Chapter 10 Popular Itineraries Africa & the Middle East
The tallest mountain on the African continent, and one of the largest freestanding volcanoes in the world, Kilimanjaro remains a revered and classic image. Its snow-capped peak rises 19,341 ft (5,895 m) above the tropical African savanna, an irresistible draw for trekkers and mountaineers from around the globe. Although no technical climbing is required to reach the summit, its challenges are often misjudged. Climbing Kilimanjaro is a serious undertaking, requiring advance planning. Unfortunately, large numbers of travelers are ill prepared, ascend too quickly, and consequently fail to reach the peak. With due preparation and more reasonable ascent rates, however, climbing “Kili” is an aspiration that many can accomplish successfully. Heart, lung, and other transplant recipients, for example, have summited Kilimanjaro safely.
Despite being higher than classic trekking destinations in Nepal, such as Kala Pattar (18,450 ft; 5,625 m) or Everest base camp (17,598 ft; 5,364 m), typical ascent rates on Kilimanjaro are considerably faster (4–6 days vs 8–12 days). The classic route up Kilimanjaro is the Marangu (40 miles; 64 km), often sold as a 5-day, 4-night trip. Nicknamed the “Coca-Cola” route, Marangu features bunkhouse accommodations and food; the trail is wide and relatively easy compared to other routes. There are at least 9 other routes up the mountain (Map 10-4), including the stunningly beautiful Machame (the so-called “whiskey” route) with its longer days and generally tougher climbs. Machame and other routes involve camping and are sold as 6- to 9-day packages, providing more opportunity to acclimatize and a greater chance to successfully summit.
Kilimanjaro can be climbed throughout the year. March–April are often the wettest months, but the weather is unpredictable, and climbers must be prepared for extreme weather and rain at any time. A 2011 review of UK companies arranging high-elevation trekking trips reported that only 16 of 93 (17%) companies offering Kilimanjaro treks complied with Wilderness Medical Society guidelines on ascending to elevation, compared with 92% of treks to Everest base camp. Moreover, fewer than half of these companies carry medications to prevent or treat altitude illness, so trekkers should be prepared to carry and understand how and when to use these medications.
Map 10-04. Kilimanjaro destination map
SLEEPING ALTITUDE (FEET)PER NIGHT ALONG CLIMBING ROUTES
|Route||Night 1||Night 2||Night 3||Night 4||Night 5||Night 6||Night 7||Night 8||Night 9|
The main medical issues for those attempting to climb Kilimanjaro include the prevention and treatment of altitude illness and the potential for drug interactions between medications used for altitude illness and antimalarial or antidiarrheal agents commonly used by travelers to Tanzania.
Altitude Illness and Acute Mountain Sickness (AMS)
Altitude illness is a major reason why only about half of those attempting to summit Kilimanjaro via Marangu reach the crater rim, known as Gilman’s Point (18,652 ft; 5,685 m), and as few as 10% reach the top, Uhuru (Freedom) Peak (19,341 ft; 5,895 m). Prevalence rates of AMS were 75%–77% in recent studies of 4- and 5-day ascents on Marangu. Those using the carbonic anhydrase inhibitor acetazolamide were significantly less likely to develop acute mountain sickness (AMS) on the 5-day ascents, but 40% or more of those taking this medication still reported AMS symptoms.
Every hiker on Kilimanjaro should receive pretravel advice on AMS, be able to recognize symptoms, and know how to prevent and treat it (see Chapter 3, High-Altitude Travel & Altitude Illness). People with certain underlying medical conditions, including pregnancy, significant underlying lung or cardiac disease, and ocular or neurologic conditions, should consult a travel health provider with specialized knowledge of altitude illness. Such travelers may be more susceptible to problems associated with travel to high elevations, or they may be taking medications that can interact with medications taken to prevent AMS.
Climbers can enhance their enjoyment of the experience and increase their chances of successfully reaching the summit by allowing more time to acclimatize.
- If Ngorongoro crater (also in Tanzania) is part of a planned combined safari/Kilimanjaro hike itinerary, travelers should try to spend the last few nights of the safari there, because its elevation (7,500 ft; 2,286 m) will aid acclimatization for the Kilimanjaro trek.
- Before attempting Kilimanjaro, travelers may acclimatize by hiking nearby Mount Meru (14,978 ft; 4,565 m) or Mount Kenya (to Point Lenana, 16,355 ft; 4,895 m). Combined climbing trips for Mount Kenya and Kilimanjaro are now offered commercially.
- Adding at least an extra day or two to the ascent of Kilimanjaro facilitates acclimatization regardless of the route, but especially on routes normally promoted as 4- to 6-day trips.
Anyone with a history of AMS susceptibility and for those in whom adequate acclimatization is not possible (i.e., most “Kili” clients), use of medications such as acetazolamide to prevent altitude illness is recommended. Acetazolamide accelerates acclimatization. It is effective in preventing AMS (when started the day before ascent) and in treating AMS. Children may take it safely. Dexamethasone is an alternative for AMS prevention in people intolerant of or allergic to acetazolamide. Climbers may also use dexamethasone to prevent high-altitude pulmonary edema (HAPE) and to prevent and treat high-altitude cerebral edema (HACE).
Travelers with signs and symptoms of altitude illness must not continue to ascend and need to descend if symptoms are worsening at the same altitude. A flexible itinerary and having an extra guide who can accompany any members of the group down the mountain if they become ill are considerations.
Travel health providers must be aware of and consider possible interactions between antimalarials and drugs used to prevent or manage AMS. The tropical malaria-endemic location of Kilimanjaro means that many trekkers will be taking antimalarial drugs during their climb. And they will likely need to continue taking malaria prophylaxis after descent, particularly if they are visiting game parks or staying overnight at elevations below 6,562 ft (2,000 m).
Although the overall prevalence of malaria is falling in Tanzania, changes in climate have expanded the range of suitable habitats for Anopheles spp., making malaria transmission in the Kilimanjaro highlands a risk. Travelers flying directly into Kilimanjaro International Airport (2,932 ft; 894 m) and going the same day to an altitude above 6,562 ft (2,000 m), have little risk of malaria. Most people, however, will be on safari or traveling before or after their Kilimanjaro trip and will be on prophylaxis (see Chapter 2, Yellow Fever Vaccine & Malaria Prophylaxis Information, by Country).
Trekking Kilimanjaro is physically demanding, requiring a good level of fitness and preparation for the elements. Weather is characterized by extremes; travelers should be prepared for tropical heat, heavy rains, and bitter cold, and should store their gear (especially sleeping duffels) in waterproof bags. Travelers should have adequate health insurance, including medical evacuation insurance, and make sure their medical care and medical evacuation policies cover any potential costs for a rescue or evacuation from the top of the mountain.
Travelers should carry a first-aid kit that includes bandages, tape, a blister kit, antibacterial and antifungal cream, antibiotics for travelers’ diarrhea, antimalarials, antiemetics, oral rehydration salts, antihistamines, analgesics, throat lozenges, and medications for altitude illness (see Chapter 6, Travel Health Kits).
- Baumgartner RW, Siegel AM, Hackett PH. Going high with preexisting neurological conditions. High Alt Med Biol. 2007 Summer;8(2):108–16.
- Davies AJ, Kalson NS, Stokes S, Earl MD, Whitehead AG, Frost H, et al. Determinants of summiting success and acute mountain sickness on Mt Kilimanjaro (5895 m). Wilderness Environ Med. 2009 Winter;20(4):311–7.
- Jackson SJ, Varley J, Sellers C, Josephs K, Codrington L, Duke G, et al. Incidence and predictors of acute mountain sickness among trekkers on Mount Kilimanjaro. High Alt Med Biol. 2010 Fall;11(3):217–22.
- Kulkarni MA, Desrochers RE, Kajeguka DC, Kaaya RD, Tomayer A, Kweka EJ, et al. 10 years of environmental change on the slopes of Mount Kilimanjaro and its associated shift in malaria vector distributions. Front Public Health. 2016 Dec 21;4:281.
- Low EV, Avery AJ, Gupta V, Schedlbauer A, Grocott MP. Identifying the lowest effective dose of acetazolamide for the prophylaxis of acute mountain sickness: systematic review and meta-analysis. BMJ. 2012 Oct;345:e6779.
- Luks AM, Swenson ER, Bartsch P. Acute high-altitude sickness. Eur Respir Rev 2017 Jan 31;26(143).
- Luks AM, McIntosh SE, Grissom CK, Auerbach PS, Rodway GW, Schoene RB, et al. Wilderness Medical Society practice guidelines for the prevention and treatment of acute altitude illness: 2014 update. Wilderness Environ Med. 2014 Dec;25(4 Suppl):S4–14.
- Luks AM, Swenson ER. Travel to high altitude with pre-existing lung disease. Eur Respir J. 2007 Apr;29(4):770–92.
- Parati G, Agostoni P, Basnyat B, Bilo G, Brugger H, Coca A, et al. Clinical recommendations for high altitude exposure of individuals with pre-existing cardiovascular conditions. Eur Heart J. 2018 May 1;39(17):1546–54.
- Ritchie ND, Baggott AV, Andrew Todd WT. Acetazolamide for the prevention of acute mountain sickness—a systematic review and meta-analysis. J Travel Med. 2012 Sep–Oct;19(5):298–307.
- Shah NM, Windsor JS, Meijer H, Hillebrandt D. Are UK commercial expeditions complying with wilderness medical society guidelines on ascent rates to altitude? J Travel Med. 2011 May–Jun;18(3):214–6.