Chapter 4Select DestinationsAsia
India is approximately one-third the size of the United States and has 4 times the population (1.2 billion people). This makes it the second most populous country in the world, behind China. Rich in history, vibrant culture, and diversity, India is the birthplace of 4 world religions: Hinduism, Buddhism, Jainism, and Sikhism. Despite the growth of megacities such as Mumbai and Delhi (both >15 million people), 70% of the population still resides in rural areas, and 60% work in agriculture. Although India is one of the fastest-growing economies in the world, the literacy rate is 74%, and the level of poverty is high. The topography is varied, ranging from tropical beaches to foothills, deserts, and the Himalayan Mountains. The north has a more temperate climate, while the south is more tropical year round. Many travelers prefer India during the winter—November through March, when the temperatures are more agreeable—although some, particularly families with children, must travel during the summer vacation time.
India is becoming more popular for US travelers, and rates of travel from the United States are increasing. International businesses are flourishing in India; tourists are flocking to the temples, beaches, and the Taj Mahal. For some new US residents, India remains their homeland, and they make frequent visits to family and friends.
Because tourists could not possibly visit all the tourist sites in India during a 2-week holiday, they usually select a part of India for any given trip. A typical itinerary in the north of India includes Delhi, Agra, and cities in Rajasthan, such as Jaipur (the “pink” city). Agra is the home of the Taj Mahal, a breathtaking monument to lost love. Along the northern travel circle, one can stop to enjoy the magnificent bird sanctuary at Keoladeo Ghana and the tiger reserve at Ran Thambore. Another frequent stop is Goa and its beaches on the western coast, where swaying coconut palms form the backdrop for great parties and old-time hippies. Mumbai, another common entry point to India, hosts Bollywood, the largest film industry in the world. Kolkata is considered the cultural capital of the country. Bengaluru (Bangalore) in the south-central region has become a worldwide information technology center and has managed to meld the very old and traditional India with a new image of a modern hub. And Varanasi boasts extraordinary experiences along the Ganges. Despite the many and varied itineraries, most health recommendations for travelers to India are similar. The incidences of some illnesses, such as those transmitted by mosquitoes, increase during the monsoon season (May–October) with the high temperatures, heavy rains, and the risk of flooding.
Some of the most important health considerations of travel to India are those for travelers who are visiting friends and relatives (VFRs). These travelers often do not seek pre-travel health advice, since they are returning to their land of origin. Such travelers may stay in rural areas often not visited by tourists or business people, live in homes, and eat and drink with their families and thus are at higher risk of many travel-related illnesses (see Chapter 8, Immigrants Returning Home to Visit Friends and Relatives [VFRs]).
All travelers to India should be up-to-date with their routine immunizations and are advised to consider hepatitis B vaccine. Particularly important is making sure that the traveler is immune to measles. India has not had a case of wild poliovirus since early 2011 and is therefore considered to have interrupted transmission. Although CDC does not currently recommend a polio booster for travelers to India, the situation is subject to change, and providers should check the most current recommendation on the India destination page.
Hepatitis A Vaccine
All travelers to India should be protected against hepatitis A. Although some assume that those born in India would have been exposed to hepatitis A in childhood and thus be immune, this may no longer be true, particularly for younger people. Providers should consider serologic testing for hepatitis A IgG in VFR travelers, or they should be immunized.
The incidence of typhoid in US citizens traveling to the Indian subcontinent has been reported to be ≥18 times higher than from any other geographic region. It is the country from which most travel-related typhoid is imported, and thus, even for short-term travel, a typhoid vaccine should be recommended. More compelling for those who are hesitant is the fact that typhoid fever acquired in India is becoming increasingly resistant to quinolone antibiotics, sometimes requiring parenteral therapy.
Japanese Encephalitis Vaccine
Although there has never been a published case of a traveler acquiring Japanese encephalitis (JE) in India, the disease is present in many parts of the country. Risk is highest during the monsoon season from May through October; however, the season may be extended or year-round in some areas, especially in the south. Vaccination is not recommended for the typical 2-week trip most travelers take to see the major tourist sites in urban areas. However, vaccination is recommended for travelers who plan to spend ≥1 month in endemic areas during the JE virus transmission season and should be considered for short-term travelers if they plan to travel outside an urban area and have an increased risk for JE virus exposures (see Chapter 3, Japanese Encephalitis). Publicized outbreaks in recent years have not been in typical tourist destinations.
India has the highest burden of rabies in the world, with estimates of 15,000–20,000 human cases per year. Dogs roam in packs in many areas of the country. Unfortunately, human rabies immune globulin is not readily available in India. If a traveler does not have preexposure rabies vaccination, a bite may result in having to leave the country for postexposure prophylaxis. Even so, a preexposure series is not recommended for all travelers to India. Cost is a consideration for many. Long-term travelers, expatriates, missionaries, and volunteers may want to obtain preexposure immunization for themselves and their children. Travelers may want to purchase a medical evacuation insurance policy that will cover travel for recommended rabies postexposure prophylaxis.
Although the intensity of malaria may be related to the season, unlike other countries in Asia, malaria is holoendemic in India (except at altitudes >2,000 m [6,561 ft]) and occurs in both rural and urban areas. Rates of Plasmodium falciparum have increased in the last 2 decades, and thus chemoprophylaxis is recommended for all destinations. For short-term travelers spending 1–2 days in Delhi in the winter, insect precautions alone may be sufficient to prevent malaria. Travelers should be reminded that malaria-transmitting mosquitoes primarily bite between dusk and dawn.
More recently in India, new strains of bacteria that are resistant to most antibiotics have been carried by travelers to many other countries, including the United States. For example, resistance to carbapenem antibiotics is conferred by enzymes such as New Delhi metallo-β-lactamase-1, which makes it more difficult to treat problems such as skin and bloodstream infections.
Dengue is endemic in all of India, although it is poorly reported at the local and national levels, and large outbreaks have occurred. The incidence is highest during the wet summer season, which includes the monsoon season (September–October). Travelers to India should take measures to protect themselves from daytime mosquito bites to prevent dengue (see Chapter 2, Protection against Mosquitoes, Ticks, & Other Insects & Arthropods).
During the last several years there have been outbreaks of chikungunya, which, like dengue, is transmitted by day-biting mosquitoes. Symptoms are similar to those of dengue and malaria, although often with severe and persistent arthralgia.
Hepatitis E is being recognized more frequently in travelers to India. A traveler who develops symptomatic hepatitis, despite being immunized against hepatitis A, will likely have hepatitis E.
Animal Bites and Wounds
In addition to rabies, other diseases can be transmitted by animal bites and wounds. Cellulitis, fasciitis, and wound infections may result from scratches or bites of any animal. Herpes B virus is carried by Old World monkeys and may be transmitted by active macaques that are kept as pets, inhabit many of the temples, and scatter themselves in many tourist gathering places. Monkeys can be aggressive and often approach travelers seeking food. When visiting temple areas that have monkeys, travelers should not carry any food in their hands, pockets, or bags. It is important to stress to travelers that monkeys and other animals should not be approached or handled at all. If travelers are bitten, they should seek medical care.
The risk for travelers’ diarrhea is moderate to high in India, with an estimated 30%–50% risk during a 2-week journey. Travelers should practice safe food and water precautions (see Chapter 2, Food & Water Precautions) and carry an antibiotic for empiric self-treatment of diarrhea (see Chapter 2, Travelers’ Diarrhea).
Tuberculosis (TB) is a major problem in India: 26% of all TB cases worldwide occur there. Unfortunately, >2% of these cases are estimated to be multidrug-resistant, and a smaller number are extensively drug-resistant. Travelers who plan to work in medical settings or in crowded institutions (such as prisons or homeless shelters) should speak to their health care providers about measures for prevention and testing for exposure after travel.
Arrival in India for the first time may be shocking to travelers who have never ventured into the developing world. The crowds, the intense colors, heat, and smells are striking and invade all the senses at once. It is difficult to enjoy the beauty without being touched by the enormity of the poverty. The close juxtaposition of the old and new is noteworthy. At times this can be overwhelming for travelers. Health care is quite variable in India and dependent on the location.
Transportation in India remains problematic. While traveling through India, travelers should be advised to carry food and beverages with them in the event of delays, almost inevitable no matter the mode of transport. Traveling by train can be harrowing, particularly having to force one’s way through the crowd and onto the train. Travelers should make sure to keep passports and valuables safe while in a crowd. Roadways are some of the most hazardous in the world. Animals, rickshaws, motor scooters, people, bicycles, trucks, and overcrowded buses compete for space in an unregulated free-for-all. Rural, nighttime driving should be discouraged, even when a paid driver has been hired. Air pollution is a problem in the major cities, so those with chronic lung disease or asthma may consider spending time outdoors when there is less traffic or staying in facilities outside major cities.
Medical tourism is a growing industry in India. Many newer medical facilities have recently opened for travelers desiring cardiac, orthopedic, dental, or plastic surgery or transplantations at a substantially lower cost than in the United States. The benefits and hazards require careful examination (see Chapter 2, Medical Tourism).
In general, travelers feel safe while in India. Peddlers and promoters are aggressive with tourists, however, and may require a firm “no.” Travelers may want to avoid making eye contact with a peddler or his goods, or they may risk having someone follow them down the street trying to sell them something. The stress of negotiating one’s way through India makes this destination a place where having a close traveling companion is important.
It is always wise to pay attention to Department of State advisories in case of issues that arise at some borders or occasional increases in religious tensions or terrorist activities.
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