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Health

There is huge geographical variation in India, so environmental issues like heat, cold and altitude can cause health problems. Hygiene is generally poor in most regions so food and water-borne illnesses are fairly common. A number of insect-borne diseases are present, particularly in tropical areas. Medical care is basic in various areas (especially beyond the larger cities) so it’s essential to be well prepared.

Pre-existing medical conditions and accidental injury (especially traffic accidents) account for most life-threatening problems. Becoming ill in some way, however, is common. Fortunately, most travellers’ illnesses can be prevented with some common-sense behaviour or treated with a well-stocked travellers’ medical kit – however, never hesitate to consult a doctor while on the road, as self-diagnosis can be hazardous.

The following information is a general guide only and certainly does not replace the advice of a doctor trained in travel medicine.

Before You Go

You can buy many medications over the counter in India without a doctor’s prescription, but it can be difficult to find some of the newer drugs, particularly the latest antidepressant drugs, blood-pressure medications and contraceptive pills. Bring the following:

  • medications in their original, labelled containers
  • a signed, dated letter from your physician describing your medical conditions and medications, including generic names
  • a physician’s letter documenting the medical necessity of any syringes you bring
  • if you have a heart condition, a copy of your ECG taken just prior to travelling

* any regular medication (double your ordinary needs)

Insurance

Don’t travel without health insurance. Emergency evacuation is expensive. Consider the following when buying insurance:

  • You may require extra cover for adventure activities such as rock climbing and scuba diving.
  • In India, doctors usually require immediate payment in cash. Your insurance plan may make payments directly to providers or it will reimburse you later for overseas health expenditures. If you do have to claim later, make sure you keep all relevant documentation.
  • Some policies ask that you telephone back (reverse charges) to a centre in your home country where an immediate assessment of your problem will be made.

Vaccinations

Specialised travel-medicine clinics are your best source of up-to-date information; they stock all available vaccines and can give specific recommendations for your trip. Most vaccines don’t give immunity until at least two weeks after they’re given, so visit a doctor well before departure. Ask your doctor for an International Certificate of Vaccination (sometimes known as the ‘yellow booklet’), which will list all the vaccinations you’ve received.

Required & Recommended Vaccinations

The only vaccine required by international regulations is yellow fever. Proof of vaccination will only be required if you have visited a country in the yellow-fever zone within the six days prior to entering India. If you are travelling to India from Africa or South America, you should check to see if you require proof of vaccination.

The World Health Organization (WHO) recommends the following vaccinations for travellers going to India (as well as being up to date with measles, mumps and rubella vaccinations):

Adult diphtheria & tetanus Single booster recommended if none in the previous 10 years. Side effects include sore arm and fever.

Hepatitis A Provides almost 100% protection for up to a year; a booster after 12 months provides at least another 20 years’ protection. Mild side effects such as headache and sore arm occur in 5% to 10% of people.

Hepatitis B Now considered routine for most travellers. Given as three shots over six months. A rapid schedule is also available, as is a combined vaccination with Hepatitis A. Side effects are mild and uncommon, usually headache and sore arm. In 95% of people lifetime protection results.

Polio Only one booster is required as an adult for lifetime protection. Inactivated polio vaccine is safe during pregnancy.

Typhoid Recommended for all travellers to India, even those only visiting urban areas. The vaccine offers around 70% protection, lasts for two to three years and comes as a single shot. Tablets are also available, but the injection is usually recommended as it has fewer side effects. Sore arm and fever may occur.

Varicella If you haven’t had chickenpox, discuss this vaccination with your doctor.

These immunisations are recommended for long-term travellers (more than one month) or those at special risk (seek further advice from your doctor):

Japanese B Encephalitis Three injections in all. Booster recommended after two years. Sore arm and headache are the most common side effects. In rare cases, an allergic reaction comprising hives and swelling can occur up to 10 days after any of the three doses.

Meningitis Single injection. There are two types of vaccination: the quadravalent vaccine gives two to three years’ protection; meningitis group C vaccine gives around 10 years’ protection. Recommended for long-term backpackers aged under 25.

Rabies Three injections in all. A booster after one year will then provide 10 years’ protection. Side effects are rare – occasionally headache and sore arm.

Tuberculosis (TB) A complex issue. Adult long-term travellers are usually recommended to have a TB skin test before and after travel, rather than vaccination. Only one vaccine given in a lifetime.

Medical checklist

Recommended items for a personal medical kit:

  • Antifungal cream, eg clotrimazole
  • Antibacterial cream, eg mupirocin
  • Antibiotic for skin infections, eg amoxicillin/clavulanate or cephalexin
  • Antihistamine – there are many options, eg cetrizine for daytime and promethazine for night
  • Antiseptic, eg Betadine
  • Antispasmodic for stomach cramps, eg Buscopam
  • Contraceptive
  • Decongestant, eg pseudoephedrine
  • DEET-based insect repellent
  • Diarrhoea medication – consider an oral rehydration solution (eg Gastrolyte), diarrhoea ‘stopper’ (eg loperamide) and antinausea medication (eg prochlorperazine). Antibiotics for diarrhoea include ciprofloxacin; for bacterial diarrhoea azithromycin; for giardia or amoebic dysentery tinidazole
  • First-aid items such as scissors, elastoplasts, bandages, gauze, thermometer (but not mercury), sterile needles and syringes, safety pins and tweezers
  • Ibuprofen or another anti-inflammatory
  • Iodine tablets (unless you are pregnant or have a thyroid problem) to purify water
  • Migraine medication if you suffer from migraines
  • Paracetamol
  • Pyrethrin to impregnate clothing and mosquito nets
  • Steroid cream for allergic or itchy rashes, eg 1% to 2% hydrocortisone
  • High-factor sunscreen
  • Throat lozenges
  • Thrush (vaginal yeast infection) treatment, eg clotrimazole pessaries or Diflucan tablet
  • Ural or equivalent if prone to urine infections

Websites

There is a wealth of travel-health advice on the internet; www.lonelyplanet.com is a good place to start. Some other suggestions:

Health Advisories

It’s a good idea to consult your government’s travel-health website before departure, if one is available:

Further Reading

Lonely Planet’s Healthy Travel – Asia & India is a handy pocket size and packed with useful information, including pre-trip planning, emergency first aid, immunisation and disease information, and what to do if you get sick on the road. Other recommended references include Travellers’ Health by Dr Richard Dawood and Travelling Well by Dr Deborah Mills – check out the website (www.travellingwell.com.au) too.

In India

Environmental Hazards

Carbon-Monoxide Poisoning

Some mountain areas rely on charcoal burners for warmth, but these should be avoided due to the risk of fatal carbon-monoxide poisoning. The thick, mattress-like blankets used in many mountain areas are amazingly warm once you get beneath the covers. If you’re still cold, improvise a hot-water bottle by filling your drinking-water bottle with boiled water and covering it with a sock.

Air Pollution

Air pollution, particularly vehicle pollution, is an increasing problem in most of India’s urban hubs. If you have severe respiratory problems, speak with your doctor before travelling to India.

Diving & Surfing

Divers and surfers should seek specialised advice before they travel to ensure their medical kit contains treatment for coral cuts and tropical ear infections. Divers should ensure their insurance covers them for decompression illness – get specialised dive insurance through an organisation such as Divers Alert Network (www.danasiapacific.org). Certain medical conditions are incompatible with diving; check with your doctor.

Drinking Water

  • Never drink tap water.
  • Bottled water is generally safe – check the seal is intact at purchase.
  • Avoid ice unless you know it has been made hygienically.
  • Be careful of fresh juices served at street stalls in particular – they may have been watered down or may be served in unhygienic jugs/glasses.
  • Boiling water is usually the most efficient method of purifying it.
  • The best chemical purifier is iodine. It should not be used by pregnant women or those with thyroid problems.
  • Water filters should also filter out most viruses. Ensure your filter has a chemical barrier such as iodine and a small pore size (less than four microns).

Heat

Many parts of India, especially down south, are hot and humid throughout the year. For most visitors it takes around two weeks to comfortably adapt to the hot climate. Swelling of the feet and ankles is common, as are muscle cramps caused by excessive sweating. Prevent these by avoiding dehydration and excessive activity in the heat. Don’t eat salt tablets (they aggravate the gut); drinking rehydration solution or eating salty food helps. Treat cramps by resting, rehydrating with double-strength rehydration solution and gently stretching.

Dehydration is the main contributor to heat exhaustion. Recovery is usually rapid and it is common to feel weak for some days afterwards. Symptoms include:

  • feeling weak
  • headache
  • irritability
  • nausea or vomiting
  • sweaty skin
  • a fast, weak pulse
  • normal or slightly elevated body temperature.

Treatment:

  • get out of the heat
  • fan the sufferer
  • apply cool, wet cloths to the skin
  • lay the sufferer flat with their legs raised
  • rehydrate with water containing one-quarter teaspoon of salt per litre.

Heat stroke is a serious medical emergency. Symptoms include:

  • weakness
  • nausea
  • a hot dry body
  • temperature of over 41°C
  • dizziness
  • confusion
  • loss of coordination
  • seizures
  • eventual collapse.

  • get out of the heat
  • fan the sufferer
  • apply cool, wet cloths to the skin or ice to the body, especially to the groin and armpits.

Prickly heat is a common skin rash in the tropics, caused by sweat trapped under the skin. Treat it by moving out of the heat for a few hours and by having cool showers. Creams and ointments clog the skin so they should be avoided. Locally bought prickly-heat powder can be helpful.

Altitude Sickness

If you are going to altitudes above 3000m, Acute Mountain Sickness (AMS) is an issue. The biggest risk factor is going too high too quickly – follow a conservative acclimatisation schedule found in good trekking guides, and never go to a higher altitude when you have any symptoms that could be altitude related. There is no way to predict who will get altitude sickness and it is quite often the younger, fitter members of a group who succumb.

Symptoms usually develop during the first 24 hours at altitude but may be delayed up to three weeks. Mild symptoms include:

  • headache
  • lethargy
  • dizziness
  • difficulty sleeping
  • loss of appetite.

AMS may become more severe without warning and can be fatal. Severe symptoms include:

  • breathlessness
  • a dry, irritative cough (which may progress to the production of pink, frothy sputum)
  • severe headache
  • lack of coordination and balance
  • confusion
  • irrational behaviour
  • vomiting
  • drowsiness
  • unconsciousness.

Treat mild symptoms by resting at the same altitude until recovery, which usually takes a day or two. Paracetamol or aspirin can be taken for headaches. If symptoms persist or become worse, immediate descent is necessary; even 500m can help. Drug treatments should never be used to avoid descent or to enable further ascent.

The drugs acetazolamide and dexamethasone are recommended by some doctors for the prevention of AMS; however, their use is controversial. They can reduce the symptoms, but they may also mask warning signs; severe and fatal AMS has occurred in people taking these drugs.

To prevent acute mountain sickness:

  • ascend slowly – have frequent rest days, spending two to three nights at each rise of 1000m
  • sleep at a lower altitude than the greatest height reached during the day, if possible. Above 3000m, don’t increase sleeping altitude by more than 300m daily
  • drink extra fluids
  • eat light, high-carbohydrate meals
  • avoid alcohol and sedatives

Insect Bites & Stings

Bedbugs Don’t carry disease but their bites can be very itchy. They usually live in furniture and walls and then migrate to the bed at night. You can treat the itch with an antihistamine.

Lice Most commonly appear on the head and pubic areas. You may need numerous applications of an antilice shampoo such as pyrethrin. Pubic lice are usually contracted from sexual contact.

Ticks Contracted walking in rural areas. Ticks are commonly found behind the ears, on the belly and in armpits. If you have had a tick bite and have a rash at the site of the bite or elsewhere, fever or muscle aches, you should see a doctor. Doxycycline prevents tick-borne diseases.

Leeches Found in humid rainforest areas. They do not transmit any disease but their bites are often intensely itchy for weeks and can easily become infected. Apply an iodine-based antiseptic to any leech bite to help prevent infection.

Bee and wasp stings Anyone with a serious bee or wasp allergy should carry an injection of adrenalin (eg an Epipen). For others pain is the main problem – apply ice to the sting and take painkillers.

Skin Problems

Fungal rashes There are two common fungal rashes that affect travellers. The first occurs in moist areas, such as the groin, armpits and between the toes. It starts as a red patch that slowly spreads and is usually itchy. Treatment involves keeping the skin dry, avoiding chafing and using an antifungal cream such as clotrimazole or Lamisil. The second, Tinea versicolor, causes light-coloured patches, most commonly on the back, chest and shoulders. Consult a doctor.

Cuts and scratches These become easily infected in humid climates. Immediately wash all wounds in clean water and apply antiseptic. If you develop signs of infection (increasing pain and redness), see a doctor.

Food

Dining out brings with it the possibility of contracting diarrhoea. Ways to help avoid food-related illness:

  • eat only freshly cooked food
  • avoid shellfish and buffets
  • peel fruit
  • cook vegetables
  • soak salads in iodine water for at least 20 minutes
  • eat in busy restaurants with a high turnover of customers

Infectious Diseases

Malaria

This is a serious and potentially deadly disease. Before you travel, seek expert advice according to your itinerary (rural areas are especially risky) and on medication and side effects.

Malaria is caused by a parasite transmitted by the bite of an infected mosquito. The most important symptom of malaria is fever, but general symptoms, such as headache, diarrhoea, cough or chills, may also occur. Diagnosis can only be properly made by taking a blood sample.

Two strategies should be combined to prevent malaria: mosquito avoidance and antimalarial medications. Most people who catch malaria are taking inadequate or no antimalarial medication.

Travellers are advised to prevent mosquito bites by taking these steps:

  • Use a DEET-based insect repellent on exposed skin. Wash this off at night – as long as you are sleeping under a mosquito net. Natural repellents such as citronella can be effective, but must be applied more frequently than products containing DEET.
  • Sleep under a mosquito net impregnated with pyrethrin.
  • Choose accommodation with proper screens and fans (if not air-conditioned).
  • Impregnate clothing with pyrethrin in high-risk areas.
  • Wear long sleeves and trousers in light colours.
  • Use mosquito coils.
  • Spray your room with insect repellent before going out for your evening meal.

There are a variety of medications available:

Chloroquine & Paludrine combination Limited effectiveness in many parts of South Asia. Common side effects include nausea (40% of people) and mouth ulcers.

Doxycycline (daily tablet) A broad-spectrum antibiotic that helps prevent a variety of tropical diseases, including leptospirosis, tick-borne disease and typhus. Potential side effects include photosensitivity (a tendency to sunburn), thrush (in women), indigestion, heartburn, nausea and interference with the contraceptive pill. More serious side effects include ulceration of the oesophagus – take your tablet with a meal and a large glass of water, and never lie down within half an hour of taking it. It must be taken for four weeks after leaving the risk area.

Lariam (mefloquine) This weekly tablet suits many people. Serious side effects are rare but include depression, anxiety, psychosis and seizures. Anyone with a history of depression, anxiety, other psychological disorders or epilepsy should not take Lariam. It is considered safe in the second and third trimesters of pregnancy. Tablets must be taken for four weeks after leaving the risk area.

Malarone A combination of atovaquone and proguanil. Side effects are uncommon and mild, most commonly nausea and headache. It is the best tablet for scuba divers and for those on short trips to high-risk areas. It must be taken for one week after leaving the risk area.

Other diseases

Avian Flu ‘Bird flu’ or Influenza A (H5N1) is a subtype of the type A influenza virus. Contact with dead or sick birds is the principal source of infection and bird-to-human transmission does not easily occur. Symptoms include high fever and flu-like symptoms with rapid deterioration, leading to respiratory failure and death in many cases. Immediate medical care should be sought if bird flu is suspected. Check www.who.int/en/or www.avianinfluenza.com.au.

Dengue Fever This mosquito-borne disease is becomingly increasingly problematic, especially in the cities. As there is no vaccine available it can only be prevented by avoiding mosquito bites at all times. Symptoms include high fever, severe headache and body ache and sometimes a rash and diarrhoea. Treatment is rest and paracetamol – do not take aspirin or ibuprofen as it increases the likelihood of haemorrhaging. Make sure you see a doctor to be diagnosed and monitored.

Hepatitis A This food- and water-borne virus infects the liver, causing jaundice (yellow skin and eyes), nausea and lethargy. There is no specific treatment for hepatitis A, you just need to allow time for the liver to heal. All travellers to India should be vaccinated against hepatitis A.

Hepatitis B This sexually transmitted disease is spread by body fluids and can be prevented by vaccination. The long-term consequences can include liver cancer and cirrhosis.

Hepatitis E Transmitted through contaminated food and water, hepatitis E has similar symptoms to hepatitis A, but is far less common. It is a severe problem in pregnant women and can result in the death of both mother and baby. There is no commercially available vaccine, and prevention is by following safe eating and drinking guidelines.

HIV Spread via contaminated body fluids. Avoid unsafe sex, unsterile needles (including in medical facilities) and procedures such as tattoos. The growth rate of HIV in India is one of the highest in the world.

Influenza Present year-round in the tropics, influenza (flu) symptoms include fever, muscle aches, a runny nose, cough and sore throat. It can be severe in people over the age of 65 or in those with medical conditions such as heart disease or diabetes – vaccination is recommended for these individuals. There is no specific treatment, just rest and paracetamol.

Japanese B Encephalitis This viral disease is transmitted by mosquitoes and is rare in travellers. Most cases occur in rural areas and vaccination is recommended for travellers spending more than one month outside of cities. There is no treatment, and it may result in permanent brain damage or death. Ask your doctor for further details.

Rabies This fatal disease is spread by the bite or possibly even the lick of an infected animal – most commonly a dog or monkey. You should seek medical advice immediately after any animal bite and commence postexposure treatment. Having pretravel vaccination means the postbite treatment is greatly simplified. If an animal bites you, gently wash the wound with soap and water, and apply iodine-based antiseptic. If you are not prevaccinated you will need to receive rabies immunoglobulin as soon as possible, and this is very difficult to obtain in much of India.

Tuberculosis While TB is rare in travellers, those who have significant contact with the local population (such as medical and aid workers and long-term travellers) should take precautions. Vaccination is usually only given to children under the age of five, but adults at risk are recommended to have pre- and post-travel TB testing. The main symptoms are fever, cough, weight loss, night sweats and fatigue.

Typhoid This serious bacterial infection is also spread via food and water. It gives a high and slowly progressive fever and headache, and may be accompanied by a dry cough and stomach pain. It is diagnosed by blood tests and treated with antibiotics. Vaccination is recommended for all travellers who are spending more than a week in India. Be aware that vaccination is not 100% effective, so you must still be careful with what you eat and drink.

Travellers’ Diarrhoea

This is by far the most common problem affecting travellers in India – between 30% and 70% of people will suffer from it within two weeks of starting their trip. It’s usually caused by a bacteria, and thus responds promptly to treatment with antibiotics.

Travellers’ diarrhoea is defined as the passage of more than three watery bowel actions within 24 hours, plus at least one other symptom, such as fever, cramps, nausea, vomiting or feeling generally unwell.

Treatment consists of staying well hydrated; rehydration solutions like Gastrolyte are the best for this. Antibiotics such as ciprofloxacin or azithromycin should kill the bacteria quickly. Seek medical attention quickly if you do not respond to an appropriate antibiotic.

Loperamide is just a ‘stopper’ and doesn’t get to the cause of the problem. It can be helpful, though (eg if you have to go on a long bus ride). Don’t take loperamide if you have a fever or blood in your stools.

Amoebic Dysentery Amoebic dysentery is very rare in travellers but is quite often misdiagnosed by poor-quality labs. Symptoms are similar to bacterial diarrhoea: fever, bloody diarrhoea and generally feeling unwell. You should always seek reliable medical care if you have blood in your diarrhoea. Treatment involves two drugs: tinidazole or metronidazole to kill the parasite in your gut and then a second drug to kill the cysts. If left untreated complications such as liver or gut abscesses can occur.

Giardiasis Giardia is a parasite that is relatively common in travellers. Symptoms include nausea, bloating, excess gas, fatigue and intermittent diarrhoea. The parasite will eventually go away if left untreated but this can take months; the best advice is to seek medical treatment. The treatment of choice is tinidazole, with metronidazole being a second-line option.

Availability of Health Care

Medical care is hugely variable in India. Some cities now have clinics catering specifically to travellers and expatriates; these clinics are usually more expensive than local medical facilities, and offer a higher standard of care. Additionally, they know the local system, including reputable local hospitals and specialists. They may also liaise with insurance companies should you require evacuation. It is usually difficult to find reliable medical care in rural areas.

Self-treatment may be appropriate if your problem is minor (eg traveller’s diarrhoea), you are carrying the relevant medication, and you cannot attend a recommended clinic. If you suspect a serious disease, especially malaria, travel to the nearest quality facility.

Before buying medication over the counter, check the use-by date, and ensure the packet is sealed and properly stored (eg not exposed to the sunshine).

Women’s Health

For gynaecological health issues, seek out a female doctor.

Birth control Bring adequate supplies of your own form of contraception.

Sanitary products Pads, rarely tampons, are readily available.

Thrush Heat, humidity and antibiotics can all contribute to thrush. Treatment is with antifungal creams and pessaries such as clotrimazole. A practical alternative is a single tablet of fluconazole (Diflucan).

Urinary-tract infections These can be precipitated by dehydration or long bus journeys without toilet stops; bring suitable antibiotics.