Destination Background

Nepal is a country of over 27 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 29,135 ft (8,848 m), the peak of Mt. Everest. About 25% 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 over 1 million people. It sits in a lush valley at 4,300 ft in altitude (1,300 m). 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 three main trekking areas: the Mt. Everest region east of Kathmandu, the Annapurna region to the west, and the Langtang region north of Kathmandu. Trekkers into the Mt. Everest region routinely sleep at altitudes of over 14,000–16,000 ft (4,200–4,900 m) and hike to altitudes over 18,000 ft (5,500 m). This prolonged exposure to very high altitudes means that tourists must be knowledgeable about the risks of high-altitude illness and may need to carry specific medications to prevent and treat the problem (see the Altitude Illness section in Chapter 2). The majority of trekkers into the Mt. Everest region arrive there by flying to a tiny airstrip at Lukla at 9,000 ft (2,700 m). The following day they reach Namche Bazaar at 11,300 ft (3,500 m). Acetazolamide prophylaxis can greatly 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 the 15- to 20-day trek around the Annapurna massif, going over a 17,700-ft (5400-m) pass. 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, rhinocerous, bears, and crocodiles. It is also possible to travel by road to comfortable lodges in the foothills that afford panoramic views of the Himalayas.

Nepal has a high risk for enterically transmitted diseases. Hepatitis A vaccine and typhoid vaccine are the two most important immunizations. The risk for typhoid fever among travelers to Nepal is one of the highest in the world.

Japanese encephalitis (JE) is endemic in Nepal, mainly in the Terai region during and immediately after the monsoon season, which usually runs from mid-June to mid-September. JE has been detected in local people living in the Kathamandu Valley (outside the city), but there have been no reported cases of JE in a tourist or expatriate in Nepal. The vaccine is not recommended for usual tourists or trekkers unless they will be spending time living in rural low-altitude areas during the season of risk. However, in recent years, expatriates living in Nepal are usually immunized against JE because they may frequently take side trips outside Kathmandu (see the Japanese encephalitis section in Chapter 2).

Malaria is not a risk for the vast majority of travelers to Nepal. There is no risk for malaria in Kathmandu or Pokhara, the two main cities in Nepal. All the main trekking routes in Nepal are free of malaria risk. Chitwan National Park is a popular tourist destination for wildlife viewing in the Terai. While it is noted that the Nepalese Ministry of Health and other regional organizations regard the Terai to be a malaria transmission area, this author, in 25 years of treating travelers in Nepal, has not seen a single case of malaria in a traveler to Chitwan, and therefore considers the risk within Chitwan National Park for malaria to be low.

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 to October, with a peak in June and July. Because this is outside the main tourist seasons, the primary impact is on expatriates who stay through the monsoon. 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.

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 asthma or even just a history of asthma may suffer exacerbations in Kathmandu, particularly after a viral upper respiratory infection. Asthma has not been a significant problem in tourists outside Kathmandu.

Rabies is highly endemic among dogs in Nepal, but in recent years there are fewer stray dogs in Kathmandu. Half of all tourist exposures (caused by bites or scratches from dogs and monkeys) that lead to postexposure rabies immunoprophylaxis occur near Swayambunath, a beautiful hilltop shrine also known as the monkey temple, so tourists should be advised to be extra cautious with both 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 that specialize in the care of foreigners almost always have complete postexposure rabies immunoprophylaxis, including human rabies immune globulin. Trekkers who are bitten in the mountains are able to return to Kathmandu within an average of 5 days.

Empiric MedicationsSince 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 significant risk, and the risk in the spring trekking season (March to 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 accounts for as much as 20% of the etiology of 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 an excellent alternative and should be used if there is no response to ciprofloxacin.

Viral upper respiratory infections (URI) are extremely common, and the percentage of these that lead to bacterial sinusitis or bronchitis is high. Trekkers may wish to carry an antibiotic, such as azithromycin, for empiric treatment of a prolonged URI that results in bronchitis or sinusitis. It is possible that more treks have been ruined by respiratory infection than by gastrointestinal illness.

EvacuationHelicopter evacuation from most areas is readily available. Communication has improved from remote areas because of satellite and cell phones, and private helicopter companies accept credit cards and are eager to perform evacuations for profit. Evacuation can sometimes take place on the same day as the request, if weather permits. Helicopter rescue is usually limited to morning hours due to afternoon winds in the mountains. The cost of helicopter evacuation ranges from $3000 to $5000.