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Medical Considerations for Cycling in Ladakh

Vaccinations

Typhoid

Diphtheria

Hepatitis A-A course of two injections, 6 months to a year apart. Even if you go to India before the second injection, it is still worth getting it on your return as the protection lasts much longer with two jabs (10 years versus only one year with a single jab).

Hepatitis B

Tetanus-Thinking has now changed with respect to tetanus boosters, and if you have had one booster in your adult life, you are deemed up-to-date.

Polio-A booster. This is taken orally, not injected.

Rabies-Although "optional", and hence not free, this is really essential. Rabies is invariably fatal if not vaccinated, whereas it appears that despite the advice to get boosters as soon as possible after being bitten, the vaccine is completely protective. This is especially true if you are going to Tibet: rabies is endemic there, and for cultural reasons the Tibetans do not kill feral dogs and so animal bites can be real medical emergencies.

The vaccine is pink-if you need to get a booster in an Indian hospital and they give you something clear and colourless, you are being swindled and not given real vaccine. Rabies vaccination is a course of three injections, on days 1, 7 and 28 after starting the course. The manufacturer recommends an expensive (~£120) course of three intramuscular injections of vaccine. However, there is evidence that a course of three small intradermal injections is just as effective, and because one can then get several injections from one vial of vaccine, it is cheaper (£15/injection).

Update June 2005: The human diploid cell vaccine referred to above has not been available in the UK for a couple of years, and now most people are given a chick embryo vaccine. This vaccine may not be as immunogenic, and so some clinics no longer offer the intradermal protocol in case adequate protection is not provided when the vaccine is administered in this fashion. This obviously makes the whole enterprise very expensive. I compromised, following the advice of Dr Jones at the travel clinic at the Western General Hospital in Edinburgh. For my 2005 booster (first course in 2001; original course recommended for three years) went with two intradermal blebs, one in each shoulder, two weeks apart, for a total of four intradermal shots. This worked out as half the cost of the 3 x intramuscular shots protocol, but should still give a decent immunogenic boost. Something to discuss with your medic before you go.

Meningitis A & C-Although no longer recommended for India, we still got vaccinated for meningitis as Ladakh is very close to Pakistan and Tibet, and not that far from Nepal, where it is still recommended.

Japanese Encephalitis B-We did not bother getting vaccinated for Japanese Encephalitis B, as this is only endemic in regions with lots of rice paddies and pig farms, and even there is hard to catch unless one is living in such an environment for a protracted period. Nowhere on the Manali-Leh route is a risk.

Malaria

Most of the Manali-Leh route is at too high an altitude for mosquitos, and even in Manali the mosquitos do not (reputedly) carry malaria. However, since the chances are one will fly into India via Delhi where malaria is endemic, malaria prophylaxis will probably be necessary. For India, a combination of chloroquine and proguanil (Paludrine) is recommended. Dose is two tablets chloroquine once/week, and two tablets proguanil once/day, starting one week before arriving in the malaria-infected zone, throughout the period spent in the infected region and continuing for four weeks after leaving.

Altitude Medicine

Manali is at 6,700 ft (2,000m), and after having climbed half the Rohtang Pass on the first day, you will not drop below 10,000 ft (3,000 m) until leaving Ladakh by aeroplane or arriving back in Manali. Acute Mountain Sickness (AMS) is therefore a real risk. It makes sense to spend a couple of days in Manali as an intermediate stage in adaptation between coming from sea level and arriving at "real" altitude on the ride (which I arbitrarily define as above 3,000 m or 10,000 ft). In addition to the sources mentioned below, we had the benefit of advice from Dr Carole McAlister, who has extensive experience of altitude medicine. She advised us that the most important thing to do is to make sure that one's ascent profile is sufficiently moderate to allow the body to adapt. The important altitude in the profile is the one at which one sleeps: whilst it is fine (indeed good, as it helps adaptation to altitude) to go higher during the day and come back down, once above about 3,000 m/10,000 ft one should try and sleep not more than 300 metres (1,000 ft) higher than where one slept the previous night. Other sources gave a bit more leeway on this-we have also heard 400 m and 600 m as maximum recommended increases in sleeping height. In practice, on the Manali-Leh route we ended up sleeping about 450 m higher than the previous night when we increased our sleeping height, which was probably pushing it a bit but we had no serious problems. Others may have a different experience. We took acetozolamide (Diamox) when increasing our altitude to help adaptation. Standard dose is 250mg twice/day, but we took 125 mg twice/day as there is evidence that this reduced dose offers the same benefit in speeding adaptation to altitude but with fewer side effects. We still noticed side effects of the Diamox such as the peculiar taste of carbonated drinks (including beer) and tingling in the fingers and toes, but they were never bad enough to force us to stop taking the drug. We also included nifedipine (Adalat) and dexamethasone in our medical kit as emergency treatments for HAPE and HACE respectively, but they were never needed. These are dangerous complications and in addition to the drugs, we would have had to flag down a bus or jeep and get the patient taken to lower altitude as quickly as possible. Basic painkillers such as aspirin were required (and sufficient) for the headaches which we experienced at altitude. Staying properly hydrated seemed to be very important for preventing headaches, especially while cycling-one has to force oneself to keep drinking, but the improvement over just drinking when thirsty was profound.

The American Centres for Disease Control and the British Mountaineering Council, amongst others, have helpful pages on recognising and treating the symptoms of altitude sickness. The BMC pages include an article on the use of drugs in treating altitude sickness and its potentially life-threatening complications (HACE, high altitude cerebral oedema, and HAPE, high altitude pulmonary oedema) here. A good general review of altitude medicine by Peter H. Hackett and Robert C. Roach appeared in the New England Journal of Medicine, (free, but registration required), July 12th 2001 issue, volume 345, number 2, pages 107-114.

The summer sun is strong in Ladakh, so take a good pair of shades, some sunscreen and a UV-protective lip balm.

Infections

When at altitude we got sore throats, coughs and colds. We treated these with antiseptic throat lozenges, coughing and blowing snot, respectively. More severe gastrointestinal infections can in the main be avoided by eating and drinking sensibly. This involved not eating salads (which could have been washed in contaminated water), ice, ice cream, tap water, unpeeled fruits and dodgy meat. Cooked food, especially vegetarian, is usually fine. Teas are usually ok as the water is boiled. (Good job too-see the picture below...) In most places bottled drinking water is available, and should be used even for cleaning teeth, etc. In places where drinking water was not available, we treated all the water by iodination for a minimum of 30 minutes (5 drops of Tincture of Iodine per litre of water). Iodinated water is so horrible it is almost undrinkable, so we removed the iodine afterwards by filtration with a 1 µm activated carbon filter. We have two water bottles that have such filters in the top for removing giardia, iodine and other contaminants, but vitamin C tablets can also be used as a neutralising agent to remove the taste of iodine.

The broad-spectrum antibiotic Ciprofloxacin (Ciproxin) was taken to treat any severe infections. One course for each member of the party, 10x500 mg tablets, one to be taken twice/day for 5 days. I also took a course of metronidazole (Flagyl) for the treatment of giardia, but it is so hard to diagnose giardia from a bacterial infection without the benefit of a laboratory that it would probably never be used: just give it a go if diarrhoea is unresponsive to ciprofloxacin. Immodium for stabilising guts with diarrhoea-especially useful if a long bus journey is on the agenda! Conjunctivitis is relatively common in India, and can be especially horrible if one wears contact lenses, so we brought some eye drops. Good laundry facilities are non-existent, and so anti-fungal talc was used to keep the skank down to an acceptable level when it was not possible to wash cycle shorts after a ride.

Cleaning Glasses in the Gutter

The proprietor of a dhaba in Khalsi, Ladakh washes the chai glasses in the gutter, ready for the next customer...

Medical Kit

Items or drugs listed in colour were actually used on our trip. In addition to the vaccinations suggested above, a private prescription from a G.P. is required for acetozolamide, nifedipine, dexamethasone, ciprofloxacin and metronidazole. Chloroquine and paludrine can be bought over the counter in the UK. In the UK, these drugs are all a reasonable price (typically a couple of quid), except the Ciprofloxacin which was £22/course. As we needed four courses, that hurt a bit, but we'd have felt like right idiots if everyone had come down with something that needed treatment, and we didn't have enough drugs. Ciprofloxacin is reputed to be available over the counter in India, much cheaper, but there is a risk that it is counterfeit. You pays your money, you takes your choice…

Triangular Bandage Ibuprofen
Strip Bandage Aspirin
Plasters Paracetomol
Sutures Immodium
Sterile Syringes Acetozolamide (Diamox)
Sterile Needles Nifedipine (Adalat)
Micropore Tape Dexamethasone
Cotton Wool Ciprofloxacin (Ciproxin)
Sterile Alcohol Wipes Metronidazole (Flagyl)
Savlon antiseptic cream Throat Lozenges
Sachets of rehydration salts/sugars Eye Drops
Safety pins (also useful as clothes pegs) Tiger balm (soothes insect bites)
Tincture of Iodine, 2% Vaseline
Charcoal/filter water bottles Lidocaine
Sunscreen (min. factor 15) Lipsalve (with UV protection)
Medicated (anti-fungal) talcum powder