India is the most frequent destination of all travelers seen in California travel medicine clinics. Of this group, visiting friends and relatives (VFR) is the most common reason for travel, although corporate travel to India is increasing. VFR travel frequently includes infants and children who are traveling to India for the first time. Most of our travelers are quite healthy and travel for relatively short periods of time. Others are elderly or very young, plan high-risk adventure travel, have high-risk medical problems (e.g., pregnancy, diabetes, asthma, immune disorders) or will live in India for a long period of time. Whatever your health status or itinerary, be certain that all medical and dental conditions are stable before your departure.

While traveling in India you may be exposed to a wide variety of air, water, and food contamination, as well as a higher rate of motor vehicle accidents and injuries. Make every attempt to avoid intense sun exposure, mosquito bites and dog bites (and licks). Try to anticipate medications or drugstore items that you might need while in India to treat medical problems or other injuries.

For current information regarding health, safety, geography, climate, US State Department warnings and political issues in India, click on Destinations. and select "India." Before traveling, review your personal, and/or corporate medical insurance to determine whether your coverage applies in India and how reimbursement will occur. Find out whether medical evacuation is provided and how it will take place, if needed. Before your trip, check early to determine the local, current medical conditions, especially malaria, and the availability of medical care. It is never too early to consider your source of water (bottled/boiled, etc.) and where you will turn if you need urgent/emergency medical care.

Immunizations
All routine childhood and adult immunizations should be reviewed and updated. This includes measles vaccine for children age 6-11 months, varicella vaccine for children and adults, tetanus-diphtheria vaccine (Tdap), influenza vaccine, and pneumococcal vaccine. The need for travel-related immunizations, including hepatitis A, hepatitis B, typhoid, rabies, Japanese encephalitis, meningitis, and cholera, should be considered. When travel is imminent and time is short, your doctor must make a decision to give immune globulin, hepatitis A vaccine, or both. Your doctor will need to review booster recommendations for all of the above immunizations. The booster recommendations are described in the immunization section for each vaccine.

Many adults who are returning to India, but lived there in the past, believe they are immune to hepatitis, traveler's diarrhea, typhoid fever, malaria and other travel-related infectious diseases. While this may be true for hepatitis A, it is certainly not true for typhoid fever or malaria. A simple blood test can determine immunity to hepatitis A and B and is recommended for adults who do not wish to be immunized because they believe they had hepatitis in the past. If immunity (antibody) is present in your blood, you do not need hepatitis immunization.

Malaria
Malaria exists in India throughout the year in the entire country. LARIAM® (mefloquine) is the most common medicine prescribed for travelers seeking preventive anti-malarial medication. It is approved for infants and children of any age. It is very bitter when taken in the compounded formulation and must be mixed with sweetened food (chocolate, jam, etc.) to mask its bitterness, especially for small children. LARIAM® (mefloquine) is a controversial drug, and it may have serious, disabling, and prolonged side effects. Check http://lariaminfo.homestead.com for further details.

A new anti-malarial drug, MALARONE®, became available in the USA in August 2000. It is an appropriate anti-malarial medication for India and has certain advantages over LARIAM® (mefloquine). Be aware, however, it is extremely expensive! ARALEN® (chloroquine) is not considered an appropriate drug for malaria prevention in India. For further general information on malaria, including preventive medications, check www.geocities.com/aaadeel/malaria.html.

The prevention of malaria includes personal protective measures to avoid mosquito bites as well as anti-malarial medications. Consider using an insect repellent that contains DEET, but be sure that the repellent contains less than 35% DEET when used on children. Minimize outdoor activity in the evening and at night, minimize skin exposure, use a permethrin-impregnated mosquito net over the bed (tucked in, of course), treat clothes with permethrin-containing products, burn pyrethroid coils in bedrooms, and consider using insecticide spray in the bedroom at night.

Some corporate travelers, especially if they travel frequently to India, may choose not to take anti-malaria medications each time. However, they must make every effort to avoid mosquito bites, as mentioned above, and seek immediate medical care if they develop a fever while traveling or upon arrival back home.

All travelers to India should recognize that no medication or personal preventive method guarantees complete protection from malaria. If you suspect that you or anyone in your family has malaria, seek medical evaluation and treatment as soon as possible. After leaving India, seek immediate attention if any unexplained fever develops during the next year.

Travelers' Diarrhea and Oral Rehydration Therapy (ORT)
Stomach and intestinal illnesses, including travelers' diarrhea, are extremely common in India. Travelers should understand the principles of food and water sanitation. Only boiled water, hot beverages (such as coffee or tea), carbonated beverages, beer and wine are considered safe to drink. Food should be selected with care. Foods of particular concern include salads, uncooked vegetables and fruit, unpasteurized milk and milk products, raw meat, and shellfish. Food that has been cooked and is still hot is generally safe. Infants younger than 6 months should either be breast-fed or be given powdered commercial formula prepared with boiled water.

In all age groups ORT is the preferred treatment of acute diarrhea and all travelers should carry a 24-hour supply of it. ORT is commonly found throughout India in powder form to be mixed with water. In the USA, ORT is available (e.g., CeraLyte® and Kaolectrolyte®) and may be carried with you for the treatment of diarrhea. If ORT is not available, an excellent alternative is to drink "clean" water and eat pretzels or salty crackers. A generic formula for ORT is 1 liter of water with 6 level teaspoons of sugar and 1 level teaspoon of salt. While adolescents and adults may take Imodium® AD or Lomotil® for mild-to-moderate travelers' diarrhea, per WHO, infants and young children should not take these medications.

Intravenous therapy is the treatment of choice for severe diarrhea in all age groups. The fluoroquinolones (e.g., Noroxin® or Cipro®) are the best antibiotics for the treatment of moderate to severe diarrhea (accompanied by fever or bloody stools) in adults, but are not approved for use in children under 18 years of age. Sulfa (Bactrim or Septra) may be used for severe diarrhea in children and is available in a liquid formulation; it does not require refrigeration. Unfortunately, sulfa-containing antibiotics are facing increasing drug resistance in India. Zithromax® (azithromycin) may also be used for children with severe diarrhea. Zithromax® is available in an oral suspension formulation and does not require refrigeration. Parents should understand the signs and symptoms of dehydration and have a plan for urgent medical evaluation and treatment if their child deteriorates/dehydrates quickly.

Based on CDC, Health Information for International Travel 2012, DHHS, Atlanta, GA, 2012; WHO, International Travel and Health, 2012, Geneva; and Dr. Richard Thompson's book Well on the Road - A Practical Guide for the International Traveler, 2013.