Chapter 4Select DestinationsAsia
Nepal is a country of >28 million people that stretches for 500 miles (805 km) along the Himalayan mountains that form the border of Nepal and Tibet. The topography rises from low plains with an altitude of 200 ft (70 m) to the highest point in the world at 29,029 ft (8,848 m), the summit of Mount Everest. Approximately 30% of tourists come to Nepal to trek into the mountains, while others come to experience the culture and stunning natural beauty. Kathmandu is the capital city, with a population of well over a million people. It sits in a lush valley at 4,344 ft (1,324 m) in altitude. Nepal’s latitude of 28° North (the same as Florida) means that the nonmountainous areas are temperate year round. Most of the annual rainfall comes during the monsoon season (June through September). The main tourist seasons are in the spring (March to May) and fall (October and November). The winter months, December through February, are pleasant in the lowlands but can be too cold to make trekking enjoyable in the high mountains.
There are 3 main trekking areas: the Mount Everest region east of Kathmandu, the Annapurna region to the west, and the Langtang region north of Kathmandu. Trekkers into the Mount Everest region routinely sleep at altitudes of 14,000–16,000 ft (4,267–4,876 m) and hike to altitudes >18,000 ft (5,486 m). This prolonged exposure to very high altitudes means that tourists must be knowledgeable about the risks of altitude illness and may need to carry specific medications to prevent and treat the problem (see Chapter 2, Altitude Illness). Most trekkers into the Mount Everest region arrive there by flying to a tiny airstrip at Lukla at 9,383 ft (2,860 m). The following day they reach Namche Bazaar at 11,290 ft (3,440 m). Acetazolamide prophylaxis can substantially decrease the chances of developing acute mountain sickness in Namche.
In the Annapurna region, short-term trekkers may choose to hike to viewpoints in the foothills without reaching any high altitudes. Others may undertake a longer trek around the Annapurna massif, going over a 17,769-ft (5,416-m) pass (the Thorung La). Roads have been constructed up the 2 major valleys of this trek, shortening the overall trekking distance and changing the nature of the experience (cars and motorcycles may be encountered along the trek). The total exposure to high altitude is less in this region than in the Everest region. The Langtang region has a high point of 14,000 ft (4,200 m).
In addition to trekking, Nepal has some of the best rafting and kayaking rivers in the world. Jungle lodges in Chitwan National Park allow tourists to view a wide range of wildlife, including tigers, rhinoceroses, bears, and crocodiles, and a huge variety of exotic birds. It is also possible to travel by road to comfortable lodges in the foothills that afford panoramic views of the Himalayas.
Travelers to Nepal are at high risk for enterically transmitted diseases. Hepatitis A vaccine and typhoid vaccine are the 2 most important immunizations. The risk of typhoid fever and paratyphoid fever among travelers to Nepal is among the highest in the world, and the prevalence of fluoroquinolone resistance is high.
Japanese encephalitis (JE) is endemic in Nepal, with highest disease risk occurring in the Terai region during and immediately after the monsoon season (June through October). JE has been identified in local residents of the Kathmandu Valley, but no cases of JE acquired in Nepal have been reported in tourists or expatriates. JE vaccine is not routinely recommended for those trekking in higher altitude areas or spending short periods in Kathmandu or Pokhara en route to such treks (see Chapter 3, Japanese Encephalitis).
Malaria is not a risk for most travelers to Nepal. There is no transmission of malaria in Kathmandu or Pokhara, the 2 main cities in Nepal. All the main trekking routes in Nepal are free of malaria transmission. Chitwan National Park is a popular tourist destination for wildlife viewing in the Terai. Although the Nepalese Ministry of Health and other regional organizations regard the Terai to be a malaria transmission area, this author, in 30 years of treating travelers in Nepal, has not seen a single case of malaria in a traveler to Chitwan, including foreign workers living in the park.
Other Health and Safety Risks
Cyclospora cayetanensis is an intestinal protozoal pathogen that is highly endemic in Nepal. The risk for infection is distinctly seasonal: transmission occurs almost exclusively from May through October, with a peak in June and July. Because this is outside the main tourist seasons, the primary effect is on expatriates who stay through the monsoon. In addition to watery diarrhea, profound anorexia and fatigue are the hallmark symptoms of Cyclospora infection. The treatment of choice is trimethoprim-sulfamethoxazole; no highly effective alternatives have been identified.
Since many tourists are heading to remote areas that do not have medical care available, they should be provided with medications for self-treatment. Travelers’ diarrhea is a risk, and the risk in the spring trekking season (March through May) is double that in the fall trekking season (October and November). All trekkers should have an antibiotic such as ciprofloxacin for empiric treatment of bacterial diarrhea. Campylobacter causes as much as 20% of the bacterial diarrhea in Nepal, and up to 70% of the Campylobacter isolates are resistant to fluoroquinolones. Although ciprofloxacin remains an excellent choice for empiric treatment of bacterial diarrhea, azithromycin is a good alternative and should be used if the diarrhea does not respond to ciprofloxacin.
Hepatitis E virus is endemic in Nepal, and several cases each year are diagnosed in tourists or expatriates. There is no vaccine commercially available against hepatitis E.
The Kathmandu Valley often has air pollution. People with chronic respiratory diseases, such as asthma and chronic obstructive pulmonary disease, may suffer exacerbations in Kathmandu, particularly after a viral upper respiratory infection. Exacerbation of chronic respiratory disease has not been a problem for tourists outside Kathmandu.
Viral upper respiratory infections are extremely common, and the percentage of these that lead to bacterial sinusitis or bronchitis is high. Trekkers should consider carrying an antibiotic, such as azithromycin, to empirically treat a respiratory infection that lasts >7 days with no sign of improvement. More treks may have been ruined by prolonged respiratory infection than by gastrointestinal illness.
Rabies is highly endemic among dogs in Nepal, but in recent years there are fewer stray dogs in Kathmandu. Half of all tourist exposures to a possibly rabid animal occur near Swayambunath, a beautiful hilltop shrine also known as the monkey temple. Tourists should be advised to be extra cautious with dogs and monkeys in this area. The monkeys can be aggressive if approached and can jump on a person’s back if they smell food in a backpack. Clinics in Kathmandu that specialize in the care of foreigners almost always have complete postexposure rabies prophylaxis, including human rabies immune globulin. Trekkers who are bitten in the mountains should be able to return to Kathmandu within an average of 5 days.
Evacuation and Medical Care
Helicopter evacuation from most areas is readily available. Communication has improved from remote areas because of satellite and cellular telephones, and private helicopter companies accept credit cards and are eager to perform evacuations for profit. Evacuation can often take place on the same day as the request, if weather permits. Helicopter rescue is usually limited to morning hours because of afternoon winds in the mountains. Helicopter rescue is billed at $2,500 per hour, with an average total cost of $7,500.
Two main clinics in Kathmandu specialize in the care of foreigners in Nepal. Contact information is available on the International Society of Travel Medicine website (www.istm.org). Hospital facilities have improved steadily over the years, and general and orthopedic emergency surgery are reliable and available in Kathmandu. The closest evacuation point for definitive care is Bangkok.
The Political Situation
The political situation in Nepal has been in transition since 1990, when a mainly peaceful democratic revolution led to a multiparty parliamentary system under a constitutional monarch. Frustration with the rate of progress in rural areas led to a Maoist insurrection and 10 years of low-grade but violent civil war. A peace agreement was reached and the monarchy abolished in 2008, but an effective government has yet to remain in place. The main effect on tourists can be disruptions to their schedule by demonstrations and strikes, but none of the political tension has been aimed at foreigners; Nepal remains a safe destination to visit. However, visitors should monitor the political situation while planning their journey.
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