Health, Safety, Vaccinations & Mountain Sickness
Health, Safety, Vaccinations & Mountain Sickness - There are no private health clinics or physicians in Bhutan, but all district headquarters towns have a hospital, and will accept travellers in need of medical attention. The best facility is the Jigme Dorji Wangchuk National Referral Hospital in Thimphu. It has general physicians and several specialists, labs and operating rooms. Treatment is free, even for tourists. If you are seriously ill or injured you should consider evacuation to the excellent medical facilities in Bangkok. It is difficult to find reliable medical care in rural areas. Your embassy and insurance company are good contacts.
Self-treatment may be appropriate if your problem is minor (eg traveller’s diarrhoea), you are carrying the appropriate medication and you cannot attend a recommended clinic. If you think you may have a serious disease, especially malaria, do not waste time – travel to the nearest quality facility to receive attention. It is always better to be assessed by a doctor than to rely on self-treatment. In most large towns there are shops that sell medicines. Many of these are available without a prescription in these medicine shops.
Food: Eating in restaurants is the biggest risk factor for contracting traveller’s diarrhoea. Ways to avoid it include eating only freshly cooked food, and avoiding shellfish and food that has been sitting around in buffets. Peel all fruit, cook vegetables and soak salads in iodine water for at least 20 minutes. Eat in busy restaurants with a high turnover of customers.
Vaccinations: Specialized travel-medicine clinics are your best source of information; they stock all available vaccines and will be able to give specific recommendations for you and your trip. The doctors will take into account factors such as past vaccination history, the length of your trip, activities you may be undertaking and underlying medical conditions, such as pregnancy.
Most vaccines don’t produce immunity until at least two weeks after they’re given, so visit a doctor four to eight weeks before departure. Ask your doctor for an International Certificate of Vaccination (otherwise known as the yellow booklet), which will list all the vaccinations you’ve received.
Recommended vaccinations: The World Health Organization recommends the following vaccinations for travellers to Bhutan (as well as being up to date with measles, mumps and rubella vaccinations):
Adult diphtheria and tetanus - Single booster recommended if none in the previous 10 years. Side effects include sore arm and fever.
Hepatitis A - Provides almost 100% protection for up to a year, a booster after 12 months provides at least another 20 years’ protection. Mild side effects such as headache and sore arm occur in 5% to 10% of people.
Hepatitis B - Now considered routine for most travellers. Given as three shots over six months. A rapid schedule is also available, as is a combined vaccination with Hepatitis A. Side effects are mild and uncommon, usually headache and sore arm. Lifetime protection occurs in 95% of people.
Polio - Bhutan’s last case of polio was reported in 1986, but it has been reported more recently in nearby Nepal and India. Only one booster required as an adult for lifetime protection. Inactivated polio vaccine is safe during pregnancy.
Typhoid -The vaccine offers around 70% protection, lasts for two to three years and comes as a single shot. Tablets are also available; however, the injection is usually recommended as it has fewer side effects. Sore arm and fever may occur.
Varicella - If you haven’t had chickenpox, discuss this vaccination with your doctor.
These immunisations may be recommended for long-term travellers (more than one month) or those at special risk:
Japanese B Encephalitis - Three injections in all. Booster recommended after two years. Sore arm and headache are the most common side effects. Rarely, an allergic reaction comprising hives and swelling can occur up to 10 days after any of the three doses.
Meningitis Single injection - There are two types of vaccination: the quadrivalent vaccine gives two to three years’ protection; meningitis group C vaccine gives around 10 years’ protection. Recommended for long-term backpackers aged fewer than 25.
Rabies - Three injections in all. A booster after one year will then provide 10 years’ protection. Side effects are rare – occasionally headache and sore arm.
Tuberculosis A - complex issue. Adult long-term travellers are usually recommended to have a TB skin test before and after travel, rather than vaccination.
High Altitude: If you are going to altitudes above 3000 meters you should get information on preventing, recognizing and treating Acute Mountain Sickness (AMS). AMS is a notoriously fickle affliction and can also affect trekkers and walkers accustomed to walking at high altitudes. AMS has been fatal at 3000 meters, although 3500 meters to 4500 meters is the usual range.
Acclimatization: With an increase in altitude, the human body needs time to develop physiological mechanisms to cope with the decreased oxygen. This process of acclimatization is still not fully understood, but is known to involve modifications in breathing patterns and heart rate induced by the autonomic nervous system, and an increase in the blood’s oxygen-carrying capabilities. These compensatory mechanisms usually take about one to three days to develop at a particular altitude. Once you are acclimatized to a given height you are unlikely to get AMS at that height, but you can still get ill when you travel higher. If the ascent is too high and too fast, these compensatory reactions may not kick into gear fast enough.
Symptoms: Mild symptoms of AMS are very common in travellers visiting high altitudes, and usually develop during the first 24 hours at altitude. Most visitors to Bhutan will suffer from some symptoms; these will generally disappear through acclimatization in several hours to several days.
Symptoms tend to be worse at night and include headache, dizziness, and lethargy, loss of appetite, nausea, breathlessness and irritability. Difficulty sleeping is another common symptom.
AMS may become more serious without warning and can be fatal. Symptoms are caused by the accumulation of fluid in the lungs and brain, and include breathlessness at rest, a dry irrigative cough (which may progress to the production of pink, frothy sputum), severe headache, lack of coordination (typically leading to a ‘drunken walk’), confusion, irrational behavior, vomiting and eventually unconsciousness.
The symptoms of AMS, however mild, are a warning – be sure to take them seriously! Trekkers should keep an eye on each other as those experiencing symptoms, especially severe symptoms, may not be in a position to recognize them. One thing to note is that while the symptoms of mild AMS often precede those of severe AMS, this is not always the case. Severe AMS can strike with little or no warning.
To prevent acute mountain sickness: Ascend slowly. Have frequent rest days, spending two to three nights at each rise of 1000 meters. If you reach a high altitude by trekking, acclimatization takes place gradually and you are less likely to be affected than if you fly directly to high altitude.
Trekkers should bear in mind the climber’s adage ‘Climb high, sleep low’. It is always wise to sleep at a lower altitude than the greatest height reached during the day. High day climbs followed by a descent back to lower altitudes for the night are good preparation for trekking at high altitude. Also, once above 3000 meters, care should be taken not to increase the sleeping altitude by more than 400 meters per day. If the terrain won’t allow for less than 400 meters of elevation gain, be ready to take an extra day off before tackling the climb.
Drink extra fluids. The mountain air is dry and cold, and moisture is lost as you breathe. Evaporation of sweat may occur unnoticed and result in dehydration.
Eat light, high-carbohydrate meals for more energy.
Avoid alcohol as it may increase the risk of dehydration, and don’t smoke.
Avoid Sedatives: When trekking, take a day off to rest and acclimatize if feeling over-tired. If you or anyone else in your party is having a tough time, make allowances for unscheduled stops.
Don’t push yourself when climbing up to passes; rather, take plenty of breaks. You can usually get over the pass as easily tomorrow as you can today. Try to plan your itinerary so that long ascents can be divided into two or more days. Given the complexity and unknown variables involved with AMS and acclimatization, trekkers should always err on the side of caution and ascend mountains slowly.
Treatment: Treat mild symptoms by resting at the same altitude until recovery, usually a day or two. Take paracetamol or aspirin for headaches. If symptoms persist or become worse, however, immediate descent is necessary – even 500 meters can help.
The most effective treatment for severe AMS is to get down to a lower altitude as quickly as possible. In less severe cases the victim will be able to stagger down with some support; in other cases they may need to be carried down. Whatever the case, do not delay, as any delay could be fatal. AMS victims may need to be flown out of Bhutan as quickly as possible – make sure you have adequate travel insurance.
The drugs acetazolamide (Diamox) and dexamethasone are recommended by some doctors for the prevention of AMS. However, you should be aware that their use is controversial. They can reduce the symptoms, but they may also mask warning signs; severe and fatal AMS has occurred in people taking these drugs. Drug treatments should never be used to avoid descent or to enable further ascent.