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Health and Safety in Nepal

Health and Safety in Nepal
  • Angie Ong
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  • September 29, 2014
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Health and Safety in Nepal

Source: Lonely Planet

Nepal does not officially require any immunizations for entry into the country, but the further off the beaten track you go, the more necessary it is to take precautions. Travelers who have come from an area infected with yellow fever are required to be vaccinated before entering the country. Record all vaccinations on an International Health Certificate, available from a doctor or government health department.

Plan ahead and schedule your vaccinations as some require more than one injection, while others should not be given together. Note that some vaccinations should not be given during pregnancy or to people with allergies.

It is recommended that you seek medical advice at least six weeks before travelling. Be aware that there is a greater risk of all kinds of disease for children and during pregnancy.

Discuss your requirements with your doctor, but vaccinations you should consider for this trip include the following:

Diphtheria & tetanus Vaccinations for these two diseases are usually combined and are recommended for everyone. After an initial course of three injections (usually given in childhood), boosters are necessary every 10 years.

Hepatitis A The vaccine for Hepatitis A (eg Avaxim, Havrix 1440 or VAQTA) provides long-term immunity (possibly lifelong) after an initial injection and a booster at six to 12 months.

Hepatitis B Vaccination involves three injections, the quickest course being over three weeks with a booster at 12 months.

Influenza ‘Flu’ is considered by many to be the most common vaccine-preventable illness in travellers. This vaccine is annual and based on the hemisphere of residence and travel destination.

Japanese B Encephalitis (JBE) JBE is a mosquito-borne viral encephalitis. At the time of writing there was a recent outbreak in the border areas of India. The risk of JBE is greatest in the Terai and during and after the monsoon. Like the rabies course, JBE vaccine is given as three injections over three to four weeks and boosted usually at three years. This vaccine is recommended for persons visiting high-risk areas and for prolonged stays.

Meningococcal Meningitis A single-dose vaccine boosted every three to five years is recommended for individuals at high risk and for extended stays.

Polio This serious, easily transmitted disease is still found in some developing countries, including Nepal. Everyone should keep up to date with this vaccination, which is normally given in childhood. A booster every 10 years maintains immunity.

Rabies Vaccination should be strongly considered for long-term or frequent travellers to countries with rabies, especially if you are engaged in activities such as running, trekking, cycling, caving, handling animals or travelling to remote areas, and for children (who may not report a bite). Pretravel rabies vaccination involves having three injections over 21 to 28 days. The vaccine obviates the need for rabies immunoglobulin, which may not be available in many areas (and is extremely expensive) and will also shorten the vaccine course: if someone who has been vaccinated is bitten or scratched by an animal they will require two vaccine booster injections, while those not vaccinated will require more. The booster for rabies vaccination is usually given after three years.

Tuberculosis The risk of tuberculosis (TB) to travellers is usually very low, unless you will be living with or closely associated with local people in high-risk areas. As most healthy adults do not develop symptoms, a skin test before and after travel to determine whether exposure has occurred may be considered. A vaccination (BCG) may be recommended for children and young adults living in these areas for three months or more.

Typhoid This vaccination is available either as an injection or oral capsules. A combined hepatitis A-typhoid vaccine was launched recently but its availability is still limited – check with your doctor to find out its status in your country.

Yellow fever This disease is not endemic in Nepal and a vaccine for yellow fever is required only if you are coming from an infected area. The record of this vaccine should be provided in a World Health Organization (WHO) Yellow Vaccination Booklet and is valid for 10 years.

Medical checklist

Following is a list of items you should consider including in your medical kit – consult your pharmacist for brands available in your country.

* Aspirin or Paracetamol (acetaminophen in the USA) for pain or fever

* Antihistamine for allergies, eg hay fever; to ease the itch from insect bites or stings; and to prevent motion sickness

* Cold and flu tablets, throat lozenges and nasal decongestant

* Multivitamins for long trips, when dietary vitamin intake may be inadequate

* Antibiotics, particularly if you’re travelling well off the beaten track; see your doctor, as antibiotics must be prescribed, and carry the prescription with you

* Anti-inflammatory (ibuprofen) for muscle and joint overuse and pain; also for headache and fever

* Loperamide or diphenoxylate ‘blockers’ for diarrhoea

* Prochlorperazine or metoclopramide for nausea and vomiting

* Rehydration mixtureto prevent dehydration, which may occur, for example, during bouts of diarrhoea; particularly important when travelling with children

* Insect repellent, sunscreen, lip balm and eye drops

* Calamine lotion, sting-relief spray or aloe vera to ease irritation from sunburn and insect bites or stings

* Antifungal cream or powder for fungal skin infections and thrush

* Antiseptic (such as povidone-iodine) for cuts and grazes

* Bandages, crepe wraps, Band-Aids (plasters) and other wound dressings

* Water purification tablets or iodine

* Scissors, tweezers and a thermometer, noting that mercury thermometers are prohibited by airlines

* Sterile kit in case you need injections in a country with medical hygiene problems; discuss with your doctor

 

Dangers & annoyances

Despite the continual stream of bad news headlines that flows out of Kathmandu, the most touristed areas of Nepal remain remarkably safe.

You can minimize the chances of bumping into trouble by heeding the following general advice:

* Register with your embassy in Kathmandu.

* Seek out local advice on safe/unsafe areas, but be skeptical of official tourist information and trekking touts.

* Keep an eye on the local press to find out about impending strikes, demonstrations and curfews.

* Don’t ever break curfews – instructions have been given to shoot those who are found breaking curfew.

* Don’t travel during bandhs (strikes) or blockades. Get very nervous if you notice that you are the only car on the streets of Kathmandu!

* Be flexible with your travel arrangements in case your transport is affected by a bandh or security situation.

* Avoid marches, demonstrations or disturbances, as they can quickly turn violent.

* Don’t trek alone, even on a day hike. Lone women should avoid travelling alone with a male guide.

* Be familiar with the symptoms of altitude sickness when trekking and observe sensible acclimatization.

* Consider flying to destinations outside Kathmandu to avoid travelling through areas where there have been disturbances.

* Avoid travelling by night buses and keep bus travel in general to a minimum.

* Be prepared to pay the Maoists a ‘tax’ if approached while trekking and budget the cash for that eventuality. Trekkers have on occasion been beaten up for not paying this tax. It’s just not worth arguing with these guys.

* Keep photocopies of your passport, visa, flight ticket and travelers cheques separate from the originals.

Scams

Be wary of deals offered by gem dealers (especially in Thamel, Kathmandu) that involve you buying stones to sell for a ‘vast profit’ at home. The dealers’ stories vary, but are usually along the lines of the dealer not being able to export the stones without paying heavy taxes, so you take them and meet another dealer when you get home, who will sell them to a local contact and you both share the profit. Travelers falling for this ruse are not as unusual as you might expect.

Other scams include young kids asking for milk; you buy the milk at a designated store at an inflated price, the kid then returns the milk and pockets some of the mark-up (you can prevent this by opening the milk).

Be wary of kids who seem to know the capital of any country you can think of; a request for money will arrive at some point. Then there are the ‘holy men’ who will do their best to plant a TIKA (a red paste denoting blessing) on your forehead, only to then demand significant payment.

Credit card scam is not unusual; travelers have bought some souvenirs only to find thousands of dollars’ worth of internet porn subscriptions chalked up on their bill.

Theft

While petty theft is not on the scale that exists in many countries, reports of theft from hotel rooms in tourist areas (including along trekking routes) are commonplace, and theft with violence is not unheard of. Never store valuables or money in your hotel room.

One of the most common forms of theft is the rifling of backpacks on the roofs of buses. Try to make your pack as theft-proof as possible – small padlocks and cover bags are a good deterrent.

There’s little chance of ever retrieving your gear if it is stolen, and even getting a police report for an insurance claim can be difficult. Try the tourist police, or if there aren’t any, the local police station. If you’re not getting anywhere, go to Interpol (01-4412602) at the Police Headquarters in Naxal, Kathmandu. The documentation requires a passport photo and photocopies of your passport and visa; the process takes two days.

In transit

Deep vein thrombosis (DVT)

Deep vein thrombosis occurs when blood clots form in the legs during plane flights, chiefly because of prolonged immobility. Although most blood clots are reabsorbed uneventfully, some may break off and travel through the blood vessels to the lungs, where they may cause life-threatening complications.

The chief symptom of DVT is swelling or pain in the foot, ankle or calf, usually but not always on just one side. When a blood clot travels to the lungs, it may cause chest pain and difficulty in breathing. Travellers with any of these symptoms should immediately seek medical attention.

To prevent the development of DVT on long flights you should walk about the cabin, perform isometric compressions of the leg muscles (ie contract the leg muscles while sitting), drink plenty of fluids, and avoid alcohol and tobacco.

While you’re there

Women travellers

Generally speaking, Nepal is a safe country for women travellers. However, women should still be cautious. Nepali men may have peculiar ideas about the morality of Western women, given Nepali men’s exposure to Western films portraying ‘immodest’ clothing and holiday flings with locals. Dress modestly, which means wearing clothes that cover the shoulders and thighs – take your cue from the local people if you need to gauge what’s acceptable. Several women have written to say that a long skirt is very useful for impromptu toilet trips, especially when trekking.

Sexual harassment is low-key but does exist. Trekking guides have been known to take advantage of their position of trust and responsibility and some lone women trekkers who hire a guide have had to put up with repeated sexual pestering.for more on this. The best advice is never to travel off the beaten track, nor to hike or trek alone with a local guide. The Chhetri Sisters trekking agency in Pokhara is run by women and specialises in providing women staff for treks.

The best chance of making contact with local women is to go trekking, as it is really only here that Nepali women have a role that brings them into contact with foreign tourists – as often as not, the man of the house is a trekking guide or porter, or is away working elsewhere, which leaves women running the lodges and the many teahouses along the routes.

Availability & cost of health care

Self-diagnosis and treatment can be risky, so you should always seek medical help. Although we do give drug dosages in this section, they are for emergency use only. Correct diagnosis is vital.

In Nepal the top-end hotels can usually recommend a good place to go for advice. In most places in Nepal standards of medical attention are so low that for some ailments the best advice is to go straight to Kathmandu.

Antibiotics should ideally be administered only under medical supervision. Take only the recommended dose at the prescribed intervals and use the whole course, even if the illness seems to be cured earlier. Stop immediately if there are any serious reactions and don’t use the antibiotic at all if you are unsure that you have the correct one. Some people are allergic to commonly prescribed antibiotics such as penicillin; carry this information (eg on a bracelet) when travelling.

Hepatitis

A general term for inflammation of the liver, hepatitis is a common disease worldwide. There are several different viruses that cause hepatitis, and they differ in the way that they are transmitted. The symptoms are similar in all forms of the illness and include fever, chills, headache, fatigue, feelings of weakness as well as aches and pains, followed by loss of appetite, nausea, vomiting, abdominal pain, dark urine, light-coloured faeces, jaundiced (yellow) skin and yellowing of the whites of the eyes. People who have had hepatitis should avoid alcohol for some time after the illness, as the liver needs time to recover.

Hepatitis A is transmitted by contaminated drinking water and food. You should seek medical advice, but there is not much you can do apart from resting, drinking lots of fluids, eating lightly and avoiding fatty foods. Hygiene and habits may contribute to the virus’ spread. In Nepal, the custom of sharing food from a single dish rather than using separate plates and a serving spoon may infect dinner companions. Hepatitis E is transmitted in the same way as hepatitis A; it can be particularly serious in pregnant women.

There are almost 300 million chronic carriers of hepatitis B in the world. It is spread through contact with infected blood, blood products or body fluids, for example through sexual contact, unsterilised needles and blood transfusions, or contact with blood via small breaks in the skin. Other risk situations include having a shave, tattoo or body piercing with contaminated equipment. The symptoms of hepatitis B may be more severe than those for type A and the disease can lead to long-term problems such as chronic liver damage, liver cancer or a long-term carrier state. Hepatitis C and D are spread in the same way as hepatitis B and can also lead to long-term complications.

There are vaccines against hepatitis A and B, but there are currently no vaccines against the other types of hepatitis. Following the basic rules about food and water (hepatitis A and E) and avoiding risk situations (hepatitis B, C and D) are important preventative measures.

HIV & AIDs

Infection with HIV may lead to AIDS, which is a fatal disease. Any exposure to blood or body fluids may put the individual at risk. The disease is often transmitted through sexual contact or dirty needles – vaccinations, acupuncture, tattooing and body piercing can be potentially as dangerous as intravenous drug use. HIV/AIDS can also be spread through infected blood transfusions; some developing countries cannot afford to screen blood used for transfusions.

If you do need an injection, ask to see the syringe unwrapped in front of you, or take a needle and syringe pack with you. Fear of HIV infection should never preclude treatment for serious medical conditions.

Malaria

At the time of writing, there has been an outbreak of cerebral malaria in remote areas of the Terai. Most malaria in Nepal is the so-called benign vivax malaria and principally occurs in areas far from those frequented by tourists. Extremely small risk is present in some areas of Chitwan National Park during the monsoon; there is no risk in Kathmandu, Pokhara, or typical Himalayan trekking routes.

Long-term travellers and expat workers in high-risk areas should consider medication prophylaxis; all travellers should practise mosquito-bite avoidance (use of netting, repellents, etc) and engage in prompt evaluation if any fever develops after travel to such areas. Again, local knowledge regarding the current situation is essential.

Rabies

This fatal viral infection is found in many countries. Many animals can be infected (such as dogs, cats, bats and monkeys) and it is their saliva that is infectious. Any bite, scratch or even lick from an animal should be cleaned immediately and thoroughly. Scrub with soap and running water, and then apply alcohol or iodine solution. Prompt medical help should be sought to receive a course of injections to prevent the onset of symptoms and death. Vaccination simplifies the treatment of animal bites.

Respiratory infections

Upper-respiratory-tract infections (such as the common cold) are a common ailment in Nepal. Why are they such a serious problem? Respiratory infections are aggravated by high altitude, cold weather, pollution, chain-smoking and overcrowded conditions, which increase the opportunities for infection.

Symptoms include fever, weakness and sore throat. Any upper-respiratory-tract infection, including influenza, can lead to complications such as bronchitis and pneumonia, which may need to be treated with antibiotics. Seek medical help in this case.

No vaccine offers complete protection, but there are vaccines against influenza and pneumococcal pneumonia that might help. The influenza vaccine is good for no more than a year.

Sexually transmitted infections

While HIV/AIDS and hepatitis B can be transmitted through sexual contact, other sexually transmitted infections (STIs) include gonorrhoea, herpes and syphilis. Sores, blisters or rashes around the genitals and discharges or pain when urinating are common symptoms. In some STIs, such as wart virus or chlamydia, symptoms may be less marked or not observed at all, especially in women. Syphilis symptoms eventually disappear completely but the disease continues and can cause severe problems in later years. Although abstinence from sexual contact is the only 100% effective prevention, using condoms is also effective. Gonorrhoea and syphilis are treated with antibiotics. The different STIs each require specific antibiotics. There is no cure for herpes or AIDS.

Travelers’ diarrhea

Simple things such as a change of water, food or climate can cause a mild bout of diarrhea, but a few rushed toilet trips with no other symptoms are not indicative of a major problem. Even Marco Polo got the runs.

Dehydration is the main danger with any diarrhea, particularly in children, pregnant women or the elderly as it can occur quite quickly. Under all circumstances fluid replacement (at least equal to the volume being lost) is the most important thing to remember. Soda water, weak black tea with a little sugar, or soft drinks allowed to go flat and diluted 50% with clean water are all good. With severe diarrhea a rehydrating solution is preferable to replace lost minerals and salts. Commercially available oral rehydration salts (ORS) are very useful; add them to boiled or bottled water. In an emergency you can make up a solution of six teaspoons of sugar and half a teaspoon of salt to a litre of boiled or bottled water. You need to drink at least the same volume of fluid that you are losing in bowel movements and vomiting. Urine is the best guide to the adequacy of replacement – if you have small amounts of concentrated urine, you need to drink more. Keep drinking small amounts often. Stick to a bland diet as you recover.

Loperamide or diphenoxylate can be used to bring relief from the symptoms, although they do not actually cure the problem. Only use these drugs if you do not have access to toilets, eg if you must travel. For children under 12 years these drugs are not recommended. Do not use these drugs if you have a high fever or are severely dehydrated.

In certain situations antibiotics may be required: diarrhea with blood or mucus (dysentery), any diarrhea with fever, profuse watery diarrhea, persistent diarrhea not improving after 48 hours and severe diarrhea. These suggest a more serious cause, in which case gut-paralyzing drugs should be avoided.

In these situations, a stool test may be necessary to diagnose what bug is causing your diarrhea, so you should seek medical help urgently. Where this is not possible the recommended drugs for bacterial diarrhea (the most likely cause of severe diarrhea in travelers) are norfloxacin 400mg or ciprofloxacin 500mg twice daily for three days. These are not recommended for children or pregnant women. The drug of choice for children would be azithromycin with dosage dependent on weight. A three-day course is given. Alternative antibiotics may be given in pregnancy, but medical care is necessary.

Two other common causes of persistent diarrhea in travelers are giardiasis and amoebic dysentery.

Amoebic dysentery

Caused by the protozoan Entamoeba histolytica, amoebic dysentery is characterized by a gradual onset of low-grade diarrhea, often with blood and mucus. Cramping, abdominal pain and vomiting are less likely than in other types of diarrhea, and fever may not be present. Infection persists until treated and can recur and cause other health problems.

You should seek medical advice if you think you have giardiasis or amoebic dysentery, but where this is not possible, tindazole or metronidazole are the recommended drugs. Treatment is a 2g single dose of tindazole daily or 250mg of metronidazole three times daily for five to 10 days.

Both metronidazole and tindazole may be obtained in Nepal and are often sold in combination with other medications. If you are going to be travelling in high mountain areas, it might be a good idea to keep your own stock of these other medications with you.

Alcohol must not be consumed during the course of taking these medications; they may cause fatigue, nausea, abdominal discomfort and metallic taste.

Cyclospora

This intestinal parasite may cause significant fatigue and abdominal discomfort. Many expatriates avoid salads and uncooked vegetables, especially during and after the monsoon when this infection is most prevalent. The parasite may be diagnosed with stool examination and antibiotic treatment is for one week.

Giardiasis

Known as giardia, giardiasis is a type of diarrhea that is relatively common in Nepal and is caused by a parasite, Giardia lamblia. Mountaineers often suffer from this problem. The parasite causing this intestinal disorder is present in contaminated water. Many kinds of mammals harbour this parasite, so you can get it easily from drinking ‘pure mountain water’ unless the area is devoid of animals. Simply brushing your teeth using contaminated water is sufficient to get giardiasis, or any other gut bug. Symptoms include stomach cramps, nausea, a bloated stomach, watery, foul-smelling diarrhea and frequent gas. Giardiasis can appear several weeks after you have been exposed to the parasite. The symptoms may disappear for a few days and then return; this can go on for several months.

Acute mountain sickness

You should take care to acclimatize slowly and take things easy for the first couple of days in areas at high altitude. Lack of oxygen at altitudes over 2500m affects most people to some extent. The effect may be mild or severe and it occurs because less oxygen reaches the muscles and the brain at high altitude, requiring the heart and lungs to compensate by working harder. Acute Mountain Sickness (AMS) – altitude sickness – is common at high elevations; relevant factors are the rate of ascent and individual susceptibility. The major risk factor in AMS is the speed with which you make your ascent.

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.

Acclimatization

AMS is linked to the low oxygen content of air at high elevation. Those who travel up to Everest Base Camp, for instance, reach an altitude where the oxygen content of the air is about half of that at sea level.

With an increase in altitude, the human body needs time to develop physiological mechanisms to cope with the decreased oxygen. This process of acclimatization is still not fully understood, but it is known to involve modifications in breathing patterns and heart rate induced by the autonomic nervous system, 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 acclimatized 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.

Symptoms

Mild symptoms of AMS are very common in travelers visiting high altitudes, and usually develop during the first 24 hours at altitude. Most visitors to the mountains of Nepal suffer from some symptoms; these generally disappear through acclimatizationb in several hours to several days.

Symptoms tend to be worse at night and include headache, dizziness, and 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.

Prevention

The best way to prevent AMS is to avoid rapid ascents to high altitudes. If you fly or bus into an area at high altitude, take it easy for at least three days – for most travellers this is long enough to get over any initial ill effects. At this point you might step up your programme by visiting a few sights around town. Within a week you should be ready for something a bit more adventurous, but do not push yourself to do anything that you are not comfortable with.

Steps to prevent Acute Mountain Sickness include:

Ascend slowly. Have frequent rest days, spending two to three nights at each rise of 1000m. If you reach a high altitude by trekking, acclimatization takes place gradually and you are less likely to be affected than if you fly directly to high altitude.

Trekkers should 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 high-altitude trekking. 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. Evaporation of sweat may occur unnoticed and 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 or sleeping pills.

When trekking, take a day off to rest and acclimatize if feeling overtired. If you or anyone else in your party is having a tough time makes allowances for unscheduled stops.

Don’t push yourself when climbing up to passes; rather, take plenty of breaks. You can usually get over the pass as easily tomorrow as you can today. Try to plan your itinerary so that long ascents can be divided into two or more days. Given the complexity and unknown variables involved with AMS and acclimatization, trekkers should always err on the side of caution and ascend mountains slowly.

Persons prone to AMS or those required to make a rapid ascent (such as rescuers) may consider taking Diamox (acetazolamide); the usual dose is 125mg to 250mg twice daily. It is essential that this medication not be used as a substitute for slow ascent, or for descent and appropriate treatment if symptoms develop. The medication is a diuretic and possibly contributes to dehydration (extra fluid intake is necessary to compensate). Diamox may cause vision and taste changes and a tingling sensation in the fingers.

Treatment

Treat mild symptoms by resting at the same altitude until recovery, which usually takes 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 – make sure that you have adequate travel insurance.

Other treatments for AMS may include oxyen, acetazolamide (Diamox), nifedipine, dexamethasone and the Gamow bag. Drug treatments should never be used to avoid descent or to enable further ascent.

Cuts & scratches

Wash any cut well and treat it with an antiseptic such as povidone-iodine or antibiotic ointment and sterile gauze dressing. Where possible avoid bandages and Band-Aids, which can keep wounds wet.

Bedbugs, lice & scabies

Bedbugs live in various places, but particularly in dirty mattresses and bedding, evidenced by spots of blood on bedclothes or on the wall. Bedbugs leave itchy bites in neat rows. Calamine lotion or a sting-relief spray may help.

All lice cause itching and discomfort. They make themselves at home in your hair (head lice), your clothing (body lice) or in your pubic hair (crabs). You catch lice through direct contact with infected people or by sharing combs, clothing and the like. Powder or shampoo treatment will kill the lice. Infected clothing should then be washed in very hot, soapy water and left in the sun to dry.

Like lice, scabies is spread by person-to-person contact and is relatively common in some schools and orphanages. Scabies is treated by specific medicated creams.

Bites & stings

Bee and wasp stings are usually painful rather than dangerous. However, people who are allergic to them may have severe breathing difficulties and require urgent medical care. Calamine lotion or a sting-relief spray will give relief and ice packs will reduce the pain and swelling.

Leeches

In damp low-lying areas, leeches may be present; they attach themselves to your skin to suck your blood. Trekkers often get them on their legs or in their boots. Salt or a lighted match end will make them fall off. Do not pull them off, as the bite is then more likely to become infected. Clean and apply pressure if the point of attachment is bleeding. An insect repellent may help keep them away.

Food

There is an old colonial adage that says ‘If you can cook it, boil it or peel it you can eat it…otherwise forget it’. Vegetables and fruit should be washed with purified or bottled water or peeled where possible. Beware of ice cream that is sold in the street or anywhere it might have melted and refrozen; if there’s any doubt (eg a power cut in the last day or two) steer well clear. Undercooked meat should be avoided.

If a place looks clean and well run and the vendor also looks clean and healthy, then the food is probably safe. In general, places that are packed with travellers or locals will be fine, while empty restaurants are questionable.

Frostbite

This is the freezing of extremities, including fingers, toes and nose. Signs and symptoms include a whitish or waxy cast to the skin, or even crystals on the surface, plus itching, numbness and pain. Warm the affected areas by immersing them in warm (not hot) water or covering with blankets until the skin becomes flushed. Frostbitten parts should not be rubbed and should be protected from further damage with bulky gauze dressings. Avoid using the frostbitten limb. Pain and swelling are inevitable. Blisters should not be broken. Get medical attention right away. Antibiotics and anti-inflammatories are often prescribed.

Heat exhaustion

Dehydration and salt deficiency can cause heat exhaustion. Take time to acclimatise to high temperatures; drink sufficient liquids and do not do anything too physically demanding.

Salt deficiency is characterised by fatigue, lethargy, headaches, giddiness and muscle cramps; salt tablets may help, but adding extra salt to your food is better.

Hypothermia

Weather in Nepal is not to be taken lightly. Even in midsummer, passes and high areas can be hit without warning by sudden snowstorms. You should always be prepared for cold, wet or windy conditions, especially if you’re out walking, hitching or trekking at high altitudes or even taking a long bus trip over mountains (particularly at night).

Hypothermia occurs when the body loses heat faster than it can produce it and the core temperature of the body falls. It is surprisingly easy to progress from very cold to dangerously cold through a combination of wind, wet clothing, fatigue and hunger, even if the air temperature is above freezing.

It is best to dress in layers; silk, wool and some of the new artificial fibres are all good insulating materials. A hat is important, as a lot of heat is lost through the head. A strong, waterproof outer layer and a ‘space’ blanket for emergencies are essential. Carry basic supplies, including food that contains simple sugars to generate heat quickly, and fluid to drink.

Symptoms of hypothermia are exhaustion, numb skin (particularly toes and fingers), shivering, slurred speech, irrational or violent behaviour, lethargy, stumbling, dizzy spells, muscle cramps and violent bursts of energy. Irrationality may take the form of sufferers claiming they are warm and trying to take off their clothes.

To treat mild hypothermia, first get the person out of the wind and rain, remove their clothing if it’s wet and replace it with dry, warm clothing. Give them hot liquids (not alcohol) and some high-energy, easily digestible food. Do not rub victims; instead, allow them to slowly warm themselves. This should be enough to treat the early stages of hypothermia. The early recognition and treatment of mild hypothermia is the only way to prevent severe hypothermia, which is a critical condition.

Sunburn

It is very easy to get sunburnt in Nepal’s high altitudes. Sunburn is more than just uncomfortable. Among the undesirable effects are premature skin ageing and possible skin cancer in later years. Sunscreen with a high sun protection factor (SPF), sunglasses and a wide-brimmed hat are good means of protection. Calamine lotion is good for treating mild sunburn.

Those with fair complexions should bring reflective sunscreen (containing zinc oxide or titanium oxide) with them. Apply the sunscreen to your nose and lips (and especially the tops of your ears if you are not wearing a hat).

Water

The number-one rule is be careful of the water and especially ice. If you don’t know for certain that the water is safe you should assume the worst. In the country you should boil your own water or treat it with water-purification tablets. Milk should be treated with suspicion as it will be unpasteurised in the countryside, although boiled milk is fine if it is kept hygienically. Soft drinks and beer are always available wherever there is a shop, and these are always safe to drink, as is tea.

Water purification

The simplest way to purify water is to boil it thoroughly. In Nepal’s higher-altitude areas water boils at a lower temperature and germs are less likely to be killed, so make sure you boil water for at least 10 minutes.

Consider purchasing a water filter for a long trip. There are two main kinds of filters. Total filters take out all parasites, bacteria and viruses, and make water safe to drink. They are often expensive, but they can be more cost-effective than buying bottled water. Simple filters (which can even be a nylon-mesh bag) take out dirt and larger foreign bodies from the water so that chemical solutions work much more effectively; if water is dirty, chemical solutions may not work at all. It’s very important when buying a filter to read the specifications, so that you know exactly what it removes from the water and what it doesn’t. Simple filtering will not remove all dangerous organisms, so if you cannot boil water it should be treated chemically.

Chlorine tablets (eg Puritabs or Steritabs) will kill many pathogens, but not giardia and amoebic cysts. Iodine is more effective for purifying water and is available in tablet form (eg Potable Aqua). Follow the directions carefully and remember that too much iodine can be harmful.

Gynaecological problems

Antibiotic use, synthetic underwear, sweating and contraceptive pills can lead to fungal vaginal infections, especially when travelling in hot climates. Fungal infections are characterised by a rash, itch and discharge. Nystatin, miconazole or clotrimazole pessaries or vaginal cream are the usual treatment, but some people use a more traditional remedy involving vinegar or lemon-juice douches, or yogurt. Maintaining good personal hygiene and wearing loose-fitting clothes and cotton underwear may help prevent these infections.

Sexually transmitted infections are a major cause of gynaecological problems. Symptoms include a smelly discharge, painful intercourse and sometimes a burning sensation when urinating. Medical attention should be sought and sexual partners must also be treated. Besides abstinence, the best thing is to practise safe sex using condoms.

Pregnancy

It is not advisable to travel to some places while pregnant as some vaccinations normally used to prevent serious diseases are not advisable during pregnancy. In addition, some diseases are much more serious for the mother (and may increase the risk of a stillborn child).

Most miscarriages occur during the first three months of pregnancy. Miscarriage is not uncommon and can occasionally lead to severe bleeding. The last three months should also be spent within reasonable distance of good medical care. Travel prior to 32 weeks is generally not a problem for pregnant women; airlines may restrict travel after this gestational time. Pregnant women should avoid all unnecessary medication, although vaccinations should still be taken where needed. Additional care should be taken to prevent illness and particular attention should be paid to diet and nutrition. Alcohol and nicotine, for example, should be avoided. Dehydration from diarrhea is especially dangerous and prompt fluid intake is often important for pregnant women.