29/09/2019
Travel Medicine for Trekkers and Climbers in the Himalayan Region
Just reaching 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 be healthy and ready to tackle the climb.
Ideally, the physical should be done by a physician who has knowledge of altitude illness and travel medicine. A cardiovascular risk assessment should be made, especially for anyone with a strong family history or over the age of 40. Himalaya is not the place you want to discover you have an illness such as asthma or a bleeding ulcer.
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.
1. : 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. Hepatitis A is the most frequent, vaccine preventable, travel related infection.
2. : Medical Kit
Your medical kit should be developed with the consultation of your physician. As pointed out, 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
3. : 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.
4. : 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.
5. : 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.
6. : Diarrhea
It 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.
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.
7. : Respiratory infections
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.
Sources
1. Center for Disease Control and Prevention (CDC). www.cdc.gov/travel/
2. World Health Organization (WHO). www.who.int/ith/. This site provides information on immunization requirements and updates on travel related infections.
