HEALTH, MEDICAL & ALTITUDE ADVICE

You should make an appointment to get a check-up with your family doctor and dentist. Below is a quick list of frequently needed immunizations. This is only a basic guide and we strongly recommend that you follow the advice given by your doctor.

*Polio: Normally you will just need one booster shot as an adult.
*Tetanus: An updated booster shot every 10 years is recommended.
*Typhoid: This series is now available in pill form and provides 5 years of coverage.
*Hepatitis (A): The Hepatitis A Vaccine (commonly called Havrix) is highly effective and provides 10 years coverage.
Hepatitis (B): The Hepatitis B Vaccine is recommended for long term travelers and those in the health care profession. Twinrix is a combined Hepatitis A and Hepatitis B vaccine.
Anti-malarial prophylactics: Typically not recommended unless traveling to lowland or jungle areas of the Terai.
Meningitis A+C: This vaccination is now recommended for Nepal. Each shot provides three years of coverage.
Rabies Vaccine: Recommended for long term travelers but optional for tourists.
Cholera: The risk of cholera to the foreign traveler or resident in Nepal is still minimal.
Japanese Encephalitis: JE is found only in the rural areas of southern Nepal or the Terai.
Yellow Fever: Yellow fever is not a disease risk in Nepal and is only required if arriving from a country where yellow fever is present.
*Diamox: A number of studies have consistently shown that the controlled taking of Diamox (Acetazolamide) can be effective in reducing some of the symptoms of AMS (acute mountain sickness). We would recommend that you ask your doctor to provide you with a small supply of Diamox (12 x 250mg tablets).

* denotes recommended shots and medication for tourists trekking in Nepal, India, Tibet, Bhutan and Pakistan

Given enough notice, your doctor or local health clinic should be able to administer all the above. Two excellent sources of up to date medical advice are: The CIWEC CLINC in Kathmandu, Nepal and the Centers for Disease Control and Prevention.

Although every trek carries a comprehensive medical kit, it is advisable to bring a small supply of first aid items for your own personal use. Base this on the following list, plus any special medications you may require:

1. Insect repellent.
2. Antiseptic cream.
3. Sun/face cream and lip screen.
4. Throat lozenges or hard candies.
5. Anti-diarrhoearal.
6. Anti-protozoan. (Flagyl). Ask your doctor.
7. Antibiotics. a broad-spectrum antibiotic. Please ask your doctor.
8. Analgesics. Aspirin, Advil or Tylenol - for headaches etc.
9. Moleskin or Second Skin for blisters.
10. Diamox. already discussed.
11. Re-hydration salts. A small tub of Gatorade powder mix is a good idea.
12. Multi-vitamin tablets are a good idea.
13. Iodine-based water purification tablets.

Acute Mountain Sickness (AMS) is a group of symptoms usually appearing together, with variations among individuals. It appears in people who have recently arrived at high altitudes or have just gained altitude, and may start anywhere from a few hours to a few days after ascending. High altitude is commonly defined as altitudes greater than 10,000 feet (3,000 meters).

Anyone trekking or climbing to, and in, high altitudes is at risk of developing AMS. Susceptibility varies from individuals and with the same person from time to time. Ascending quickly will increase its likelihood, and those who had it previously have a greater chance of getting it again. Physical conditioning has absolutely no influence on susceptibility. In fact, fit individuals tend to go faster and therefore may have a higher incidence. Overexertion and dehydration contribute to AMS and may be a predisposing factor. The key is to move at a slow, steady, comfortable pace, stay well hydrated and listen to your body.

The big concern here is dehydration, which can lead to rapid weakness and the inability. The following are the most common symptoms of AMS:

HEADACHE is by far the most common single symptom. It can vary from a minor nuisance to a severe throbbing. The severity of the headache is a good guide to its significance. A minor headache can be from a hard day of exertion, sun, cold or dehydration. This will usually disappear with some fluids and rest. The morning upon waking, is a good time to judge symptoms. A headache upon awakening is probably due to altitude and should be taken more seriously. This may be accompanied by nausea or even vomiting. A headache may be noticed on a descent from a pass or summit. This is a delayed altitude effect and probably due to the exertion on ascending. Aspirin can be taken to help relieve the pain. As with all AMS symptoms, timely descent is the best course of action if symptoms persist.

INSOMNIA is the inability to sleep. Altitude insomnia is characterized by difficulty falling asleep and frequent wakening during the course of the night. It is most noticeable during the first week of the trip due to the foreign sleeping accommodations, jet lag, time change and other factors. This usually improves during the second week. Insomnia becomes a problem when lack of sleep interferes with daytime functioning. All sleeping medications, barbiturates and opiates should be used with caution at high altitudes. Dalmane, a mild sleeping medication, can be useful. Diamox, a diuretic, helps with the body's acclimatization process and can also be useful. Check with your physician before acquiring and/or using such medication.

GASTROINTESTINAL SYMPTOMS
Rarely does a person with AMS have a good appetite at high altitude. The better the appetite at higher altitudes, the better a person is acclimatizing. Nausea is a problem, but will eventually pass as a person acclimatizes. Vomiting is a more serious problem. If not accompanied by other AMS symptoms, it is probably a 'stomach flu'. If it is in combination with diarrhea, fever or chills, it is usually dysentery, not acute mountain sickness. The big concern here is dehydration, which can lead to rapid weakness and the inability for that person to continue. Continue to drink fluids, rehydration powders are helpful, and descend to lower elevations. To control nausea and vomiting in AMS, Compazine or Phenergan suppositories can be taken.

PULMONARY SYMPTOMS
The cold, dry air of the mountains can cause a deep, hacking cough on exertion. Hard candies, throat lozenges and proper hydration usually help relieve this problem. A frequent cough in association with severe breathlessness on exertion or mild breathlessness at rest (compared to companions) could be an indication of high altitude pulmonary edema. Proper diagnosis, medication and descent are the course of action in this case.

PERIODIC BREATHING
Irregular breathing is a common complaint above 10,000 feet (3,000 meters). It is the most noticeable at night, and characterized by four breaths or so, and then no breathing for as long as 10 or 15 seconds. This period of no breathing, apnea, will usually cause a person to waken in a panic. This symptom seems to be quite harmless and no cause for worry. It is caused by a change in the control of breathing within the brain. Diamox has been shown to improve this condition.

LASSITUDE is defined as weariness, indifference and/or fatigue. It differs from exhaustion which usually responds to 24 hours of rest. Lassitude progresses over 24 to 48 hours. A person may not get out of their tent for meals, talk with others or even refuse to drink sufficient fluids. This can lead to unconsciousness over the next 12 to 24 hours. It may occur without a headache, vomiting or shortness of breathe. The person will usually exhibit a loss of coordination. Immediate descent is required!

ATAXIA is a lack of coordination and balance that is very noticeable. Due to the lack of oxygen to the brain, this is a serious sign. Descent is necessary and oxygen if available. This condition can become serious 6 to 12 hours after it is diagnosed. Ataxia may also be seen in hypothermia. Rest and warmth are recommended after proper descent.

REDUCED URINE OUTPUT
This is a difficult sign to evaluate. Proper fluid intake should be followed by regular, clear and copious urine output at high altitudes. Retention of fluids at high altitudes could be a sign of not acclimatizing properly, and should alert a person to be wary of AMS and other symptoms.

This by no means to be taken as a full and comprehensive explanation of acute mountain sickness, but rather a brief discussion on the most common symptoms, and what a person needs to be aware of before and after arrival at high altitudes.

The following reference books will provide a more thorough and complete discussion of acute mountain sickness:

Mountain Sickness: Prevention, Recognition and Treatment. Peter H. Hackett, MD.
Medicine for Mountaineering. James A. Wilkerson, MD.
Going Higher: The Story of Man and Altitude. Charles Houston, MD.
High Altitude Physiology Study. Charles Houston, MD.
The Pocket Doctor: Your Ticket to Good Health While Travelling. Stephen Bezruchka, MD.
The Medical Guide for Third World Travellers: A Comprehensive Self-Care Handbook. Robin and Dessery.

DIAMOX AND HIGH ALTITUDES

The following is a discussion on the use of Diamox (acetazolamide) for the prevention and treatment of symptoms of acute mountain sickness (AMS) at high altitudes. This discussion is by no means intended to be comprehensive, since new studies and research regarding the use of this drug are continually being conducted.

There are no medications which are recommended routinely for prevention of acute mountain sickness. Indeed, it is strongly felt that medication for this purpose may be harmful, both because of side effects and giving one a false sense of security.

Diamox is one of a few drugs that have been subjected to controlled studies. It is now generally agreed that Diamox does reduce the incidence and severity of acute mountain sickness, even in mild cases. This has been determined statistically on large numbers of people. For a given individual, however, the medication in no way should be thought of as a guarantee of freedom from mountain sickness. Serious mountain sickness has been reported, although rarely, in persons taking Diamox.

Until recently, it was thought that for effective prevention Diamox must be taken one or two days prior to ascent. We now know that it works quite quickly, and does not have to be started until the day of the ascent, or even after reaching high altitude. Diamox can be taken for the first few days at altitude and then discontinued, or continued until the highest altitude is reached. If symptoms of acute mountain sickness occur when the medication is stopped, it should be immediately started again. Recommended dosage is 250mg. (one tablet) twice a day. Side effects most noted are numbness and tingling in fingers, toes or face, which is thought to be related to direct action on peripheral nerves, and an increase in urine output. Some people have reported a sluggishness or mild depression while using Diamox.

Diamox's exact mechanism of benefit is unknown. It is a mild diuretic. It does make the blood a bit more acidic, thus allowing one to hyperventilate more, raising the blood oxygen content, without experiencing the symptoms of hyperventilation. It also decreases the cerebrospinal fluid pressure by slowing its formation, and has recently been shown to be a respiratory stimulant during sleep at high altitudes.

As one can see, Diamox is a powerful drug, and not to be regarded lightly. Therefore, it is not recommended routinely. It is recommended, however, for those persons who routinely experience acute mountain sickness, even with gradual ascent and following the recommended preventive measures. Such a person is more susceptible to acute mountain sickness than others because of individual physiological characteristics. For these people, Diamox may be an alternative to giving up the high mountains in favor of the beaches.

Please consult your physician before beginning a program of Diamox. Your physician should be able to write you a prescription.