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On-line - http://www2.ncid.cdc.gov/travel/yb/utils/ybGet.asp?section=NIR&obj=altitude.htm
Print 2 page pdf
see also Australian consular advice: www.smartraveller.gov.au/zw-cgi/view/Advice/Nepal

TREKKING 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 trekkers.

RECOMMENDED VACCINES

  • 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

TRAVELLERS DIARRHOEA
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.

DANGERS

  • 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. (Betadine)
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
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.
They include:

  • 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

DENGUE
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.
ALTITUDE SICKNESS
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 a hangover.
Severe AMS: It may begin with little or no warning. There are two types of severe AMS

  • 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)

OTHER CONSIDERATIONS
Other Considerations
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 consideration.
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 & coffee.
Prolonged Travel: Extra pair of spectacles
Dental Check up advisable - Dental treatment in developing countries could be a health risk.
Travel Insurance:
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 prevention fails.
Fluids
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 day.)
  • 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, Co-trimoxazole.)
  • 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 attention

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
Mild AMS
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.
Severe AMS
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 descent.
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.

Rabies
Post-exposure immunisation
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.

Malarone:  - 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 not adequate.
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 them.

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 - www.who.int/ith/chapter07_03.html#10)

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 recommended)

  • Quinine (adult dose 600 mg three times a day for 7 days) - eg pregnancy
    see also WHO year book (Stand by treatment)- www.who.int/ith/chapter07_03.html#10

(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.
Last edited: 14-Sep-2005

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 today.
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 - internet only)
Australian Immunisation Handbook, 8th Edition - 9/2003 - Part1 - Part 2 & Part 3 (large pdf files)
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.

 

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