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Bhutan



Capital: Thimphu

Time Zone: +5.5 hours.
Tel. Country Code: 975
USADirect Tel.: 0
Electrical Standards: Electrical Current 220/50 (volts/hz). A variety of power outlets are used, but most plugs have two or three round pins. Grounding Adaptor Plugs C, D, F.


Travel Advisory - Bhutan

Malaria, Japanese encephalitis, and dengue fever occur throughout SE Asia and the Indian sub-Continent. Insect-bite protection is essential. Hepatitis E, spread by contaminated water, is also a threat. There is no vaccine. Pregnant women are at special risk. Take measures, as needed, to purify your water outside of first-class hotels.

Dr. Rose Recommends for Travel to Bhutan


Resource Links

NaTHNaC
World Health Organization
CDC
Travel Health Services
Country Insights
Travel Warnings
Consular Information
Foreign Commonweatlh Office

Embassies

No formal diplomatic relations exist between the United States and Canada and Bhutan.
The U.S. Embassy in New Delhi, Tel: [91] (11) 688-9033, handles informal diplomatic contact with this country.

• Canadian Cooperation Office
Tel: [975] (2) 322-109 or 332-615; [975] 17110040 (mobile phone)
Fax: [975] (2) 332-614
E-Mail: canada@druknet.bt

There is no British representation in Bhutan. The nearest consular office is the British Deputy High Commission in Kolkata (formerly Calcutta).

• BRITISH DEPUTY HIGH COMMISSION
1A Ho Chi Minh Sarani
Kolkata
Main switchboard: [91] (33) 2288 5173-76
Telephone: [91] (33) 2288 5173-76
[91] (33) 2288 6536 After office hours
Fax: [91] (33) 2288 3996 Visa Section
E-mail: kolkata@fco.gov.uk

Entry Requirements

HIV Test: Not required.

Required Vaccinations: Yellow fever vaccine is required for all travelers >1 year of age arriving from any country in the yellow fever endemic zones in Africa or the Americas. Not recommended or required otherwise.

Passport Information

Passport/Visa: Independent travel is not permitted in Bhutan. A passport and visa are required for entry into and exit from Bhutan. Visa applications are available from selected travel agencies. Travel agencies will usually arrange for a traveler’s entry visa and clearance. Most visitors, including those on official U.S. government business, should obtain visas prior to entering the country. For additional entry/exit information, please contact the Bhutan Mission to the United Nations (Consul General), 763 First Avenue, New York, NY 10017, telephone (212) 682-2268, fax (212) 661-0551.

Vaccinations: Recommended and Routine

Yellow fever vaccine is required for all travelers >1 year of age arriving from any country in the yellow fever endemic zones in Africa or the Americas. Not recommended or required otherwise.

Hepatitis A: Recommended for all travelers >1 year of age not previously immunized against hepatitis A.

Hepatitis B: Recommended for all non-immune travelers at potential risk for acquiring this infection. Hepatitis B is transmitted via infected blood or bodily fluids. Travelers may be exposed by needle sharing and unprotected sex; from acupuncture, tattooing or body piercing; when receiving non-sterile medical or dental injections, or unscreened blood transfusions; by direct contact with open skin sores on an infected person. Recommended for long-term travelers, expatriates, and any traveler requesting protection against hepatitis B infection.

Influenza: Vaccination recommended for all travelers >6 months of age who have not received a flu shot in the previous 12 months.

Japanese Encephalitis: Recommended for travelers planning to visit rural farming areas for >4 weeks and under special circumstances, such as a known outbreak of Japanese encephalitis.

Polio: A one-time dose of IPV vaccine is recommended for any traveler >age 18 who completed the primary childhood series but never received an additional dose of polio vaccine as an adult. Available data do not indicate the need for more than a single lifetime booster dose with IPV (Inactivated Polio Vaccine).

Rabies: Recommended for travelers spending time outdoors in rural areas where there is an increased the risk of animal bites. Children are considered at higher risk because they tend to play with animals and may not report bites. Pre-exposure vaccination eliminates the need for rabies immune globulin in the event of a high-risk animal bite, but does not eliminate the need for treatment with the vaccine.

Routine Immunizations: Immunizations against tetanus-diphtheria, measles, mumps, rubella (MMR vaccine) and varicella (chickenpox) should be updated, if necessary, before departure. MMR protection is especially important for any female of childbearing age who may become pregnant.
• The new Tdap vaccine, ADACEL, which also boosts immunity against pertussis (whooping cough) should be considered when a tetanus-diphtheria booster is indicated.


Typhoid: Recommended for all travelers.

Yellow Fever: Yellow fever vaccine is required for all travelers >1 year of age arriving from any country in the yellow fever endemic zones in Africa or the Americas. Not recommended or required otherwise.

Hospitals / Doctors

Medical care is substandard in this the country, including the capital, Thimphu. Health service is provided through a four-tiered network consisting of a National Referral Hospital, Regional Referral Hospitals, District Hospitals and Basic Health Units. Shortages of routine medications and supplies may be encountered. There is no medical school in this country.
• All travelers should be up-to-date on their immunizations and are advised to carry a medical kit as well as antibiotics to treat travelers diarrhea or other infections; they should bring drugs for malaria prophylaxis, if needed according to their itinerary. Travelers who are taking regular medications should carry them properly labeled and in sufficient quantity to last for the duration of their trip; they should not expect to obtain prescription or over-the-counter drugs in local stores or pharmacies in this country - the equivalent drugs may not be available, or be of unreliable quality.
• Travelers are advised to obtain comprehensive travel insurance with specific overseas coverage. Policies should cover: ground and air ambulance transport, including evacuation to home country; payment of hospital bills; 24-hour telephone assistance. In the event of a serious illness or injury that can't be treated adequately in this country, the traveler should be flown by air ambulance to India or Bangkok.

Destination Health Info for Travelers

AIDS/HIV: There is a low prevalence of AIDS/HIV in Bhutan. Heterosexual contact remains the primary mode of transmission.
• Transmission of HIV can be prevented by avoiding: sexual contact with a high-risk partner; injecting drug use with shared needles; non-sterile medical injections; unscreened blood transfusions.
• The threat of HIV/AIDS should not be a primary concern for the traveler. However, there may be a concern for a subset of travelers who may be exposed to HIV, the virus that causes AIDS, through contact with another person’s body fluids or blood. Although travel has contributed in a general way to the global spread of AIDS, fear of traveling because of this disease is not warranted.

Accidents & Medical Insurance: Accidents and injuries are the leading cause of death among travelers under the age of 55 and are most often caused by motor vehicle and motorcycle crashes; drownings, aircraft crashes, homicides, and burns are lesser causes.
• Heart attacks cause most fatalities in older travelers.
• Infections cause only 1% of fatalities in overseas travelers, but, overall, infections are the most common cause of travel-related illness.
• MEDICAL INSURANCE: Travelers are advised to obtain, prior to departure, supplemental travel health insurance with specific overseas coverage. The policy should provide for direct payment to the overseas hospital and/or physician at the time of service and include a medical evacuation benefit. The policy should also provide 24-hour hotline access to a multilingual assistance center that can help arrange and monitor delivery of medical care and determine if medevac or air ambulance services are required.
Health insurance is essential.

Acute Mountain Sickness (AMS)/Altitude Illness: The northern region of Bhutan consists of an arc of glaciated mountain peaks with an extremely cold climate at the highest elevations. Most peaks in the north are over 7,000 m above sea level; the highest point is the Kula Kangri, at 7,553 m, and Gangkhar Puensum, at 7,541 m. Most of the designated trekking routes are between 3,000 m and 6,000 m elevation.
Acute mountain sickness (AMS), also known as altitude illness, is a common malady above 2,400 m (8,000 ft), especially if you have not had a chance to acclimatize by ascending gradually. The prevalence of AMS varies between 15% and 75%, depending on your speed of ascent, altitude gained, sleeping altitude, and individual susceptibility. Acute mountain sickness can progress to high altitude cerebral edema (HACE) or be associated with high altitude pulmonary edema (HAPE). You should intersperse your ascent with rest days and avoid, if possible, increasing your sleeping altitude by more than 1,000 - 1,500 feet each night. To reduce further your risk of AMS, take acetazolamide (Diamox), starting the day prior to beginning your ascent. Acetazolamide is a respiratory stimulant that speeds acclimatization and is about 75% effective. It may also reduce the risk of HAPE.
• Symptoms of AMS include mild to moderate headache, loss of appetite, nausea, fatigue, dizziness and insomnia. Mild AMS usually resolves with rest plus medication for headache and nausea. You can also take acetazolamide to treat mild AMS.
• Under no circumstances should you continue to ascend (especially to a higher sleeping altitude) if you have any persistent symptoms of altitude illness. In the absence of improvement or with progression of symptoms you should descend (at least 500 m) to a lower altitude.
• Dexamethasone (Decadron) is a steroid drug used for treating AMS and HACE. You should carry stand-by treatment doses. You can take dexamethasone together with acetazolamide to treat mild- to moderate-AMS.
• More severe AMS (increasing headache, vomiting, increasing fatigue or lethargy) may indicate the incipient onset of high-altitude cerebral edema (HACE)—recognized by confusion, difficulty with balance and coordination, staggering gait. Start treatment with dexamethasone and descend immediately.
• Increasing dry cough and breathlessness at rest may indicate high altitude pulmonary edema (HAPE). Nifedipine, sildenafil (Viagra), or tadalafil (Cialis) can be used for both the prevention and treatment of HAPE. Dexamethasone and the asthma drug salmeterol (Serevent) also will prevent HAPE.
• Descent, combined with medication (and oxygen, if available) is the best treatment for more severe AMS, HACE or HAPE. Consider helicopter evacuation if the situation is urgent.

Caution: Prior to departing for a high-altitude trip, consult with a physician about the use of medications for preventing/treating altitude illness.
Further advice:
http://www.ismmed.org
http://www.altitudemedicine.org
http://www.basecampmd.com/expguide/highalt.shtml
http://wwwn.cdc.gov/travel/yellowBookCh6-AltitudeIllness.aspx
• High-Altitude Illness (NEJM) http://content.nejm.org/cgi/content/extract/345/2/107

Avian Influenza A (Bird Flu): There are no reports of Avian Influenza in this country.
• H5N1 avian influenza is predominantly a disease of birds. The virus does not pass easily from birds to people and does not to pass from person to person (except in very rare cases of close contact with an infected blood relative).
• The risk to humans from avian influenza is believed to be very low and no travel restrictions are advised, except travelers should avoid visiting animal markets, poultry farms and other places where they may come into close contact with live or dead poultry, or domestic, caged or wild birds and their excretions. In addition, travelers are advised to:
1. Cook poultry and egg dishes thoroughly. (Well-cooked poultry is safe to eat.)
2. Wash hands frequently with soap and water if around poultry.

• The World Health Organization (WHO) does not recommend travel restrictions to countries experiencing outbreaks of H5N1 avian influenza in birds, including those countries which have reported associated cases of human infection.

The usual vaccines against influenza are not protective against “bird flu.”
Oseltamivir (Tamiflu) is somewhat effective in the treatment of H5N1 avian influenza. It seems to be effective in some cases, but may fail in others. Recently, resistant strains have been reported. In addition, the dosage and duration of treatment appear to be different in severe H5N1 cases.

Cholera: This disease is reported active in this country, but most travelers are at low risk for infection. Cholera vaccine is recommended only for relief workers or health care personnel who are working in a high-risk endemic area under less than adequate sanitary conditions, or travelers who work or live in remote, endemic or epidemic areas and who do not have ready access to medical care. Canada, Australia, and countries in the European Union license an oral cholera vaccine. The cholera vaccine is not available in the United States.
• The main symptom of more severe cholera is copious watery diarrhea.
• Antibiotic therapy is a useful adjunct to fluid replacement in the treatment of cholera by substantially reducing the duration and volume of diarrhea and thereby lessening fluid requirements and shortening the duration of hospitalization.
• A single 1-gm oral dose of azithromycin is effective treatment for severe cholera in adults. This drug is also effective for treating cholera in children. (NEJM:http://content.nejm.org/cgi/content/short/354/23/2452)

Dengue Fever: Cases of dengue fever reported in 2008 from Gatiya and from Lower Phuentsholing town. Dengue is endemic in southern plains region, year-round, with risk elevated during the rainy season, May through mid-October.
Dengue fever is a mosquito-transmitted, flu-like viral illness widespread in the Indian sub-Continent. Symptoms consist of sudden onset of fever, headache, muscle aches, and a rash. A syndrome of hemorrhagic shock can occur in severe cases.
• Dengue is transmitted via the bite of an infected Aedes aegypti mosquito. Aedes mosquitoes feed predominantly during daylight hours. All travelers are at risk and should take measures to prevent daytime mosquito bites. Insect-bite prevention measures include applying a DEET-containing repellent to exposed skin and applying permethrin spray or solution to clothing and gear.
• There is no vaccination or medication to prevent or treat dengue.
A dengue fever map is at: http://www.nathnac.org/ds/c_pages/documents/dengue_map.pdf


Food & Water Safety: All water should be regarded as being potentially contaminated. Water used for drinking, brushing teeth or making ice should have first been boiled or otherwise sterilized. Milk is unpasteurised and should be boiled. Powdered or tinned milk is available and is advised, but make sure that it is reconstituted with pure water. Avoid all dairy products. Only eat well-cooked meat and fish, preferably served hot. Pork, salad and mayonnnaise may carry increased risk. Vegetables should be cooked and fruit peeled.

Hepatitis: All travelers not previously immunized against hepatitis A should be vaccinated against this disease. Travelers who are non-immune to hepatitis A (i.e. have never had the disease and have not been vaccinated) should take particular care to avoid potentially contaminated food and water. Travelers who will have access to safe food and water are at lower risk. Those at higher risk include travelers visiting friends and relatives, long-term travelers, and those visiting areas of poor sanitation.
• Hepatitis E is hyperendemic and is the predominant cause of acute adult hepatitis in Bhutan. Sporadic outbreaks as well as large epidemics of hepatitis E occur. Transmission of the hepatitis E virus (HEV) occurs primarily through drinking water contaminated by sewage and also through raw or uncooked shellfish. Farm animals (primarily pigs) may serve as a viral reservoir. In developing countries, prevention of hepatitis E relies primarily on the provision of clean water supplies and overall improved sanitation and hygiene. There is no vaccine.
• The overall hepatitis B (HBsAg) carrier rate in the general population is estimated at 2% to 7%. Hepatitis B is transmitted via infected blood or bodily fluids. Travelers may be exposed by needle sharing and unprotected sex; from non-sterile medical or dental injections, and acupuncture; from unscreened blood transfusions; by direct contact with open skin lesions of an infected person. The average traveler is at low risk for acquiring this infection. Vaccination against hepatitis B is recommended for: persons having casual/unprotected sex with new partners; sexual tourists; injecting drug users; long-term visitors; expatriates, and anybody wanting increased protection against the hepatitis B virus.
• Hepatitis C is endemic with a prevalence of 1.3% in the general population. Most hepatitis C virus (HCV) is spread either through intravenous drug use or, in lesser-developed countries, through blood contamination during medical procedures. Over 200 million people around the world are infected with hepatitis C - an overall incidence of around 3.3% of the population of the world. Statistically, as many people are infected with HCV as are with HIV, the virus that causes AIDS.

Influenza: Flu is transmitted November to March. Flu vaccine is recommended for travelers >6 months of age.

Japanese Encephalitis (JE): There is no data regarding affected areas, but the southern border regions with India may be a risk. The Centers for Disease Control and Prevention (CDC) recommends JE vaccination for travelers spending more than 30 days in an endemic environment, or less than 30 days in areas with epidemic transmission. However, the use of an arbitrary cutoff cannot protect all travelers. Advance knowledge of trip details, accommodation and purpose, as well as local geography, is warranted to give adequate advice. Is travel occurring during the peak transmission season? In general, travelers to rural areas (especially where there is pig rearing and rice farming) should be vaccinated if the duration of their trip exceeds 3 to 4 weeks. They may consider vaccination for trips of shorter duration if more intense exposure is anticipated, especially during unprotected outdoor activities in the evening. Vaccination is advised for expatriates living in this country.
• Japanese encephalitis is transmitted by night-biting Culex mosquitoes. All travelers should take measures to prevent mosquito bites, especially in the evening and overnight. Insect-bite prevention measures include applying a DEET-containing repellent to exposed skin, applying permethrin spray or solution to clothing and gear, and sleeping under a permethrin-treated bednet.

Malaria: Endemic at moderate to high levels. Risk is present year-round in the south and southeastern districts bordering India, including urban areas. Risk generally limited to the Duars Plain and the mountain valleys of the Lesser Himalayas up to 1,700 meters elevation. Risk may be elevated during the rainy season, May through mid-October. Thimbu is risk free. P. falciparum causes 45% of cases countrywide, P. vivax the remainder.
• Prophylaxis with atovaquone/proguanil (Malarone), mefloquine (Lariam), doxycycline, or primaquine (G6-PD test required) is recommended in risk areas.

A malaria map is located on the Fit for Travel website (www.fitfortravel.nhs.uk), which is compiled and maintained by experts from the Travel Health division at Health Protection Scotland (HPS). Go to www.fitfortravel.nhs.uk and select Malaria Map from the Bhutan on the Destinations menu.

Malaria is transmitted via the bite of an infected female Anopheles mosquito. Anopheles mosquitoes feed predominantly during the hours from dusk to dawn. All travelers should take measures to prevent evening and nighttime mosquito bites. Insect-bite prevention measures include applying a DEET-containing repellent to exposed skin, applying permethrin spray or solution to clothing and gear, and sleeping under a permethrin-treated bednet. DEET-based repellents have been the gold standard of protection under circumstances in which it is crucial to be protected against insect bites that may transmit disease. Nearly 100% protection can be achieved when DEET repellents are used in combination with permethrin-treated clothing.
NOTE: Picardin repellents (20% formulation, such as Sawyer GoReady or Natrapel 8-hour) are now recommended by the CDC and the World Health Organization as acceptable non-DEET alternatives to protect against malaria-transmitting mosquito bites. Picaridin is also effective and ticks and biting flies.
• You should consider the diagnosis of malaria if you develop an unexplained fever during or after being in this country.
• Long-term travelers who may not have access to medical care should bring along medications for emergency self-treatment should they develop symptoms suggestive of malaria, such as fever, chills, headaches, and muscle aches, and cannot obtain medical care within 24 hours.

Other Diseases/Hazards: Brucellosis (reported in low numbers), filariasis (currently not reported), leprosy (highly prevalent; an estimated 5–10 cases/1,000 population), leptospirosis, scabies, murine and scrub typhus, trachoma, typhoid fever, and intestinal worms (whipworms, roundworms, hookworms) are reported.

Rabies: Highly prevalent. Dogs are the primary source of human infection. All dog and animal bites should be medically evaluated for possible post-exposure treatment. Although rabies is rare among tourists—there is risk. No one should pet or pick up any stray animals. All children should be warned to avoid contact with unknown animals.
Pre-exposure rabies vaccine is recommended for: persons anticipating an extended stay; for those whose work or activities may bring them into contact with animals; for people going to rural or remote locations where medical care is not readily available; for travelers desiring extra protection. Children are considered at higher risk because they tend to play with animals and may not report bites.

All animal bite wounds, especially from a dog, should be thoroughly cleansed with soap and water and then medically evaluated for possible post-exposure treatment, regardless of your vaccination status. Pre-exposure vaccination eliminates the need for rabies immune globulin, but does not eliminate the need for two additional booster doses of vaccine.

Note: If adequate rabies treatment is not available locally, immediate medical evacuation to India is advised to a facility that can provide post-exposure treatment.

Travelers' Diarrhea: Water supplies in Bhutan are frequently contaminated as a result of substandard sanitary conditions. Prevention of diarrhea consists primarily in following strict adherence to safe food and drink guidelines. Outside of hotels and resorts, we recommend that you boil, filter or purify all drinking water or drink only bottled water or other bottled beverages and do not use ice cubes. Avoid unpasteurized milk and dairy products. Do not eat raw or undercooked food (especially meat, fish, raw vegetables—these may transmit intestinal parasites, as well as bacteria). Peel all fruits.
• Good hand hygiene reduces the incidence of travelers’ diarrhea by 30%.
• A quinolone antibiotic, or azithromycin, combined with loperamide (Imodium), is recommended for the treatment of diarrhea. Diarrhea not responding to antibiotic treatment may be due to a parasitic disease such as giardiasis, amebiasis, or cryptosporidiosis.
• Seek qualified medical care if you have bloody diarrhea and fever, severe abdominal pain, uncontrolled vomiting, or dehydration.


Tuberculosis: Tuberculosis is highly endemic in Bhutan with an annual occurrence was greater than or equal to 40 cases per 100,000 population. Tuberculosis (TB) is transmitted following inhalation of infectious respiratory droplets. Most travelers are at low risk. Travelers at higher risk include those who are visiting friends and relatives (particularly young children), long-term travelers, and those who have close contact, prolonged contact with the local population. There is no prophylactic drug to prevent TB. Travelers with significant exposure should have PPD skin testing done to evaluate their risk of infection.

Typhoid Fever: Typhoid is the most serious of the Salmonella infections. Typhoid vaccine is recommended for all people traveling to or working in Bhutan, especially if visiting smaller cities, villages, or rural areas and staying with friends or relatives where exposure might occur through food or water. Current vaccines against Salmonella typhi are only 50-80% protective and do not protect against Salmonella paratyphi. the cause of paratyphoid fever. (Paratyphoid fever bears similarities with typhoid fever, but the course is generally more benign.) Travelers should continue to practice strict food, water and personal hygiene precautions, even if vaccinated.