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Nepal
Summary of recommendationsMedicationsImmunizations
Recent outbreaksOther infectionsFood and water precautions
Insect and Tick ProtectionGeneral adviceAmbulance and Emergency Services
Medical facilitiesTraveling with childrenTravel and pregnancy
MapsEmbassy/Consulate LocationSafety information

 

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Summary of recommendations:

All travelers should visit either their personal physician or a travel health clinic 4-8 weeks before departure.

Malaria: Prophylaxis with Lariam (mefloquine), Malarone (atovaquone/proguanil), or doxycycline is recommended for all areas at altitudes less than 1200 m (3937 ft). There is no malaria risk in Kathmandu or on typical Himalayan treks.
Vaccinations:

Hepatitis A

Recommended for all travelers

Typhoid

Recommended for all travelers

Polio

One-time booster recommended for any adult traveler who completed the childhood series but never had polio vaccine as an adult

Yellow fever

Required for all travelers arriving from a yellow-fever-infected area in Africa or the Americas. Not recommended otherwise.

Japanese encephalitis

For travelers who may spend a month or more in rural areas and for short-term travelers who may spend substantial time outdoors in rural areas, especially after dusk

Hepatitis B

Recommended for all travelers

Rabies

For travelers spending a lot of time outdoors, or at high risk for animal bites, or involved in any activities that might bring them into direct contact with bats

Measles, mumps, rubella (MMR)

Two doses recommended for all travelers born after 1956, if not previously given

Tetanus-diphtheria

Revaccination recommended every 10 years

Medications

Travelers' diarrhea is the most common travel-related ailment. The cornerstone of prevention is food and water precautions, as outlined below. All travelers should bring along an antibiotic and an antidiarrheal drug to be started promptly if significant diarrhea occurs, defined as three or more loose stools in an 8-hour period or five or more loose stools in a 24-hour period, especially if associated with nausea, vomiting, cramps, fever or blood in the stool. A quinolone antibiotic is usually prescribed: either ciprofloxacin (Cipro)(PDF) 500 mg twice daily or levofloxacin (Levaquin) 500 mg once daily for a total of three days. Quinolones are generally well-tolerated, but occasionally cause sun sensitivity and should not be given to children, pregnant women, or anyone with a history of quinolone allergy. Alternative regimens include a three day course of rifaximin (Xifaxan) 200 mg three times daily or azithromycin (Zithromax) 500 mg once daily. Rifaximin should not be used by those with fever or bloody stools and is not approved for pregnant women or those under age 12. Azithromycin should be avoided in those allergic to erythromycin or related antibiotics. An antidiarrheal drug such as loperamide (Imodium) or diphenoxylate (Lomotil) should be taken as needed to slow the frequency of stools, but not enough to stop the bowel movements completely. Diphenoxylate (Lomotil) and loperamide (Imodium) should not be given to children under age two.

Most cases of travelers' diarrhea are mild and do not require either antibiotics or antidiarrheal drugs. Adequate fluid intake is essential.

If diarrhea is severe or bloody, or if fever occurs with shaking chills, or if abdominal pain becomes marked, or if diarrhea persists for more than 72 hours, medical attention should be sought.

Though effective, antibiotics are not recommended prophylactically (i.e. to prevent diarrhea before it occurs) because of the risk of adverse effects, though this approach may be warranted in special situations, such as immunocompromised travelers.

Malaria in Nepal: prophylaxis is recommended for all areas at altitudes less than 1200 m (3937 ft). There is no malaria risk in Kathmandu or on typical Himalayan treks.

Either mefloquine (Lariam), atovaquone/proguanil (Malarone)(PDF), or doxycycline may be given. Mefloquine is taken once weekly in a dosage of 250 mg, starting one-to-two weeks before arrival and continuing through the trip and for four weeks after departure. Mefloquine may cause mild neuropsychiatric symptoms, including nausea, vomiting, dizziness, insomnia, and nightmares. Rarely, severe reactions occur, including depression, anxiety, psychosis, hallucinations, and seizures. Mefloquine should not be given to anyone with a history of seizures, psychiatric illness, cardiac conduction disorders, or allergy to quinine or quinidine. Those taking mefloquine (Lariam) should read the Lariam Medication Guide (PDF). Atovaquone/proguanil (Malarone) is a combination pill taken once daily with food starting two days before arrival and continuing through the trip and for seven days after departure. Side-effects, which are typically mild, may include abdominal pain, nausea, vomiting, headache, diarrhea, or dizziness. Serious adverse reactions are rare. Doxycycline is effective, but may cause an exaggerated sunburn reaction, which limits its usefulness in the tropics.

Long-term travelers who may not have access to medical care should bring along medications for emergency self-treatment should they develop symptoms suggestive of malaria, such as fever, chills, headaches, and muscle aches, and cannot obtain medical care within 24 hours. See malaria for details. Symptoms of malaria sometimes do not occur for months or even years after exposure.

Insect protection measures are essential.

For further information concerning malaria in Nepal, go to Roll Back Malaria or the World Health Organization - South East Asia Region.

Altitude sickness may occur in travelers who ascend rapidly to altitudes greater than 2500 meters. Acetazolamide is the drug of choice to prevent altitude sickness. The usual dosage is 125 or 250 mg twice daily starting 24 hours before ascent and continuing for 48 hours after arrival at altitude. Possible side-effects include increased urinary volume, numbness, tingling, nausea, drowsiness, myopia and temporary impotence. Acetazolamide should not be given to pregnant women or those with a history of sulfa allergy. For those who cannot tolerate acetazolamide, the preferred alternative is dexamethasone 4 mg taken four times daily. Unlike acetazolamide, dexamethasone must be tapered gradually upon arrival at altitude, since there is a risk that altitude sickness will occur as the dosage is reduced.

Travel to high altitudes is not generally recommended for those with a history of heart disease, lung disease, or sickle cell disease.

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Immunizations

The following are the recommended vaccinations for Nepal:

Hepatitis A vaccine is recommended for all travelers over one year of age. It should be given at least two weeks (preferably four weeks or more) before departure. A booster should be given 6-12 months later to confer long-term immunity. Two vaccines are currently available in the United States: VAQTA (Merck and Co., Inc.) (PDF) and Havrix (GlaxoSmithKline) (PDF). Both are well-tolerated. Side-effects, which are generally mild, may include soreness at the injection site, headache, and malaise.

Older adults, immunocompromised persons, and those with chronic liver disease or other chronic medical conditions who have less than two weeks before departure should receive a single intramuscular dose of immune globulin (0.02 mL/kg) at a separate anatomic injection site in addition to the initial dose of vaccine. Travelers who are less than one year of age or allergic to a vaccine component should receive a single intramuscular dose of immune globulin (see hepatitis A for dosage) in the place of vaccine.

Typhoid vaccine is recommended for all travelers. It is generally given in an oral form (Vivotif Berna) consisting of four capsules taken on alternate days until completed. The capsules should be kept refrigerated and taken with cool liquid. Side-effects are uncommon and may include abdominal discomfort, nausea, rash or hives. The alternative is an injectable polysaccharide vaccine (Typhim Vi; Aventis Pasteur Inc.) (PDF), given as a single dose. Adverse reactions, which are uncommon, may include discomfort at the injection site, fever and headache. The oral vaccine is approved for travelers at least six years old, whereas the injectable vaccine is approved for those over age two. There are no data concerning the safety of typhoid vaccine during pregnancy. The injectable vaccine (Typhim Vi) is probably preferable to the oral vaccine in pregnant and immunocompromised travelers.

Polio vaccine is recommended (see "Recent outbreaks" below). Any adult who received the recommended childhood immunizations but never had a booster as an adult should be given a single dose of inactivated polio vaccine. All children should be up-to-date in their polio immunizations and any adult who never completed the initial series of immunizations should do so before departure. Side-effects are uncommon and may include pain at the injection site. Since inactivated polio vaccine includes trace amounts of streptomycin, neomycin and polymyxin B, individuals allergic to these antibiotics should not receive the vaccine.

Japanese encephalitis vaccine is recommended for long-term (1 month) travelers to rural areas or travelers who may engage in extensive unprotected outdoor activities in rural areas, especially in the evening, during shorter trips. Outbreaks of Japanese encephalitis occur annually in Nepal. The prevalence is greatest in the Terai plains along the southern border with India. Transmission is from July to December, with a peak during the monsoon season from mid-August to early November. The vaccine is not advised for those travelling only to high-altitude areas. For a map of Japanese encephalitis cases in Nepal, go to the World Health Organization — South-East Asia Region.

The recommended vaccine is IXIARO , given 0.5 cc intramuscularly, followed by a second dose 28 days later. The series should be completed at least one week before travel. The most common side effects are headaches, muscle aches, and pain and tenderness at the injection site. Safety has not been established in pregnant women, nursing mothers, or children under the age of two months.

Hepatitis B vaccine is recommended for all travelers if not previously vaccinated. Two vaccines are currently licensed in the United States: Recombivax HB (Merck and Co., Inc.) (PDF) and Engerix-B (GlaxoSmithKline) (PDF). A full series consists of three intramuscular doses given at 0, 1 and 6 months. Engerix-B is also approved for administration at 0, 1, 2, and 12 months, which may be appropriate for travelers departing in less than 6 months. Side-effects are generally mild and may include discomfort at the injection site and low-grade fever. Severe allergic reactions (anaphylaxis) occur rarely.

Rabies vaccine is recommended for travelers spending a lot of time outdoors, for travelers at high risk for animal bites, such as veterinarians and animal handlers, for long-term travelers and expatriates, and for travelers involved in any activities that might bring them into direct contact with bats. Children are considered at higher risk because they tend to play with animals, may receive more severe bites, or may not report bites. The prevalence of rabies is high in Nepal. The chief risk is from stray dogs, followed by monkeys (especially at the Kathmandu monkey temple). Bites from cats and squirrels may also cause infection. A complete preexposure series consists of three doses of vaccine injected into the deltoid muscle on days 0, 7, and 21 or 28. Side-effects may include pain at the injection site, headache, nausea, abdominal pain, muscle aches, dizziness, or allergic reactions.

Any animal bite or scratch should be thoroughly cleaned with large amounts of soap and water and local health authorities should be contacted immediately for possible post-exposure treatment, whether or not the person has been immunized against rabies.

Tetanus-diphtheria vaccine is recommended for all travelers who have not received a tetanus-diphtheria immunization within the last 10 years.

Measles-mumps-rubella vaccine: two doses are recommended (if not previously given) for all travelers born after 1956, unless blood tests show immunity. Many adults born after 1956 and before 1970 received only one vaccination against measles, mumps, and rubella as children and should be given a second dose before travel. MMR vaccine should not be given to pregnant or severely immunocompromised individuals.

Meningococcal vaccine is recommended by the U.K. Department of Health for all visits longer than a few days, but is not recommended by the Centers for Disease Control or Health Canada. Meningococcal vaccine has few side-effects. Mild redness at the injection site may occur. Young children may develop transient fever.

 

Cholera vaccine is not generally recommended, even though cholera occurs in Nepal, because most travelers are at low risk for infection. Two oral vaccines have recently been developed: Orochol (Mutacol), licensed in Canada and Australia, and Dukoral, licensed in Canada, Australia, and the European Union. These vaccines, where available, are recommended only for high-risk individuals, such as relief workers, health professionals, and those traveling to remote areas where cholera epidemics are occurring and there is limited access to medical care. The only cholera vaccine approved for use in the United States is no longer manufactured or sold, due to low efficacy and frequent side-effects.

Yellow fever vaccine is required for all travelers arriving from a yellow-fever-infected country in Africa or the Americas, but is not recommended or required otherwise. Yellow fever vaccine (YF-VAX; Aventis Pasteur Inc.) (PDF) must be administered at an approved yellow fever vaccination center, which will give each vaccinee a fully validated International Certificate of Vaccination. Yellow fever vaccine should not in general be given to those younger than nine months of age, pregnant, immunocompromised, or allergic to eggs.

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Recent outbreaks

An increased number of cases of typhoid fever was reported from Saptari district (Sagarmatha) in July 2014. In June 2007, a typhoid outbreak was reported from Baglung district in the Western region of Nepal. In November 2006, a typhoid outbreak was reported from Manthali, the headquarters of Ramechhap district in central Nepal, affecting more than 200 people. A smaller outbreak, involving more than 20 people, was reported at about the same time from Kimaghngwa VDC of Sankhuwasabha district, which borders China. Typhoid vaccine is recommended for all travelers to Nepal. Cases of typhoid fever which show increased resistance to quinolones or third-generation cephalosporins, the antibiotics often used to treat these infections, have recently been reported among travelers to India and Nepal.

An outbreak of hepatitis E was reported from Biratnagar, Morang District, in May 2014. Hepatitis E virus is transmitted by contaminated food or water. The mortality rate is particularly high in pregnant women. As below, travelers to Nepal should not consume any liquids unless bottled or boiled.

A Measles outbreak was reported in June 2011 from Sikwakataiya VDC (village development community) in Mahottari district, Nepal, affecting more than 400 children (see ProMED-mail). All travelers born after 1956 should make sure they have had either two documented measles immunizations or a blood test showing measles immunity. This does not apply to people born before 1957, who are presumed to be immune to measles. Although measles immunization is usually begun at age 12 months, children between the ages of 6 and 11 months should be given an initial dose of measles or MMR vaccine before traveling to Nepal.

Cholera outbreaks are regularly reported from Nepal. The most recent was reported from Kathmandu in July 2011. In August 2010, an outbreak was reported from Nepalgunj, a city on the border with India, causing 1400 cases and eight deaths, and from Banke district, causing more than 500 cases and at least six deaths. In July 2009, a cholera outbreak occurred in Jajarkot district in the Mid Western Region, killing more than 300 people in Jajarkot and surrounding areas by August. Further investigation indicated that other bacteria besides Vibrio cholerae, the bacteria that cause cholera, were involved in the outbreak (see ProMED-mail; July 24 and August 19, 2009; March 24 and August 9 and 20, 2010). In October 2007, cholera outbreaks were reported from the remote Kalikot district in western Nepal, killing at least 60 people, and from Saptari district, about 190 km (118 miles) southeast of the capital Kathmandu, resulting in 34 fatalities. In September 2007, a cholera outbreak was reported from Chitawan District in central Nepal, affecting more than 200 people. In October 2006, a small outbreak was reported from Myagdi district in western Nepal. Cholera vaccine is recommended only for high-risk individuals, such as relief workers, health professionals, and those traveling to remote areas where cholera epidemics are occurring and there is limited access to medical care.

An outbreak of acute encephalitis syndrome spread from northern India to Nepal in the summer of 2010, causing nine deaths as of September. Some of the cases were caused by Japanese encephalitis virus, but the cause of many cases has still not been identified. For further information, go to ProMED-mail.

The first poultry outbreak of H5N1 avian influenza ("bird flu") was reported from Nepal in January 2009, involving chickens and ducks in Kakarbhitta in the eastern district of Jhapa, near the Indian border. Additional cases were reported from Jhapa district in February. The most recent poultry outbreaks were reported from a farm in Chitwan, Narayani, in December 2010; from a farm near the Jadibuti area of Bhaktapur in November 2011; from a farm in the region of Bagmati in December 2012 and from Lalitpur in February 2014. No human cases have been reported to date.

Most travelers are at extremely low risk for avian influenza, since almost all human cases in other countries have occurred in those who have had direct contact with live, infected poultry, or sustained, intimate contact with family members suffering from the disease. The Centers for Disease Control and the World Health Organization do not advise against travel to countries affected by avian influenza, but recommend that travelers should avoid exposure to live poultry, including visits to poultry farms and open markets with live birds; should not touch any surfaces that might be contaminated with feces from poultry or other animals; and should make sure all poultry and egg products are thoroughly cooked. A vaccine for avian influenza was recently approved by the U.S. Food and Drug Administration (FDA), but produces adequate antibody levels in fewer than half of recipients and is not commercially available. The vaccines for human influenza do not protect against avian influenza. Anyone who develops fever and flu-like symptoms after travel to Nepal should seek immediate medical attention, which may include testing for avian influenza. For further information, go to the World Health Organization, Health Canada, the Centers for Disease Control, and ProMED-mail.

A malaria outbreak was reported in October 2006 from Banke district, near Nepal's southern border with India. Approximately 1200 people were affected, including 32 deaths. See NATHNAC for further information. Malaria prophylaxis is recommended for all travelers to the areas along Nepal's southern border with India.

Outbreaks of Japanese encephalitis were reported from eastern and southern Nepal in August 2006 (see ProMED-mail; August 30, 2006). A much larger outbreak occurred in August 2005, chiefly involving the western, mid-western and far-western regions of the country. As of November 6, a total of 2398 suspected cases had been identified, of which 11% were fatal. See the World Health Organization and NATHNAC for further information.

Japanese encephalitis is transmitted by Culex mosquitoes, which breed in ground pools, especially flooded rice fields, and bite primarily after dusk. Most infections are asymptomatic, but the virus may spread to the brain, which is frequently fatal. Those who survive may show evidence of mental retardation or other neurological deficits. Japanese encephalitis vaccine is not recommended for all travelers to Nepal, but is advised for those who will be visiting rural areas in affected states for more than one month or who may engage in extensive unprotected outdoor activities in rural areas, especially in the evening, during shorter trips. All travelers to Nepal should protect themselves from mosquito bites by applying insect repellent and keeping themselves covered.

A single case of polio was reported in May 2006 from the west-central region in the interior of the country. One case of polio was also reported from Sarlahi district, Central Division, in August 2005. All travelers to Nepal should make sure they have been fully immunized against polio.

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Other infections

Two cases of dengue fever were reported in May 2010 from Kathmandu, where the disease does not ordinarily occur. Dengue has also been reported from the Tarai and inner-Tarai districts. Dengue fever is a flu-like illness which may be complicated by hemorrhage or shock. The infection is transmitted by Aedes mosquitoes, which bite primarily in the daytime and favor densely populated areas, though they also inhabit rural environments. No vaccine is available at this time. Insect protection measures are essential, as outlined below.

The incidence of visceral leishmaniasis is increasing. The most recent outbreak began in June 2000, at the onset of the monsoon season, in the Terai plain in the southern part of the country; see ProMED-mail for details.

Leptospirosis occurs in Nepal.

Lymphatic filariasis is reported (see the World Health Organization - South-East Asia Region for further information).

HIV (human immunodeficiency virus) infection is reported, but travelers are not at risk unless they have unprotected sexual contacts or receive injections or blood transfusions.

For a country health profile of Nepal, go to the World Health Organization.

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Food and water precautions

Do not drink tap water unless it has been boiled, filtered, or chemically disinfected. Do not drink unbottled beverages or drinks with ice. Do not eat fruits or vegetables unless they have been peeled or cooked. Avoid cooked foods that are no longer piping hot. Cooked foods that have been left at room temperature are particularly hazardous. Avoid unpasteurized milk and any products that might have been made from unpasteurized milk, such as ice cream. Avoid food and beverages obtained from street vendors. Do not eat raw or undercooked meat or fish. Some types of fish may contain poisonous biotoxins even when cooked. Barracuda in particular should never be eaten. Other fish that may contain toxins include red snapper, grouper, amberjack, and sea bass.

All travelers should bring along an antibiotic and an antidiarrheal drug to be started promptly if significant diarrhea occurs, defined as three or more loose stools in an 8-hour period or five or more loose stools in a 24-hour period, especially if accompanied by nausea, vomiting, cramps, fever or blood in the stool. Antibiotics which have been shown to be effective include ciprofloxacin (Cipro), levofloxacin (Levaquin), rifaximin (Xifaxan), or azithromycin (Zithromax). Either loperamide (Imodium) or diphenoxylate (Lomotil) should be taken in addition to the antibiotic to reduce diarrhea and prevent dehydration.

If diarrhea is severe or bloody, or if fever occurs with shaking chills, or if abdominal pain becomes marked, or if diarrhea persists for more than 72 hours, medical attention should be sought.

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Insect and Tick Protection

Wear long sleeves, long pants, hats and shoes (rather than sandals). For rural and forested areas, boots are preferable, with pants tucked in, to prevent tick bites. Apply insect repellents containing 25-50% DEET (N,N-diethyl-3-methylbenzamide) or 20% picaridin (Bayrepel) to exposed skin (but not to the eyes, mouth, or open wounds). DEET may also be applied to clothing. Products with a lower concentration of either repellent need to be repplied more frequently. Products with a higher concentration of DEET carry an increased risk of neurologic toxicity, especially in children, without any additional benefit. Do not use either DEET or picaridin on children less than two years of age. For additional protection, apply permethrin-containing compounds to clothing, shoes, and bed nets. Permethrin-treated clothing appears to have little toxicity. Don't sleep with the window open unless there is a screen. If sleeping outdoors or in an accommodation that allows entry of mosquitoes, use a bed net, preferably impregnated with insect repellent, with edges tucked in under the mattress. The mesh size should be less than 1.5 mm. If the sleeping area is not otherwise protected, use a mosquito coil, which fills the room with insecticide through the night. In rural or forested areas, perform a thorough tick check at the end of each day with the assistance of a friend or a full-length mirror. Ticks should be removed with tweezers, grasping the tick by the head. Many tick-borne illnesses can be prevented by prompt tick removal.

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General advice

Bring adequate supplies of all medications in their original containers, clearly labeled. Carry a signed, dated letter from the primary physician describing all medical conditions and listing all medications, including generic names. If carrying syringes or needles, be sure to carry a physician's letter documenting their medical necessity.Pack all medications in hand luggage. Carry a duplicate supply in the checked luggage. If you wear glasses or contacts, bring an extra pair. If you have significant allergies or chronic medical problems, wear a medical alert bracelet.

Make sure your health insurance covers you for medical expenses abroad. If not, supplemental insurance for overseas coverage, including possible evacuation, should be seriously considered. If illness occurs while abroad, medical expenses including evacuation may run to tens of thousands of dollars. For a list of travel insurance and air ambulance companies, go to Medical Information for Americans Traveling Abroad on the U.S. State Department website. Bring your insurance card, claim forms, and any other relevant insurance documents. Before departure, determine whether your insurance plan will make payments directly to providers or reimburse you later for overseas health expenditures. The Medicare and Medicaid programs do not pay for medical services outside the United States.

Pack a personal medical kit, customized for your trip (see description). Take appropriate measures to prevent motion sickness and jet lag, discussed elsewhere. On long flights, be sure to walk around the cabin, contract your leg muscles periodically, and drink plenty of fluids to prevent blood clots in the legs. For those at high risk for blood clots, consider wearing compression stockings.

Avoid contact with stray dogs and other animals. If an animal bites or scratches you, clean the wound with large amounts of soap and water and contact local health authorities immediately. Wear sun block regularly when needed. Use condoms for all sexual encounters. Ride only in motor vehicles with seat belts. Do not ride on motorcycles.

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Ambulance and Emergency Services

For an ambulance in Nepal, call the Red Cross at 4228094, the Chamber of Commerce at 4230213/4222890, or Norvic Hospital at 4258554, 9810-23390.

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Medical facilities

For high quality Western medical care in Nepal, go to the CIWEC Clinic in Kathmandu (Yak and Yeti Road, Durbar Marg; PO Box 12895, tel. 977-1-422 8531, 424 1732 fax: 977-1-422 4675; website: http://www.ciwec-clinic.com; Visa and MasterCard accepted). Many expatriates also use the Nepal International Clinic (GPO Box 3596, Laldurbar, Kathmandu; ph. 977-1-4434 642 / 4435 357; website http://www.nepalinternationalclinic.com; Visa, MasterCard, and American Express accepted). In Patan, medical care for travelers is available at the Patan Private Clinic (tel. 5522278, 5522266), which is affiliated with Patan Hospital. For a list of other hospitals, clinics and physicians in Nepal, go to the U.S. Embassywebsite. If you are an American citizen who needs consular assistance with a medical emergency, call the U.S. Embassy at 411-179 (after hours 410-531). Except for CIWEC and a small number of other facilities, medical care in Nepal is limited. Many doctors and hospitals will expect payment in cash, regardless of whether you have travel health insurance.

Serious medical problems will require air evacuation to cities with state-of-the-art medical facilities, usually Singapore, Bangkok, or New Delhi. Evacuation may be difficult for those on treks in remote areas. According to the U.S. State Department, "Illnesses and injuries suffered while hiking in remote areas often require evacuation by helicopter to Kathmandu. Those trekking in remote areas of Nepal should factor the high costs of a potential helicopter rescue into their financial considerations. Travelers are urged to consider purchasing medical evacuation insurance if they plan to visit remote areas."

For dental care, many travelers go to Healthy Smiles (Pvt. Ltd.) (0pposite Hotel Ambassador, below VAUDE; Ananda Bhavan, Lazimpat Kathmandu, tel. 977 1 4420800 / 4444689; email: hs@smilenepal.com; website www.smilenepal.com).

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Traveling with children

Before you leave, make sure you have the names and contact information for physicians, clinics, and hospitals where you can obtain emergency medical care if needed (see the U.S. Embassy website).

All children should be up-to-date on routine childhood immunizations, as recommended by the American Academy of Pediatrics. Children who are 12 months or older should receive a total of 2 doses of MMR (measles-mumps-rubella) vaccine, separated by at least 28 days, before international travel. Children between the ages of 6 and 11 months should be given a single dose of measles vaccine. MMR vaccine may be given if measles vaccine is not available, though immunization against mumps and rubella is not necessary before age one unless visiting a country where an outbreak is in progress. Children less than one year of age may also need to receive other immunizations ahead of schedule (see the accelerated immunization schedule).

The recommendations for malaria prophylaxis are the same for young children as for adults, except that (1) dosages are lower; and (2) doxycycline should be avoided. DEET-containing insect repellents are not advised for children under age two, so it's especially important to keep children in this age group well-covered to protect them from mosquito bites.

When traveling with young children, be particularly careful about what you allow them to eat and drink (see food and water precautions), because diarrhea can be especially dangerous in this age group and because the vaccines for hepatitis A and typhoid fever, which are transmitted by contaminated food and water, are not approved for children under age two. Baby foods and cows' milk may not be available in developing nations. Only commercially bottled milk with a printed expiration date should be used. Young children should be kept well-hydrated and protected from the sun at all times.

Be sure to pack a medical kit when traveling with children. In addition to the items listed for adults, bring along plenty of disposable diapers, cream for diaper rash, oral replacement salts, and appropriate antibiotics for common childhood infections, such as middle ear infections.

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Travel and pregnancy

International travel should be avoided by pregnant women with underlying medical conditions, such as diabetes or high blood pressure, or a history of complications during previous pregnancies, such as miscarriage or premature labor. For pregnant women in good health, the second trimester (18–24 weeks) is probably the safest time to go abroad and the third trimester the least safe, since it's far better not to have to deliver in a foreign country.

Before departure, make sure you have the names and contact information for physicians, clinics, and hospitals where you can obtain emergency obstetric care if necessary (see the U.S. Embassy website). In general, pregnant women should avoid traveling to countries which do not have modern facilities for the management of premature labor and other complications of pregnancy.

As a rule, pregnant women should avoid visiting areas where malaria occurs. Malaria may cause life-threatening illness in both the mother and the unborn child. None of the currently available prophylactic medications is 100% effective. Mefloquine (Lariam) is the drug of choice for malaria prophylaxis during pregnancy, but should not be given if possible in the first trimester. If travel to malarious areas is unavoidable, insect protection measures must be strictly followed at all times. The recommendations for DEET-containing insect repellents are the same for pregnant women as for other adults.

Strict attention to food and water precautions is especially important for the pregnant traveler because some infections, such as listeriosis, have grave consequences for the developing fetus. Additionally, many of the medications used to treat travelers' diarrhea may not be given during pregnancy. Quinolone antibiotics, such as ciprofloxacin (Cipro) and levofloxacin (Levaquin), should not be given because of concern they might interfere with fetal joint development. Data are limited concerning trimethoprim-sulfamethoxazole, but the drug should probably be avoided during pregnancy, especially the first trimester. Options for treating travelers' diarrhea in pregnant women include azithromycin and third-generation cephalosporins. For symptomatic relief, the combination of kaolin and pectin (Kaopectate; Donnagel) appears to be safe, but loperamide (Imodium) should be used only when necessary. Adequate fluid intake is essential.

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Maps

Helpful maps are available in the University of Texas Perry-Castaneda Map Collection and the United Nations map library. If you have the name of the town or city you'll be visiting and need to know which state or province it's in, you might find your answer in the Getty Thesaurus of Geographic Names.

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Embassy/Consulate Location

(reproduced from the U.S. State Dept. Consular Information Sheet)

U.S. citizens living in or visiting Nepal are strongly encouraged to obtain updated information on travel and security within Nepal by reviewing recent warden messages on the U.S. Embassy's home page. Americans are strongly urged to register at the Consular Section of the U.S. Embassy in Nepal. The U.S. Embassy is located at Pani Pokhari in Kathmandu, telephone (977) (1) 441-1179; fax (977) (1) 444-4981. Citizens may also register by accessing the U.S. Embassy's home page at http://kathmandu.usembassy.gov/ or by e-mail at wardenKTM@state.gov. Please include the following information: full name; date of birth; U.S. passport number, date and place of issuance; home address and phone number; emergency contact person's name, phone number, fax or e-mail address; travel/medevac insurance information; address and phone number in Nepal; travel or trekking agency contact in Nepal; planned itinerary in Nepal; and traveling companions' names and nationalities. Finally, please indicate to whom, if anyone, the Embassy may divulge information regarding your welfare and whereabouts in Nepal.

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Safety information

For information on safety and security, go to the U.S. Department of State, United Kingdom Foreign and Commonwealth Office, Foreign Affairs Canada, and the Australian Department of Foreign Affairs and Trade.

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