Chapter 10 Popular Itineraries 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 68 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.
India is becoming more popular for US travelers, and rates of travel from the United States are increasing. Tourists are flocking to the temples, beaches, and the Taj Mahal, and international business is flourishing. For some new US residents, India remains their homeland, and they make frequent visits to see 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 Ranthambore (see Map 10-13). 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. What used to be the backdrop for great parties and old-time hippies, Goa 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 for travelers visiting friends and relatives (VFRs). They often do not seek pretravel health advice, since they are returning to their land of origin. But because they may stay in rural areas not often visited by tourists or business people, live in homes, and eat and drink with their families, they are at higher risk of many travel-related illnesses (see Chapter 9, Visiting Friends & Relatives: VFR Travel).
Map 10-13. India destination map
All travelers to India should be up-to-date with 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 7 years of being polio-free in January 2018. Polio vaccine is no longer recommended for US travelers to India. However, all travelers (residents and nationals) coming 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 (see Chapter 4, 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. Consider serologic testing for hepatitis A IgG in VFR travelers, or immunize.
More than 80% of typhoid fever cases in the United States are in people who traveled to India or other countries in south Asia (see Chapter 4, Typhoid & Paratyphoid Fever). Thus, even for short-term travel, a typhoid vaccine is recommended. Patients hesitant to be vaccinated may be persuaded by learning 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 (see Chapter 4, Japanese Encephalitis). Risk is highest during the monsoon season (from May through October) although the season may be extended or even 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; publicized outbreaks in recent years have not been in typical tourist destinations. JE vaccine is recommended for those planning to spend ≥1 month in endemic areas during the JE virus transmission season. Consider giving JE vaccine to those planning repeated, short-term travel and to those planning short-term travel to periurban areas with an increased risk for JE virus exposure.
India has the highest burden of rabies in the world, with estimates of 18,000–20,000 human cases per year (see Chapter 4, Rabies). 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).
A preexposure rabies vaccine series is not recommended for all travelers to India, and cost may be a consideration. Long-term travelers, expatriates, missionaries, and volunteers may, however, want to obtain preexposure immunization for themselves and their children. Without preexposure rabies vaccination, bitten travelers may have to leave the country to receive postexposure prophylaxis. Encouraging travelers to think about purchasing a medical evacuation insurance policy that will cover travel for recommended rabies postexposure prophylaxis and education about bite avoidance and management should be a part of every pretravel consultation.
Active cholera transmission has been reported from India in recent years. Check the destination page at www.cdc.gov/travel for current recommendations.
Unlike other countries in Asia, malaria is holoendemic in India (except at elevations >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 chemoprophylaxis is recommended for all destinations. Remind travelers that malaria-transmitting mosquitoes primarily bite between dusk and dawn (see Chapter 2, Yellow Fever Vaccine & Malaria Prophylaxis Information, by Country; Chapter 3, Mosquitoes, Ticks & Other Arthropods; and Chapter 4, Malaria).
Strains of bacteria 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 (Escherichia coli, Klebsiella spp., and Salmonella spp.) and gram-positive (Staphylococcus aureus) bacteria in India. In particular, bacterial resistance to carbapenems, third-generation cephalosporins, fluoroquinolones, and even colistin are becoming more common.
DENGUE, CHIKUNGUNYA, AND ZIKA
Dengue is endemic to all of India except at high elevation in mountainous regions (see Chapter 4, Dengue). Poorly reported at the local and national levels, large outbreaks continue to occur, including in many urban areas. 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 3, Mosquitoes, Ticks & Other Arthropods).
During the last several years there have been outbreaks of chikungunya, transmitted by day- and night-biting mosquitoes. Symptoms are similar to those of dengue and malaria, although often with severe and persistent arthralgia (see Chapter 4, Chikungunya).
Zika is a risk in India. Because of the risk of birth defects in infants born to women infected with Zika during pregnancy, women who are pregnant or trying to become pregnant should research the most recent recommendations at www.cdc.gov/zika.
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
Diseases other than rabies can be transmitted by animal bites and wounds. 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 Chapter 4, 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 travelers. When visiting temples, 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. If bitten, travelers should seek immediate 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. Discuss self-treatment for diarrheal illness (see Chapter 2, Travelers’ Diarrhea), and remind travelers to practice safe food and water precautions (see Chapter 2, Food & Water Precautions).
India has among the highest prevalence of TB worldwide; approximately one-fourth of all TB cases worldwide occur there. An estimated 2%–3% of newly diagnosed cases are multidrug resistant; a smaller percentage are extensively drug resistant.
Travelers who plan to work in high-risk settings or in crowded institutions (e.g., medical clinics, hospital, prison, or homeless shelter populations) are at risk for TB exposure. Discuss with them the importance of testing before and after travel, and measures for disease prevention. Travelers should have a tuberculin skin test or TB blood test before leaving the United States. If the test is negative, repeat the test 8–10 weeks after the returning from India.
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 4, Tuberculosis). Limited access to BCG and lack of expertise in administering the vaccine in the United States are also barriers.
Travelers who have never before ventured into the developing world may be shocked when arriving in India for the first time. The crowds and the intense colors, heat, and smells are striking and invade all the senses at once. It is difficult to enjoy the beauty of the country without being touched by the enormity of its poverty. The close juxtaposition of the old and new is noteworthy. At times this culture shock can be overwhelming (see Chapter 3, Mental Health).
Transportation in India remains problematic. Recommend carrying food and beverages in the event of delays, which are almost inevitable no matter the mode of transport. Traveling by train can be particularly harrowing, 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 crowds.
India’s roadways are some of the most hazardous in the world, with large numbers of traffic-related—including pedestrian—deaths (see Chapter 8, Road & Traffic Safety). 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. Advise travelers to avoid overcrowded buses and not to travel by bus into the interior of the country or on curving, mountainous roads. Discourage nighttime driving (in particular, long-distance travel), 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 (see Chapter 3, Air Quality & Ionizing Radiation).
Medical tourism is a growing industry in India. Many newer medical facilities have opened recently 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 9, Medical Tourism). The quality of health care is quite variable in India and depends on the location.
In general, travelers feel safe while in India, although peddlers and promoters are aggressive with tourists. 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. In such instances, a firm “no” should suffice. The stress of negotiating one’s way through India makes it a place where having a close traveling companion is important. It is always wise to pay attention to US 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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