Vaccinations for Nepal

Nepal does not require any vaccinations for entry. The following are recommended by most international travel medicine authorities for travellers to Nepal:

Strongly Recommended

Hepatitis A: Transmitted through contaminated food and water - extremely relevant in Nepal. A two-dose vaccine series provides 25+ years of protection. Ideally complete both doses before travel (second dose 6 months after first) but even a single dose before departure provides significant short-term protection.
Typhoid: Bacterial infection from contaminated food/water. The injectable Vi polysaccharide vaccine or oral Ty21a vaccine are both effective. Particularly important for Terai and rural travel.
Tetanus/Diphtheria/Polio (Td/Tdap): Ensure your boosters are current (within 10 years for Td, within 5 years if significant wound risk).
Hepatitis B: Three-dose series over 6 months, or accelerated 3-dose series over 21 days (complete in advance). Relevant for any possibility of medical treatment or exposure to blood.

Recommended for Specific Activities or Areas

Rabies (pre-exposure): Strongly recommended for trekkers - particularly those going to remote areas far from rapid medical care. Dog bites and monkey bites (Swayambhunath, Pashupatinath) are the primary risk. The pre-exposure series (3 doses) does not eliminate the need for post-exposure treatment but dramatically reduces urgency and complexity. Begin at least 4 - 6 weeks before travel.
Japanese Encephalitis: Relevant for Terai visitors (Chitwan, Bardiya, Lumbini) during monsoon and early post-monsoon (May - October). A 2-dose vaccine provides effective protection. Not required for highland trekking or Kathmandu/Pokhara city visits.
Malaria prophylaxis: Required for the Terai lowlands during monsoon and early post-monsoon. See the malaria section below.

Water Safety in Nepal

Do not drink tap water in Nepal. Urban water systems in Kathmandu are not reliably safe for drinking; rural water sources (wells, springs, streams) carry bacterial and parasitic contamination risks. Options for safe drinking water:

Commercially bottled water: Available everywhere; safe but contributes significantly to plastic waste, particularly at high altitude where plastic disposal is problematic. Buy large bottles (1.5 - 2L) rather than single-use 500 mL bottles.
Boiled water: Available at all teahouses free of charge or for a small fee (NPR 30 - 50). Completely safe when properly boiled.
UV purification (SteriPen): A UV pen device kills bacteria, viruses, and protozoa (including Giardia) in 45 - 90 seconds. Effective on clear water; less effective on turbid water (pre-filter through a cloth). Recommended for any trekking above 4,000 m where boiled water may not always be available.
Chemical purification: Iodine or chlorine tablets are effective backup. Iodine has an unpleasant taste (countered by Vitamin C tablets added after treatment); chlorine dioxide tablets (Aquatabs, Micropur) have less taste impact and are effective against Cryptosporidium.
Filter water stations: Available at Namche Bazaar (3,440 m) and several other major trekking stops - treated water at NPR 50 - 100 per litre. An excellent combination of safety and sustainability above the snow line.

Stomach Illness and Prevention

Traveller's diarrhoea is the most common medical problem affecting Nepal visitors - some estimates suggest 30 - 40% of visitors experience some degree of gastrointestinal disruption, particularly in the first 3 - 5 days as the gut adjusts to new bacterial environments. Effective prevention:

Handwashing: The single most effective prevention. Soap and water before every meal; hand sanitiser as backup when soap unavailable. The trail toilet facilities are variable; hand hygiene after using them is critical.
Avoid salads and raw vegetables: Below 4,000 m, washing water quality at restaurants is uncertain. Cooked vegetables and cooked food are safe; raw salads carry significant risk at budget restaurants and teahouses.
Meat caution: Chicken and pork below 3,000 m where cold chain management is unreliable. Freshly cooked and served hot. Yak meat above 4,000 m is generally safe due to natural cold temperature storage. Eggs from boiled or fully fried are safe.
Choose busy restaurants: High turnover means food is freshly cooked; slow restaurants have food sitting at room temperature for hours.

Treatment

If diarrhoea strikes:

Oral rehydration salts (ORS) - replace the fluid and electrolyte loss immediately; dehydration at altitude significantly worsens all symptoms
Loperamide (Imodium) - slows gut motility; useful for managing symptoms during travel or a trek day; does not treat the underlying cause
Azithromycin or Ciprofloxacin - antibiotic treatment for confirmed or suspected bacterial diarrhoea (bloody stool, high fever, severe cramping) - carry one course and use with medical advice if available
If symptoms include bloody diarrhoea, high fever, or persist beyond 3 days, seek medical care in Kathmandu or Pokhara

Altitude Sickness Overview

Acute Mountain Sickness (AMS), High Altitude Cerebral Oedema (HACE), and High Altitude Pulmonary Oedema (HAPE) are the altitude-related conditions that make Nepal trekking potentially dangerous above 3,000 m. AMS - characterised by headache, nausea, fatigue, sleep disruption, and appetite loss - is common and manageable with rest and proper acclimatisation. HACE (brain swelling) and HAPE (lung fluid) are life-threatening and require immediate descent.

The cardinal rule: never ascend with AMS symptoms. If you have a headache at altitude that doesn't resolve with rest, water, and paracetamol within a few hours, rest at your current altitude for a full day before ascending further. If symptoms worsen, descend immediately - descent is the only reliable treatment.

Diamox (acetazolamide) 125 - 250 mg twice daily is the standard prophylactic medication - consult your doctor before travel for appropriate use. Note that Diamox is a sulfonamide; those with sulfa drug allergies should not use it.

Malaria and Dengue in Nepal

Malaria risk in Nepal is limited to the Terai lowlands below 1,200 m - Chitwan, Bardiya, Lumbini, and the Terai plains generally. Risk is highest during and immediately after the monsoon (May - November). The dominant plasmodium species in Nepal is P. vivax (less severe than P. falciparum but with relapse potential).

Prophylaxis for Terai visitors during monsoon season: Atovaquone/proguanil (Malarone), Doxycycline, or Chloroquine (check current resistance patterns with your travel doctor as recommendations change). Kathmandu, Pokhara, and all mountain trekking routes above 1,200 m are malaria-free.

Dengue fever is present in Nepal's lowlands and increasingly reported in Kathmandu during and after the monsoon. Dengue is transmitted by day-biting Aedes mosquitoes - repellent use during daytime hours is important in affected areas. There is no prophylactic medication; DEET-based repellent and long sleeves are the primary prevention tools.

Rabies Risk and Dog Bite Protocol

Nepal has a significant stray dog population, and bites occur occasionally to trekkers and travellers. Nepal's rabies vaccination coverage in the dog population is improving but incomplete. Monkeys at Swayambhunath and Pashupatinath also occasionally bite. The risk protocol:

If bitten by a dog, monkey, or other mammal: wash the wound immediately and thoroughly with soap and water for at least 15 minutes; apply antiseptic; seek medical care as soon as possible
Post-exposure treatment (PEP) - rabies immunoglobulin (RIG) + vaccine series - is available at Kathmandu hospitals. Begin within 24 hours of exposure if possible.
If you have had the pre-exposure vaccine series (3 doses), post-exposure treatment is simpler (2 vaccine doses; no RIG required) and the timeline is less urgent
Rabies is uniformly fatal once symptomatic; post-exposure treatment is extremely effective if initiated promptly

Medical Kit for Nepal Trekkers

Paracetamol and Ibuprofen (headache, fever, mild AMS)
Diamox (acetazolamide) - altitude sickness prophylaxis; prescription required in most countries
Loperamide (Imodium) + Oral Rehydration Salts
Azithromycin 500 mg (antibiotic for severe diarrhoea or respiratory infection)
Ciprofloxacin 500 mg (backup antibiotic)
Antihistamine (Cetirizine) for allergic reactions
Wound care: adhesive plasters, wound closure strips, antiseptic wipes, iodine solution
Blister treatment: compeed/moleskin, needle for draining, alcohol wipes
Elastic bandage (ankle support)
Thermometer (digital)
Pulse oximeter - essential for any trekking above 3,500 m; SpO2 below 80% at rest at altitude indicates significant altitude illness
Dexamethasone 4 - 8 mg - emergency HACE/HAPE treatment; discuss use protocol with a doctor before travel
High-factor sunscreen (SPF 50+)
Insect repellent (DEET 30%+ for Terai travel)

Medical Facilities in Nepal

Kathmandu: Good facilities at several international-standard clinics - CIWEC Hospital (Lazimpat; the primary clinic for trekker health issues), Nepal International Clinic, B&B Hospital. Emergency care at Tribhuvan University Teaching Hospital and Norvic International Hospital.
Pokhara: Manipal Teaching Hospital provides reasonable emergency care. Western Regional Hospital is the main government facility.
On major trekking routes: Basic health posts at Namche Bazaar, Pheriche (Khumbu), and Manang (Annapurna) are staffed by medically trained personnel during peak season. The Pheriche Himalayan Rescue Association (HRA) clinic is staffed by volunteer physicians and provides AMS assessment and advice free of charge.
Remote treks: No medical facilities. Guide and medical kit + insurance for helicopter evacuation are your complete medical system.

Travel Insurance and Helicopter Evacuation

Travel insurance with helicopter evacuation coverage is not optional for Nepal trekking above 3,000 m - it is a minimum safety requirement. A helicopter evacuation from the Khumbu above Namche to Kathmandu costs USD 5,000 - 8,000. Hospitalisation and repatriation can exceed USD 20,000 - 50,000 for a serious medical event. Travel insurance covering trekking altitude and helicopter evacuation costs USD 50 - 150 for a month from most international providers.

Key insurance requirements for Nepal trekking:

Altitude coverage up to the maximum altitude of your planned trek (specify at least 6,000 m for EBC or Three Passes)
Helicopter evacuation coverage (emergency helicopter rescue from mountain terrain)
Emergency medical treatment and hospital coverage
Medical repatriation to your home country

Check the fine print: some policies exclude trekking above 4,000 m or require additional riders for high-altitude activities. Reputable providers for Nepal trekking insurance include World Nomads, True Traveller, Safety Wing, and Battleface.