Health & safety
Pack medications in their original, clearly labelled containers. A signed and dated letter from your physician describing your medical conditions and medications, including generic names, is very useful. If carrying syringes or needles, be sure to have a physician’s letter documenting their medical necessity. If you have a heart condition, bring a copy of your ECG taken just prior to travelling.
If you take any regular medication, bring double your ordinary needs in case of loss or theft. You’ll be able to 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.
Even if you are fit and healthy, don’t travel without health insurance – accidents do happen. Declare any existing medical conditions you have – the insurance company will check if your problem is pre-existing and will not cover you if it is undeclared. You may require extra cover for adventure activities such as rock climbing and scuba diving. If your health insurance doesn’t cover you for medical expenses abroad, consider getting extra insurance. If you’re uninsured, emergency evacuation is expensive; bills of over US$100, 000 are not uncommon.
It’s a good idea to find out in advance if your insurance plan will make payments directly to providers or if it will reimburse you later for overseas health expenditures. (In many countries doctors expect payment in cash.) Some policies offer lower and higher medical-expense options; the higher ones are chiefly for countries that have extremely high medical costs, such as the USA. You may prefer a policy that pays doctors or hospitals directly rather than you having to pay on the spot and claim from your insurance company later. 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.
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Specialised travel-medicine clinics are your best source of information; they stock all available vaccines and will be able to give specific recommendations for you and your trip. The doctors will take into account factors such as past vaccination history, the length of your trip, activities you may be undertaking and underlying medical conditions, such as pregnancy.
Most vaccines don’t give immunity until at least two weeks after they’re given, so visit a doctor four to eight weeks before departure. Ask your doctor for an International Certificate of Vaccination (otherwise known as the ‘yellow booklet’), which will list all the vaccinations you’ve received.
The World Health Organization (WHO) recommends these vaccinations for travellers to India (as well as being up to date with measles, mumps and rubella vaccinations) :
Adult diphtheria and 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 In 2007 polio was still present in India. 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 if you only visit urban areas. The vaccine offers around 70% protection, lasts for two to three years and comes as a single shot. Tablets are also available, however, 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:
Japanese B Encephalitis Three injections in all. Booster recommended after two years. Sore arm and headache are the most common side effects. Rarely, 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.
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.
There is a wealth of travel health advice on the internet. Some good places to start:
Centers for Disease Control and Prevention (CDC; www.cdc.gov) Good general information.
MD Travel Health (www.mdtravelhealth.com) Provides complete travel health recommendations for every country, updated daily.
World Health Organization (WHO; www.who.int/ith/) Its superb book International Travel & Health is revised annually and available online.
Lonely Planet’s Healthy Travel – Asia & India is a handy pocket size and packed with useful information, including pretrip 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 of Travelling Well (www.travellingwell.com.au).
Recommended items for a personal medical kit:
Antifungal cream, eg Clotrimazole
Antibacterial cream, eg Muciprocin
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
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 Norfloxacin or 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
Indigestion tablets, eg Quick Eze or Mylanta
Iodine tablets (unless you are pregnant or have a thyroid problem) to purify water
Laxative, eg Coloxyl
Migraine medication if you suffer from them
Pyrethrin to impregnate clothing and mosquito nets
Steroid cream for allergic/itchy rashes, eg 1% to 2% hydrocortisone
Sunscreen and hat
Thrush (vaginal yeast infection) treatment, eg Clotrimazole pessaries or Diflucan tablet
Ural or equivalent if prone to urine infections
Jammu and Kashmir (with the exception of Ladakh) are subject to political violence: travellers should seek consular advice before entering any area bordering Pakistan. Similar advice should also be sought before travelling to Assam, Nagaland, Tripura and Manipur in northeast India. There is a high security risk in Bihar and Jharkhand. Several Indian cities suffered violent attacks during 2008-2009 including Bangalore, Ahmedabad, New Delhi and Mumbai. Check out Safe Travel for updated government warnings or the Thorn Tree travel forum for advice from other travellers.
India has an unenviable reputation for crime and scams, but most problems can be avoided with a bit of common sense and an appropriate amount of caution. Scams change as dodgy characters try to stay ahead of the game, so chat with other travellers and tourism officials to stay abreast of the latest hazards.
Contaminated food & drink
In past years, some private medical clinics have provided patients with more treatment than necessary to procure larger payments from travel insurance companies – get a second opinion if possible. In the late 1990s, several travellers were killed in a dangerous food scam in Agra and Varanasi after being fed food spiked with bacteria by restaurants linked to dodgy clinics. This scam has thankfully been quashed, but there’s always the chance it could reappear.
Most bottled water is legit, but always ensure the lid seal is intact and check that the bottom of the bottle hasn’t been tampered with. Crush plastic bottles after use to prevent them being misused later, or better still, bring along water-purification tablets or a filtration system to avoid adding to India’s plastic-waste mountain.
Marijuana and other ‘recreational’ drugs are widely available in India, and highly illegal. A few towns allow the legal sale of bhang (marijuana) for religious reasons, but elsewhere, courts treat possession of cannabis as severely as possession of heroin.
If you do choose to take drugs, use your common sense. Be aware that the police target foreign drug users in bribe scams. Bhang is frequently administered in food and drinks that can be incredibly potent, leaving intoxicated travellers vulnerable to robbery or accidents.
In the Kullu region of Himachal Pradesh, dozens of travellers have disappeared or been murdered in the hills, with suspicion falling on local drug gangs. Don’t assume strangers are harmless because they share your interest in drugs.
The sheer mass of humanity at India’s festivals provides an incredible spectacle, but every year pilgrims are crushed or trampled to death on temple processions and train platforms. Be extra careful around large crowds at these times, and travel on conventional trains rather than special pilgrim services.
Care is also needed during the Holi festival. Foreigners get doused with water and coloured dye like everyone else, and a few people have been scarred by dodgy chemicals. Consider buying a cheap set of throwaway clothes specifically for this festival. There’s also a tradition of guzzling alcohol and bhang at many festivals, and female travellers have been groped by spaced-out blokes. It’s wise to seek a companion before venturing onto the streets at festival time.
India is notorious for scams designed to separate travellers from their money, often with the promise of a chance to get rich quick. Don’t be fooled – any deal that sounds to good to be true invariably is.
Be highly suspicious of claims that you can purchase goods cheaply in India and sell them easily at a profit elsewhere. Precious stones and carpets are favourites for this con. Operators who practise such schemes are deceptively friendly and after buttering you up with invitations to their home, free meals etc, they begin pouring out sob stories about not being able to obtain an export licence. And therein lies the opportunity for you to ‘get rich quick’ – by carrying or mailing the goods home and selling them to the trader’s overseas representatives at a profit. Many can provide forged testimonials from other travellers. Without exception, the goods are worth a fraction of what you paid and the ‘representatives’ never materialise.
It also pays to be cautious when sending goods home. Shops have been known to swap high-value items for junk when posting goods to home addresses. If you have any doubts, send the package yourself from the post office. Be very careful when paying for souvenirs with a credit card. Government shops are usually legitimate; private souvenir shops have a reputation for secretly running off extra copies of the credit-card imprint slip, which will be used for phoney transactions after you have left the shop. Insist that the trader carries out any credit-card transaction on the counter in front of you. Alternatively, take out cash from an ATM and avoid the risk.
While it’s only a minority of traders who are involved in dishonest schemes, many souvenir vendors are involved in the commission racket.
Beaches can have dangerous rips and currents and there are drowning deaths each year. Always check locally before swimming anywhere in the sea and be careful of currents when swimming in any rivers, including the sacred Ganges River at Rishikesh.
Many private travel agencies make extra money by scamming travellers for tours and travel tickets. Make sure you are clear what is included in the price of any tour (get this in writing) to avoid charges for hidden ‘extras’ later on.
Be cautious of anyone offering tours to Kashmir in Delhi and other traveller centres. Some travel agents exploit travellers’ safety concerns to make extra cash from tours that you can do just as easily (and safely) on public transport. Always check the security situation before you travel and make your own tour arrangements after you arrive to cut out these dodgy middlemen.
When buying a bus, train or plane ticket anywhere other than the registered office of the transport company, make certain you are getting the ticket class you paid for. It is not uncommon for travellers to book a deluxe bus or AC train berth and arrive to find a bog-standard ordinary bus or a less comfortable sleeper seat.
Theft & druggings
Theft is a risk in India, as it is anywhere else. On buses and trains, keep luggage securely locked (minipadlocks and chains are available at most train stations) and lock your bags to the metal baggage racks or the wire loops found under seats; padlocking your bags to the roof racks on buses is also a sensible policy.
Thieves tend to target popular tourist train routes, such as Delhi to Agra. Be extra alert just before the train departs; thieves often take advantage of the confusion and crowds. Airports are another place to exercise caution; after a long flight you’re unlikely to be at your most alert.
Occasionally, tourists (especially those travelling solo) are drugged and robbed during train or bus journeys; a friendly stranger strikes up conversation, offers you a spiked drink (to send you to sleep), then makes off with everything you have. Politely decline drinks or food offered by strangers – stomach upsets are a convenient excuse.
Unfortunately some travellers make their money go further by helping themselves to other peoples – take care in dormitories. For lost credit cards, immediately call the international lost/stolen number; for lost/stolen travellers cheques, contact the Amex or Thomas Cook office in Delhi.
A good travel-insurance policy is essential; keep the emergency contact details handy and familiarise yourself with the claims procedure. Keep photocopies of your passport, including the visa page, separately from your passport (these are also useful for obtaining permits), as well as a copy of your airline ticket. You could also email scans to yourself.
The safest place for your money and your passport is next to your skin, either in a money belt or a secure pouch under your shirt. If you carry your money in a wallet, keep it in your front trouser pocket, never the back pocket (the ‘pickpocket’s friend’). Bum bags are often targeted by thieves as they are usually full of goodies.
It is usually wise to peel off at least US$100 and store it away separately from your main stash; however, keep your main stash and other valuables on your person. Also, separate big notes from small bills so you don’t publicly display large wads of cash when paying for services or checking into hotels.
In dodgy-looking hotels, put your money belt under your pillow when you sleep, and never leave your valuable documents and travellers cheques in your hotel room when you go out (even under your mattress). Better hotels will have a safe for valuables, and the YMCA and other hostels normally provide a locker where you can use your own padlock. For peace of mind, you may also want to use your own padlock in hotels where doors are locked with a padlock (common in cheaper hotels). If you cannot lock your hotel room securely from the inside at night, stay somewhere else.
Touts & commission agents
With so many businesses dependent on tourism, competition is cut-throat. Many hotels and shops drum up extra business by paying commission to local fixers who bring tourists through the doors. These places tend to be unpopular for a reason – prices will invariably be raised (by as much as 50%!) to pay the fixer’s commission. To get around this, ask taxis or rickshaws to drop you at a landmark rather than your real destination, so you can walk in alone and pay the normal price.
Train and bus stations are often swarming with touts – if anyone asks if this your first trip to India, say you’ve been here several times, as this is usually a ruse to gauge your vulnerability. You’ll often hear stories about the hotels that refuse to pay commissions being ‘full’, ‘under renovation’ or ‘closed’. Check things out yourself. Be very sceptical of phrases like ‘my brother’s shop’ and ‘special deal at my friend’s place’.
On the flip side, touts can be beneficial if you arrive in a town without a hotel reservation when some big festival is on, or during the peak season – they’ll know which places have beds.
Deep Vein Thrombosis (DVT)
Deep vein thrombosis (DVT) occurs when blood clots form in the legs during plane flights, chiefly because of prolonged immobility. The longer the flight, the greater the risk. Though most blood clots are reabsorbed uneventfully, some may break off and travel through the blood vessels to the lungs, where they may cause life-threatening complications.
The chief symptom of DVT is swelling or pain of the foot, ankle or calf, usually but not always on just one side. When a blood clot travels to the lungs, it may cause chest pain and difficulty in breathing. Travellers with any of these symptoms should immediately seek medical attention.
To prevent the development of DVT on long flights, walk about the cabin, perform isometric compressions of the leg muscles (ie contract the leg muscles while sitting), drink plenty of fluids, and avoid alcohol and tobacco.
Jet lag & motion sickness
Jet lag is common when crossing more than five time zones; it results in insomnia, fatigue, malaise or nausea. To avoid jet lag try drinking plenty of fluids (nonalcoholic) and eating light meals. Upon arrival, seek exposure to natural sunlight and readjust your schedule (for meals, sleep etc) as soon as possible.
Antihistamines such as dimenhydrinate (Dramamine), promethazine (Phenergan) and meclizine (Antivert, Bonine) are usually the first choice for treating motion sickness. Their main side effect is drowsiness. An herbal alternative is ginger, which works like a charm for some people.
India is far more accepting of children than most Western nations, but extra caution is required as the normal risks are amplified in these hot and crowded conditions. Pay close attention to hygiene and be very vigilant around traffic. Also keep children away from monkeys and local dogs, which carry all sorts of diseases. See Lonely Planet’s Travel with Children, and the travelling with children section of Lonely Planet’s Thorn Tree forum (thorntree.lonelyplanet.com) for more advice.
Many hotels have ‘family rooms’ and almost all will provide an extra bed for a small additional charge, though cots are rare. Upmarket hotels may offer baby-sitting facilities and/or kids’ activity programmes – inquire in advance. Upmarket hotels also have cable TV with English-language children’s channels (cheaper hotels only have cartoons in Hindi).
On Indian trains, children under four travel free and children aged five to 12 pay half-price. Most airlines charge 10% of the adult far for infants and 50% for under-12s.
Many tourist attractions charge a reduced entry fee for children under 12 (or children aged under 15 in some states).
Food & drink
Children are welcome in most restaurants, but only upmarket places and fast-food chains have highchairs and children’s menus. Across India, nappy-changing facilities are usually restricted to the (often cramped) restaurant toilet. Getting children to eat unfamiliar food is another challenge, though Western fast food is widely available and snack food such as pakoras (deep-fried battered vegetables), dosas (paper-thin lentil-flour pancakes) and finger chips (seasoned potato chips) goes down fairly easily. As long as it is peeled or washed in purified water, fruit can offset the unhealthiness of lots of fried food. Bottled water, cartons of fruit juice and bottles of soft drink are usually safe to drink. Some children also warm to sweet milky chai (tea).
Avoiding stomach upsets is a daily battle – washing hands with soap or rubbing alcohol is your first line of defence. If your child takes special medication, bring along an adequate stock. Note that rabid animals also pose a risk. Check with a doctor before departure about the correctly recommended jabs and drug courses for children in India.
Travel with infants
Standard baby products such as nappies (diapers) and milk powder are available in most large cities and tourist centres. If you’ve got a fussy baby, consider bringing powdered milk or baby food from home. Also bring along high-factor sunscreen, a snug-fitting wide-brimmed hat and a washable changing mat for covering dirty surfaces. Breast-feeding in public is generally not condoned by Indian society.
Although things are changing, particularly in the big cities, India remains a conservative country, especially so when it comes to the role of women. Despite a long history of erotic art, female sexuality is hidden away in modern Indian society. Combined with local attitudes to sex, the skimpy clothing and culturally inappropriate behaviour of a minority of foreign women have had a ripple effect on the perception of foreign women in India. The situation hasn’t been helped by the Hollywood film industry traditionally portraying Western women as sexual objects.
One unfortunate consequence of this is that many female travellers experience sexual harassment in India – predominantly lewd comments and invasion of privacy, though groping is not uncommon. Most cases are reported in urban centres of North India and prominent tourist towns elsewhere. The problem barely exists in Buddhist regions like Sikkim and Ladakh, making these areas a welcome bolt hole to escape the hassle of the plains.
While there’s no need to be paranoid, you should be aware that your behaviour and dress code is under scrutiny, and that local men may have a misguided opinion of how foreign women behave. Getting constantly stared at is something you’ll have to get used to. Just be thick-skinned and try to rise above it. It’s best to refrain from returning male stares, as this may be considered a come-on; dark glasses can help.
Other harassment women have encountered include provocative gestures, jeering, getting ‘accidentally’ bumped into on the street and being followed. Exuberant special events such as the Holi festival can be notorious for this. Women travelling with a male partner are less likely to be harassed. However, mixed couples of Indian and non-Indian descent may get disapproving stares, even if neither individual actually lives in India.
Ultimately, there are no sure-fire ways of shielding yourself from sexual harassment, even if you do everything ‘right’ – use your own judgement and instincts, and err on the side of caution if you are unsure. These warnings may seem a little daunting, but most men are not out to bother you and thousands of female travellers rise above these challenges every year.
Sanitary pads and tampons are available from pharmacies in all large cities and most tourist centres. Carry additional stocks for travel off the beaten track.
Warding off sexual harassment is often a matter of adjusting your behaviour to match the prevailing social norms in India. Avoiding culturally inappropriate clothing can help enormously. Steer clear of sleeveless tops, shorts, miniskirts (ankle-length skirts are recommended) and any other skimpy, see-through or tight-fitting clothing. Baggy clothing that hides the contours of your body is the way to go.
In some areas, such as Goa and Mumbai, there’s generally a more liberal attitude towards dress. Beachwear is normally fine on the beach and party clothes are OK for nightclubs, but away from these areas, take your cues from local women. Most Indian women wear saris, salwar kameez, or long shorts and a T-shirt whenever swimming in public view. When returning from the beach, use a sarong to avoid stares on the way back to your hotel.
Indian dress, when done properly, makes a positive impression and can dramatically cut down the harassment and stares. The salwar kameez is regarded as respectable attire and wearing it will reflect your respect for local dress etiquette. The flowing outfit is also surprisingly cool in the hot weather, and the dupatta (long scarf) worn with it is very handy if you visit a shrine that requires your head to be covered.
Going into public wearing a choli (small tight blouse worn under a sari) or a sari petticoat (which many foreign women mistake for a skirt) is rather like strutting around half dressed – don’t do it. Read personal experiences proffered by fellow women travellers on the India page at www.journeywoman.com.
Women have reported being molested by masseurs and other therapists, especially in Varanasi and McLeod Ganj. No matter where you are, try to check the reputation of any teacher or therapist before going to a solo session. If you feel uneasy at any time, leave. For gynaecological health issues, seek out a female doctor.
Keep conversations with unknown men short – getting involved in inane conversations with men can be misinterpreted as a sign of sexual interest. Questions such as ‘Do you have a boyfriend?’ or ‘You are looking very beautiful’ are indicators that the conversation may be taking a steamy tangent. Some women prepare in advance by wearing a pseudo wedding ring, or by announcing early on in the conversation that they are married or engaged (even if it isn’t true).
If you still get the uncomfortable feeling that a man is encroaching on your space, he probably is. A firm request to keep away is usually enough, especially if your voice is loud enough to draw the attention of passers-by. Alternatively, the silent treatment (not responding to questions at all) can be remarkably effective.
When interacting with men on a day-to-day basis, adhere to the local practice of not shaking hands. Instead, say namaste – the traditional, respectful Hindu greeting – and bow slightly with the hands brought together at the chest or head level.
Female filmgoers will probably feel more comfortable (and decrease the chances of potential harassment) by going to the cinema with a companion. Lastly, it’s wise to arrive in towns before dark and, of course, always avoid walking alone at night, especially in isolated areas.
‘Bird Flu’ or Influenza A (H5N1) is a subtype of the type A influenza virus. This virus typically infects birds and not humans; however, in 1997 the first documented case of bird-to-human transmission was recorded in Hong Kong. Currently very close 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 typical influenza-like symptoms with rapid deterioration leading to respiratory failure and death in many cases. The early administration of antiviral drugs, such as Tamiflu, is recommended to improve the chances of survival. At this time it is not routinely recommended for travellers to carry Tamiflu with them – rather immediate medical care should be sought if bird flu is suspected. At the time of writing there have been no recorded cases in travellers or expatriates.
There is currently no vaccine available to prevent bird flu. For up-to-date information check these two websites:
Coughs, colds & chest infections
Around 25% of travellers to India will develop a respiratory infection. This usually starts as a virus and is exacerbated by environmental conditions, such as pollution in the cities, or cold and altitude in the mountains. Commonly a secondary bacterial infection will intervene – marked by fever, chest pain and coughing up discoloured or blood-tinged sputum. If you have the symptoms of an infection seek medical advice or commence a general antibiotic.
This mosquito-borne disease is becomingly increasingly problematic in the tropical world, especially in the cities. As there is no vaccine available it can only be prevented by avoiding mosquito bites. The mosquito that carries dengue bites day and night, so use insect avoidance measures at all times. Symptoms include high fever, severe headache and body ache (dengue was previously known as ‘breakbone fever’). Some people develop a rash and experience diarrhoea. There is no specific treatment, just rest and paracetamol – do not take aspirin as it increases the likelihood of haemorrhaging. See a doctor to be diagnosed and monitored.
A problem throughout the region, 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.
The only sexually transmitted disease that can be prevented by vaccination, hepatitis B is spread by body fluids. The long-term consequences can include liver cancer and cirrhosis.
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 currently no vaccine, and prevention is by following safe eating and drinking guidelines.
HIV is 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.
Present year-round in the tropics, influenza (flu) symptoms include fever, muscle aches, 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. Like most mosquito-borne diseases it is becoming a more common problem in affected countries. 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 a third of infected people will die while another third will suffer permanent brain damage.
For such a serious and potentially deadly disease, there is an enormous amount of misinformation concerning malaria. You must get expert advice as to whether your trip actually puts you at risk. For most rural areas, the risk of contracting malaria far outweighs the risk of any tablet side effects. Before you travel, seek medical advice on the right medication and dosage for you.
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 made by taking a blood sample.
Two strategies should be combined to prevent malaria – mosquito avoidance and antimalaria 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-containing 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 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. The effectiveness of the chloroquine and Paludrine combination is now limited in many parts of South Asia. Common side effects include nausea (40% of people) and mouth ulcers.
The daily tablet doxycycline is a broad-spectrum antibiotic that has the added benefit of helping to prevent a variety of tropical diseases, including leptospirosis, tick-borne disease and typhus. The 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 – you can help prevent this by taking your tablet with a meal and a large glass of water, and never lying down within half an hour of taking it. It must be taken for four weeks after leaving the risk area.
Lariam (mefloquine) has received much bad press, some of it justified, some not. This weekly tablet suits many people. Serious side effects are rare but include depression, anxiety, psychosis and having fits. 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.
The new drug Malarone is 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.
Around 30, 000 people die in India each year from rabies. This uniformly fatal disease is spread by the bite or 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 almost impossible to obtain in much of India.
Sexually transmitted diseases most common in India include herpes, warts, syphilis, gonorrhoea and chlamydia. People carrying these diseases often have no signs of infection. Condoms will prevent gonorrhoea and chlamydia but not warts or herpes. If after a sexual encounter you develop any rash, lumps, discharge or pain when passing urine, seek immediate medical attention. If you have been sexually active during your travels, have an STD check on your return home.
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 pre- and post-travel TB testing. The main symptoms are fever, cough, weight loss, night sweats and tiredness.
This serious bacterial infection is also spread via food and water. It gives a high and slowly progressive fever, 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.
This is by far the most common problem affecting travellers – between 30% and 70% of people will suffer from it within two weeks of starting their trip. In over 80% of cases, traveller’s diarrhoea is caused by a bacteria (there are numerous potential culprits), and therefore responds promptly to treatment with antibiotics. Treatment with antibiotics will depend on your situation – how sick you are, how quickly you need to get better, where you are etc.
Traveller’s 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 norfloxacin, ciprofloxacin or azithromycin will kill the bacteria quickly.
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. Seek medical attention quickly if you do not respond to an appropriate antibiotic.
Amoebic dysentery is very rare in travellers but is often misdiagnosed by poor-quality labs. Symptoms are similar to bacterial diarrhoea, ie 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.
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.
Air pollution, particularly vehicle pollution, is an increasing problem in most of India’s major cities. If you have severe respiratory problems, speak with your doctor before travelling to any heavily polluted urban centres. This pollution also causes minor respiratory problems, such as sinusitis, dry throat and irritated eyes. If troubled by the pollution, leave the city for a few days and get some fresh air.
Eating in restaurants is the biggest risk factor for contracting traveller’s diarrhoea. Ways to avoid it include eating only freshly cooked food, and avoiding shellfish and food that has been sitting in buffets. Peel all fruit, cook vegetables and soak salads in iodine water for at least 20 minutes. Eat in busy restaurants with a high turnover of customers.
Many parts of India are hot and humid throughout the year. For most people it takes at least two weeks to 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. Take it easy when you first arrive. Don’t eat salt tablets (they aggravate the gut); drinking rehydration solution or eating salty food helps. Treat cramps by stopping activity, resting, rehydrating with double-strength rehydration solution and gently stretching.
Dehydration is the main contributor to heat exhaustion. Symptoms include feeling weak, headache, irritability, nausea or vomiting, sweaty skin, a fast, weak pulse and a normal or slightly elevated body temperature. Treatment involves getting out of the heat and/or sun, fanning the sufferer and applying cool wet cloths to the skin, laying the sufferer flat with their legs raised and rehydrating with water containing ¼ teaspoon of salt per litre. Recovery is usually rapid and it is common to feel weak for some days afterwards.
Heat stroke is a serious medical emergency. Symptoms come on suddenly and include weakness, nausea, a hot dry body with a body temperature of over 41°C, dizziness, confusion, loss of coordination, fits, and eventually collapse and loss of consciousness. Seek medical help and commence cooling by getting the person out of the heat, removing their clothes, fanning them and applying cool wet cloths or ice to their body, especially to the groin and armpits.
Prickly heat is a common skin rash in the tropics, caused by sweat being trapped under the skin. The result is an itchy rash of tiny lumps. Treat it by moving out of the heat and into an air-conditioned area 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.
Tropical fatigue is common in long-term expatriates based in the tropics. It’s rarely due to disease and is caused by the climate, inadequate mental rest, excessive alcohol intake and the demands of daily work in a different culture.
If you are going to altitudes above 3000m, you should get information on preventing, recognising and treating Acute Mountain Sickness (AMS). The biggest risk factor for developing altitude sickness is going too high too quickly – you should follow a conservative acclimatisation schedule such as can be found in all good trekking guides – and you should 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 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 and 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 and 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, however, 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.
It is always wise to sleep at a lower altitude than the greatest height reached during the day, if possible. Also, once above 3000m, care should be taken not to increase the sleeping altitude by more than 300m per day.
Drink extra fluids. The mountain air is dry and cold and moisture is lost as you breathe.
Eat light, high-carbohydrate meals.
Avoid alcohol and sedatives.
Insect bites & stings
Bedbugs don’t carry disease but their bites are very itchy. They live in the cracks of furniture and walls and then migrate to the bed at night to feed on you. You can treat the itch with an antihistamine. Lice inhabit various parts of your body but most commonly your head and pubic area. Transmission is via close contact with an infected person. They can be difficult to treat and you may need numerous applications of an antilice shampoo such as pyrethrin. Pubic lice are usually contracted from sexual contact.
Ticks are contracted after 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 experience symptoms such as 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 are found in humid rainforest areas. They do not transmit any disease but their bites are often intensely itchy for weeks afterwards and can easily become infected. Apply an iodine-based antiseptic to any leech bite to help prevent infection.
Bee and wasp stings mainly cause problems for people who are allergic to them. Anyone with a serious bee or wasp allergy should carry an injection of adrenaline (eg an Epipen) for emergency treatment. For others pain is the main problem – apply ice to the sting and take painkillers.
Fungal rashes are common in humid climates. 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. Tinea versicolor is also common – this fungus causes small, light-coloured patches, most commonly on the back, chest and shoulders. Consult a doctor.
Cuts and scratches become easily infected in humid climates. Take meticulous care of any cuts and scratches to prevent complications such as abscesses. Immediately wash all wounds in clean water and apply antiseptic. If you develop signs of infection (increasing pain and redness), see a doctor. Divers and surfers should be particularly careful with coral cuts, as they become easily infected.
Even on a cloudy day sunburn can occur rapidly. Always use a strong sunscreen (at least factor 30), making sure to reapply after a swim, and always wear a wide-brimmed hat and sunglasses outdoors. Avoid lying in the sun during the hottest part of the day (10am to 2pm). You can get burnt very easily when you are at high altitudes so be vigilant once above 3000m. If you become sunburnt, stay out of the sun until you have recovered, apply cool compresses and take painkillers for the discomfort. One-percent hydrocortisone cream applied twice daily is also helpful.
In most places in India, supplies of sanitary products (pads, rarely tampons) are readily available. Birth control options may be limited, so bring adequate supplies of your own form of contraception. 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 can be precipitated by dehydration or long bus journeys without toilet stops; bring suitable antibiotics. For gynaecological health issues, seek out a female doctor.
Pregnant women should receive specialised advice before travelling. The ideal time to travel is in the second trimester (between 16 and 28 weeks), when the risk of pregnancy-related problems is at its lowest and pregnant women generally feel at their best. Always carry a list of quality medical facilities available at your destination and ensure you continue your standard antenatal care at these facilities. Avoid rural travel in areas with poor transport and substandard medical facilities. Most of all, ensure that your travel insurance policy covers all pregnancy-related possibilities, including premature labour.
Malaria is a high-risk disease for pregnant women, and WHO recommends that they do not travel to areas with Chloroquine-resistant malaria. None of the more effective antimalarial drugs are completely safe in pregnancy.
Traveller’s diarrhoea can quickly lead to dehydration and result in inadequate blood flow to the placenta. Many of the drugs used to treat various diarrhoea bugs are not recommended in pregnancy. Azithromycin is considered safe.