This viral infection is transmitted by the day-time biting Aëdes aegypti mosquito typically found in urban, suburban, and rural areas.
A Yellow Fever vaccination certificate is only required for travellers coming from a country with risk of Yellow Fever transmission. The vaccination requirement is imposed by this country for protection against Yellow Fever since the principal mosquito vector Aëdes aegypti is present in its territory.
Risk of Yellow Fever transmission exists in these countries:
AFRICA - Angola, Benin, Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Republic of the Congo, Democratic Republic of the Congo, Côte d'Ivoire, Equatorial Guinea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Kenya, Liberia, Mali, Mauritania, Niger, Nigeria, Rwanda, Senegal, Sierra Leone, South Sudan, Sudan, Togo, Uganda.
AMERICAS - Argentina, Bolivia, Brazil, Colombia, Ecuador, French Guiana, Guyana, Panama, Paraguay, Peru, Suriname, Trinidad and Tobago, Venezuela.
Note: A vaccination certificate is required for children of all ages. However, Yellow Fever vaccination is not recommended for children under nine months of age. If travel is unavoidable and the child's physician considers vaccination unwise, ask for a certificate on the physician's own stationary stating the child's age being less than one year as a contraindication to vaccination. Although this is in accordance with World Health Organization resolutions, some countries may not honour such a certificate and the infant may be put under surveillance upon arrival.
If your medical practitioner has advised you against the Yellow Fever vaccine for medical reasons, a vaccination waiver should be issued. Be aware that problems may arise when crossing borders and your vaccination waiver may not be honoured. See example of a Yellow Fever vaccination waiver.
Your trip is a good occasion for a reminder to keep your routine immunizations updated; more than 80% of adults in developed countries have not maintained their immunization status. The following vaccinations are recommended for your protection and to prevent the spread of infectious diseases.
Tetanus, Diphtheria, Pertussis, Measles, Mumps, Rubella, Poliomyelitis should be reviewed and updated if necessary. Note: Many of these vaccine preventable illnesses are making a resurgence due to non-vaccination, incomplete vaccination, and waning immunity. It is important to keep your routine immunization up-to-date.
Seasonal influenza vaccination is recommended for all travellers over 6 months of age, especially for children, pregnant women, persons over 65, and those with chronic health conditions such as asthma, diabetes, lung disease, heart disease, immune-suppressive disorders, and organ transplant recipients. Note: In the northern hemisphere the flu season typically runs from November to April and from April to October in the southern hemisphere. If the flu vaccine is not available at the time of departure, contact your doctor or travel health clinic regarding influenza anti-viral protection.
Pneumococcal vaccine is recommended for persons over the age of 65 and persons of any age suffering from cardiovascular disease, diabetes, renal disorders, liver diseases, sickle cell disease, asplenia, or immuno-suppressive disorders.
The Hepatitis A virus (HAV) is primarily transmitted from person to person via the fecal-oral route, including through contaminated water and food, such as shellfish or uncooked vegetables and fruit, prepared by infected food handlers.
The virus is present worldwide, but the level of prevalence depends on local sanitary conditions. HAV circulates widely in populations living in areas with poor hygiene infrastructure. In these areas, persons usually acquire the virus during childhood when the illness is asymptomatic (but still infective to others) or mild, and end up developing full immunity. Large outbreaks in these countries are rare. In contrast, a large number of non-immune persons are found in highly industrialized countries where community wide outbreaks can occur when proper food handling or good sanitation practices are not maintained including in daycare centres, prisons, or mass gatherings.
In many cases, the infection is asymptomatic (persons do not exhibit symptoms). Those with symptoms will usually get ill between 15 to 50 days after becoming infected. Symptoms include malaise, sudden onset of fever, nausea, abdominal pain, and jaundice after a few days. The illness can range from mild to severe lasting from one to two weeks or for several months. Severe cases can be fatal especially in older persons. Most infections are asymptomatic in children under six years of age, but infants and children can continue to shed the virus for up to six months after being infected, spreading the infection to others. Many countries are now including vaccination against Hepatitis A in their childhood vaccination schedules.
Prevention: Practice good personal hygiene, including washing your hands frequently and thoroughly, drink boiled or bottled water, eat well cooked foods, and peel your own fruits.
All non-immune persons, especially travellers, should be vaccinated. Two vaccines are available for persons over one year of age. Two doses are needed for full protection (the second dose is given 6 to 12 months after the first dose (HAVRIX) or 6 to 18 months after the first dose (VAQTA). TWINRIX is a vaccine against Hepatitis A and Hepatitis B. It is available for persons over 18 years of age. Three doses are needed for full protection. The second dose is given 1 month after the first, and the third 6 months later. For an accelerated schedule four doses are needed at 0, 7, 21, 31 days and the last dose 12 months later.
This intestinal infection, caused by Salmonella typhi bacteria, is transmitted from person to person primarily through ingestion of contaminated food and water in areas with poor sanitary and hygienic conditions. Prevention includes good personal hygiene such as washing your hands frequently, ensuring safe water supply, eating well cooked foods, and peeling your own fruits. Vaccination is also recommended for travellers' protection.
Cholera is an acute gastro-intestinal infection caused by vibrio cholerae bacteria. Risk of infection to travellers is low and vaccination is advised only for medical and rescue personnel working in endemic areas.
The best protection is to avoid potentially contaminated water and food. See IAMAT's 24 World Climate and Food Safety Charts describing the sanitary condition of water, dairy products, and food in 1440 cities. Meticulous food and water hygiene are essential when travelling in endemic areas.
Persons living and working in inadequate sanitary conditions and those with impaired defence mechanisms (deficient production of gastric acid due to surgery for duodenal or gastric ulcers), persons on antacid therapy, and users of cannabis (smoking marijuana reduces acid secretion of the stomach) are more susceptible to cholera infection. The World Health Organization announced in 1991 that Cholera vaccination certificates are no longer required by any country or territory.
The Hepatitis B virus is transmitted through infected blood products, sexual intercourse, or infected items such as needles or razor blades, and may cause severe liver damage.
Vaccination is recommended for persons on working assignments in the health care field (dentists, physicians, nurses, laboratory technicians), or for those working in close contact with the local population (teachers, aid workers, missionaries), or persons foreseeing sexual relations with locals. This vaccine is often combined with the Hepatitis A vaccine and affords excellent long-term protection for both viral diseases.
This viral infection is transmitted by Culex mosquitoes in Asia and Southeast Asia. Transmission occurs throughout the year in tropical and sub-tropical climates, and during late spring, summer, and early fall in temperate areas. The mosquitos breed in flooded rice fields and irrigation projects. Pigs and some bird species are natural carriers of the virus.
Travellers to endemic areas should take measures to prevent 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. Using a permethrin-treated bed net will also decrease risk of infection.
Vaccination is recommended for persons travelling extensively in rural areas, living and working near rice growing rural and suburban areas, as well as other irrigated land where exposure to mosquitos transmitting the disease is high. Children are especially susceptible to the infection.
The infection is endemic in the southern plains bordering India (Terai Districts). Cases have also been reported from the highlands, including the Kathmandu valley. Transmission occurs from June to October.
This viral infection is transmitted through the saliva of infected animal bites which affects the brain and the spinal cord, and may be fatal.
A series of three (3) pre-exposure rabies vaccination shots is advised for persons planning an extended stay or on working assignments in remote and rural areas, particularly in Africa, Asia, Central and South America. The pre-exposure series simplifies medical care if the person has been bitten by a rabid animal. Although this provides adequate initial protection, a person potentially exposed to rabies will require two (2) additional post-exposure innoculations.
Persons who have not received the pre-exposure shots need five (5) injections in addition to rabies immune globulin (RIG). RIG is in short supply around the world and may not be available in remote areas. If a traveller has had the three pre-exposure shots, they will only need additional two shots; they do not need RIG.
Children are especially vulnerable since they may not report scratches or bites. They should be cautioned not to pet dogs, cats, monkeys, or other mammals. Any animal bite or scratch must be washed repeatedly with copious amounts of soap and water. Seek medical attention immediately.
The recommendations for vaccinations outlined above are intended as guidelines only. Your immunization needs depend on your health status, previous immunizations received, and your travel itinerary. Seek further advice from your doctor or travel health clinic.
Malaria risk is present in the country; areas of risk are specified:
Risk is present in all areas below 1200m / 3937ft.
Note: Kathmandu and the northern high altitude areas of Nepal are risk free.
If you are flying into Kathmandu and visiting the northern Himalayan districts, you do not need to take malaria suppressive medication. However, if you are travelling from India overland into Nepal, and throughout the southern parts of the country, you must follow malaria suppressive medication guidelines.
Malaria risk is present below the altitude of: 1200 meters
High risk months for Malaria are: January - December
Malaria transmission vector(s): A. minimus minimus
(see Anopheles code chart)
Incidence of Plasmodium falciparum Malaria: 12%
Of the five species of human malaria parasites, Plasmodium falciparum is the most dangerous. The remaining percentage represents malaria infections that may be caused by one or more of the following parasites: Plasmodium vivax, Plasmodium ovale, Plasmodium malariae, and Plasmodium knowlesi.
Areas with drug resistant Malaria: Multi-drug resistant (chloroquine and sulfadoxine-pyrimethamine) P. falciparum malaria is present in all malarious areas of Nepal.
Suppressive Medication Guide: Anti-malarial advice for this country
For details on anti-malarial drug side-effects, dosages for children and pregnant women, medications used around the world, and comprehensive protection measures, see: How to Protect Yourself Against Malaria (pdf)
Outdoor air pollution (a mix of chemicals, particulate matter, and biological materials that react with each other) contributes to breathing problems, chronic diseases, increased hospitalization, and premature mortality. Cities and rural areas around the world are affected by air pollution.
No matter where you travel, you will not be able to escape air pollution. Exposure and concentration of pollutants can affect your health. When planning your trip, consider your health status, age, destination, length of trip and season to help you mitigate the effects of air pollution.
Short term symptoms of exposure to air pollution include itchy eyes, nose and throat, wheezing, coughing, shortness of breath, chest pain, headaches, nausea, and upper respiratory infections (bronchitis and pneumonia). It also exacerbates asthma and emphysema. Long term effects include lung cancer, cardiovascular disease, chronic respiratory illness, and developing allergies. Air pollution is also associated with heart attacks and strokes.
Prevention: Comply with air pollution advisories (ask around and observe what locals are doing) and avoid strenuous activity. If you have asthma or chronic obstructive pulmonary disease (COPD), carry an inhaler, antibiotic, and oral steroid (consult your doctor to see what is best for you). It is recommended that older travellers get a physical exam that includes a stress and lung capacity test prior to departure. Newborns and young children should minimize exposure as much as possible or consider not travelling to areas with poor air quality. Ask your medical practitioner if a face mask is advisable for you.
>> For city and country air pollution levels, see the World Health Organization.
Nepal reports very high concentrations of particulate matter (PM10 - particles with an aerodynamic diameter smaller than 10 µm) contributing to low air quality.
Altitude Illnesss occurs as a result of decreased oxygen pressure at high altitudes. The illness is divided into three syndromes recognized by a cluster of symptoms arising from rapid ascent to high altitudes, especially more than 2400m / 7874ft. All non-acclimatized travellers, including children, are potentially at risk of developing altitude illness which depends on level of exertion, speed of ascent, altitude reached, humidity, oxygen, and air pressure levels, as well as personal susceptibility. The human body is able to acclimatize to high altitude but must be given time to do so, ideally 3 to 5 days.
The first syndrome, Acute Mountain Sickness (AMS), is characterized by headache, fatigue, loss of appetite, nausea and sometimes vomiting, dizziness, insomnia and disturbed sleep appearing 2 to 12 hours after arrival at high altitude. Symptoms usually disappear within 24 to 72 hours as the body acclimatizes to the altitude. If AMS symptoms persist, rest and medication is needed. Do not continue to ascend to a higher altitude if symptoms persist. If there is no improvement descend to a lower altitude, by at least 300m / 984ft.
In rare cases AMS progresses to the second syndrome, High Altitude Cerebral Edema (HACE), which is characterized by worsening AMS symptoms, drowsiness, confusion, staggering gate and ataxia (lack of voluntary muscle coordination). Immediate descent to lower altitude is important since developing HACE symptoms can be life threatening if untreated immediately. HACE is rare at altitudes below 3600m / 11811ft.
The third syndrome, High Altitude Pulmonary Edema (HAPE), affects the lungs and is characterized by increased breathlessness with exertion progressing to breathlessness during rest, a dry cough, chest tightness or congestion, rapid heart beat, general weakness, and blue / purple skin tissue coloration. Developing HAPE symptoms can be life threatening if untreated. Immediate descent to a lower altitude and administration of oxygen are imperative.
Descending immediately, combined with medication (and oxygen, if available), is the best treatment for severe AMS, HACE, or HAPE. Consider evacuation if necessary.
Acclimatizing to high altitudes:
Prevention: Plan your ascent over several days to ensure proper acclimatization (at altitudes of more than 2400m / 7874ft, ascend at a rate of no more than 300m / 984ft per day). Learn about the symptoms before you go and heed the warnings when symptoms appear. Do not continue to higher altitude, especially to sleep, when symptoms appear even if you feel they are minor. Descend to a lower altitude (at least 300m / 984ft) if symptoms persist while resting at your current altitude.
The Himalayas mountain range in Nepal has eight of the world’s 14 peaks over 8000 m, including the highest of them all, Mt. Everest and many others with peaks between 5000 m and 6500 m. Popular trekking routes bring tourists to elevations between 4000 m and 6000 m.
Dengue is a viral infection caused by four types of viruses (DENV) belonging to the Flavivirdae family. The viruses are transmitted through the bite of infected Aëdes aegypti and A. albopictus female mosquitoes that feed both indoors and outdoors during the daytime (from dawn to dusk). Dengue is present in tropical and subtropical areas of Central America, South America, Africa, Asia, and Oceania. It's found predominantly in urban and suburban settings and higher rates of transmission occur during rainy seasons.
All travellers are at risk during epidemics. Long-term travellers and aid or missionary workers going to areas where Dengue is endemic are at higher risk.
In some cases, Dengue infection is asymptomatic (persons do not exhibit symptoms). Those with symptoms get ill between 4 to 7 days after the bite. The infection is characterized by flu-like symptoms which include a sudden high fever coming in separate waves, pain behind the eyes, muscle, joint, and bone pain, severe headache, and a skin rash characterized by bright red spots.
The illness may progress to Dengue Hemorrhagic Fever (DHF). Symptoms include severe abdominal pain, vomiting, diarrhea, convulsions, bruising, and uncontrolled bleeding. High fever can last from 2 to 7 days. Complications can lead to circulatory system failure and shock, and can be fatal. Exposure to one type of Dengue virus does not provide immunity to the other three types. Contracting Dengue more than once increases the risk of developing Dengue Hemorrhagic Fever.
Prevention: Travellers should take measures to prevent mosquito bites during the daytime. Insect-bite prevention measures include applying a DEET-containing repellent to exposed skin, applying permethrin spray (or solution) to clothing and gear, wearing long sleeves and pants, getting rid of water containers around dwellings and ensuring that door and window screens work properly. There is currently no preventive medication or vaccine against Dengue.
Risk of Dengue fever exists In the low lying areas along the border with India.
Hepatitis E (HEV) is a viral infection causing inflammation of the liver. It is primarily acquired by ingesting water contaminated with fecal matter. The virus is also transmitted from person to person through the fecal-oral route as a result of poor body hygiene practices. In some regions (Europe and Japan) pigs, deer, and wild boars are known to be reservoirs for the infection and Hepatitis E can be contracted by eating raw or undercooked meat such as pig liver and venison. The infection is present worldwide, although its prevalence varies in different regions.
Travellers going to areas with poor sanitation are at greater risk of Hepatitis E infection.
Symptoms usually appear between 2 to 9 weeks after infection and include fever, fatigue, lack of appetite, abdominal pain, and jaundice. Treatment is based on alleviating the symptoms until they disappear.
Prevention: Only drink filtered or water treated with chlorine or iodine. Eat well cooked meats, and wash your hands frequently and thoroughly. There is currently no commercially available preventive vaccine or medication against Hepatitis E.
High risk of Hepatitis E exists in Nepal.
Food-transmitted parasitic infections can be prevented by washing salads and/or vegetables or thoroughly cooking food to destroy infective eggs. Travellers should avoid raw or undercooked food that may be contaminated. Soil-transmitted infections may be avoided by not walking barefoot and not touching soil with bare hands.
Amoebiasis (amoebic dysentery) is a parasitic infection causing intestinal disease. Transmission occurs by eating food that is contaminated with feces from an infected person or drinking water containing amoebic cysts. Transmission also occurs sexually by fecal/oral contact. Infection rates are highest in areas where sanitation is poor.
Ancylostomiasis (hookworm, Necator americanus) is an intestinal parasite of humans. It causes mild diarrhea and abdominal pain. Humans can become infected by direct contact with contaminated soil, generally through walking barefoot, or accidentally swallowing contaminated soil. Do not walk barefoot or touch soil with bare hands where hookworm is common or where there may be fecal contamination of soil. Common in tropical and subtropical regions.
Angiostrongyliasis (roundworm) is a parasitic infection found mainly among people who eat snails, prawns, crabs, vegetables, contaminated by the mucous of infected slugs, land snails or aquatic snails.
Ascariasis (roundworm, Ascaris lumbricoides) is an intestinal helminthic disease. The primary route of infection is ingestion of eggs from contaminated soil or vegetables.
Trichuriasis (whipworm, Trichuris trichuria, Trichuris vulpis) is an intestinal parasite of humans, primarily affecting children. They may become infected if they ingest soil contaminated with whipworm eggs. Some outbreaks have been traced to contaminated vegetables (due to presumed soil contamination). Most commonly found in countries with warm, humid climates.
Risk is present in Nepal.
Leishmaniasis is a parasitic infection caused by different species of Leishmania protozoa. It is transmitted through the bite of infected female sandflies (Phlebotomus, Lutzomyia, and Psychodopygus species). These nocturnal insects bite from dusk to dawn and are often found in forests, stone and mud walls cracks, and animal burrows. They are very tiny silent flyers (they do not hum) and their bite might go unnoticed.
Persons at risk of exposure to sand flies include adventure travellers, bird watchers, missionaries, army personnel, construction workers, and researchers on night time assignments. Leishmaniasis is clinically divided into three major categories: cutaneous, mucocutaneous, and visceral.
Cutaneous leishmaniasis is the most common form of the infection and is divided into two geographic areas of occurence:
Symptoms of cutaneous leishmaniasis include skin lesions (which develop after several weeks to months after infection) and swollen glands. The lesions - closed or open sores - can change overtime in size and appearance, they are usually painless, but can become painful if infected with bacteria. The lesions can take a long time to heal and usually leaves scarring.
Infections with some strains of New World cutaneous leishmaniasis may develop into mucocutaneous leishmaniasis, years after the initial skin lesions seem to have healed completely. The infection spreads to the nose, mouth, and throat causing sores and bleeding. This complication can occur when the initial cutaneous leishmaniasis has not been treated.
Visceral leishmaniasis, also know as kala-azar, is caused by some Leishmania species that invade the liver, spleen, bone marrow, and skin.
Symptoms include fever, weight loss, and enlarged liver. Advanced untreated visceral leishmaniasis can be fatal, particularly if other underlying medical conditions such as tuberculosis, pneumonia, and dysentry are present. This form of leishmaniasis is very rare in travellers but it affects local populations in remote areas of India, Nepal, Bangladesh, Sudan, South Sudan, Ethiopia, and Brazil.
Prevention: Avoid dusk to dawn outdoor activities. Presoak protective clothing with permethrin insecticide. Use insect repellent containing DEET on exposed skin and sleep under permethrin treated bed nets or in air conditioned areas. (Sand flies are very small, 2-3 mm, and may be able to enter through regular screens and nettings. Insecticide treated screens and nets can reduce risk of entry). There is no preventive vaccination or medication against leishmaniasis. Treatment options depend on identifying the infective leishmania species and the extent of the infection, but generally includes antifungal and antibacterial ointments.
>> For Leishmaniasis images, life cycle, and distribution maps, see Infection Landscapes.
Visceral leishmaniasis occurs year-round, mostly in rural areas in districts of the southeastern Terai region at elevations below 1000 metres. Districts include Bara, Dhanukha, Jhapa, Mahottari, Makwanpur, Morang, Parsa, Rautahat, Saptari, Sarlahi, Siraha, Sunsari, and Udaipur, adjoining the Indian state of Bihar.
Leptospirosis is caused by bacteria belonging to the genus Leptospira. It is a zoonosis (an animal disease that can spread to humans) affecting domestic and wild animals such as cattle, dogs, cats, pigs, and rodents. Humans can become sick when they come into contact with water, food, soil, and mud contaminated with the urine of infected animals. The bacteria can enter through skin abrasions and mucous membranes of the mouth, eyes, and nose. Leptospirosis occurs worldwide, but is endemic (usually seasonally) in tropical and subtropical areas with poor sanitation and in agricultural areas with livestock operations or rodent infestations. Outbreaks can also occur after storms, heavy rainfalls, or floods.
Travellers involved in adventure travel or outdoor activities such as swimming, canoeing, whitewater rafting, kayaking, or camping are at risk. Visiting farms, rice paddies, or sugar cane fields can also increase risk of exposure. Leptospirosis is an occupational hazard for farmers, veterinarians, rescue workers and military personnel.
The infection is characterized by flu-like symptoms which can appear anywhere from 2 to 30 days (usually 7 to 10 days) after being infected. Symptoms include sudden fever, headache, muscle pain, chills, red itchy eyes, difficulty urinating, a skin rash, nausea, vomiting, and diarrhea. A second, more severe, phase of the illness – also known as Weil's disease – may progress to kidney or liver failure, jaundice, cardiac failure, meningitis (inflammation of the brain), and respiratory failure. Treatment usually includes antibiotics. Human to human transmission of leptospires bacteria is rare.
Prevention: Avoid swimming or wading in water potentially contaminated with urine, including in canals, swamps, lakes, and rivers. If this cannot be prevented, wear protective clothing and footwear when coming into contact with potentially infected water, soil, or animals. Outdoor sports travellers and persons with occupational risk may want to consult their healthcare provider about taking preventive medication to avoid infection. In North America, there is currently no commercially available vaccine against Leptospirosis.
Avoid unprotected sexual contact. If you are going to have sex with a stranger, use latex or polyurethane condoms consistently and correctly. Bring your own condoms from home.
Some countries continue to have entry restrictions for travellers with HIV / AIDS. See NAM aidsmap for details on this country.
Diarrhea is the most common cause of illness during travel. The source of illness is the ingestion of contaminated food or water, person-to-person transmission, or recreational exposure to water bodies. The infective agents can be bacteria, viruses, protozoa or toxins found in food. Good personal hygiene practices (including frequent and thorough hand washing), proper food handling, and water purification are the most effective methods to prevent infection.
Consult your doctor for the best treatment options tailored to your needs, including taking prescription medication on your trip in case you suffer from diarrhea. Travellers with chronic conditions are more susceptible to infections and should consider taking preventive medication.
See our Guide to Healthy Travel for prevention and treatment tips.
Tuberculosis (TB) is an airbone bacterial infection caused by Mycobacterium tuberculosis. TB can be acquired by breathing contaminated air droplets coughed or sneezed by a person nearby who has active Tuberculosis. Humans can also get ill with TB by ingesting unpasteurized milk products contaminated with Mycobacterium bovis, also known as Bovine Tuberculosis.
Tuberculosis occurs worldwide and commonly spreads in cramped, overcrowded conditions. The most common form of the infection is pulmonary TB which affects the lungs. In some cases, the bacteria can also attack the lymphatic system, central nervous system, urogenital area, joints, and bones.
The risk for travellers is low. There is no evidence that pulmonary TB is more easily transmitted in airplanes or other forms of public transportation. However, travellers with immuno-compromised systems, long-term travellers, and those visiting friends and relatives in areas where Tuberculosis is endemic are at greater risk. Humanitarian and healthcare personnel working in communities with active TB are also at increased risk. Persons with active TB should not travel.
Tuberculosis treatment involves taking antibiotics for a minimum of 6 months. Drug-resistant TB is a major concern as an increasing number of people are no longer able to be treated with previously effective drugs. Due to misuse of antibiotic therapies, patients can develop multi-drug resistant Tuberculosis (MDR TB). When a second line of antibiotics fail to cure the multi-drug resistant infection, it is known as extensively drug-resistant Tuberculosis (XDR TB).
Prevention: Avoid exposure to people known to who have active Tuberculosis and only consume pasteurized milk products. Travellers at higher risk should have a pre-departure tuberculin skin test (TST) and be re-tested upon their return home. Those at increased risk should also consult their healthcare provider to determine if the Bacillus Calmette-Guérin (BCG) vaccine is recommended.
Tuberculosis is highly endemic and a major public health problem in Nepal.
Hantavirus Pulmonary Syndrome (HPS) is a rare infection caused by viruses belonging to the Bunyaviridae family. It is a zoonosis (an animal disease that can spread to humans) transmitted by infected deer mice and other wild rodents through their urine, feces, and saliva. HPS viruses are found in the Americas, while related viruses causing Hemorrhagic Fever with Renal Syndrome (HFRS) exist worldwide.
Travellers can get ill when they breath aerosols (air droplets) contaminated with the virus. Campers, hikers, and cave explorers are at risk if they come into direct contact with infected rodents or their nesting areas. HPS and HFRS are also occupational hazards for trades workers (plumbers, electricians), pest control workers, and wildlife researchers.
Hantavirus Pulmonary Syndrome symptoms usually appear 2-4 weeks after infection and include fever, backache, muscle aches especially in the thighs, hips, and shoulders), general weakness and fatigue. Some people may also experience abdominal pain, diarrhea, and vomiting. The disease may progress to more severe symptoms, usually 10 days later, with difficulty breathing, shortness of breath, and coughing.
Hemorrhagic Fever with Renal Syndrome symptoms usually appear 1-2 weeks after infection and are much more severe than in patients with Hantavirus Pulmonary Syndrome. Infected persons experience fever, intense headaches, back and abdominal pain, chills, nausea, blurred vision, red eyes, or a rash. The disease may progress into uncontrolled bleeding, kidney failure, and shock. If untreated, both HPS and HFRS can be fatal.
Prevention: Travellers should avoid direct contact with wild rodents by choosing camp sites that are open and dry, do not rest on grassland or haystacks, and remove food sources that may attract rodent activity. Rodent control in and around the home remains the best way to prevent infection. There is no preventive medication or vaccine against Hantavirus.
>> For Hantavirus images, life cycle, and distribution maps, see Infection Landscapes.
Plague is mostly a zoonotic bacterial infection of rodents caused by Yersinia pestis and is transmitted to humans and animals through bites by infected fleas. Person to person infection can occur through respiratory secretions. Rapid diagnosis and treatment with antibiotics is imperative since untreated infection has a high mortality rate. The Plague vaccine is no longer commercially available.
Most travellers are not at risk from the Plague, however, persons who may be occupationally exposed to wild rodents (anthropologists, archeologists, geologists, spelunkers) or hunters, hikers, and campers in endemic areas must avoid contact with rodents.
Risk is present in the western half of Nepal.
All local water should be considered contaminated. All water used for drinking, brushing teeth, and making ice cubes should be boiled (bring water to a rolling boil). Hot tea is advised as a beverage.
Milk should be boiled before consumption because of possible improper refrigeration during distribution. Powdered and evaporated milk are available and safe. Butter should not be used as a table food. Cream, ice cream, and whipped cream should not be consumed. Cheese, unless cured, is best avoided. Yoghurt is safe only if it is known to be made from pasteurized milk.
All meat, poultry, and fish must be well cooked and served while hot. Pork is best avoided; vegetables should be well cooked and served hot. Salads are best avoided. Fruits with intact skins should be peeled by you just prior to consumption. Avoid raw and undercooked eggs, and dishes prepared with raw eggs (steak tartar, mayonnaise, and dressings). Avoid cold buffets, uncured cheeses, custards, and any frozen desserts.
First rate hotels and restaurants serve purified drinking water and reliable food. However, the hazard is left to your judgement.
Gastro-intestinal infections are the most common illnesses affecting travellers and can occur in any country you are visiting. Proper food handling, drinking purified water, and maintaining good personal hygiene are key to prevention. Below is a summary of the agents causing gastro-intestinal illnesses.
It is estimated that about 85% of traveller’s diarrhea is caused by bacteria of which the following are the most important agents:
Enterotoxigenic Escherichia coli (ETEC) and Enteroaggregative Escherichia coli (EAEC) account for most cases of traveller’s diarrhea associated with contaminated food and water world wide. They are the cause of large outbreaks in developed countries when food and water sanitation have not been properly maintained. Symptoms include watery stools, abdominal cramps, and possible vomiting lasting three to seven days.
Campylobacter jejuni is more prevalent in developing countries and is associated with contaminated water, undercooked food, and unpasteurized milk. Symptoms include diarrhea, abdominal cramps, and fever lasting from two to ten days.
Salmonella enteritidis is associated with contaminated eggs, poultry, milk, fruits, and uncooked vegetables. Symptoms include diarrhea, vomiting, abdominal cramps, and fever lasting from four to seven days. Infected persons can become asymptomatic carriers and shed the bacteria for years, becoming the source of infection for others through poor hygiene practices.
Shigellosis is a human infection caused by one of four species and transmitted by fecal-oral route due to unsanitary conditions, contaminated food and water, and overcrowded living conditions. Symptoms include diarrhea, abdominal cramps, fever, and may cause bloody diarrhea and mucous lasting four to seven days.
Vibrio cholera is associated with contaminated water, raw and undercooked seafood. Cholera infection in travellers is rare; symptoms include watery diarrhea and vomiting lasting three to seven days, but can lead to severe dehydration and death in undernourished persons. Vibrio parahaemolyticus is also related to the consumption of raw and undercooked seafood. Vibrio vulnificus is associated with contaminated shellfish and raw oysters in particular, and has caused septicemia in persons with liver disorders.
Gastro-intestinal infections caused by viruses account for about 5%. The main agents are Norovirus, associated with outbreaks at large gatherings and on cruise ships, and Rotavirus, which is more prevalent in developing countries. Symptoms include vomiting, diarrhea, fever, and myalgia lasting 12 to 60 hours.
Gastro-intestinal infections with protozoa account for about 10% of traveller’s diarrhea, but may cause prolonged illnesses (lasting weeks) and cause serious complications if not diagnosed in a timely manner.
Giardia lamblia (Giardiasis) and Entamoeba hystolytica (Amebiasis) are the most important agents in this category and both infections are acquired through contaminated food and water, as well as person to person transmission due to poor hygiene practices. Cryptosporidium and Cyclospora cayetanensis are implicated with contaminated food, water, and fresh produce (berries).
Toxins Causing Food Poisoning
Clostridium perfringens is the most important agent causing food poisoning in developed countries. The spores of the bacterium germinate on cooked food that is cooled and stored at room temperature over a prolonged period of time. After ingestion, the spores produce an enterotoxin in the small intestine causing abdominal pain, diarrhea, and vomiting. Foods implicated are meats and poultry.
Staphylococcus aureus enterotoxins are spread by unsanitary practices of infected persons. The foods implicated are custards, creamy desserts, meats, and salads.
Clostridium botulinum bacteria produce a very potent toxin. It is associated with improperly canned food, lightly preserved vegetables, salted fish, and meats. Symptoms include nausea, vomiting, and neurological symptoms such as blurred and double vision, paralysis of respiratory and motor muscles that may progress rapidly.
Fish and shellfish can be contaminated with the toxins produced by marine micro-organisms called dinoflagellates found in all oceans, especially in coral reef areas. Larger fish have usually more toxins accumulated in the skin, musculature, and organs, as these toxins are passed up through the food chain. The toxins are not destroyed through cooking, smoking, or freezing, they are odorless and tasteless, and do not alter the appearance of the fish.
Ciguatera Fish poisoning is the most common illness in this category. The most affected fish are amberjack, barracuda, grouper, kahala, parrotfish, sea bass, red snapper, surgeon fish, ulua. Symptoms usually appear within a few hours but can be delayed for a day or more and include nausea, vomiting diarrhea, muscle pain, itchiness, dizziness and temperature reversal (hot feels cold and cold feels hot). Symptoms can last for months. Persons who had a previous episode of ciguatera fish poisoning should avoid a second exposure as symptoms will be more severe. Prevention: Avoid large fish (more than 2.5 to 3 kilos [6 lbs]) or fillet of large fish, avoid head, roe, intestines and liver where the toxin is more concentrated.
Scombroid poisoning is the result of improper handling and refrigeration of fish containing high levels of natural occurring histidine (amino acid in protein). Contamination with bacteria will convert histidine to histamine-causing symptoms similar to allergic reactions, which occur very rapidly and include headache, abdominal cramps, diarrhea, itching, flushed face, and paralysis may occur. Scombroid poisoning occurs worldwide and affects fish from the Scombridae family: yellow tuna, mackerel, skipjack, and bonito. It can also affect other species such as herring, bluefish, sardine, anchovy, amberjack, and mahi-mahi. Prevention: Proper handling and immediate refrigeration of catch.
Shellfish poisoning is associated with the algal blooms (red tides) occurring in temperate and tropical areas. Shellfish – oysters, clams, cockles, mussels, crabs, lobsters – filter or ingest toxins produced by dinoflagellates micro-organisms. Each different toxin produces characteristic symptoms:
- Symptoms of diarrheic shellfish poisoning occur about 30 minutes to hours after ingestion and include nausea, vomiting, and diarrhea. Recovery occurs within two to three days.
- Symptoms of neurotoxic shellfish poisoning appear rapidly after ingestion and include tingling of mouth, arms and legs, stomach upset, and severe muscle pain. Recovery occurs within two to three days.
- Symptoms of paralytic shellfish poisoning appear rapidly after ingestion and include nausea, numbness of face arms and legs, headache, loss of coordination and dizziness, in severe cases respiratory failure and paralysis may lead to death.
- Symptoms of amnesic shellfish poisoning occur within 24 hours of ingestion and include vomiting, diarrhea, and disorientation. Permanent short-term memory loss has been observed, and in severe cases seizures, paralysis, and death may occur. Persons with kidney disease are especially vulnerable.
Puffer Fish poisoning (Fugu) is caused by a tetrodotoxin accumulating mainly in the liver, intestines and ovaries of puffer fish, ocean sunfish, globe fish, and porcupine fish. Symptoms appear between six and 20 hours and include profuse sweating, salivation, headache, hypothermia, and neurological symptoms of paralysis and respiratory failure. The mortality rate is very high.
Travel is enjoyable, but there is no doubt that it can be stressful. Even if you don't have a prior history of mental illness, travel stress, mood changes, anxiety and other mental health concerns can unexpectedly affect you and potentially disrupt your trip. Studies show that psychiatric emergencies are the leading cause for air evacuations along with injuries and cardiovascular disease.
Your mental and physical health prior to, and during, a trip determines how well you will cope with travel stress. Consider the following:
Mental illness is an under recognized public health concern and travellers often have difficulty accessing adequate emergency psychiatric care abroad. While some countries are leading the way in mental healthcare and treatment, 30% of countries do not have a budget dedicated to mental health and 64% do not have any mental health legislation or it's outdated.
Accessibility to a psychiatrist varies from more than 10 per 100,000 to fewer than 1 per 300,000 people. Almost 70% of psychiatric beds are in mental hospitals rather than general hospitals or in integrated community care facilities.*
Persons with mental health concerns have the additional burden of dealing with stigma ? negative attitudes and behaviour towards their illness. Prejudice and discrimination towards mental illness may determine the type of medical care you will receive abroad.
* World Health Organization: Mental Health, Human Rights and Legislation Framework.
April 25, 2013
Do you know if your travel destination country has malaria? If so, would you take medication to prevent a malaria infection?
March 28, 2013
Do you understand how your immune system works to protect you from disease? Do you know how vaccines work?
February 28, 2013
Guest post by Dr. Erik McLaughlin