Recommendations for Travelers going to India
The India subcontinent is of course a large area but certain generalizations may be made as to which immunizations are recommended overall, with specific advice added for travelers doing specific activities or visiting certain geographic areas.
Travelers or those visiting friends and relatives must remember that even if they were born in India they may no longer have current immunity to certain diseases. Immunizations remain one of the best ways of preventing diseases but the advice and planning that goes along with avoiding illnesses are even more important.
This article will discuss some of the common questions people have who travel to India and are general. For specific medical advice travelers should consult their family doctor or a qualified travel clinic.
These immunizations (vaccines) are strongly recommended to all travelers to India regardless of duration or destination. Manitoba Health does not cover travel visits and your Physician or Travel clinic may charge a fee.
Tetanus Diphtheria (Td) should be up to date and given every 10 yrs. Tetanus and diptheria are worldwide and should be given to everyone every 10 years.
Polio (IPV or Salk vaccine) This may also be combined with Td (Td-polio) or given separately (IPV), and should be given to travelers traveling outside North America. Polio is almost eradicated worldwide but is still a problem in Africa and India. Travelers should get a booster every 10 years.
Hepatitis A vaccine is also strongly recommended. Hepatitis A is acquired from contaminated food or water and can make people very sick. The vaccine gives protection for 12 months. A second dose, which must be given no sooner than 6 months, will boost this protection to at least 10-20 yrs. Many people who grew up in India (or even rural Manitoba) had “Infectious Jaundice Hepatitis” when they were young which is Hepatitis A. The disease is not so severe in children but can kill older adults. A physician can do a simple blood test to check for immunity to Hepatitis A if there is a reason to suspect that they had this because once you recover you are then immune for life. This test takes one week or less to get the results. If an immune person receives a hepatitis A vaccine there is no harm.
Typhoid infections are spread by food and water and are more common in India than in other countries and should be considered especially for longer stays and extended or off the beaten path travels. Injectable Typhoid (Typherix or Typhim Vi) is good for 2 years. An oral typhoid vaccine is good for 5 years.
Other common childhood vaccines
Although not always discussed in great detail, everyone should have finished his or her childhood immunization by adulthood. If doubt exists a blood test which takes a week to get back to determine if immunity is present. If tests reveal that a person is not immune to chickenpox or measles then they should get these vaccines, as they are at greater risk of these diseases overseas and could bring these infections back to Canada.
Other vaccines to Consider
Hepatitis B is a different virus that also causes hepatitis but it is acquired through blood and body fluids. It is more common, easier to catch and kills more people than HIV.
Risk factors for Hepatitis B include: contact with blood and bodily fluids, unclean needles, unprotected sex (although even condoms do not reduce the risk to zero), IV drugs, and blood transfusions. People who will be staying longer than 3-6 months in countries where Hepatitis B is very high are also recommended to have this vaccine. We also recommend Hepatitis B vaccine for those who have family members with Hepatitis B because over time accidental contacts can spread this (sharing toothbrushes or razors).
Hepatitis B should be given in 2 full doses one month apart with a booster dose after 6 months.
All the different brands of Hepatitis A and B are equally effective. Some people prefer the pre mixed vaccine of “Twinrix” but if they use this one they must receive 2 full doses to be adequately protected against either Hep A or B.
Traveler's Diarrhea is diarrhea caused during travel by exposure to bacteria, viruses and parasites, although traveler's diarrhea is usually referred to by the development of sudden diarrheic symptoms following a bacteria infection.
We recommend of course that people be careful what they eat but traveler's diarrhea also even happens to those who are careful since they may be infected through another's careless preparation or contamination of food.
Pepto-Bismol and Imodium may be taken for mild symptoms.
Taking 2 tablets of pepto-bismol 4 times daily has been shown in medical studies to decrease travelers' diarrhea by one half.
We recommend a broad-spectrum antibiotic to be taken during the early stages of traveler's diarrhea. This will rapidly treat the diarrhea and prevent the loss of fluids and body salts, which will make one very sick in a tropical environment.
Dukoral (a vaccine) has been licensed in Canada against “travelers diarrhea” but is only effective against 1 in 5 cases of traveler's diarrhea and lasts 3 months. In contrast taking pepto-bismol decreases traveler's diarrhea by 50%.
Travelers having diarrhea starting after their return may have an intestinal parasite. If you suspect that you may have a parasite check with a physician.
General Insect precautions
Many species of mosquitoes exist causing different diseases: malaria, dengue, Japanese encephalitis, Filariasis (elephantitis) and others. It is important for travelers not to be bitten since some of these infections are hard to protect against them and have no cure.
We recommend good clothing (light loose fitting and covering the limbs), DEET 30% applied to exposed skin, and Permethrin insecticide applied to clothing. Permethrin is an insecticide made from the Chrysanthemum flowers and studies have shown that when it is applied to fabric and mosquito netting it is effective in killing or stunning mosquitoes and other bugs. It is available as “R+C”spray over the counter
Dengue fever is a viral illness transmitted by daytime biting mosquitoes. At present there is no vaccination or treatment. We recommend that you check if the area you are going to has dengue and take appropriate precautions. Dengue mosquitoes bite in the day like the ones that transmit west Nile Disease in Manitoba.
Yellow Fever There is no Yellow fever in India
Malaria is a severe parasite transmitted by night biting mosquitoes
Malaria is present in much of India
In the next article we will discuss other important illnesses to be aware of. Malaria cannot be vaccinated against and travelers must take an antimalarial drug.
Other diseases like, Rabies and Japanese Encephalitis are important and deadly but these vaccines are also very expensive. We will discuss situations where travelers do need them but the vast majority of travelers do not.
Traveling to India
Last issue we discusses the common basic immunizations for a trip to India. We will now focus on extra vaccines or medications that are needed.
Malaria is a parasite transmitted by a nighttime biting mosquito whose bite infects a person. It is present in all areas, including the cities of Delhi and Bombay
and in areas at altitudes <2000 m (6,561 ft) in Himachal Pradesh, Jammu,
Kashmir, and Sikkim.
No vaccine is available yet so the best way to prevent malaria is to not get bitten. Malarious mosquitoes are small and not always noticed so travelers going to an area with malaria are recommended to take an oral antimalarial pill which is in fact a poison that works against the parasite and not the person.
No antimalarial works 100% though so even if a person was careful and took their pills they could still get malaria although in these cases they would not get sick as fast and would be easier to treat. People infected not taking medication can die very quickly.
There are several types of antimalarials and all have had some type of side effect but these are not a problem for most people. The choice of what pill to take depends on the individual person and where they are going.
The British originally used chloroquine, as part of “Gin and Tonic” but malaria in India is now resistant to this.
The 3 other antimalarials are reasonable choices for India
Mefloquine (Larium) is a weekly pill that is effective although it is known to cause vivid dreams and people with anxiety, depression, heart conduction block and seizures shouldn't take it. Very rarely people have become extremely agitated on mefloquine. Despite all this it is still a useful drug and may be given to children as well.
Doxycycline (Vibramycin) is a tetracycline antibiotic and acts against malaria but has to be taken daily. It is very well tolerated, but some people have irritation to their esophagus and increased sensitivity to the sun. Women also get more yeast infections.
Malarone is a new drug also taken daily; it has less side effects than Mefloquine but side effects have been reported particularly mouth ulcers. It is also more expensive.
All antimalarials must also be continued after exposure since the parasite can reside in the body.
For chloroquine, mefloquine and doxycycline people must take medication for 4 additional weeks while with Malarone this is for 7 additional days.
Malaria is a very serious disease and can be very hard to diagnose. It is the one disease not to miss because it can kill very quickly. Even the tests don t always show it so travelers must be carefully scrutinized with any unexplained fever even months after they return.
Rabies causes 60,000 deaths worldwide, half of which are in India. Infections with rabies occur when the virus is first inoculated into the victim and then absorbed into a susceptible cell where it multiplies. The virus then enters nerve endings. The virus will migrate to the brain and once the virus has then entered the brain, rabies symptoms begin to occur. Rabies is almost universally fatal afterwards. The term rabies refers only to when the person has the fatal condition
PREVENTION AND TREATMENT OF RABIES Pre-exposure vaccination is giving the rabies vaccine to people who might be exposed to rabies.
The vaccine is given in three doses at days 0, 7, 28, (or 21) with a booster at 1 year and every 5 years after. It eliminates the need for post exposure immunoglobulin treatment after a rabid bite, which may not even be available in certain countries.
It also simplifies post exposure treatment to only 2 vaccine doses after being bitten. People who should be vaccinated include researchers working with rabies, veterinarians, and remote travelers. Spulunkers may also be at risk of rabies from bats. Children of long-term travelers might also be at high risk of rabies in developing countries. POST BIT TREATMENT Cleaning bites is the most important step in preventing rabies. This should be done as soon as possible, first by flushing the wound with soap and water, followed by 70% alcohol, or tincture of iodine
Travelers to India should be aware of the danger of rabies. Immunization is also very expensive.
If bitten physicians in India are very experienced and should be consulted immediately.
Japanese encephalitis This is a mosquito-acquired infection. This mosquito is present near rice paddies and pig farms so only travelers to such rural areas are at risk. It is present in the South: Goa May-Oct, Tamil Nadu Oct-Jan; Karnataka Aug-Dec; Mandya Distr. April-June Andrha Pradesh Sept-Dec; North 7-12; and outbreaks are reported in West Bengal, Bihar, Karnataka, Tamil Nadu, Andrha Pradesh, Assam, Uttar Pradesh, Manipur, and Goa; Most infections are not symptomatic.
1 in 250 infections cause illness after 5-15 days of incubation. Illness begins with a high fever, changes in mental status, gastrointestinal symptoms, and headache followed by disturbances in speech, gout or other motor problems. Symptoms progress to stupor and coma. 5-30% of cases are fatal and 1/3 of survivors may have neurological injury. The Japanese Encephalitis vaccine is given in 3 doses administered at 0,7, and 14-21 days, with a booster at 3 years. Side effects of vaccination include local redness and soreness at vaccination site, low-grade fever, and muscle aches. Allergic reactions to JEV have occurred up to 20-336 hours after vaccination, which are treatable with Corticosteroids and antihistamines.
This vaccine is only for travelers at high risk.