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A How-to for Healthy, Happy Holidays
A chat with the capital’s leading travel medicine center on how you can stay healthy as you trek and explore.
Evangeline Neve in conversation with Prativa Pandey, M.D.
This month we are focusing on trekking, and along with all the adventures and experiences, we don’t want to neglect the vital health and safety angle, so we thought we’d go straight to the horse’s mouth and visit CIWEC hospital. It’s been open since 1982, and while it caters to all facets of healthcare, including dentistry, cancer care, and more, it’s most famous as a center for travel medicine. Dr. Prativa Pandey has been its medical director since 1998, and she took some time out of her busy schedule to answer a few of our questions. We hope these tips and information will be assets to your trekking plans, though of course it is not a substitute for your own doctor’s advice.
Q: What’s the major health problem you see in travelers who visit Nepal? Is it stomach problems?
A: Yes, the gastrointestinal is about 30%, that’s hard data; respiratory infections about 16%, and then muscular-skeletal about 10%, and then skin problems, fevers, high-altitude illness—we see about 7%.
(Of course, I’m curious to know if the respiratory problems are on the rise, because of the dust, but Dr. Pandey says that they are really about the same, according to their statistics of those that come to CIWEC for treatment.)
Q: What is the biggest thing that foreigners with no experience in this part of the world can do to stay healthy, especially those traveling outside the valley for trekking?
A: For travelers in general, they will mainly have gastrointestinal illnesses, mainly acute diarrhea. Some 30-60% of travelers who come to Nepal will develop diarrhea during their stay here—that’s data backed by research. You have to focus on good food and water precautions, maintain good food hygiene, eat foods that are cooked fresh and served hot, and avoid foods that are cooked earlier in the day and left around. In our study, we found that quiche and lasagna that were cooked earlier in the day and then reheated and served caused high rates of diarrhea. The younger the person is, the higher the rates, as well.
Q: So, the younger travelers have more trouble than the older ones? I would have thought it would have been the other way around, that the younger ones would have a better, stronger immune system.
A: Because the older travelers have been exposed to pathogens over the years, their bowels are exposed to different pathogens, while the younger ones, their guts are more naive, so they tend to get more infections.
Q: I never thought about it that way before, but it makes sense.
A: We’ve emphasized: cook it, boil it, peel it, or forget it, but a lot of studies have shown that that doesn’t really help prevent diarrhea.
Q: Why not?
A: It doesn’t seem to, because it could be something—like a process, (someone) touching, a fly sitting on food, something like that.
Q: So, you’re saying it’s almost impossible at a certain level to prevent it?
A: Yes, that’s why we say: Be prepared to self-treat. These days, a new issue has come up; travelers who travel mainly to South Asia and take antibiotics for diarrhea are at a high risk for colonizing their gut with resistant bacteria, and then take it back home and give it to the community, as well. What we don’t know is what that translates into in clinical practice. That’s not been studied, but what has been studied is that people will take these resistant bacteria in their guts back home. So, there is a tendency now to not treat mild diarrhea with an antibiotic. Moderate to severe—yes, treat with an antibiotic, because 80% of the time it’s due to bacteria. So, this is something new.
And what we say, especially for diarrhea, is that you don’t need to finish the course, a single tablet might be effective. So, in fact, even if we give out three tablets—one tablet a day, for three days—if you’re better, it’s not necessary to continue, at least not in this instance with travelers’ diarrhea, because we want to prevent the person getting resistant bacteria in their gut. So, if one tablet is effective, there’s no need to continue and finish the three-day course.
Q: Would you recommend that people who are going trekking take that medicine with them?
A: Yes, there’s a big push on self-treatment in the travel medicine community, because they feel that if a person is seen at a hospital they might be exposed to multiple antibiotics, multiple drugs. Poly-pharmacy is a rule around here, people are given two-three different antibiotics, painkiller, anti-spasmodic, anti-this, anti-that, so a person with diarrhea might easily get eight different medications, and also could then be hospitalized. So, a different issue has come up. The Western travel medical community, at least, feels that self-treatment is much better. For diarrhea, azithromycin is the antibiotic of choice, and a single tablet can be effective, and then you stop once you’re better. It’s a once-a-day antibiotic, 500 mg once a day for three days, and if you’re better the next day, then you stop. You don’t have to continue and finish it, because once the bacteria starts to clear, your system will take care of it, it’ll clear the rest of the infection. Even if untreated with an antibiotic, you can clear your diarrhea infections by yourself, but that could take a long time, so you’re just speeding up the process by taking the antibiotic. A lot of times now, for mild illness, we say that it’ll clear by itself; just focus on your foods, and for mild diarrhea, good fluid replacement.
Q: Well, I’ve often thought of that as common sense, but I am surprised to hear it coming from a medical professional, especially here, where medicine is often all too quickly prescribed, even for colds and the like.
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Q: Next, what about altitude related illnesses?
A: We see a lot of altitude related illnesses, especially in the trekking season, the most common of which is acute mountain sickness (AMS), About 50% of trekkers to the Everest region will get AMS, but not everyone gets it badly—some rest and get better and then move on. Only a small percentage will develop the severe form of altitude illnesses called high-altitude pulmonary edema and high-altitude cerebral edema, and those need to descend. And, of course, there are a lot of helicopters that bring sick persons back from the mountains.
Q: When I went trekking a few years ago, it was recommended that we take Diamox tablets, is that still the best thing to do? Is that preventively helpful, or not?
A: Yes, you can take acetazolamide (Diamox); it is preventively helpful, the dose is 125 mg twice a day, so half a tablet twice a day. It works. It helps you to acclimatize, especially if people have been sensitive on a previous trip. There’s a genetic susceptibility to altitude sickness, some people don’t get it at all, and are very resistant to getting altitude illness, while others are very sensitive. So, especially if you know that you are sensitive, from a previous trip, or if you are just flying in to a high-altitude location, then it’s worthwhile to take the Diamox prophylaxis.
Q: So, it’s preventive, but does it help after you’re already unwell?
A: It helps, but it helps more as a preventive than as a treatment. And there are some side-effects like tingling around the mouth and toes and fingers, but that’s almost universal—almost 95% of the people will get it. People need to know about that, because some people worry about it a lot if they aren’t aware. And it alters the taste of carbonated drinks. If you drink Coca-Cola after a Diamox tablet, it makes you feel really bad. That’s also something to know.
Q: That’s good to know! I sure would worry, especially about the numbness.
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Q: Anything else?
A: So, after diarrhea, we see a lot of altitude problems during the season, and a lot of patients have both, and this is much more common in the spring months that in the fall months. In April-May-June, the risk of diarrhea is double in Nepal.
Q: Why?
A: We think it’s the flies in the environment, although we haven’t proven it. There are a lot more flies starting in March, in the pre-monsoon dry months, so the risk of diarrhea is double. The hygiene and sanitation hasn’t changed in the last thirty years, it’s the same—the numbers don’t change.
Q: You mean these percentages have been steady all of these years?
A: Yes, steady. And, for instance, in Jamaica, they have cut down the rates of gastrointestinal illness by improving restaurant hygiene, so at one point it was started here, a project with the World Bank that was working on improving restaurant hygiene, and they were doing some studies in the Pokhara area. This was before the earthquake, but since then I haven’t heard any more about it. You can really improve things by improving restaurant hygiene, because as a tourist you have to eat out all the time. You have to eat three meals out, so you’re very susceptible. It’s small things, really. And, because these people’s guts have not been exposed to a lot of these bacteria, even a small amount can cause problems.
Q: What is the situation with infectious diseases that you read about in papers and that are often very frightening for tourists: cholera, dengue fever, malaria, and so on? I had always been told that malaria was not a problem in the Kathmandu valley, but recently I heard that, with rising temperatures there are starting to be cases here. Is that true?
A: It’s not a problem. We personally have not seen a single case of malaria in travelers that was acquired within Nepal in the past twenty-five years that I’ve been here. It’s imported. Right now, we have a patient with malaria who got it in Ghana. It comes mostly from Africa, and a small number of cases from South East Asia. Malaria is declining in Nepal, and any cases tend to be in the Terai. So, we are saying that there is no malaria in Kathmandu, Pokhara, and the trekking routes, and even for short visits to Chitwan National Park we don’t recommend any prophylaxis.
There are some pockets of malaria in the west Terai, a little bit in the center, and a little bit toward the far-east, but those are small pockets, and the risk of malaria is very negligible for travelers. And, regarding dengue fever, we’ve had maybe one or two cases in the past two-three years—it came to Nepal in 2010 in a big way, there were lots of cases in the Chitwan area, and subsequently in Jhapa and Nepalgunj. Now, this year, we are hearing of cases in Dhading, but I have not heard of dengue acquired within Kathmandu. It is present, but in very small numbers, not like the thousands of cases they have in India, Sri Lanka, Thailand, etc. And, the rates of typhoid in Nepal have gone down in the foreign population. I’m not aware of the trends in the local population, but amongst foreigners, the rates of typhoid and hepatitis have gone down. So, I feel that Nepal is a relatively safe country for travel, because these serious vector borne diseases like malaria, dengue, and so on exist in very small numbers.
Q: Well, that is certainly very reassuring to hear, and I think others, particularly those visiting here for the first time, will feel the same.
A: I think the stomach is the weak area here, and the altitude, for people who go trekking, and respiratory infections with the cold and the flu and pneumonia. Pneumonia, we feel we see a little bit more of that than other things.
Q: What do you think is the cause of that?
A: Well, most of the time it is due to bacteria. It’s very difficult to figure out. A lot of the people who get it have been trekking.
Q: Are there any other tips that you would give to a traveler in Nepal?
A: They must buy travel insurance that covers rescue. That’s number one, especially if they are trekking. And, drink boiled or bottled water. The one-liter bottles you can trust, but the 20-liter jars that are found very cheaply in different places you can’t really trust. They are often not sealed, the quality is very variable. I wouldn’t trust those. One-liter sealed bottles should be okay to drink. Sometimes, people have found some bacteria in those, but once we tested twenty-five brands of one-liter bottles and we didn’t find any problems in those.
Q: Some people, also for environmental reasons, have been using Steripens or chlorine drops, etc. Obviously, it takes more planning and effort, but from a health viewpoint, are those effective?
A: The Steripen is good. You could use iodine or chlorine drops, those are effective. Except, they don’t kill a parasite called cyclospora, but that parasite is only found in June, July, and August, which aren’t even the usual trekking months. Other times, chlorine and iodine are okay to use. Steripen is good, a lot of people are traveling with those, but you do need to have the water very clear for the Setripen to work. If that’s the case, Steripen will work well. I agree that the bottled water creates a lot of environmental pollution. I wish they could be recycled, reused somehow.
So, overall, I’d say to focus on food and water, travel insurance, use something to prevent mosquito bites, especially if you’re going to Chitwan National Park, places like that, use a repellant, sleep inside a mosquito net, and of course, prevent sexually transmitted infections by using condoms if you have a new partner. And also animal bites—there is a risk of rabies. It’s not a high rate, but it’s a 100% fatal disease, so even if you have a low risk, if you get bitten, you need full treatment. The risk for animal bites is more common for city people, in Kathmandu. We’ve studied this. The Kathmandu expatriates had a higher risk than a traveler who is on a trek. People should be pre-immunized, or if they’re not, and they get bitten, they need to seek help. It’s expensive. I’d recommend it if they can afford it. It’s expensive in the West, not as much here, but people need to know that they should seek help if they are bitten by an animal, whether it’s a domestic or wild animal. Tourists get bitten by monkeys; people who live here don’t so much, which requires that they get rabies post-exposure treatment, and they need to wash their wound thoroughly with soap and water, apply an antiseptic, and then seek help, because they need shots of the rabies vaccine. That is an important thing that people need to keep in mind, and the safety issues with altitude that we just mentioned, also.
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It was a brief but incredibly informative conversation for me. I learned so much from speaking with Dr. Pandey that I hadn’t been aware of before, and cleared up a few erroneous assumptions I’d had, too. The doctor also showed me some incredible photos of frostbite damage and its treatment; CIWEC is involved in pioneering a new treatment for frostbite that has shown a lot of promise. And, while we hope it’s something we won’t ever need, it’s sure good to know where you can go if you should.
In summary, here’s a starter list for recommendations of what to bring with you when traveling outside the valley: azithromycin, Diamox, Loperamide (bowel stopper), antiseptic cream, oral rehydration salts, gauze, and band-aids—and of course, evacuation insurance.
