycycline: It is an alternative to mefloquine for short-term travellers.
Doxycycline at 100 mg/day is approved for a period of up to 8 weeks only (NHMRC 1994) but
is probably safe for longer use. Side Effects include thrush, stomach & bowel upsets,
(particularly if medication is taken on an empty stomach) and sunlight sensitivity. The
exaggerated sunburn reaction may be minimised by avoidance of sunlight, using sunscreen
and taking the drug in the evening. Drinking copious quantities of water after swallowing the
drug is recommended to reduce heartburn. Using Doxycycline may make the
Contraceptive pill unreliable. The Therapeutic guidelines 2002 states that: "A
second form of contraception is not necessary, but may be offered." & "Women
who develop breakthrough bleeding might consider using barrier methods for the
duration of antibiotic therapy". Discuss this
matter with your doctor.
Mefloquine: Side-effects ('Lariam') Minor side
effects such as nausea, vomiting, heartburn and loose stools occur in about 20% of users,
but this is no more frequent than with other antimalarials and usually subside with
continued use. Taking ½ tab twice a week with food, and drinking copious water with medication will
help reduce these.
Unfortunately mefloquine frequently produces annoying
adverse neurological effects such as insomnia, vivid dreams, dizziness, mental clouding,
anxiety and coordination problems. These are sufficient to interfere with daily activities
in up to 10% of users and are probably aggravated by use of alcohol and cannabis.
Disabling side effects sufficient to recommend the cessation of mefloquine occur in 0.5%
of users. However despite this, some 5 - 10% of users will stop the drug. Consequently
any person requiring a clear mind and good co-ordination should not use mefloquine. This may involve travellers to high altitude and definitely those contemplating aqualung
(scuba) diving. Other contra indications include persons with a history of seizures, neuro-psychiatric disorder, the first 3 months of pregnancy and those with cardiac
conduction problems. Women are advised to use contraceptives during and for 3 months after
administration of mefloquine.
Mefloquine is probably best commenced 3 -4 weeks before
entering a malarious area as it takes this long to build up to satisfactory blood levels.
(half life of 21 days). Also this provides time to detect those travellers that
develop unacceptable side-effects and thus enable a change in medication.
Commencing 1 or 2 weeks before departure is
A recent report involving soldiers taking mefloquine 250mg daily for 3 days to enable a
quick build up in blood levels was surprisingly well tolerated.
US authorities are prepared to use mefloquine for up to 2 years continuously in Peace
Corps Volunteers overseas.
Serious neuropsychological side effects can occur when mefloquine is used in high doses.
(click important note )
see also Malarial misconceptions: http://www.hc-sc.gc.ca/pphb-dgspsp/publicat/ccdr-rmtc/00vol26/26s2/26s2n_e.html or copy
Proguanil: One of the safest antimalarial drugs. Mouth ulcers is an annoying complication in up to
37% of travellers. (when taken with Chloroquine). Proguanil is taken 2 tabs daily,
starting 1 day before entering malarial area and continuing for 4 weeks after
leaving the area.
Chloroquine is taken 2 tabs weekly
. Confusing your tablets could be deadly.
Contrarily to WHO recommendations, Australian travel physicians mostly limit the use of Chloraquine + Proguanil,
to travellers unable to take mefloquine or doxycycline.
Stand by Treatment
Since malaria can become life-threatening within a short time you should not delay
seeking medical attention. Travellers who are likely to be more than 24 hours away from
medical help, are often given one or more treatment courses of the following to take with
Business persons & Frequent Travellers
Some travellers make
frequent short stops to endemic areas, over a prolonged period of time. Such travellers may
eventually choose to reserve chemoprophylaxis for high-risk areas only. Malarone
may be the most useful malarial prevention drug here, as it only needs to be
taken for 1 week after leaving the malarial area. When antimalarial drugs are
not used, rigorous self-protection measures against mosquito bites should be
employed and they should be prepared for an
attack of malaria: they should always carry a course of antimalarials for stand-by
emergency treatment, seek immediate medical care in cases of fever, and take
self-treatment if medical help is not available.*(*p 135 WHO 2002 year book
Standby malarial treatment:
- Malarone (Atovaquone +
Proguanil) - The dosage is 4 tabs daily for 3 days with food and is now considered the drug of choice. (but
expensive approx $100 Aus).
- Riamet (Co-artemether which contains
artemether 20mg and lumefantrine 120mg) - 4 tablets twice a day 3 days.
Advantage of being very quick acting.
Fansidar (3 tablets for an adult)
- becoming less reliable
Mefloquine for adults > 65kg, 3 tablets followed 6-8
hours later by another 1 tablet (high side effects & no longer
Quinine (adult dose 600 mg three times a day for 7 days) -
see also WHO year book (Stand by
(Nb. If taking malarone for prevention, a supply of
Riamet should be taken)
ICT Malaria P.f/P.v test
- This test, provides a
realistic alternative for people in this category, particularly those who have had
significant side-effects from either mefloquine or doxycycline. This test detects circulating antigens of falciparum malaria. A finger prick blood sample
gives a result in 5 minutes. For Plasmodium falciparum infection the test is close to 100%
reliable, but false positives can occur (rheumatoid factor, previously treated
malaria in the last month). For vivax malaria reliabilty is very low. The test is stable at 37 degrees C for 4 months. Cost approx $30 for 2 test kit.
NB. The test is very reliable in experienced hands but reliability in a sick
febrile traveller (self testing) is questionable.
Preventive drugs should be continued after treatment for
malaria. As serious neurological side effects may occur when mefloquine is used in
the high doses needed for treatment, it should only be used in a true emergency situation
when medical attention is not available. Standby use of mefloquine is not recommended for
persons already taking mefloquine for malarial prevention.
(click important note ) -- Also see Full Information
Dengue & Dengue haemorrhagic fever
The "Dengue" mosquito ( Aedes aegpti ) prefers to feed on humans and
has invaded urban tropical environment of many countries including Australia. It is
considered the most important mosquito spread viral disease in the world
Severe headache, bone & muscle pain, high fever and rash usually occur 4-6 days after
an infected bite. There is no vaccination available so avoiding bites is essential.
Anyone suspected of being infected with Dengue, especially the haemorrhagic form
(large bruises on skin, bleeding gums or blood from nose or bowel) should seek medical
assistance immediately. If untreated or inappropriately treated Dengue haemorrhagic fever
can be fatal.
Information mostly taken from: "International
Travel and Health" (WHO year book -
Australian Immunisation Handbook, 8th Edition - 9/2003 - Part1 - Part 2 & Part 3 (large pdf
Centre for Disease Control, USA - www.cdc.gov/travel Travel Health Seminar Oct 96, June 97,Feb 98, March 99, May 2000, August 2002 &
March 2005 - Victorian Medical Postgraduate Foundation.
Manual of Travel Medicine,
Melbourne, Oct 2004.
Updated 06/09/2006. Additional references & disclaimer.