Nepal Travel Health Advice

Health Risks

MALARIA
Infection is spread by the night-time - dusk to dawn - biting female Anopheles mosquito.
Malaria risk is present in the country; areas of risk are specified:

Risk is present in all areas below 2000m / 6562ft.
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 S2 malaria suppressive medication guidelines.

Malaria risk is present below the altitude of: 2000 meters

High risk months for Malaria are: January - December

Malaria transmission vector(s): A. minimus minimus

Incidence of Plasmodium falciparum Malaria: 30%
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.

OTHER HEALTH RISKS OF INTEREST TO TRAVELLERS

The health risks listed below are some of the most common non-vaccine preventable illnesses that can affect travellers. We update our travel health information daily with any new confirmed outbreaks so check back here before your trip for updates. Please note that some infectious diseases are not reported or under reported, preventing us from giving you the full picture of the health risk.

Air Pollution
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.

Risk: No matter where you travel, you will not be able to escape air pollution since cities and rural areas worldwide are affected by air pollution. Exposure and concentration of pollutants can adversely 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.

Symptoms: Short term symptoms resulting from 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 Illness
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.
Risk: 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.
Symptoms: 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 heartbeat, 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:
•    Your ascent schedule should include rest days and flexibility in case you need to slow down and adjust to the new altitude. A gradual ascent to high altitude, possibly over a few days, is ideal. If this is not possible, make sure to allow extra time to acclimatize: 1 day for every 1000m / 3280ft.
•    Avoid strenuous exercise for the first two days and avoid all alcoholic beverages for the first few days.
•    Set a reasonable pace, avoid over exertion, and keep hydrated. Do not overload yourself with extra gear. If you are camping at high altitudes, ensure that there is good ventilation when using camp stoves and heaters in confined spaces.
•    Consult with your healthcare provider if taking acetazolamide (Diamox) or other medication to help with acclimatization is appropriate for you.
•    Persons with chronic medical conditions such as angina, heart failure, pulmonary diseases, and diabetes should consult with a high altitude medicine specialist before going travelling to mountainous areas.

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
Dengue is a viral infection caused by five types of viruses (DENV) belonging to the Flavivirdae family. The viruses are transmitted through the bite of infected Aëdes aegypti and Aëdes albopictus female mosquitoes that feed both indoors and outdoors during the daytime (from dawn to dusk). In 2013, scientists confirmed the existence of a fifth Dengue virus serotype which could pose a further challenge to developing a vaccine against the infection in humans.

Risk: The viruses are present in tropical and subtropical areas of Central America, South America, Africa, Asia, and Oceania. 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. Dengue occurs in urban and suburban settings with higher transmission rates happening during the rainy season.

Symptoms: 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. Dengue fever cases have been reported in Nepal (Kathmandu). For the latest information on Dengue fever outbreaks please go to: ProMED-mail. Dengue/DHF Update (43): Americas, Asia. ProMED-mail 2014; July 02: 20140702.2581071 Accessed on July 02, 2014.

Hepatitis E
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.

Risk: The infection is present worldwide, although its prevalence varies in different regions. Travellers drinking untreated water, eating undercooked meats, or going to areas with poor sanitation are at greater risk of Hepatitis E. The infection is present worldwide, although its prevalence varies in different regions.

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.

Hepatitis E is highly endemic in Nepal.

Intestinal Parasites | Soil-Transmitted Helminths
Parasitic worms are organisms that can live and replicate in the gastro-intestinal system. These soil-transmitted helminths (hookworms, roundworms, whipworms) are transmitted through the fecal-oral route as a result of poor sanitary practices. The most common infections that can affect travellers are Ascariasis, Hookworm, and Trichuriasis which are Neglected Tropical Diseases (NTDs)*.

Risk: Travellers can get ill when worm eggs are ingested by:
•    Eating raw, unwashed, or improperly handled fruits and vegetables.
•    Drinking contaminated water or beverages.
•    Touching the mouth with dirty hands or through improper hand washing.
•    Practising poor body hygiene.

Ascariasis: The infection is caused by Ascaris lumbricoides roundworm and is typically found in tropical and sub-tropical areas. Persons with light infections may not exhibit any symptoms. Those who develop symptoms start with a persistent cough, wheezing, shortness within 1 week of getting infected as a result of larvae migrating to the lungs and throat. The second set of symptoms, including abdominal pain, nausea, vomiting, diarrhea, bloody or worm in stools, fatigue, weight loss appear a few weeks (up to 2 or 3 months) later as the roundworms become adults and the females lay eggs which are shed through feces. The parasite can live in humans for up to 2 years. Children are particularly affected by this illness because they tend to play in and eat dirt. Treatment includes taking anthelmintic drugs.

Hookworm | Ancyclostomiasis: This intestinal infection is primarily caused by Necator americanus, followed by Ancylostoma duodenale, and to a lesser extent by Ancylostoma ceylanicum nematodes typically found in tropical and sub-tropical areas. Persons with light infections may not exhibit any symptoms. Those who develop symptoms first get a skin rash where the larvae penetrate the skin. Abdominal pain, diarrhea, loss of appetite, weight loss, and fatigue occur as the migrated larvae grow into adults and mate in the gastro-intestinal system. The eggs produced by the females are shed through feces. Note that the Ancylostoma duodenale hookworm can also be acquired by ingesting soil or sand through dirty hands or unwashed fruits and vegetables.A typical sign of this infection is anemia (iron deficiency). Treatment includes taking anthelmintic drugs.

Trichuriasis: The infection in humans is caused by the Trichuris trichuria whipworm and occurs worldwide, especially in areas with no proper sewage disposal. Persons with light infections may not exhibit any symptoms. Those who exhibit symptoms have diarrhea, containing blood, mucous, and water as a result of the swallowed eggs hatching in the caecum, the pouch-like area of the large intestine, and the larvae migrate to the lining the colon to grow into adulthood and mate. The eggs produced by the females are shed through feces. Severe cases include abdominal pain, chronic diarrhea, and rectal prolapse. Whipworms can live in humans for years. Children are particularly affected by this illness because they tend to play in and eat dirt. Treatment includes taking anthelmintic drugs.

Risk is present in Nepal.

Leishmaniasis
Leishmaniasis is a parasitic infection caused by different species of Leishmania protozoa. It is transmitted through the bite of infected female sandflies belonging to the Phlebotomus, Lutzomyia, and Psychodopygus species. These insects can bite at any time of the day, but are most active 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. Leishmaniasis is clinically divided into three major categories – cutaneous, mucocutaneous, and visceral – and is a Neglected Tropical Disease (NTD)*.

Risk: Adventure travellers, bird watchers, missionaries, army personnel, construction workers, and researchers on night time assignments are at higher risk of being exposed to sand flies.

Cutaneous Leishmaniasis is the most common form of the infection and is found in two geographic areas:
• Old World Cutaneous Leishmaniasis is present in the Mediterranean basin (southern Europe and North Africa), the Middle East, southwest and central Asia, and the tropical areas of Africa. The majority of cases are reported from the following countries: Afghanistan, Algeria, Iran, Iraq, Saudi Arabia and Syria. Old World cutaneous leishmaniasis is a mostly self-limiting skin disease in adults, but depending on the species, infected infants and children can develop the visceral form of the disease.
• New World Cutaneous Leishmaniasis is common in rural areas but can also be acquired in semi-urban and urban areas. It also occurs in rainforests and arid areas. New World cutaneous leishmaniasis is present in parts of North America (occasional cases are reported from the states of Texas and Oklahoma), Mexico, Central and South America, with Brazil and Peru reporting the majority of cases.

Symptoms of Cutaneous Leishmaniasis: Initial symptoms include skin lesions, which develop after several weeks or months after being infected, 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 leave 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 of Visceral Leishmaniasis: Usually appear weeks or months after being infected and 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 any activity that may disturb sandfly habitats, especially from dusk to dawn. 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.

* Neglected Tropical Diseases are chronic infections that are typically endemic in low income countries. They prevent affected adults and children from going to school, working, or fully participating in community life, contributing to stigma and the cycle of poverty.
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.

Sexually Transmitted Infections
Sexually transmitted infections (STIs), also known as Sexually Transmitted Diseases (STDs), are caused by bacteria, viruses or parasites and are transmitted via unprotected sex (oral, anal, or oral) and skin to skin genital contact.

Bacterial infections include Bacterial Vaginosis, Chlamydia, Gonorrhea, Lyphogranuloma venerum (LGV) and Syphilis. Viruses cause Genital Herpes, Hepatitis B, Human Papillomavirus (HPV) and Human Immunodeficiency Virus (HIV). Parasites are responsible for Trichomoniasis and pubic lice.

STIs occur worldwide, but some infections like chancroid, lymphogranuloma vernerum (LGV), and Granuloma Inguinale are more common in less industrialized countries.

Risk: Travellers are at high risk of acquiring STIs if they have unprotected sex outside a monogamous relationship, engage in casual sex, or use the services of sex workers. During travel, some people may be less inclined to follow social mores dictating their behaviour back home and look for adventurous opportunities involving sex. Long term travellers may also be at increased risk due to feelings of loneliness or being homesick.

Travellers should also be aware of sexual tourism and how it spreads STIs. Sexual tourism is travel for the procurement of sex abroad. Travellers participating in this type of exploitive tourism use the services of sex workers or children that are forced to engage in the trade as a result of deceptive practices or are part of human trafficking networks. It’s illegal in many countries and you can be prosecuted in your home country for engaging in sexual exploitation of minors abroad. Sexual violence such as rape or assault can also increase risk of STI.

Symptoms: In many cases you can spread a sexually transmitted infection unknowingly because you are asymptomatic (do not exhibit symptoms). Depending on the infection, symptoms can appear within days or weeks (Chlamydia, Gonorrhea, Genital Herpes), weeks or months (Hepatitis B, Syphilis, HIV) after the initial infection. Common symptoms, which may appear alone or in combination include abnormal genital discharge, burning sensation when urinating, bleeding after intercourse or between periods, rashes and sores in the genital or anal areas, swollen lymph glands in the groin, and sudden fever or appearance of flu-like symptoms.

Note that the sudden or eventual disappearance of symptoms does not mean you are cured from the infection since it can return or manifest itself in different symptoms. Many sexually transmitted infections can be treated with antibiotics (although there is mounting evidence that Gonorrhea is becoming increasingly resistant to antibiotics) or antivirals. If left untreated, infections can lead to infertility, pelvic inflammatory disease, cancer, chronic liver conditions, pregnancy complications, and birth defects.

Prevention: Always practice safe sex. Pack your own male and / or female condoms. Note that condoms obtained abroad may have higher breakage rates, may be expired, or may have been stored in hot or humid places compromising their effectiveness. Use your condom correctly and do not use oil based lubes. If you engage in oral sex use a male condom or dental dam. Keep in mind that birth control methods such as oral contraceptives, injections, IUDs, or diaphragms do not prevent STI transmission, and that condoms aren’t fully effective from infections acquired via skin-to-skin contact like genital herpes.

Avoid behaviour that increases your chances of contracting an STI such as casual sex with a stranger or a sex worker. Drinking heavily or taking mind-altering drugs will impair your judgement and inhibitions during a sexual encounter, putting you at risk of making unsafe choices like not using a condom. If you already practice safe sex, avoid getting tattoos, body piercings, or acupuncture treatments. Also don’t share razors, toothbrushes, or needles. If you have engaged in risky sexual activities or suspect that you may have an STI, visit a healthcare provider immediately. If the results confirm that you have an STI, inform all your sex partners and encourage them to seek medical attention.

Hepatitis B and Human Papillomavirus (HPV) can also be prevented through vaccination.

Note: Some countries continue to have entry restrictions for travellers with HIV / AIDS. Consult your destination country's embassy or consulate to get the latest information.

Traveller's Diarrhea
The term Traveller's Diarrhea is used to describe gastro-intestinal infections affecting travellers caused by ingesting bacteria, viruses, and protozoa. These micro-organisms are found worldwide and are typically transmitted from person to person via the fecal-oral route – an infected person who does not practice proper hand or body hygiene passes on the infection to another person when handling food and water. Traveller's Diarrhea is the most common illness among travellers.

Risk: Traveller’s Diarrhea can happen when:
•    Eating raw, under cooked, unwashed, or improperly handled meat, poultry products, dairy products, fruits, vegetables, shellfish, and seafood.
•    Drinking contaminated water or beverages.
•    Inadvertently ingesting fecal matter, protozoa eggs, or viruses by touching the mouth with dirty or improperly washed hands.
•    Eating out in restaurants, from buffets, or from street vendors where food handling and hygienic practices are not followed properly.

Prevention: The golden rule to prevent gastro-intestinal infections is: Boil it, Cook it, Peel it, or Forget it! However, it’s not just about what you eat, it’s also important to consider where you eat. It’s not always easy to know if a restaurant or food vendor follows proper food handling and hygienic practices (properly cleaning cutting boards, utensils, sink to wash hands, refrigeration). Be cautious of food that has been stored uncovered, has been improperly refrigerated, or has been standing out for a long time such as buffets.

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.

HEALTH RISKS FOR SPECIFIC TRAVELLERS
The health risks listed below are of interest to travellers who undertake special activities like adventure travel or ecotourism, long term travellers, visiting friends and family, or those on work assignments abroad. We update our travel health information daily with any new confirmed outbreaks so check back here before your trip for updates. Please note that some infectious diseases are not reported or under reported, preventing us from giving you the full picture of the health risk.

Lymphatic Filariasis
Lymphatic Filariasis, also known as Elephantiasis, is a parasitic infection caused by the Wuchereria bancrofti, Brugia malayi, and Brugia timori nematode worms transmitted to humans through the bite of infected Aedes, Culex, Anopheles, and Mansonia mosquitoes. The disease targets the body's lymphatic system. The infective microscopic larvae (microfilariae) develop in the vector mosquitoes and are injected into humans through a blood meal. In the human host, they reproduce and mature over a period of one year and live in the body for approximately 4 to 6 years. The larvae hatched in humans are ingested by feeding mosquitoes who pass the infection on to another person, continuing the infectious cycle. Lymphatic Filariasis is a Neglected Tropical Disease (NTD)*.

Risk: Lymphatic Filariasis is present in Africa, Central and South America, South Asia, and the Pacific Islands. There is a greater risk for long term travellers visiting endemic areas. Persons on long term work assignments like humanitarian workers, missionaries, and military personnel are also at risk.

Symptoms: The infection is typically characterized by extreme swelling of limbs or genitals. The majority of cases are asymptomatic (persons do not exhibit symptoms) although the worms can damage kidneys and lymph nodes over a long period of time without a person showing external symptoms. A severe infection, which may not show up for years, causes swelling in the genitals, breasts, arms and legs and may progress to lung disease. Treatment includes taking the anthelmintic drugs diethylcarbamazine (DEC) and albendazole.

Prevention: Travellers should take precautions against mosquito bites by wearing light coloured clothing, using DEET-containing repellent on exposed skin, applying a permethrin spray (or solution) to clothing and gear, and sleeping under a permethrin-treated bed net. There is no preventive medication or vaccine against Lymphatic Filariasis.
* Neglected Tropical Diseases are chronic infections that are typically endemic in low income countries. They prevent affected adults and children from going to school, working, or fully participating in community life, contributing to stigma and the cycle of poverty.

Lymphatic filariasis is present in Nepal.

Plague

Plague is a zoonosis (an animal disease that can spread to humans) caused by Yersinia pestis bacteria. It is transmitted to humans from rodents such as squirrels, chipmunks, woodrats, prairie dogs, rabbits, and mice through the bite of an infected flea. There are three forms of the infection:
1.    Bubonic plague primarily affects the lymph nodes.
2.    Septicemic plague affects the bloodstream and can be contracted by handling infected animals.
3.    Pneumonic plague affects the lungs and can spread from person to person, though rarely, through contaminated air droplets.

Risk: Plague is primarily found in arid regions of Africa, South America, Asia, and North America. Hikers, campers, hunters, and persons occupationally exposed to wild rodents in endemic areas such as anthropologists, archeologists, geologists, spelunkers are at greater risk of exposure.

Symptoms: Flu-like symptoms appear 1 to 10 days after being bitten, including fever, headache, chills, muscle pain, weakness. The illness is also characterized by painful lymph glands. If untreated, the infection can spread to the bloodstream, also known as septicemic plague, which is accompanied by abdominal pain, shock, and internal bleeding of organs and skin tissue may turn black. Pneumonic plague can also develop if bubonic or septicemic plague is untreated. In this case, the patient has shortness of breath chest pain, and may cough blood or watery mucous. Shock and respiratory failure can become fatal. Rapid diagnosis and treatment with antibiotics is important for a full recovery. Patients need to be isolated to prevent possible spread of the infection to others.

Prevention: Ensure that your accommodations or camping area is free of rodents and remove any food sources or potential nesting materials. Avoid direct contact with rodents, carnivores who eat rodents, and dead animal tissues. Make sure cats and dogs around you do not carry fleas. There is currently no commercially available vaccine or preventive medication against Plague.

Risk is present in the western half of Nepal.

Tuberculosis

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. 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.

Risk: Tuberculosis occurs worldwide and commonly spreads in cramped, overcrowded conditions. There is no evidence that pulmonary TB is more easily transmitted in airplanes or other forms of public transportation. Travellers with a compromised immune system, long-term travellers, and those visiting friends and relatives (VFR travellers) 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.

Symptoms: Persons with active TB have symptoms which include excessive coughing (sometimes with blood), chest pain, general weakness, lack of appetite, weight loss, swollen lymph glands, fever, chills, and night sweats. It can be misdiagnosed for bronchitis or pneumonia. If untreated, active TB can lead to fatalities.

The majority of persons with the illness (90% to 95%) have latent TB infection (LTBI) and do not exhibit any symptoms. The bacteria can remain inactive for many years and the chance of developing active TB diminishes over time.
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.