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  Travel Medicine for Trekkers and Climbers in the Himalayan Region

 By Larry Rigsby M.D.

Dr. Larry Rigsby, practices as an Internal Medicine physician in Montgomery, AL. He is a regional medical director for Eagle Hospital, a medical consultant for Himalaya Inc. and has a great interest in high altitude medicine and physiology. He is a mountaineer and have been on several expeditions to Alaska including Denali and Moose's tooth. He recently climbed Ama Dablam in the Himalaya and will be  on the north or Tibetan side of Everest this spring.

He plans to do a series on mountain medicine to help promote safety in the mountains and keep climbers and trekkers up to speed on the latest medical info available. The first in the series is on Travel Medicine with subsequent articles on Altitude illness, hypothermia , frostbite etc. These will be updated periodically. He is willing to do a short Q&A, submit questions to  

Travel Medicine for Trekkers and Climbers in the Himalayan Region

Just getting to base camp healthy is half the battle. Unfortunately, every year a number of climbers or trekkers will have to abort their plans due to illness. Whereas gastroenteritis or bronchitis might not be considered such a major illness at sea level, it can be devastating at altitude. This article will focus on preparation and preventive measures which can be taken to help insure you will arrive at base camp healthy and ready to tackle the climb.

Preparation: It is important to get a physical examination at least 4-6 weeks, or longer, in advance of your trip. This is important so you may identify and correct any problems which may be uncovered. This will also allow adequate time for your immunizations (see below).

Ideally, the physical should be done by a physician who has knowledge of altitude illness and travel medicine. The physical should evaluate your general health and screen for illnesses such as hypertension, diabetes mellitus, anemia, ulcer disease, cardiovascular disease and lung problems such as asthma. A cardiovascular risk assessment should be made, especially for anyone with a strong family history or over the age of 40. 8000 meters is not the place you want to discover you have an illness such as asthma or a bleeding ulcer.

Get a good dental check up and correct any problems. Again, an abscessed tooth can put an end to a climb. Prepare your medical kit (see below) in advance and make sure you are not allergic to the medications or that they do not interfere with any current medication you are taking. For example, you cannot use Diamox or Acetazolamide if you are allergic to sulfa. It might be wise to take Diamox and see how you react prior to taking this for the first time at altitude. Altitude is not a place to experiment with anything.

Avoid burnout. Pretend as if you are leaving two weeks prior to the scheduled date. Have your gear ready and bags packed two weeks prior to departure. Don’t over train and don’t overwork. Just as a marathoner would do, try to peak in your training 2-3 weeks before and then begin a taper. At this point in time, just maintain your level of fitness. A last minute effort may well lead to injury or over training. If this happens, a level of fatigue will set in that will take a while to resolve. This can also affect the immune system and lead to an increased susceptibility to viral illness such as colds and influenza.

Keep up your nutrition and hydration during this time.

As the saying goes “The hay is in the barn.” Enjoy your family and the excitement of the upcoming adventure.

Immunizations: Travelers should update their routine immunizations and have adequate immunity to measles, mumps, rubella, tetanus, diphtheria, pertussis, varicella and Hemophilus influenza

type b infection. Climbers going to Asia or Africa should have adequate poliovirus vaccination. Influenza vaccine should be considered, and pneumococcal vaccine considered if indicated.

Hepatitis A is the most frequent, vaccine preventable, travel related infection. The hepatitis A vaccine is indicated for most non-immune travelers in the developing world. Typhoid vaccine should be considered as well. Vaccination against hepatitis B, rabies, yellow fever, cholera, meningococcal disease and encephalitis might be considered depending on the area of travel and level of exposure. These vaccines are not indicated for travelers to the Himalayan region.

The Center for Disease Control and Prevention (CDC) has a web site: www.cdc.gov/travel/. This site provides information on immunization requirements and updates on travel related infections. The World Health Organization (WHO) has a similar site: www.who.int/ith/.

The risk of malaria is considered low for trekkers or climbers going to the Himalayan region. If your travels take you elsewhere, you need to consult with your physician or the CDC web site to see whether malaria prophylaxis is indicated.

Medical Kit: Your medical kit should be developed with the consultation of your physician. As pointed out earlier, high altitude is not the place you want to have a drug or allergic reaction. You should have an ample supply of your regular prescription medicines such as blood pressure or diabetic medications. It is not a bad idea to have a dual supply, one in your carry on and the other in your checked luggage.

Consider taking the following items in your medical kit:

  • Blister kit

  • Sunscreen

  • Bandages

  • Insect repellent containing DEET

  • Topical antibiotic cream

  • Iodine tablets and/or water filter

  • Diamox or Acetazolamide

  • Acetaminophen or Tylenol for analgesia

  • Ibuprofen or Advil for analgesia and as an anti-inflammatory agent

  • Immodium or Lomotil for diarrhea

  • A nasal decongestant such as Afrin

  • Pepcid or Zantac for heartburn

  • An antibiotic, especially a Quinolone such as Ciprofloxacin or Leavaquin

  • A prescription pain medication such as Tylenol with codeine or Hydrocodone

  • An asthma inhaler if you are prone to exercise induced asthma or asthma associated with bronchitis or upper respiratory infections

Transportation Associated Illness: During air flight, barotrauma can occur to the ears and sinuses due to the pressure differential. This can cause pain in the ears and sinuses and diminished hearing. This is especially the case if one has an upper respiratory infection. It is important to chew or swallow during ascent and descent. Use a nasal decongestant spray if you have a head cold or upper respiratory infection.

Prevent viral infections. Be careful of handshaking and wash your hands frequently.

Prevent blood clots. Extended air travel may increase the risk for venous thrombosis or blood clots. This is controversial. However, it is reasonable for all travelers to do the following:

  • Avoid dehydration by consuming a lot of fluids

  • Avoid alcohol

  • Avoid constrictive clothing

  • Move about the cabin every one to two hours

  • Change positions in your seat frequently and flex and unflex the knees and ankles

  • Aspirin may be helpful, but it is not formally recommended

Travelers crossing several time zones may experience jet lag. Melatonin is a popular treatment for this. This is of unproved benefit. The body clock normally resets at one hour per day. Engaging in an activity in sunlight shortly after your arrival at your destination may help.

The cabins are not fully pressurized in commercial jets flying at high altitude. The atmospheric pressure is equivalent to approximately 2500 meters above sea level. For the fit mountaineer or trekker, this is inconsequential. However, for someone with existing cardiopulmonary condition, this can pose a problem.  

In Katmandu: Heads up here. Don’t blow it in Katmandu. There is a lot of excitement here and there is a lot of disease waiting to happen. Chill out. Stay relaxed and focus. Continue to rest, hydrate, and avoid alcohol. Limit your time out in the city. You can buy your souvenirs and celebrate on your way home. Now is the time to be diligent with handwashing and prevention of traveler’s diarrhea, upper respiratory infections and bronchitis (see below).

Specific Travel Related Illness: As noted, hepatitis A is the most frequent vaccine preventable, travel related illness. The risk for hepatitis A is 300 per 100,000 travelers per month in developing countries. The incidence is much higher in backpackers and those traveling in remote regions. Hepatitis A vaccine is recommended. Four weeks after the first dose of the vaccine, immunity develops in approximately 95% of individuals. Two doses provides long term immunity. Intramuscular immune globulin can be given to those requiring immediate immunity.

Diarrhea is the most common illness of travelers. This is termed travelers diarrhea or “turista”. It can occur in up to 60% of travelers. The incidence is high in Katmandu. The highest risk months are from April to July. This risk does not diminish with the length of stay and the attack rate in one study was 49% per month during the first two years of residence. Approximately 20% of people affected will be bedridden for several days and up to 40% have to change their trip itinerary. This can be devastating to a climber or trekker.

The usual organisms are enterotoxigenic E. coli, Campylobacter, Shigella, and Salmonella. Viral causes and parasites such as Giardia and Cryptospiridium are less common.

Most cases occur between 4 and 14days after arrival. The illness generally lasts 1-5 days. The classic symptoms of “turista” are malaise, weakness, loss of appetite, and abdominal cramps followed by watery diarrhea. Low grade fever may occur. More severe forms may have symptoms of colitis with blood and pus in the stool. Belching and indigestion are typical of giardiasis. Most cases are self limited. However, antibiotic therapy has been shown to reduce the duration from 3-4 days to 1-2 days with as little as one dose of antibiotic. Most of the organisms responsible are sensitive to the Quinolone antibiotics such as Ciprofloxacin, Levaquin, or Norfloxacin. The current treatment recommendation is 1-5 days of treatment with either: Ciprofloxacin 500 mg. twice daily, Norfloxacin 400 mg twice daily, or Levaquin 500 mg daily. Pepto Bismol tablets or liquid can be given in large doses. Azithromycin or Zithromax may be helpful. Some species of Campylobacter have become resistant to the Quinolone antibiotics and should be sensitive to Zithromax or Azithromycin.

Antimotility drugs such as Loperamide (Immodium) or Diphenoxylate (Lomotil) can be used to control the diarrhea. Caution should be exercised using these drugs when bloody diarrhea is present.

Fluid replacement is the most important aspect of treatment. This should be done with an oral rehydrating solution which contains sodium and glucose. The intestine is able to absorb water if sodium and glucose are present. Packets of oral rehydration solution are available. You can make your own solution using one teaspoon of salt and eight teaspoons of sugar in one liter of water. One cup of orange juice and two bananas can be added for potassium.

If symptoms persist with intractable vomiting, diarrhea, increasing abdominal, pain, fever, and bloody diarrhea; medical attention should be sought.

Prevention is the key. The following measures can be taken to help prevent “turista”.

  • Water should be purified. This can be done either by boiling for 5-10 minutes, using iodine tablets or solution and waiting approximately 30 minutes, use of a compact water filter, or adding two drops of 5% sodium hypochlorite (bleach) to 1 quart of water and waiting 30 minutes.

  • Wash hands with soap and water frequently and especially before eating.

  • Avoid uncooked food (other than peeled fruits or vegetables).

  • Avoid unbottled beverages and unpasteurized dairy products.

  • Eat well-cooked hot foods.

  • Use bottled water for drinking and brushing teeth.

  • Avoid ice cubes.

  • Remember alcohol does not sterilize water or ice.

  • Beware of Chang!

  • Condiments on the table can be contaminated.

Next to diarrhea, respiratory infections are the most common illnesses affecting travelers. If indicated, pneumococcal pneumonia and influenza vaccines are advised.

Avoid excessive outdoor exposure in areas of heavy air pollution, especially during hot or humid times of the day. Avoid prolonged exposure to fumes from indoor cooking and stoves, especially in tea houses.

Most cases of bronchitis are self limited and do not require specific antibiotic treatment. For symptoms that persist, especially if the cough is productive, an antibiotic such as Zithromax or Levaquen would be a reasonable choice. If the cough is accompanied by fever, pleuritic or sharp chest pain, or shortness of breath, you may be dealing with something more serious such as pneumonia. Immediate medical attention would be advisable in this circumstance.

Dr Larry Rigsby is willing to do a short Q&A, submit questions to  

We ask you to consider giving or helping with: The dream is to build a series of clinics across Nepal.


1. Ryan, E., Kin, K. Health Advice and Immunizations for Travelers. N Eng J Med, 2000, Vol. 342:1716.

2. Thielman, N, Guerrant, R. Acute Infectious Diarrhea. N Eng J Med, 2004, 350:38.

3. Hoge, C, Shlim, D, et al. Epidemiology of Diarrhea Among Expatriate Residents Living in a Highly Endemic Environment. JAMA, 1996, 275:533.

4. Center for Disease Control and Prevention (CDC). www.cdc.gov/travel/

5.       World Health Organization (WHO). www.who.int/ith/.

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