Time Zone: +5:30 hours GMT. No daylight savings time in 2008.
Tel. Country Code: 91
Electrical Standards: Electrical current is 230/50 (volts/hz). United Kingdom Style Adaptor Plug and European Style Adaptor Plug. Grounding Adaptors Plugs C, F.
Travel Advisory - India
Malaria, Japanese encephalitis, and dengue fever occur throughout SE Asia and the Indian sub-Continent. Insect-bite protection is essential. Hepatitis E, spread by contaminated water, is also a threat. There is no vaccine. Pregnant women are at special risk. Take measures, as needed, to purify your water outside of first-class hotels.
Dr. Rose Recommends for Travel to India
Americans living or traveling in India are encouraged to register with the nearest U.S. Embassy or Consulate through the State Department travel registration web site and to obtain updated information on travel and security in India. Americans without Internet access may register in person with the nearest U.S. Embassy or Consulate. By registering, American citizens make it easier for the Embassy or Consulate to contact them in case of emergency.
HIV Test: Required for all students over 18, anyone between the ages of 18 and 70 with a visa valid for 1 year or more, and anyone extending a stay to a year or more, excluding accredited journalists and those working in foreign missions
Required Vaccinations: Yellow fever vaccination required for all travelers >9 months of age arriving from any yellow fever endemic zone country in Africa or the Americas, including Trinidad and Tobago.
Passport/Visa: U.S. citizens require a valid passport and valid Indian visa to enter and exit India for any purpose. Visitors, including those on official U.S. government business, must obtain visas at an Indian Embassy or Consulate abroad prior to entering the country, as there are no provisions for visas upon arrival. Each visitor should carry photocopies of the bio-data page of the traveler's U.S. passport and the page containing the Indian visa in order to facilitate obtaining an exit visa from the Indian government in the event of theft or loss of the passport.
• For the most current information on entry and exit requirements, contact the Embassy of India inWashington, DC:
Vaccinations: Recommended and Routine
Hepatitis A: Recommended for all travelers over 1 year of age.
Hepatitis B: Recommended for all non-immune travelers who might be exposed to blood or body fluids from unsafe/unprotected sexual contact; from injecting drug use with shared/re-used needles and syringes; from medical treatment with non-sterile (re-used) needles and syringes. Recommended for any traveler requesting protection against hepatitis B infection.
Influenza: Vaccination recommended for all travelers >6 months of age who have not received a flu shot in the previous 12 months.
Japanese Encephalitis: Recommended for travelers to rural areas (especially where there is pig rearing and rice farming) if the duration of their trip exceeds 3 to 4 weeks.
• Vaccination is advised for expatriates living in this country.
• All travelers should take measures to prevent mosquito bites, especially in the evening and during the night.
Polio: A one-time dose of IPV vaccine is recommended for any traveler >age 18 who completed the primary childhood series but never received received an additional dose of polio vaccine as an adult. Available data do not indicate the need for more than a single lifetime booster dose with IPV (Inactivated Polio Vaccine).
Rabies: Recommended for travelers spending time outdoors in rural areas where there is an increased the risk of animal bites, especially bites from dogs. Children are considered at higher risk because they tend to play with animals and may not report bites. Pre-exposure vaccination eliminates the need for rabies immune globulin in the event of a high-risk animal bite, but does not eliminate the need for treatment with the vaccine.
Routine Immunizations: Immunizations against tetanus-diphtheria, measles, mumps, rubella (MMR vaccine) and varicella (chickenpox) should be updated, if necessary, before departure. MMR protection is especially important for any female of childbearing age who may become pregnant.
• The new Tdap vaccine, ADACEL, which also boosts immunity against pertussis (whooping cough) should be considered when a tetanus-diphtheria booster is indicated.
Typhoid: Recommended for all travelers.
Yellow Fever: A certificate of vaccination is required for all travelers >1 year of age arriving from any country in the yellow fever endemic zones in Africa or the Americas.
Hospitals / Doctors
High-level, Western-style medical care is available in urban centers, but in rural areas, medical care is rudimentary. All travelers should be up-to-date on their immunizations and are advised to carry a medical kit as well as antibiotics to treat travelers diarrhea or other infections; they should bring drugs for malaria prophylaxis, if needed according to their itinerary. Travelers who are taking regular medications should carry them properly labeled and in sufficient quantity to last for the duration of their trip; they should not expect to obtain prescription or over-the-counter drugs in local stores or pharmacies in this country - the equivalent drugs may not be available; may be of dubious origin; may be counterfeit, or of unreliable quality.
• Travelers are advised to obtain comprehensive travel insurance with specific overseas coverage. Policies should cover: ground and air ambulance transport, including evacuation to home country; payment of hospital bills; 24-hour telephone assistance. This coverage is especially important for people traveling outside of major cities or to remote areas of this country.
A U.S. Embassy U.S. Citizen Services in New Delhi has a list of doctors here.
Decompression chambers are located at the naval base in Port Blair, Andaman and Nicobar Islands, and at the Goa Medical College, Goa.
Medical facilities used by travelers in India include:
East-West Rescue Services include: Medical Case Monitoring and update. Arrangement oF Doctors appointments
◦ House calls/Hotel visit by Doctor
- Cost containment
- Funds transfer
- Medical Transportation
- Investigation of fraudulent medical claims
- Search & Rescue
- Repatriation of Mortal remains
- Emergency Medical Backup at location
Standby Coverage for corporates, Embassies, Travel groups
Medical Reports and updates:
East-West Rescue can obtain full medical reports from hospitals and physicians and provide advice on the treatment being given. They can professionally monitor a patient at any hospital in the territories we cover. Doctors confer with the treating doctors and monitor the care the patient receives and also provide daily medical reports to the concerned family, organization, assistance or Insurance company.
All specialties. Many international clients. New Delhi's busiest private emergency facility.
Talwar Medical Centre
Well-equipped medical/surgical facility. All specialties.
The Bangalore Hospital
Marble City Hospital & Research Center
Jabalpur, Madhya Pradesh
This facility has cardiothoracic and neurosurgery capability.
Full ull range of medical/surgical services.
Dr. Agrawal Singhal Tanu
Travel Health Specialist & Pediatrician
Pre-Travel Vaccination, Post-Travel Medical Consultation
On-Site Diagnostic Laboratory.
A state-of-the art modern facility in the heart of the Gujarat state,
Preferred for private patients
Dr. Santanu Chatterjee
Internal Medicine & Travel Medicine
The Tropical Medicine Bureau
Pre-Travel Vaccination, Post-Travel Medical Consultation
On-Site Diagnostic Laboratory.
Destination Health Info for Travelers
AIDS/HIV: The Government of India estimates that in 2006, about 2.45 million Indians were living with HIV (1.75 - 3.15 million) with an adult prevalence rate of 0.41%. India’s highly heterogeneous epidemic is largely concentrated in six states — in the industrialized south and west, and in the north-eastern tip. On average, HIV prevalence in those states is 4–5 times higher than in the other Indian states. HIV prevalence is highest in the Mumbai-Karnataka corridor, the Nagpur area of Maharashtra, the Nammakkal district of Tamil Nadu, coastal Andhra Pradesh, and parts of Manipur and Nagaland.
The Indian epidemic continues to be concentrated in populations with high risk behavior characterized by unprotected paid sex, anal sex, men who have sex with men (MSM), and injecting drug use with contaminated injecting equipment. HIV prevalence is high among sex workers (both male and female) and their clients. Several high risk groups have high HIV prevalence, and sexual networks are wide and inter-digitating. According to India’s National AIDS Control Organization (NACO), the bulk of HIV infections in India occur during unprotected heterosexual intercourse. Consequently, and as the epidemic has matured, women account for a growing proportion of people living with HIV (38 percent in 2005), especially in rural areas. The low rate of multiple partner concurrent sexual relationships among the wider community seem to have, so far, protected the larger body of people with 99 percent of the adult Indian population being HIV negative. However, although overall prevalence remains low, even relatively minor increases in HIV infection rates in a country of more than one billion people could translate into large numbers of people becoming infected.
Source: The World Bank
• The threat of HIV/AIDS should not be a primary concern for the traveler. However, there may be a concern for a subset of travelers who may be exposed to HIV, the virus that causes AIDS, through contact with another person’s body fluids or blood. Although travel has contributed in a general way to the global spread of AIDS, fear of traveling because of this disease is not warranted.
• Transmission of HIV can be prevented by avoiding: sexual contact with a high-risk partner; injecting drug use with shared needles; non-sterile medical injections; unscreened blood transfusions.
Accidents & Medical Insurance: Accidents and injuries are the leading cause of death among travelers under the age of 55 and are most often caused by motor vehicle and motorcycle crashes; drownings, aircraft crashes, homicides, and burns are lesser causes. Important safety rules to follow are 1) Do not drive at night, 2) Do not rent a motorcycle, moped, bicycle, or motorbike, even if you are experienced, and 3) Don't swim alone, at night, or if intoxicated.
• Heart attacks cause most fatalities in older travelers.
• Infections cause only 1% of fatalities in overseas travelers, but, overall, infections are the most common cause of travel-related illness.
• MEDICAL INSURANCE: Travelers are advised to obtain, prior to departure, supplemental travel health insurance with specific overseas coverage. The policy should provide for direct payment to the overseas hospital and/or physician at the time of service and include a medical evacuation benefit. The policy should also provide 24-hour hotline access to a multilingual assistance center that can help arrange and monitor delivery of medical care and determine if medevac or air ambulance services are required.
Animal Hazards: Animal hazards include snakes (kraits, cobras, coral snakes, vipers), scorpions, spiders, and leeches (abundant in the streams, marshes, and jungles). Stray and sometimes viscous dogs may be encountered and should be considered rabid.
Anthrax: In July 2010 at least 25 people fell ill with suspected anthrax contracted from dead animals in Dukatola village in Orissas Sundergarh district. Dukatola village and its nearby hamlets, are located some 500 km [310 mi] from the state capital Bhubaneswar.
Anthrax is a bacterial disease that mostly affects animals and spreads to humans through consumption of contaminated meat.
Avian Influenza (Bird Flu):
• H5N1 avian influenza is predominantly a disease of birds. The virus does not pass easily from birds to people and does not to pass from person to person (except in very rare cases of close contact with an infected blood relative).
• The risk to humans from avian influenza is believed to be very low and no travel restrictions are advised, except travelers should avoid visiting animal markets, poultry farms and other places where they may come into close contact with live or dead poultry, or domestic, caged or wild birds and their excretions. In addition, travelers are advised to:
1. Cook poultry and egg dishes thoroughly. (Well-cooked poultry is safe to eat.)
2. Wash hands frequently with soap and water if around poultry.
• The World Health Organization (WHO) does not recommend travel restrictions to countries experiencing outbreaks of H5N1 avian influenza in birds, including those countries which have reported associated cases of human infection.
The usual vaccines against influenza are not protective against “bird flu.”
Oseltamivir (Tamiflu) is somewhat effective in the treatment of H5N1 avian influenza. It seems to be effective in some cases, but may fail in others. Recently, resistant strains have been reported. In addition, the dosage and duration of treatment appear to be different in severe H5N1 cases.
Chikungunya Fever: As of April 29, 2014, the Directorate of National Vector Borne Disease Control Programme in India has reported over 2,700 suspected cases of chikungunya fever, with no deaths reported. The most affected areas are the Karnataka, followed by Andhra, Goa, and Kerala states. ProMED reports )as many as 63 persons in Keezhakarai and surrounding villages in Ramanathapuram district [Tamil Nadu] have been confirmed with chikungunya fever.
Since January 2014, a growing number of cases of chikungunya fever has been reported in parts of Asia, including Thailand, Malaysia, and India.
Since April 2014, the chikungunya fever outbreak has been on-going in 8 states/provinces in India (Andaman & Nicobar Islands, Andhra Pradesh, Delhi, Gujarat, Karnataka, Kerala, Madhya Pradesh, Maharashtra and Tamil Nadu.) with possible spread to neighboring states.
Symptoms chikungunya fever include fever, headache, fatigue, nausea, vomiting, muscle pain, rash, and joint pain. Acute Chikungunya fever typically lasts a few days to several weeks, but as with dengue, West Nile fever, and other arboviral fevers, some patients have prolonged fatigue lasting several weeks.
• To prevent this disease, and other arboviral illnesses, you should take measures to prevent mosquito bites. Insect-bite prevention measures include applying a DEET-containing repellent (such as Ultrathon) to exposed skin, applying permethrin spray or solution to clothing and gear, and sleeping under a permethrin-treated bednet at night.
• Other mosquito-borne diseases, such as dengue fever and malaria, can be confused with chikungunya fever. If you develop a fever while in India, it is important to consider the diagnosis of malaria.
Cholera: Cholera outbreaks occur frequently in India. An outbreak was reported in September 2007 from the state of Orissa in eastern India, causing almost 200 deaths. In the same month, another outbreak was reported from Ambala Cantonment in Haryana. Other outbreaks have occurred in the Bally municipality area of Howrah in West Bengal, from Mumbai, from Tibba Village in Nurpur Bedi area of Ropar district, and elsewhere. Although this disease is reported to be active, the threat to tourists is relatively low. Cholera is an rare disease in travelers from developed countries. Cholera vaccine is usually recommended only for relief workers or health care personnel who are working in a high-risk endemic area under less than adequate sanitary conditions, or travelers who work or live in remote, endemic or epidemic areas and who do not have ready access to medical care. Canada, Australia, and countries in the European Union license an oral cholera vaccine. The cholera vaccine is not available in the United States.
• The main symptom of more severe cholera is copious watery diarrhea.
• Antibiotic therapy is a useful adjunct to fluid replacement in the treatment of cholera by substantially reducing the duration and volume of diarrhea and thereby lessening fluid requirements and shortening the duration of hospitalization.
• A single 1-gm oral dose of azithromycin is effective treatment for severe cholera in adults. This drug is also effective for treating cholera in children. (Reference: NEJM)
Crime/Security/Civil Unrest: We advise you not to travel to the state of Jammu and Kashmir (north India), other than to the Ladakh region via Manali, or by air to the regions main city of Leh, due to frequent armed clashes, terrorist activities and violent demonstrations.
There is an ongoing dispute between India and neighbouring Pakistan regarding Jammu and Kashmir. Serious security problems remain in Srinagar, the capital of Jammu and Kashmir, as well as other parts of the state. In the recent past tourists and foreigners have been kidnapped in Kashmir.
Borders with Pakistan: We advise you not to travel in the immediate vicinity of the border with Pakistan (northern and western India), other than at the international border crossing at Atari, India and Wagah, Pakistan. We advise you to reconsider your need to travel to the north-eastern states of Assam, Nagaland, Tripura and Manipur. If you do decide to travel to these areas, you should exercise extreme caution. Armed robbery, kidnapping, extortion and terrorism have occurred regularly in these states.
Crime: Women travelers, especially when traveling alone, often receive unwanted attention and have been sexually harassed and assaulted. Women should avoid walking alone at night in deserted areas, including city streets, village lanes and beaches. There have been a number of sexual offences against foreign women in Delhi and Goa. There have been instances where single women staying on houseboats in Kashmir have been intimidated and harassed by houseboat employees.
Petty theft is common in crowded areas such as markets, airports and bus and railway stations. Thieves on motorcycles commonly snatch shoulder bags and jewelery, especially gold chains. Travelers have been robbed and assaulted after consuming spiked drinks or food. Incidents of tourists riding in taxis and rickshaws being robbed and assaulted have been reported. Prepaid taxi services should be used and taxis already carrying passengers should be avoided. Some travelers have been intimidated or tricked into purchasing items which are grossly overvalued after accepting unsolicited approaches for provision of various services, particularly for assistance with shopping for jewelery, gems and carpets.
• Hikers have been attacked and have disappeared in the Kulu/Manali district in Himachal Pradesh, particularly on more remote trekking routes. Hikers are strongly urged not to hike alone and to obtain detailed information in advance about proposed hiking routes. You and your group should register your presence with the local police and with the Australian High Commission, New Delhi.
• Local Travel: Driving in India is dangerous due to poorly maintained and congested roads and accidents frequently occur. Roads are often shared with pedestrians, carts, cattle and other livestock and are particularly dangerous at night due to insufficient or non-existent street lighting. Local driving practices are often undisciplined and aggressive with poorly maintained vehicles. If a driver hits a pedestrian or cow, the occupants of the vehicle are at risk of being attacked or becoming victims of extortion. For further advice, see the bulletin on Overseas Road Safety from
Motorcycle riders are required by law to wear helmets. If you intend to ride a motorcycle, you should check that your travel insurance policy covers injuries sustained in motorcycle accidents.
In order to drive in India, travelers must have either a valid Indian driver’s license or an International Driving Permit, together with their regular driving license. An Bus services are often overcrowded and drivers may lack adequate training. You are required by law to carry your passport at all times.
Dengue Fever: (see map) Dengue Fever continues to be a problem in India. Seventy nine new cases were of dengue fever were reported in early October 2012 in Delhi. Total cases have mounted to 3938 in 2013. Along with the dengue cases, 20 new Chikungunya cases have been reported in the capital. No vaccine is currently available.
An outbreak of dengue fever was reported from Kolkata (Calcutta) in July 2009, causing more than 70 cases. An outbreak was reported from the campus of the Medical College in Kerala in April 2009 and again in June 2009. The number of dengue cases reported in 2008 was 3 times more than those reported during the same period in 2007, MCD officials report. Between January and December 2007, over 3,500 cases were reported. The most affected areas were Kerala, Maharashtra, Gujarat and Delhi.
Periodic epidemics of dengue and dengue hemorrhagic fever occur in urban and semi-rural areas countrywide below 1,000 meters elevation, with most outbreaks occurring in the north-central states. Relatively few cases are reported from the western states. In southern areas, the risk of dengue is year-round. In the northern states, the risk is elevated from April through November.
Dengue fever is a mosquito-transmitted, flu-like viral illness widespread in the Indian sub-Continent. Symptoms consist of sudden onset of fever, headache, muscle aches, and a rash. A syndrome of hemorrhagic shock can occur in severe cases. There is no vaccination or medication to prevent or treat dengue.
• Dengue is transmitted via the bite of an infected Aedes aegypti mosquito. Aedes mosquitoes feed predominantly during daylight hours. All travelers are at risk and should take measures to prevent daytime mosquito bites. Insect-bite prevention measures include applying a DEET-containing repellent (such as Ultrathon) to exposed skin and applying permethrin spray or solution to clothing and gear.
Filariasis: Bancroftian filariasis, which transmitted by mosquitoes, is widespread in southern, central, and northern India, especially in Uttar Pradesh and Bihar States. Malayan filariasis occurs in southern India, especially Kerala State. The risk to tourists is low. All travelers, however, should take standard measures to prevent insect bites.
Hand, Foot and Mouth Disease: An outbreak of hand, foot, and mouth disease was reported from Calcutta in September 2007. HFMD is transmitted via respiratory droplets and is characterized by fever, blisters and rashes on the hands, feet and buttocks. The World Health Organization (WHO) provides information on preventative measures.
• According to the WHO recommendations it is NOT necessary to restrict travel or trade on account of this illness.
Hepatitis: All travelers not previously immunized against hepatitis A should be vaccinated against this disease. Travelers who are non-immune to hepatitis A (i.e. have never had the disease and have not been vaccinated) should take particular care to avoid potentially contaminated food and water. Travelers who will have access to safe food and water are at lower risk. Those at higher risk include travelers visiting friends and relatives, long-term travelers, and those visiting areas of poor sanitation.
• Hepatitis E is endemic and sporadic cases and outbreaks occur regularly. Hepatitis E accounts for 70% of cases of sporadic, acute viral hepatitis and 95% of “epidemic” hepatitis in India. (An outbreak of hepatitis E was reported from Kashmir in August 2007.) Transmission of the hepatitis E virus (HEV) occurs primarily through drinking water contaminated by sewage and also through raw or uncooked shellfish. Farm animals may also serve as a viral reservoir. In developing countries, prevention of hepatitis E relies primarily on the provision of clean water supplies and overall improved sanitation and hygiene. There is no vaccine.
• Hepatitis B is hyperendemic. The overall hepatitis B (HBsAg) carrier rate in the general population is estimated at >8%. Hepatitis B is transmitted via infected blood or bodily fluids. Travelers may be exposed by needle sharing and unprotected sex; from non-sterile medical or dental injections, and acupuncture; from unscreened blood transfusions; by direct contact with open skin lesions of an infected person. The average traveler is at low risk for acquiring this infection. Vaccination against hepatitis B is recommended for: persons having casual/unprotected sex with new partners; sexual tourists; injecting drug users; long-term visitors; expatriates, and anybody wanting increased protection against the hepatitis B virus.
• Hepatitis C is endemic at a moderately high level with a prevalence of 1.8% in the general population. Most hepatitis C virus (HCV) is spread either through intravenous drug use or, in lesser-developed countries, through blood contamination during medical procedures. Over 200 million people around the world are infected with hepatitis C - an overall incidence of around 3.3% of the population of the world. Statistically, as many people are infected with HCV as are with HIV, the virus that causes AIDS.
Influenza: Influenza is transmitted from November through March in areas north of the Tropic of Cancer and throughout the year in areas south of that. The flu vaccine is recommended for all travelers over age 6 months who have not had a flu shot in the previous 12 months.
Japanese Encephalitis (JE-see map): There is a continuing outbreak of JE in West Bengal. West Bengal state neighbors Bihar state, which has had a significant number of encephalitis cases this year (2014). These cases in West Bengal may or may not be related to those that have been occurring in Bihar state. Encephalitis with fever could be caused by various viruses, and the start of the monsoon season brings on the Japanese encephalitis virus transmission season.
• The Centers for Disease Control and Prevention (CDC) recommends JE vaccination for travelers spending more than 30 days in an endemic environment, or less than 30 days in areas with epidemic transmission. However, the use of an arbitrary cutoff cannot protect all travelers. Advance knowledge of trip details, accommodation and purpose, as well as local geography, is warranted to give adequate advice. Is travel occurring during the peak transmission season? In general, travelers to rural areas (especially where there is pig rearing and rice farming) should be vaccinated if the duration of their trip exceeds 3 to 4 weeks. They may consider vaccination for trips of shorter duration if more intense exposure is anticipated, especially during unprotected outdoor activities in the evening. Vaccination is advised for expatriates living in this country.
• Japanese encephalitis is transmitted by night-biting Culex mosquitoes. All travelers should take measures to prevent mosquito bites, especially in the evening and overnight. Insect-bite prevention measures include applying a DEET-containing repellent to exposed skin, applying permethrin spray or solution to clothing and gear, and sleeping under a permethrin-treated bednet.
Leishmaniasis: Cases of visceral leishmaniasis, transmitted by sand flies, occur in large numbers in rural areas, especially in the northeastern states, with Bihar having the greatest incidence. Sporadic cases of cutaneous leishmaniasis have been reported in the western states along the Pakistani Indian border. Most cases of cutaneous leishmaniasis occur in adults in urban or periurban hutment areas (slums).
• The parasites that cause leishmaniasis are transmitted by the bite of the female phlebotomine sandfly. Sandflies bite mostly in the evening and at night. They breed in ubiquitous places: in organically rich, moist soils (such as found in the floors of rain forests), animal burrows, termite hills, and the cracks and crevices in stone or mud walls, and earthen floors, of human dwellings.
• All travelers should take measures to prevent sandfly bites. Insect-bite prevention measures include applying a DEET-containing repellent to exposed skin, permethrin (spray or solution) to clothing and gear, and sleeping under a permethrin-treated bednet.
Malaria: A rise in cases of malaria in Dakshina Kannada and Udupi continues to be a matter of concern for the state government. The 2 districts together have reported more than 9800 cases of malaria in 2014, which is [much] more than 50 per cent of the total cases of malaria in thestate, which has recorded a total of 12 141 cases.
Malaria prophylaxis and insect protection measures are recommended for all travelers to India. The risk of acquiring malaria is low for the average traveler. The travelers at highest risk are those visiting friends and relatives. Malaria is present countrywide year-round, excluding high altitude areas (above 2,000 meters elevation) of the states of Himachal Pradesh, Jammu and Kashmir, and Sikkim. Malaria risk occurs year-round in the tropical cities of Mumbai (Bombay), Calcutta, and Madras. Malaria risk in the more temperate Delhi is seasonal, with the major risk being from July to November, peaking in September.
• High-risk malarious areas include the states of Chhattisgarh, Orisa, Jharkhand, West Bengal, Goa (mainly P. vivax), and the states east of Bangladesh.
Overall, there is a decreasing incidence of malaria in travelers to India. In addition, the proportion of P. falciparum in travelers has declined. P. vivax now accounts for 80% of all cases in travelers.
• Current prophylaxis regimen: Prophylaxis with atovaquone/proguanil (Malarone), mefloquine (Lariam), doxycycline, or primaquine (G6PD test required) is recommended for travel to malarious areas of this country.
Note: Outside of high-risk areas (see above), some European countries are advocating standby emergency self-treatment protocols or meticulous bite-bite prevention measures plus risk awareness instead of chemoprophylaxis. Coartem® is now available in the U.S. by prescription. Coartem is a fixed-dose combination of two antimalarials. It is a highly-effective three-day malaria treatment with cure rates of over 96% and is recommended for standby treatment.
A malaria map is located on the Fit for Travel website, which is compiled and maintained by experts from the Travel Health division at Health Protection Scotland (HPS)
Malaria is transmitted via the bite of an infected female Anopheles mosquito. Anopheles mosquitoes feed predominantly during the hours from dusk to dawn. All travelers should take measures to prevent evening and nighttime mosquito bites. Insect-bite prevention measures include applying a DEET-containing repellent, such as Ultrathon, to exposed skin, applying permethrin spray or solution to clothing and gear, and sleeping under a permethrin-treated bednet. DEET-based repellents have been the gold standard of protection under circumstances in which it is crucial to be protected against insect bites that may transmit disease. Nearly 100% protection can be achieved when DEET repellents (such as Ultrathon) are used in combination with permethrin-treated clothing.
NOTE: Picardin repellents (20% formulation, such as Sawyer GoReady or Natrapel 8-hour) are now recommended by the CDC and the World Health Organization as acceptable non-DEET alternatives to protect against malaria-transmitting mosquito bites. Picaridin is also effective and ticks and biting flies.
• You should consider the diagnosis of malaria if you develop an unexplained fever during or after being in this country.
• Long-term travelers who may not have access to medical care should bring along medications for emergency self-treatment should they develop symptoms suggestive of malaria, such as fever, chills, headaches, and muscle aches, and cannot obtain medical care within 24 hours.
Marine Hazards: Stingrays, sea wasps, cones, jellyfish, sea urchins, and anemones are common in India’s coastal waters and are potential hazards to unprotected swimmers.
Meningitis: Since January 2009, local health officials in India have reported 230 deaths and 2,000 possible cases of meningitis in the northeastern states of Tripura, Meghalaya, and Mizoram. These states are in the part of India bordered by Bangladesh to the west and Myanmar (Burma) to the east. In January 2009, ProMED reported an outbreak of meningococcal meningitis with 132 deaths in Meghalaya (ProMED-mail 17, January 2009). Meghalaya is in northeast India, about 100 miles north of Dacca, Bangladesh. In June 2005, an outbreak of meningococcal meningitis, predominantly type A, was reported in Delhi.
Recommendations for Travelers:
Travelers to this part of India or to any other area currently experiencing meningitis epidemics should receive the quadrivalent meningococcal vaccine. Protection develops 7-10 days after receiving the vaccine, so travelers should get vaccinated at least 10 days before travel, if possible. Travelers leaving in less than 10 days still need to get vaccinated before travel.
Other Diseases/Hazards: Trypanosomiasis (sleeping sickness; three cases reported from Maharastra in 2007, including one from Mumbai). The first case of human trypanosomiasis has now been discovered in India. The specialist investigations conducted, at the request of WHO and the Maharashtra Public Health Department, has led to the identification of the parasite and the treatment of the patient, a farmer from the State of Maharashtra. who proved to be infected by Trypanosoma evansi. T. evansi usually infects only animals, particularly cattle.
• Anthrax (cutaneous, primarily from contact with infected, freshly slaughtered animals)
• Angiostrongyliasis (human cases from ingesting raw snails, slugs, prawns, fish, land crabs, and vegetables)
• Brucellosis (humans acquire infection by ingestion of unpasteurized milk products or, less commonly, ingestion of poorly cooked meat from infected animals, by direct or indirect exposure to the organism through mucous membranes or broken skin, or by inhalation of infectious material)
• Crimean-Congo hemorrhagic fever (may occur near the Pakistani border)
• Cysticercosis (neurocysticercosis causes 2% of epileptic seizures in this country)
• Dracunculiasis (reported only from Rajasthan State)
• Kyasanur Forest disease (tick-borne arboviral fever; risk elevated during the dry season)
• Fasciolopsiasis (giant intestinal fluke; acquired by eating aquatic plants, such as water chestnuts)
• Leptospirosis (An outbreak of leptospirosis was reported from Gujarat State in August 2006, following heavy rains. In July 2006, a leptospirosis outbreak was reported from Mumbai (Bombay), and in May 2006, an outbreak was reported from Vadaserikara in Pathanamthitta District, Kerala, in the southern part of India.)
• Indian tick typhus (tick-borne hemorrhagic fever has been reported in the forest areas in Karnataka State; rickettsial disease, similar to boutonneuse fever)
• Helminthic infections (ascariasis, ancylostomiasis, trichuriasis, and strongyloidiasis are prevalent)
• Paragonimiasis (human lung fluke; cases from ingesting raw crabs)
• Trachoma (widespread in rural areas)
• Typhus (both murine and scrub typhus occur)
• West Nile fever
Plague: There is no risk to travelers at this time. Outbreaks of plague occurred in western India in 1994, but this epidemic was declared over as of 1996.
Poliomyelitis: This disease remains active in this country. Eighty-three new cases were reported in week ending 29 January, 2008 from Bihar and Uttar Pradesh.
• All travelers to India should be fully immunized against polio. This require a polio booster for those travelers who were immunized as children, but not vaccinated since.
Rabies: More than 30,000 human cases occur annually, and there is potential risk to travelers. Travelers should seek immediate treatment of any animal bite, especially if from a dog. (India has the highest incidence of dog rabies in the world). Rabies vaccination is indicated following the unprovoked bite of a dog, cat, bat, or monkey. Bites by other animals should be considered on an individual basis.
• Rabies vaccine is recommended for: persons anticipating an extended stay; for those whose work or activities may bring them into contact with animals; for people going to rural or remote locations where medical care is not readily available; for travelers desiring extra protection. Children are considered at higher risk because they tend to play with animals and may not report bites.
• Pre-exposure vaccination eliminates the need for rabies immune globulin, but does not eliminate the need for two additional booster doses of vaccine. Prompt medical evaluation and treatment of any animal bite is essential, regardless of vaccination status.
Road Safety: Travel by road in India is dangerous and tiring. Outside major cities, main roads & highways are poorly maintained and always congested. Most main roads often have only two lanes, with poor visibility and inadequate warning markers. Heavy traffic, including overloaded trucks & buses, scooters, pedestrians & livestock, is the norm. Travel at night is particularly hazardous. All travelers by car should hire only a well-maintained vehicle with qualified driver. Travel by train is advised in lieu of motor vehicle, where possible and practical.
Schistosomiasis: There is a negligible, to no risk, of schistosomiasis in India. A focus may occur in Gimvi village along the western coast in Maharashtra State, but this is not confirmed.
• Schistosomiasis is transmitted through exposure to contaminated water while wading, swimming, and bathing. Schistosoma larvae, released from infected freshwater snails, penetrate intact skin to establish infection. All travelers to endemic areas should avoid swimming, wading, or bathing in freshwater lakes, ponds, streams, cisterns, aqueducts, or irrigated areas. There is no risk in chlorinated swimming pools or in seawater.
Travelers' Diarrhea: High risk year-round, countrywide. Risk is higher in rural villages. Water supplies are frequently obtained from wells which commonly are contaminated. Untreated sewage, industrial wastes, and agricultural runoffs contaminate most of India’s rivers. Piped water supplies throughout India are quite limited and all water should be considered nonpotable outside of first-class hotels. Water- and food-borne diseases are a risk in this country.
• We recommend that you boil, filter or purify all drinking water or drink only bottled water or other bottled beverages and do not use ice cubes. Avoid unpasteurized milk and dairy products. Do not eat raw or undercooked food (especially meat, fish, raw vegetables—these may transmit intestinal parasites, as well as bacteria). Peel all fruits.
• Wash your hands with soap or detergent, or use a hand sanitizer gel, before you eat. Good hand hygiene helps prevent travelers’ diarrhea.
• A quinolone antibiotic, or azithromycin, combined with loperamide (Imodium), is recommended for the treatment of diarrhea. Diarrhea not responding to antibiotic treatment may be due to a parasitic disease such as giardiasis, amebiasis, or cryptosporidiosis.
• Seek qualified medical care if you have bloody diarrhea and fever, severe abdominal pain, uncontrolled vomiting, or dehydration.
Tuberculosis (TB): Tuberculosis is a major health problem in this country with 2% of the population infected and an annual incidence of greater than or equal to 40 cases per 100,000 population. Tuberculosis (TB) is transmitted following inhalation of infectious respiratory droplets. Most travelers are at low risk. Travelers at higher risk include those who are visiting friends and relatives (particularly young children), long-term travelers, and those who have close contact, prolonged contact with the local population. There is no prophylactic drug to prevent TB. Travelers with significant exposure should have PPD skin testing done to evaluate their risk of infection.
• Multi-drug-resistant TB (MDR-TB): The overall rates for MDR-TB among new smear-positive cases in the region is 2.8% among new cases and 18.8% among people receiving prior treatment for TB for one month or more. Outbreaks of multi-drug-resistant strains of tuberculosis are highest in India, China, Russia, South Africa and Bangladesh. Extensively drug-resistant TB (XDR-TB) that can be treated neither with the two principal anti-TB drugs nor with more expensive second-line drugs, may be increasing.
Typhoid Fever: An outbreak of typhoid fever was reported in June 2007 from the Kangpokpi area of Senapati district, Manipur State. Typhoid fever is the most serious of the Salmonella infections. Typhoid vaccine is recommended by the CDC for all people traveling to or working in the Indian sub-Continent, especially if visiting smaller cities, villages, or rural areas and staying with friends or relatives where exposure might occur through food or water. Current vaccines against Salmonella typhi are only 50-80% protective and do not protect against Salmonella paratyphi, the cause of paratyphoid fever. (Paratyphoid fever bears similarities with typhoid fever, but the course is generally more benign.) Travelers should continue to practice strict food, water and personal hygiene precautions, even if vaccinated.
Note: Two cases of paratyphoid fever were reported in 2010 from Varadaiahpalem, Chittoor District, Andhra Pradesh.
Yellow Fever: There is no yellow fever risk in India. A vaccination certificate, however, is required for travelers > 1 year of age arriving from infected or endemic countries, including Trinidad & Tobago.