Chapter 4 Select Destinations Asia
India is approximately one-third the size of the United States and has 4 times the population (almost 1.3 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 more than 20 million people), India’s rural population is still twice that of its urban population. Although India is one of the fastest-growing economies in the world, the literacy rate varies by state (64%–94%), the level of poverty is high, and the life expectancy is about 66 years. 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. In addition, India has a large and growing medical tourism sector.
Because tourists could not possibly visit all the 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, Varanasi, and cities in Rajasthan, such as Jaipur (the Pink City) and Udaipur. 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 (see Map 4-13). Varanasi, sacred to Hindus, Buddhists, and Jains, welcomes Hindu pilgrimages and boasts extraordinary experiences along the Ganges. A more southern route might swing through Goa and its beautiful beaches along the western coast, a destination in the past forming the backdrop for great parties and old-time hippies, which has now become a haven for writers and artists boasting a chic new culture. Mumbai, a common entry point to India, hosts Bollywood, the largest film industry in the world. Kolkata (Calcutta) is considered the cultural capital of the country. Bengaluru (Bangalore) in the south-central region is both the garden city and India’s Silicon Valley. The old seaside town of Kochi (Cochin) shows evidence of its Portuguese heritage, and Hyderabad shows off its old granite fort, many mosques, and bazaars. 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 pretravel 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]).
Map 4-13. India destination map
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, obtained its polio-free certification from the World Health Organization in March 2014, and celebrated 5 years of being polio-free in January 2016. Polio vaccine is no longer recommended for US travelers. However, all travelers (residents and nationals) from countries reporting cases of polio should check to see if there is a requirement for a dose of polio vaccine prior to entry into India.
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.
More than 80% of typhoid fever cases in the United States are in people who traveled to India or other countries in south Asia. Thus, even for short-term travel, a typhoid vaccine should be recommended. Patients who are hesitant to be vaccinated may find it even more compelling that typhoid fever acquired in south Asia is becoming increasingly resistant to quinolone antibiotics, sometimes requiring parenteral therapy.
Paratyphoid fever, a similar disease caused by Salmonella enterica serovar Paratyphi A, B, and C, has become increasingly prevalent in south Asia, but typhoid vaccines are not protective against this infection.
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 as well, if they plan repeated travel or travel to periurban areas 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 18,000–20,000 human cases per year. Dogs roam in packs in many areas of the country. Unfortunately, human rabies immune globulin is not readily available except in some clinics in major cities. Information about such clinics can be obtained from the website of the International Society of Travel Medicine (www.istm.org). Otherwise, if a traveler has not received 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. However, education about bite avoidance and management should be a part of every pretravel consultation. 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 extremely rare in travelers, cholera is a possible risk in parts of India. Cholera vaccine is not routinely recommended for most travelers on typical tourist itineraries, but it may be considered for those at higher risk, such as those who are visiting friends and relatives or traveling for humanitarian aid work in disaster areas.
Although the intensity of malaria transmission may be related to the season, unlike other countries in Asia malaria is holoendemic in India (except at altitudes >6,562 ft [2,000 m]) and occurs in both rural and urban areas. Rates of Plasmodium falciparum have increased in the last few decades, and thus chemoprophylaxis is recommended for all destinations. Travelers should be reminded that malaria-transmitting mosquitoes primarily bite between dusk and dawn.
Strains of bacteria that are resistant to most antibiotics have been carried by travelers from India to many other countries, including the United States. High rates of resistance to multiple antibiotics have been shown among gram-negative (such as, Escherichia coli, Klebsiella spp., and Salmonella spp.) and gram positive (such as Staphylococcus aureus) bacteria in India. In particular, bacterial resistance to carbapenems, third-generation cephalosporins, fluoroquinolones, and even colistin are becoming more common.
Dengue is endemic in all of India except at high elevation in mountainous regions. It is poorly reported at the local and national levels, and large outbreaks continue to occur, including in many urban areas. The incidence is highest during the wet summer season, which includes the monsoon season (May–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 Arthropods).
During the last several years there have been outbreaks of chikungunya, which is transmitted by day- and night-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. 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 (see Chapter 3, B virus). Monkeys can be aggressive and often seek food from travelers. 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% likelihood of developing diarrhea during a 2-week journey. Travelers should practice safe food and water precautions (see Chapter 2, Food & Water Precautions). Providers should discuss with the traveler when it may be appropriate to self-treat for diarrheal illness (see Chapter 2, Travelers’ Diarrhea).
India has among the highest prevalences of TB; approximately one-fourth of all TB cases worldwide occur there. Roughly 2%–3% of newly diagnosed cases are estimated to be multidrugresistant, and a smaller percentage are extensively drug-resistant. Travelers who anticipate possible prolonged exposure to people with TB because they will routinely come in contact with clinic, hospital, prison, or homeless shelter populations should have a tuberculin skin test or TB blood test before leaving the United States. If the test is negative, they should have a repeat test 8–10 weeks after returning from India. Travelers who plan to work in high-risk settings or in crowded institutions (such as medical clinics, hospitals, prisons, or homeless shelters) should consult their health care providers about measures for prevention and testing before and after travel. Use of bacillus Calmette-Guérin (BCG) vaccine in health care workers who will have increased risk of tuberculosis during travel has recently been proposed, although this recommendation remains controversial (see Chapter 3, Tuberculosis). Access to vaccine and lack of expertise in administering the vaccine are also barriers.
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.
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, which are 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, and India has a large number of traffic-related deaths, including pedestrian deaths. Animals, rickshaws, motor scooters, people, bicycles, trucks, and overcrowded buses compete for space in an unregulated free-for-all. Fasten seat belts when riding in cars and wear a helmet when riding bicycles or motorbikes. Avoid overcrowded buses, travel by bus into the interior or on curving, mountainous roads, and long-distance travel at night. 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). Health care is quite variable in India and dependent on the location.
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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