Author(s): Kristin VanderEnde, Meghna Desai

Destination Overview

India is approximately one-third the size of the United States but has 4 times the population—almost 1.4 billion people—making it the second most populous country in the world, behind China. Rich in history, culture, and diversity, India is the birthplace of 4 of the world’s religions: Buddhism, Hinduism, Jainism, and Sikhism. India is experiencing rapid urbanization, as noted in the growth of megacities (e.g., Delhi, Mumbai). India’s topography is varied, ranging from tropical beaches to deserts, foothills, and the Himalaya Mountains. Northern India has a more temperate climate; the south is more tropical year-round. Many travelers prefer India during the winter (November–March), when temperatures are more agreeable.

Because of India’s size, short-term travelers usually select a region of the country to visit for any given trip. A typical itinerary to the north includes the cities of Agra, Delhi, Varanasi, and cities in Rajasthan State (e.g., Jaipur [the Pink City] and Udaipur). More southern routes might swing through the beaches of Goa and the cities of Bengaluru (Bangalore) and Mumbai. In the east, Kolkata (Calcutta) is considered the cultural capital of the country.

Despite the many and varied itineraries, most health recommendations for travelers to India are similar. The incidence of some illnesses (e.g., those transmitted by mosquitoes) is greater during the monsoon season (June–September), which has high temperatures, heavy rains, and the risk of flooding. Travelers visiting friends and relatives (VFRs) require extra consideration. Because they might stay in rural areas not often visited by tourists or businesspeople, live in homes, and eat and drink with their families, VFR travelers are at greater risk for many travel-related illnesses (see Sec. 9, Ch. 9, Visiting Friends & Relatives: VFR Travel). Some VFR travelers might not seek pretravel health advice since they are returning to their land of origin.

Infectious Disease Risks

All travelers to India should be up to date with routine immunizations. Infants 6–11 months old should get 1 dose of measles-mumps-rubella (MMR) vaccine before travel to India; this dose does not count as part of the routine childhood vaccination series. Vaccination against hepatitis A, hepatitis B, and coronavirus disease 2019 (COVID-19) is recommended for travelers to India; specific guidance varies by age of the traveler (see the disease-specific chapters in Section 5). Additionally, India requires travelers coming from countries reporting cases of polio to show proof of oral polio vaccination; travelers should check with the Ministry of Health to learn if there is a requirement for a dose of polio vaccine prior to entry into India.

Enteric Infections & Diseases

Cholera

Active cholera transmission has been reported from India in recent years and might be underreported. For current cholera vaccine recommendations for travel to India, refer to the destination page on the Centers for Disease Control and Prevention (CDC) Travelers’ Health website. For more information on cholera, see Sec. 5, Part 1, Ch. 5, Cholera.

Giardiasis

Giardiasis (see Sec. 5, Part 3, Ch. 12, Giardiasis) is a major cause of diarrheal disease and is associated with morbidity in both children and adults in India. Travelers should maintain good hand hygiene, avoid drinking tap water, and should exclusively consume boiled, bottled, or filtered water (see Sec. 2, Ch. 9, Water Disinfection).

Hepatitis E

Hepatitis E virus is transmitted through fecally contaminated water and person-to-person through the fecal–oral route (see Sec. 5, Part 2, Ch. 10, Hepatitis E). Highly endemic to India, hepatitis E is a major cause of acute viral hepatitis and acute liver failure. Infection during pregnancy puts people at greater risk for severe disease as well as adverse pregnancy outcomes (e.g., miscarriage, neonatal demise).

Travelers drinking untreated water or going to areas with poor sanitation are at risk for infection. Travelers should maintain good hand hygiene; avoid tap water; drink only boiled, bottled, or filtered water; and eat thoroughly cooked meats (see Sec. 2, Ch. 8, Food & Water Precautions). Travelers immunized against hepatitis A who develop symptomatic hepatitis likely have hepatitis E.

Travelers’ Diarrhea

Travelers’ diarrhea (TD) is acquired through ingestion of contaminated food, water, or beverages, particularly in places where basic hygiene and sanitation infrastructure is poor. Both cooked and uncooked foods are potential vehicles for infection if handled improperly. The risk for TD is high in India; travelers have >60% likelihood of developing TD during a 2-week journey. Discuss self-treatment for diarrheal illness with travelers (see Sec. 2, Ch. 6, Travelers’ Diarrhea, and Sec. 2, Ch. 8, Food & Water Precautions).

Typhoid & Paratyphoid Fever

In the United States, ≈85% of cases of typhoid fever are in people who traveled to India or other countries in South Asia (see Sec. 5, Part 1, Ch. 24, Typhoid & Paratyphoid Fever). Thus, even for short-term travel, typhoid vaccine is recommended. Patients hesitant to be vaccinated might be persuaded by learning that typhoid fever acquired in South Asia is typically multidrug-resistant, and in a growing number of instances extensively drug–resistant. Remind all travelers to India to also practice good hand hygiene and follow safe food and water precautions.

Paratyphoid fever, a clinically similar disease caused by Salmonella enterica serotypes Paratyphi A, B, and C, has become increasingly prevalent in South Asia, but typhoid vaccines are not protective against this infection.

Respiratory Infections & Diseases

Coronavirus Disease 2019

All travelers going to India should be up to date with their COVID-19 vaccines.

Endemic Fungi

Four environmentally transmitted fungal pathogens are predominant to India; risk to travelers varies by activity and underlying health conditions.

Aspergillosis

Aspergillus spp. are airborne fungi that cause a broad array of illnesses ranging from mild to severe. Azole resistance and unavailability of amphotericin B complicate treatment. Most severe aspergillosis illness occurs in patients who are severely immunocompromised or critically ill.

Cryptococcosis

Cryptococcus neoformans exists in the environment worldwide. The fungus is typically found in soil, on decaying wood, in tree hollows, or in bird droppings. When inhaled, C. neoformans can cause a pneumonia-like illness. C. neoformans also is known to cause meningitis, especially in people who are immunocompromised or living with HIV. Diagnostic testing is limited in India.

Histoplasmosis

In areas where Histoplasma spp. are endemic, occupational and recreational (e.g., bat or birdwatching, cave exploration) activities that disrupt the soil surface can release infectious mold spores into the air. If inhaled, these spores can cause acute pulmonary disease and, more rarely, focal or disseminated extrapulmonary infection (see Sec. 5, Part 4, Ch. 2, Histoplasmosis).

Mucormycosis

Various modes of transmission (inhalation being most common) for Mucorales spp. have been described. Underlying diabetes mellitus and glucocorticoid steroid use are among the major risk factors for mucormycosis in India. Mucormycosis has become a risk among patients recovering from COVID-19 and is associated with poor outcomes in these patients.

Influenza

Influenza virus circulation in India usually peaks during the monsoon season (June–September) with secondary peaks during winter (November–February). Furthermore, the actual timing of the influenza season varies across the country due to differences in regional climates. Influenza vaccine coverage in India is assumed to be very low (no official data are available). Travelers who receive the Northern Hemisphere influenza vaccine might not be fully protected from the viral strain circulating in India and should observe all necessary behavioral precautions to protect themselves from influenza, including frequent handwashing and respiratory etiquette. Travelers to India are strongly encouraged to receive an influenza vaccine directed against the Southern Hemisphere influenza strains from their health care providers, either in the United States (if available) or in India.

Tuberculosis

Approximately 25% of all tuberculosis (TB) cases worldwide are reported from India. Travelers planning to work in high-risk settings or in crowded institutions (e.g., homeless shelters, hospitals, medical clinics, prisons) are at risk for exposure. Travelers visiting ill friends or relatives or engaging in congregate activities (e.g., religious gatherings) also can face TB exposure risk.

Discuss the importance of testing before and after travel, and measures travelers can take to prevent disease. Travelers with anticipated exposure risks should undergo tuberculin skin testing have an interferon-γ release assay (IGRA) before leaving the United States (see Sec. 5, Part 1, Ch. 23, . . . perspectives: Testing Travelers for Mycobacterium tuberculosis Infection). If a tuberculin skin test is used, CDC recommends the 2-step method for establishing a baseline. If the predeparture test results are negative, repeat the same type of test 8–10 weeks after the traveler returns from India.

Use of bacillus Calmette-Guérin (BCG) vaccine in health care workers who will have increased risk of exposure during travel has been proposed, although this recommendation remains controversial (see Sec. 5, Part 1, Ch. 22, Tuberculosis). US Food and Drug Administration–approved BCG formulations are no longer available in the United States.

Sexually Transmitted Infections & HIV

As of 2019, an estimated 2.3 million people in India were living with HIV infection. Although the reported adult HIV prevalence in India is low, prevalence is much greater in specific locations (e.g., in the states of Manipur, Mizoram, Nagaland) and among high-risk populations (e.g., people who inject drugs, transgender people, men who have sex with men, and female sex workers). Condomless sex increases a traveler’s risk for HIV and other sexually transmitted infections, including chlamydia, gonorrhea, and syphilis.

Indian law penalizes acts related to prostitution, including running a brothel, soliciting, and trafficking. High-quality condoms and other barrier methods are available for sale in drugstores in India. Homosexuality is not illegal in India.

Skin Infections

Superficial Dermatophytosis

In addition to emerging viral and multidrug- resistant bacterial pathogens, superficial dermatophytosis has become a significant problem for travelers to India, largely due to the presence of a widespread fungal strain that is highly resistant to treatment. Indiscriminate use of topical antifungal + highly potent steroid combination preparations is believed to have contributed to the rise of the fungal strain. Travelers who develop a rash they think is ringworm should be aware that creams sold widely in drugstores in India can worsen the infection and cause other health problems. Consider prescribing a product that travelers can take in their travel health kit. For severe or recurrent infections, consider posttravel molecular testing for species identification (see Sec. 11, Ch. 8, Dermatologic Conditions).

Soil- & Waterborne Infections

Helminths

India accounts for 65% of soil-transmitted helminth infections in Southeast Asia, and 27% of all cases globally. Pathogens are found in both urban and rural areas, and include roundworm (Ascaris lumbricoides), hookworm (Ancylostoma duodenale and Necatur americanus), and whipworm (Trichuris trichiura). Symptoms might be nonspecific and include abdominal pain, diarrhea (with blood or mucous), fatigue, nausea, vomiting, and weight loss. To reduce the risk for infection, travelers should pay attention to hand hygiene, safe food and water precautions, and always wear shoes (see Sec. 5, Part 3, Ch. 13, Soil-Transmitted Helminths).

Vectorborne Diseases

Chikungunya, Dengue & Zika

During the last several years, India has experienced outbreaks of chikungunya, transmitted by infected Aedes species (Ae. aegypti or Ae. albopictus) mosquitoes. Chikungunya symptoms are similar to those of dengue and malaria, but often with severe and persistent arthralgia (see Sec. 5, Part 2, Ch. 2, Chikungunya).

Dengue is transmitted by infected Aedes species (Ae. aegypti or Ae. albopictus) mosquitoes and is endemic to all of India except at high elevation in mountainous regions (see Sec. 5, Part 2, Ch. 4, Dengue). Large outbreaks can occur, including in many urban areas. Incidence is greatest during the wet summer season, which includes the monsoon season (June–September). Aedes mosquitoes bite both indoors and outdoors. Travelers to India should take measures to protect themselves from mosquito bites (see Sec. 4, Ch. 6, Mosquitoes, Ticks & Other Arthropods).

Zika is a risk in India. Because of the possibility for birth defects in infants born to mothers infected with Zika during pregnancy, people who are pregnant or trying to become pregnant should review the most recent recommendations.

Japanese Encephalitis

Japanese encephalitis (JE) virus is present throughout the country. Transmission occurs mostly from May–October in northern states and year-round in southern states. The JE virus is transmitted to humans who live and work in rural areas (typically around rice paddies and irrigation systems), primarily by Culex mosquitoes that feed on infected birds, pigs, and other mammals. Symptoms include diarrhea, fever, severe headache, vomiting, general weakness, and neurological symptoms. Vaccination is recommended for people traveling extensively in rural areas, long-term travelers, and people assigned to work in endemic areas (see Sec. 5, Part 2, Ch. 13, Japanese Encephalitis).

Leishmaniasis (Kala Azar)

Visceral leishmaniasis (VL), transmitted by sandflies (Phlebotomus argentipes), presents with acute fever and splenomegaly (see Sec. 5, Part 3, Ch. 15, Visceral Leishmaniasis). Travelers to India should take measures to protect themselves from both day- and night-biting sandflies (see Sec. 4, Ch. 6, Mosquitoes, Ticks & Other Arthropods).

Lymphatic Filariasis

Lymphatic filariasis (LF) is transmitted by several mosquito vectors that bite during day, evening, and night, including Aedes, Anopheles, and Culex mosquito spp. (see Sec. 5, Part 3, Ch .9, Lymphatic Filariasis). LF presents with lymphedema and elephantiasis many years after the infection; in men, LF can present with hydrocele (swelling of the scrotum). In most instances, short-term travelers are at low risk because multiple bites over time are necessary for infection. Long-term travelers and expatriates are at greater risk.

Malaria

For the most up-to-date malaria prevention information for India, please visit Yellow Fever Vaccine and Malaria Prevention Information, by Country.

Rickettsial Diseases

Rickettsial infections, including outbreaks, are present across India; scrub typhus is the most common (see Sec. 5, Part 1, Ch. 18, Rickettsial Diseases). Infection is seasonal (after the rainy season), more prevalent in rural areas, and often presents with nonspecific signs and symptoms. Travelers should wear long sleeves and pants and protect exposed skin with insect repellents when visiting potential vector-infested areas, especially areas with forest and vegetation (see Sec. 4, Ch. 6, Mosquitoes, Ticks & Other Arthropods). Counsel travelers to seek prompt medical care for acute fever onset, rash, or eschar (tan, brown, or black tissue) around an insect bite.

Yellow Fever

India has no risk for yellow fever (YF), and CDC has no recommendations for travelers to receive YF vaccine before going to India. The Government of India, however, has strict and carefully defined country entry requirements for proof of vaccination against yellow fever from travelers ≥9 months old (infants <9 months old exempted) arriving from areas with risk of yellow fever virus transmission (for details, see Sec. 2, Ch. 5, Yellow Fever Vaccine and Malaria Prevention Information, by Country).

Environmental Hazards & Risks

Air Quality

Air pollution is a major public health problem across India, and travelers might encounter high-level exposures to various pollutants in urban, peri-urban, and rural settings. All travelers to India should be aware of local air pollution concerns and any advisories in effect on a day-to-day basis (see Sec. 4, Ch. 3, Air Quality & Ionizing Radiation). Vulnerable groups (e.g., children, older people) and people with preexisting health conditions (e.g., asthma, chronic lung disease, coronary artery disease) are particularly at risk for adverse outcomes. When air quality is poor or expected to deteriorate, travelers should avoid outdoor activities and follow local health guidance from the Government of India, Ministry of Environment and Forests (MOEF), Central Pollution Control Board, and the US Embassy and US Consulates in India.

Altitude Illness & Acute Mountain Sickness

Popular tourist destinations in India include the high-elevation Himalayas. Inform travelers visiting these areas about the early symptoms of altitude illness and acute mountain sickness, to not ascend to higher elevations when experiencing symptoms, and to descend if symptoms become worse while resting at the same elevation (see Sec. 4, Ch. 5, High Elevation Travel & Altitude Illness). Travelers with certain underlying medical problems can be at increased risk for adverse events associated with travel to high elevations and should consult a physician familiar with this topic prior to departure.

Animal Bites & Rabies

India has the highest burden of rabies in the world; rabid dogs are common (see Sec. 5, Part 2, Ch. 18, Rabies). Travelers bitten or scratched by a dog or other mammal in India might have limited or no access to postexposure rabies treatment; rabies immune globulin is generally not available in India. Encourage travelers to consider purchasing a medical evacuation insurance policy that will cover travel to receive recommended rabies postexposure prophylaxis. Discuss preexposure rabies vaccination with travelers who have high exposure risk, including adventure travelers, campers, cave explorers, children, people for whom there is an occupational exposure risk (e.g., veterinarians, wildlife biologists), and people visiting rural areas.

Animal bites and wounds can transmit diseases other than rabies. Cellulitis, fasciitis, and wound infections can result from the scratch or bite of any animal. Potentially fatal to humans, B virus is carried by macaques (see Sec. 5, Part 2, Ch. 1, B virus). These Old World monkeys inhabit many of the temples in India, scatter themselves in many tourist gathering places, and are kept as pets. Macaques can be aggressive and often seek food from people. When visiting temples, travelers should not carry any food in their bags, hands, or pockets. Stress to travelers that they should not approach or attempt to handle monkeys or other animals. If bitten, travelers should seek immediate medical care.

Travelers, particularly those going to rural areas, should be aware of the risk for snake bites, and should take precautions to wear solid shoes or boots and use a flashlight when walking outside at night.

Climate & Sun Exposure

Sun exposure and heat-related illnesses are concerns for travelers in India, particularly during summer months and at high elevations (see Sec. 4, Ch. 1, Sun Exposure, and Sec. 4, Ch. 2, Extremes of Temperature). Travelers should eat and drink regularly, wear loose and lightweight clothing, and limit physical activity at times when temperatures are high.

Natural Disasters

Natural disasters, including cyclones, droughts, earthquakes, floods, and landslides, are not uncommon in India. Travelers should become aware of the natural disaster risks at their destination. Encourage US citizens and nationals traveling and living in India to enroll in the US Department of State’s Smart Traveler Enrollment Program to receive information from the US embassy on safety conditions, and to help the US embassy in India contact them in an emergency, including during natural disasters.

Safety & Security

Crime

Crime does occur in India, but rarely is it directed toward foreign travelers; verbal and sometimes physical harassment of female foreign travelers is a concerning exception. Although most victims of harassment are locals, attacks in tourist areas highlight the fact that visitors to India are also at risk and should exercise vigilance and situational awareness. Petty crimes (e.g., pickpocketing, purse snatching) are very common when using public transportation, while out walking, and in heavily populated tourist areas.

Mass Gatherings

Drawing tens of millions of people, Kumbh Mela is the largest mass gathering event / religious pilgrimage in the world. Celebrated according to the Hindu calendar, Kumbh Mela occurs 4 times over an approximately 12-year cycle. During each observance of this normally 4-month long festival, pilgrims ritually bathe in one of 4 sacred rivers in India; in 2021, Kumbh Mela was limited to 30 days due to the COVID-19 pandemic. Mass casualty trauma (e.g., crush injuries, stampedes) and transmission of antimicrobial-resistant organisms and enteric and respiratory pathogens are among the more serious risks to health and safety associated with attendance (see Sec. 9, Ch. 10, Mass Gatherings).

Political & Religious Unrest

Demonstrations and general strikes (bandh) often cause inconvenience. Religious violence occurs occasionally. Travelers should obey curfews and travel restrictions, and avoid demonstrations and rallies because of the potential for violence.

Terrorism

India continues to experience terrorist and insurgent activities that can affect US citizens directly or indirectly. Terror attacks have targeted public places (e.g., cinemas, hotels, markets, mosques, restaurants in large urban areas, trains and train stations), including some places frequented by tourists. Although an attack can occur at any time, they generally take place during the busy evening hours in markets and other crowded places. Travelers should pay attention to US Department of State advisories regarding issues that arise at some borders, religious tensions, or terrorist activities. In times of instability, travelers should seek guidance from the US Embassy or Consulates in India website for appropriate action (see Sec. 4, Ch. 11, Safety & Security Overseas).

Traffic-Related Injuries

India’s roadways are some of the most hazardous in the world, and have large numbers of traffic- related deaths, including among pedestrians (see Sec. 8, Ch. 5, Road & Traffic Safety). Animals, bicycles, overcrowded buses, motor scooters, people, rickshaws, and trucks all compete for space on streets and roads, increasing the risk for crashes. Travelers should fasten seat belts when riding in cars, and wear a helmet when riding bicycles or motorbikes. Advise travelers to avoid boarding overcrowded buses and not to travel by bus into the interior of the country or on curving, mountainous roads. Discourage nighttime driving (long-distance travel in particular), even with a hired, paid driver.

Availability & Quality of Medical Care

While India ranks highly in the international quality standards maintained at its major private hospitals that employ the bulk of the country’s doctors, it lags in postoperative care (e.g., environment, hygiene, infection control) and regulations (e.g., facilitators, hospitals, insurance, medicolegal issues) as compared to regional competitors.

Travelers needing medical care while traveling can contact the US embassy in India for referrals, speak to a hotel concierge, or see links to find medical treatment by category, and a list of hospitals accredited by the National Accreditation Board for Hospitals & Healthcare Providers (Constituent Board of the Quality Council of India). Most major hospitals in big cities accept payment by major credit cards; hospitals and doctors in smaller cities might only accept cash.

Medical Tourism

Well-trained English-speaking health care practitioners and low cost for high-quality treatment make India a health care destination for a mix of alternative (ayurveda, homeopathy, yoga), curative (cosmetic, surgical), and wellness medicine.

Acknowledgments

The authors would like to acknowledge substantial contributions to the sections on vectorborne, foodborne, and waterborne diseases from Dr. Kayla Laserson, Bill & Melinda Gates Foundation, India. We thank the following people for their expert review and contributions across various sections of the chapter: Dr. Syed Asrafuzzaman, Department of Health and Human Services (Availability & Quality of Medical Care); Mr. Yvon Guillaume, US Department of State (Safety & Security); Dr. John Jereb, CDC (Tuberculosis); Dr. Deepika Joshi and Dr. Melissa Nyendak, CDC India (HIV & Sexually Transmitted Infections); Dr. Vikas Kapil, CDC (Air Quality); Dr. Siddhartha Saha, CDC India (Influenza); and Dr. Anoop Velayudhan, Indian Council of Medical Research (Fungal Infections and Superficial Dermatophytosis).