Time Zone: +5.45 hours. No daylight savings time in 2008.
Tel. Country Code: 977
USADirect Tel.: 0
Travel Advisory - Nepal
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 Nepal
U.S. citizens requiring emergency assistance may contact the Embassy at any time. For an emergency involving death, arrest, serious illness or injury, or anything that threatens the life or safety of a U.S. citizen in Nepal, call 423-4000 during normal business hours. Tell the operator that you have an emergency and ask to be transferred to the American Citizen Services Unit. After normal business hours, emergency assistance is available by calling 01-400-7266 or 01-400-7269. If calling from the United States, first dial 011-977- and then omit the next zero (for example, the normal business hours number would be 011-977-1-423-4000). If dialing from most other countries, begin by dialing 00-977.
To contact the Nepal police, simply dial 100.
HIV Test: Not required.
Required Vaccinations: Yellow fever vaccine is required for all travelers arriving from any country in the yellow fever endemic zones in Africa or the Americas.
Passport/Visa: A passport and visa are required. Travelers may obtain visas prior to travel. Visas and information on entry/exit requirements can be obtained from the Embassy of Nepal at 2131 Leroy Place, N.W., Washington, D.C.20008, telephone (202) 667-4550, or the Consulate General in New York at (212) 370-3988. Active duty U.S. military and Department of Defense contractors must obtain a country clearance from their parent units to be forwarded to the Defense Attach•s Office at the U.S. Embassy in Kathmandu for both official and unofficial travel to Nepal.
Tourists may also purchase two-month, single-entry visas or two-month, multiple-entry visas upon arrival at Tribhuvan International Airport in Kathmandu and at the following land border points of entry: Kakarvitta, Jhapa District (Eastern Nepal), Birgunj, Parsa District (Central Nepal), Kodari, Sindhupalchowk District (Northern Border), Belahia, Bhairahawa (Rupandehi District, Western Nepal), Jamunaha, Nepalgunj (Banke District, Mid-Western Nepal), Mohana, Dhangadhi (Kailali District, Far Western Nepal), and Gadda Chauki, Mahendranagar (Kanchanpur District, Far Western Nepal).
Vaccinations: Recommended and Routine
Hepatitis A: Recommended for all travelers >1 year of age not previously immunized against hepatitis A.
Hepatitis B: Recommended for all non-immune travelers who might be exposed to blood or body fluids from unsafe/unprotected sexual contact; from injecting drug use; from medical treatment with non-sterile (re-used) needles and syringes. Recommended for any traveler requesting protection against hepatitis B.
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 to rural areas (especially where there is pig rearing and rice farming) should consider vaccination if the duration of their trip exceeds 3 to 4 weeks.
• Vaccination is advised for expatriates living in this country.
• All travelers should take measures to prevent mosquito bites, especially in the evening and during the night.
Meningococcal (Meningitis): Vaccination is advised for those travelers anticipating close, extended contact with the indigenous population.
Polio: A one-time dose of IPV vaccine is recommended for any traveler >age 18 who completed the primary childhood series but never received 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: Travelers entering the country from an endemic area are required to present a certificate of immunization against yellow fever. Vaccination is not recommended or required otherwise.
Hospitals / Doctors
Medical care in Nepal is extremely limited and is generally not up to Western standards. Typical travelers' complaints can be addressed by the clinics in Kathmandu, and some surgeries can also be performed in the capital. However, serious illnesses often require evacuation to a more advanced medical facility (in Singapore, Bangkok or New Delhi ). Illnesses and injuries suffered while on trek in remote areas often require evacuation by helicopter to Kathmandu.
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 traveling in lower elevations in The Terai, 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 may be of unreliable quality.
• Travelers are advised to obtain travel insurance that provides for emergency aeromedical transport to Kathmandu or to a more advanced medical facility in India or another country in the event of serious illness or injury.
Recommended medical facilities:
• CIWEC Clinic Travel Medicine Center
Yak & Yeti Road
Tel:  (1) 228531, 241732
 (1) 224675
The CIWEC Clinic provides walk-in and emergency treatment for expatriates and travelers. Rabies, JE, and other vaccines are available.
• The Travel Medicine Center operates every day of the week including weekends and holidays. Regular appointments are available from 9-00 am to 4-30 pm Monday through Friday. Emergency visits are available on weekends and after hours. One of the doctors is on call at all times, and can be reached by phoning the Travel Medicine Center (442-4111) or simply by showing up at the center if phone lines are busy. Immunizations are available seven days a week from 9:00 a.m. to 4:30 p.m. (except lunch hour 12-1 PM).
• The Travel Medicine Center of the CIWEC Clinic is one of the most famous destination travel clinics in the world. The clinic was established in 1982 to meet the need for a Western standard clinic to treat foreign tourists, diplomats and aid workers in Nepal. The clinic is known internationally both for the high level of care afforded to patients, and for its reliable research and information about health risks in Nepal. The Travel Medicine Center was the first clinic situated in a developing country that was selected by the International Society of Travel Medicine to participate in its global surveillance program for emerging diseases among travelers. The clinic also serves as a Family Practice Center for the resident foreign and Nepalese communities. The clinic has recently moved to a greatly expanded new facility across from the British Embassy in Lainchaur-Lazimpat, in the heart of Kathmandu.
• Associated Resource: Himalyan Rescue Association:
• Patan Hospital
Tel:  (1) 522278
Patan Hospital is the third largest hospital in the Kathmandu Valley. It provides care to the indigenous population of this country, often at no charge. Foreigners should be aware that the care and the facilities are not on par with western expectations. The hospital is located 20 minutes by car from the airport, local tourist spots, and major hotels. Recent developments include an orthopedics ward, ICU, computerization of the pharmacy, and a private ward to increase charity funds. Patan also serves as a teaching hospital for a three year nursing school operated by UNM, as well as post graduate residence programs in three medical specialties.
Medical care for travelers is available at the Patan Private Clinic (Tel: 5522278, 5522266), which is affiliated with Patan Hospital.
• Baidya & Bansam Hospital
Tel:  (1) 531933
B&B Hospital is a 100-bed private hospital. Emergency services are available 24 hours a day with an attending physician on site. The facility is unable to handle neurosurgical or cardiothoracic trauma. Cardiothoracic trauma is referred to Bir Hospital which can be reached in 30 minutes. B&B Hospital can handle other major trauma cases, multiple trauma cases, the multiple injured, and mass casualties.
• Bir Hospital (300 beds); general medical and surgical facility; blood bank. Bir Hospital is the oldest government hospital in Nepal that has been providing service to the poor people from across the country since its establishment. It has also provides post-graduate training to medical, surgical and other specialists.
• United Mission Hospital (100 beds); general medical and surgical facility.
Destination Health Info for Travelers
AIDS/HIV: When HIV is transmitted through unprotected sex in Asia, it’s often during paid sex. More people in Asia engage in sex work (either as a client or a worker), than any other type of behavior that can carry a high risk of HIV infection. In South and South East Asian countries outside India, it’s thought that sex workers and their clients accounted for almost half of people living with HIV in 2007.
• Injecting drug use also is a major driving factor in the spread of HIV throughout Asia, notably in China, Indonesia and Vietnam, as well as Nepal.
In China, nearly half of all people infected with HIV are believed to have become infected through injecting drug use, and in North-East India injecting drug use is the most common HIV transmission route. There is often an overlap between communities of IDUs (injecting drug users) and communities of sex workers in Asia, as those who sell sex may do it to fund a drug habit, or they may have become involved in sex work first before turning to drug use.
• Sex between men accounted for some of the earliest recorded cases of HIV in Asia, and transmission through this route is still a prominent feature of many countries’ epidemics. Most men who have sex with men (MSM) in Asia do not identify themselves as gay because of cultural norms that discourage homosexuality; in some cases they may even be heads of families, with children.13 This means that MSM can serve as a ‘bridge’ for HIV to spread into the broader population. HIV outbreaks are becoming evident among MSM in Cambodia, China, Nepal, Pakistan, Thailand and Vietnam. (Source: www.Avert.org)
• 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.
• 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.
Altitude Sickness (AMS): The Himalayas mountain range of Nepal has eight of the world’s 14 peaks over 8000 m, including the highest of them all, Mt. Everest and numerous others with peaks between 5000 m and 6500 m. Popular trekking routes bring tourists to elevations between 4,000 m and 6,000 m during treks that last 2 to 3 weeks.
Acute mountain sickness (AMS), also known as altitude illness, is a common malady above 2,400 m (8,000 ft), especially if you do not have 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. (Himalayan Rescue Association: http://www.himalayanrescue.org)
Caution: Prior to departing for a high-altitude trip, consult with a physician about the use of medications for preventing/treating altitude illness.
• High-Altitude Illness (NEJM) http://content.nejm.org/cgi/content/extract/345/2/107
Avian Influenza (Bird Flu): The first outbreak of H5N1 avian influenza was reported from Nepal in January 2009, involving chickens and ducks in Kakarbhitta in the eastern district of Jhapa. No human cases have been reported.
• Avian influenza A (H5N1) 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 influenza A (H5N1) in birds, including those countries which have reported associated cases of human infection. To date, no cases of avian influenza A (H5N1) illness have been identified among short-term travelers visiting countries affected by outbreaks among poultry or wild birds.
Cholera: This disease is active in this country and multiple outbreaks were reported in 2007. Cholera, however, rarely occurs in travelers from developed countries. 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)
Crime/Security/Civil Unrest: We advise you to exercise a high degree of caution in Nepal due to the unpredictable security situation. Demonstrations, strikes and illegal roadblocks are possible throughout the country and often occur without notice. You should avoid demonstrations and large public gatherings as they can turn violent.
• Enforced national and local strikes (bandhs), during which most businesses are closed and vehicles are not allowed on the road, can be called without notice. Lack of transport and blockades on roads and highways during strikes can make travel very difficult and cause major traffic disruptions.
Blockades of Kathmandu can also occur without notice, making travel outside of Kathmandu Valley difficult. Demonstrations and bandhs have been held recently in protest against increased fuel costs, public transport costs, and severe fuel shortages.
• There have been reports of taxi drivers being intimidated and attacked for carrying passengers during local strikes (bandhs) and blockades. Travelers using private vehicles, including foreigners, have also been victims of intimidation and attack.
Violent demonstrations have occurred in the Terai region in southern Nepal resulting in many deaths and injuries. There have been continued incidents of serious crime in the region.
• Crime: Petty theft is common and is increasing, especially at tourist sites, on buses and in hotel rooms. Pick pocketing is common in Kathmandu, particularly in Thamel, the major tourist area. The level of crime has increased. There have been armed robberies and assaults (including sexual assaults) on tourists. Women, in particular, should not travel alone.
• Extortionists continue to approach trekkers and climbers demanding bogus donations or taxes. Victims have been assaulted, detained or threatened with violence until they pay. Many cases of extortion have occurred within the Annapurna Conservation Area (site of the well-known Annapurna Circuit and Annapurna Sanctuary trekking routes).
• Local Travel: You are strongly urged to avoid travel on public buses and microbuses and congregating at or near bus stops. There has been an increase in reports of taxi drivers refusing to use meters and charging rates well above the usual meter cost.
• Road travel in the Terai can be extremely difficult, due to curfews, strikes called at short notice and violent demonstrations. Travel in some parts of the country remains difficult as a result of damage caused by severe flooding in 2008. Travelers to Saptari and Sunsari districts may be required to take significant detours because of the damage to roads.
• Road travel at night in rural areas and travel by long-distance buses, which are generally overcrowded and poorly maintained, is dangerous. For safety and security reasons, travel after dark should be avoided. Roads are often poorly maintained, driving standards are variable and adherence to traffic laws is poor. For further advice, see the bulletin on Overseas Road Safety from Smartraveller:
• Special regulations apply to mountaineering expeditions and all expedition members are required to have permits. Australians wishing to climb in Nepal should seek information either through reputable trekking companies in Nepal or Australia or from the Nepalese Embassy in Canberra or Consulates-General in Australia (Brisbane, Melbourne, Perth and Sydney).
Trekking can be dangerous. If you choose to trek in Nepal, you should only use reputable trekking companies with professional guides. You should not trek alone. Before departing on a trek you should seek an update from the trekking company on the security situation in the area you intend to visit. Information about trail conditions and possible hazards in the northern regions can be obtained from the Himalayan Rescue Association (phone (997) 1 4440-292 / 4440-293).
Dengue Fever: ProMED, September 2010, reports an outbreak of dengue fever in Chitwan affecting more than 7 000 people with at least 19 deaths. Chitwan is located in southern Nepal, near the Indian border, and there is little to no risk of travelers to other areas of the country, especially those traveling to Kathmandu and trekking to higher altitudes.
• Dengue is transmitted via the bite of an infected Aedes aegypti mosquito. Aedes mosquitoes feed predominantly during daylight hours. All travelers to risk areas should take measures to prevent mosquito bites. Insect-bite prevention measures include applying a DEET- or picaridin-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 this disease.
• Depending on your itinerary, you should consider the diagnosis of dengue if you develop an unexplained fever during or after being in this country. A dengue fever map is at: http://www.nathnac.org/ds/c_pages/documents/dengue_map.pdf
Hepatitis: Hepatitis A is highly endemic in Nepal. 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 highly endemic and accounts for the majority (up to 95%) of clinical cases of acute viral hepatitis in adults in Nepal. Sporadic cases and outbreaks occur. Transmission of the hepatitis E virus (HEV) occurs primarily through drinking water contaminated by sewage and also through raw or uncooked shellfish. 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 1% to 3%. HBV infection is common in Nepal but the HBsAg carrier rate is much lower than reported from other Asian countries. 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 at low levels, with a prevalence of <2% in the healthy 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: Influenza is transmitted from November through March. Flu vaccine is recommended for travelers over 6 months of age who have not had a flu shot in the previous 12 months.
Japanese Encephalitis (JE): Highly endemic in rural areas of the Terai plain and Inner Terai zone, including hills, mountains, and also the Kathmandu Valley, especially in the southern agricultural areas bordering India, at elevations below 1,000 meters. Between 1 Jan and 20 Sep 2007, 1010 cases, of which 117 were confirmed, have been reported in the Terai area. Japanese encephalitis occurs year-round but transmission increases between June and October, declining in late September. This raises the question as to whether all resident expatriates and tourists to Kathmandu Valley should receive the vaccine against JE. What is the risk of a foreigner acquiring JE in Nepal? The actual risk is difficult to calculate, as there has not been a single case of JE in a foreigner in Nepal. This does not mean that it is not possible for a foreigner to get the disease, but that the actual risk must be extremely low. Short term travelers who will stay in Kathmandu for a week or two and who will go trekking are the lowest risk individuals and do not need to be immunized against JE. Longer term travelers who will reside in Kathmandu particularly in the post-monsoon period from August to October may wish to consider immunization against JE. Foreigners who will be living in known JE endemic areas, such as most of the Terai and long term expatriates who live in Kathmandu particularly in the rural areas of the valley should be immunized against JE. Japanese encephalitis vaccine is available at most travel clinics in the United States and Canada, and also at the Kalimati Clinic in Kathmandu.
Geographic Distribution of Japanese Encephalitis:
Leishmaniasis: Visceral leishmaniasis (kala-azar) occurs year-round, primarily in rural areas in districts of the southeastern Terai region at elevations below 1,000 meters. Districts include Bara, Dhanukha, Jhapa, Mahottari, Makwanpur, Morang, Parsa, Rautahat, Saptari, Sarlahi, Siraha, Sunsari, and Udaipur, adjoining the Indian state of Bihar.
The parasites that cause leishmaniasis are transmitted by the bite of the female phlebotomine sand fly. Sandflies bite in the evening and at night. Contrary to what their name suggests, sandflies are not found on beaches. They are usually found in forests, the cracks of stone or mud walls, or animal burrows.
• All travelers should take measures to prevent sandfly bites. Insect-bite prevention measures include applying a DEET-containing repellent (such as Ultrathon) to exposed skin, permethrin (spray or solution) to clothing and gear, and sleeping under a permethrin-treated bednet. The use of bednets has also been shown to be strongly protective.
Malaria: Malaria occurs in Nepal only in a few areas of the Terai, or lowland areas of Nepal below 1,200 meters elevation in plains districts of Bara, Dhanukha, Kapilvastu, Mahotari, Parsa, Rautahat, Rupandehi, and Sarlahi. Most risk occurs along the Indian border. (An outbreak was reported in October 2006 from Banke district, near the southern border with India.) Malaria occurs year-round in endemic areas but transmission increases during the monsoon season, usually July through October. Kathmandu and the northern Himalayan districts are malaria-free. P. vivax accounts for 90% of malaria cases countrywide, with P. falciparum accounting for the remainder. Chloroquine-resistant P. falciparum has been reported, particularly near the Indian border.
• Atovaquone/proguanil (Malarone), mefloquine (Lariam), doxycycline, or primaquine (requires G6PD test) prophylaxis is recommended when traveling to malarious 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 Nepal page on the Destinations menu or A-Z Index.
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: Picaridin repellents (20% formulation, such as Sawyer Picaridin 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 a malaria endemic region of this country.
Meningitis: Occurs countrywide, but routine vaccination is no longer recommended by the CDC for visitors to this country.
Other Diseases/Hazards: AIDS (low incidence; reported primarily in prostitutes who become infected in India)
• Cutaneous myiasis (fly larvae in skin; one dose of ivermectin may be curative)
• Filariasis (lymphatic filariasisi occurs primarily in the southern terai)
• Hookworm disease
Poliomyelitis (Polio): A case of polio was reported in 2006 from the west-central region in the interior of the country. Another case of polio was reported from Sarlahi district, Central Division, in 2005. All travelers should be fully immunized. A one-time dose of IPV (Inactivated Polio 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.
Rabies: This disease is prevalent, especially in Dang district, western Nepal. Annually, about one in 6,000 foreigners in Nepal receive an animal bite for which rabies vaccination is recommended. Human rabies is usually transmitted by dog bites, but bites by monkeys should also be considered dangerous.
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.
• Pre-exposure vaccination eliminates the need for rabies immune globulin (RIG) , but does not eliminate the need for two additional booster doses of vaccine. Prompt medical evaluation and treatment of any animal bite is essential, regardless of vaccination status.
Travelers' Diarrhea: The food and drink in first-class restaurants and hotels In Kathmandu are generally considered safe. A high risk of diarrhea, however, is associated with reheated food and blended fruit and yogurt drinks. Potentially contaminated water should be boiled or filtered, especially to remove parasites, such as cryptosporidia, which are not killed by chlorine. The three most common causes of diarrhea in Nepal are E. coli, campylobacter, and shigella bacteria. A quinolone antibiotic, or azithromycin, combined with loperamide (Imodium), is recommended for the treatment of acute diarrhea. Diarrhea not responding to treatment with a quinolone may be due to a parasitic disease such as giardiasis, amebiasis, cryptosporidiosis or cyclosporiasis. Diarrhea caused by cyclospora parasites (cyclosporiasis is common in Nepal—up to 7% of expatriates are infected) will respond to treatment with trimethoprim/sulfamethoxazole).
Tuberculosis: Tuberculosis is highly endemic in Nepal 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: This disease is highly endemic and cases are reported to be on the rise in the Dhawalagiri region. Typhoid is the most serious of the Salmonella infections. Typhoid vaccine is recommended by the CDC for all people traveling to or working in Nepal, 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.