India

India is about one-third the size of the United States, with a population of over 1 billion people—the seventh largest country and the second most populous. Rich in history, vibrant culture, and diversity, it is home to the origin of four world religions: Hinduism, Buddhism, Jainism, and Sikhism. Despite the growth of megacities such as Mumbai (14 million) and Delhi (12 million), 70% of the population still resides in rural areas and 60% work in agriculture. Although India is one of the fastest-growing economies, the literacy rate is still only 60%, with a high level of poverty. The topography is varied, ranging from tropical beaches to foothills, deserts, and the Himalayan Mountains. The north sees 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 U.S. 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; and for some new U.S. residents, India remains their homeland, with frequent visits to family and friends.

Just as one could not visit all the tourist sites in the United States during a 2-week holiday, tourists 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. 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. 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. 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 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 individuals often travel without seeking 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 greater risk of many travel-related illnesses.

mmunizations
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. Serology for hepatitis A IgG should be checked in these VFR travelers, or they should be immunized.

Typhoid Vaccine
The incidence of typhoid in U.S. citizens traveling to the Indian subcontinent has been reported to be at least 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, one of the typhoid vaccines 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, often requiring parenteral therapy.

Japanese Encephalitis (JE) Vaccine
Although there has been an absence of reported cases in travelers, there is a risk for JE, particularly during the monsoon season from May to October. In the south, some areas experience cases year round. Vaccination is not recommended for the typical tourist unless they will be traveling for extended periods during the monsoon season or will be out of doors and exposed in rice-growing areas (see the Japanese encephalitis section in Chapter 2). Publicized outbreaks in recent years have not been in typical tourist destinations. The cost–benefit of the vaccine needs consideration, especially for travelers on a budget.

Rabies Vaccine
India has one of the highest incidences of rabies in the world, with estimates of 30,000–50,000 human cases per year. Dogs roam in packs in all areas of the country. Unfortunately, human rabies immune globulin is not readily available in India, so that if someone does not have pre-exposure rabies vaccination, a bite may result in the traveler having to leave the country for postexposure prophylaxis. Even so, a pre-exposure 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 ensure their children receive a pre-exposure series. Travelers may want to check to see if medical evacuation policies purchased prior to leaving home will cover travel for recommended rabies postexposure prophylaxis.

Malaria
Although the intensity of malaria may be related to the season, unlike other countries in Asia, malaria is holoendemic in India and occurs in both rural and urban areas. Rates of Plasmodium falciparum have increased over the last two decades, and thus chemoprophylaxis is recommended for all destinations. For very short-term travelers spending 1–2 days in Delhi, a major city, in the winter, insect precautions alone may be sufficient for malaria prevention.

Other InfectionsDengue
Large outbreaks have occurred in India, particularly in the north, and particularly at the end of the monsoon season (September–October).

Hepatitis E
This illness is being recognized with greater frequency 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
Aside from 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 very aggressive and often approach travelers because they are commonly fed. It is important to stress to travelers that monkeys and other animals should not be handled at all and bites can be dangerous. First aid should include vigorous washing with soap and water until medical assistance is accessed.

Travelers’ Diarrhea (TD)
The risk for TD is moderate to high in India, with an estimated 30%–50% risk during a 2-week journey. Travelers should carry an antibiotic for empiric self-treatment of TD.

Miscellaneous
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 very 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 system is exciting, and negotiating a busy railway station is an experience. 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.

In general, travelers feel safe while in India. Peddlers and promoters are aggressive with tourists, however, and may require a firm “no” to leave tourists alone. It is always wise to pay attention to U.S. Department of States advisories in case of issues that arise at some borders or occasional increases in religious tensions.