There are plenty of scare stories about the health risks of travelling in India, but in fact cases of serious illness are very much the exception rather than the rule. Standards of hygiene and sanitation have increased greatly over the past couple of decades and there’s no reason you can’t stay healthy throughout your trip – indeed many travellers now visit the Subcontinent without even experiencing the traditional dose of “Delhi belly”. Having said that, it’s still important to be careful, keep your resistance high and to be aware of the dangers of untreated water, mosquito bites and undressed open cuts.
It’s worth knowing, if you are ill and can’t get to a doctor, that almost any medicine can be bought over the counter without a prescription.
When it comes to food, be wary of dishes that appear to have been reheated. Anything boiled, fried or grilled (and thus sterilized) in your presence is usually all right, though seafood and meat can pose real risks if they’re not fresh; anything that has been left out for any length of time, or stored in a fridge during a power cut, is best avoided. Raw unpeeled fruit and vegetables should always be viewed with suspicion, and you should steer clear of salads unless you know they have been washed in purified water.
Be vigilant about personal hygiene: wash your hands often, especially before eating. Keep all cuts clean, treat them with iodine or antiseptic (a liquid or dry spray is better in the heat) and cover them to prevent infection.
Advice on avoiding mosquitoes is offered under “Malaria”. If you do get bites or itches, try not to scratch them: it’s difficult, but infection and tropical ulcers can result if you do. Tiger balm and even dried soap may relieve the itching.
Finally, especially if you are going on a long trip, have a dental check-up before you leave home.
No inoculations are legally required for entry into India, but diphtheria, typhoid and hepatitis A jabs are recommended for travellers to many parts of the country, and it’s worth ensuring that you are up to date with tetanus, polio and other boosters. Vaccinations for hepatitis B, rabies, meningitis, Japanese encephalitis and TB are only advised if you’re travelling to remote areas or working in environments with an increased exposure to infectious diseases.
Transmitted through contaminated food and water or through saliva, hepatitis A can lay a victim low for several months with exhaustion, fever and diarrhoea. Symptoms include yellowing of the whites of the eyes, general malaise, orange urine (though dehydration could also cause that) and light-coloured stools. If you think you have it, get a diagnosis as soon as possible, steer clear of alcohol, get lots of rest – and try to avoid passing it on. More serious is hepatitis B, transmitted like AIDS through blood or sexual contact.
Typhoid fever is also spread through contaminated food or water, but is rare in most parts of India. It produces a persistent high temperature with malaise, headaches and abdominal pains, followed by diarrhoea.
Cholera, spread the same way as hepatitis A and typhoid, causes sudden attacks of watery diarrhoea with cramps and debilitation. Again, this disease rarely occurs in India, breaking out in isolated epidemics; there is a vaccination but it offers very little protection. Most medical authorities now recommend immunization against meningococcal meningitis (ACWY) too. Spread by airborne bacteria (through coughs and sneezes for example), it is a very unpleasant disease that attacks the lining of the brain and can be fatal.
Rabies is widespread throughout the country, and the best advice is to give dogs and monkeys a wide berth – do not play with animals at all, no matter how cute they might look. If you’re bitten or scratched and it breaks the skin, immediately wash the wound gently with soap or detergent, apply alcohol or iodine if possible, and go straight away, to the nearest hospital for an anti-rabies jab.
For up-to-the-minute information, make an appointment at a travel clinic. These clinics also sell travel accessories, including mosquito nets and first-aid kits.
Medical resources for travellers
International Society for Travel Medicine w istm.org. A full list of clinics worldwide specializing in travel health.
In the UK and Ireland
Hospital for Tropical Diseases Travel Clinic UK t 020 7387 4411, w thehtd.org.
MASTA (Medical Advisory Service for Travellers Abroad) UK t 0870 606 2782, w masta-travel-health.com. Forty clinics across the UK.
Tropical Medical Bureau Republic of Ireland t 1850 487674, w tmb.ie.
In the US and Canada
Canadian Society for International Health Canada w csih.org. Extensive list of travel health centres in Canada.
CDC US t 1 877 394 8747, w cdc.gov. Official US government health site, including travel.
In Australia, New Zealand and South Africa
Netcare Travel Clinics South Africa w travelclinic.co.za. Travel clinics in South Africa.
Travellers’ Medical & Vaccination Centre Australia w tmvc.com.au. Website listing travellers’ medical and vaccination centres throughout Australia, New Zealand and South Africa.
The sun and the heat can cause a few unexpected problems. Before they’ve acclimatized, many people get a bout of prickly heat rash, an infection of the sweat ducts caused by excessive perspiration that doesn’t dry off. A cool shower, zinc oxide powder (sold in India) and loose cotton clothes should help. Dehydration is another possible problem, so make sure you’re drinking enough liquid, and drink rehydration salts frequently, especially when hot and/or tired. The main danger sign is irregular urination (only once a day for instance); dark urine definitely means you should drink more (although it could also indicate hepatitis).
The sun can burn, or even cause sunstroke; a high-factor sun block is vital on exposed skin, especially when you first arrive. A light hat is also a very good idea, especially if you’re doing a lot of walking around in the sun.
Finally, be aware that overheating can cause heatstroke, which is potentially fatal. Signs are a very high body temperature, without a feeling of fever but accompanied by headaches and disorientation. Lowering body temperature (taking a tepid shower for example) and resting in an air-conditioned room is the first step in treatment; also take in plenty of fluids and seek medical advice if the condition doesn’t improve after 24 hours.
Malaria is one of the Subcontinent’s big killers and it’s essential that you check with your doctor whether you’ll need to take anti-malarial medication for your visit. The disease, caused by a parasite carried in the saliva of female Anopheles mosquitoes, can be found in many parts of India, and is especially prevalent in the northeast, although non-existent in the high Himalayan regions (there’s a useful malaria map of the country at w fitfortravel.nhs.uk, showing varying levels of risk across the country). Malaria has a variable incubation period of a few days to several weeks, so you can become ill long after being bitten – which is why it’s important to carry on taking the tablets even after you’ve returned home.
Ideas about appropriate antimalarial medication tend to vary from country to country and prophylaxis remains a controversial subject; it’s important that you get expert medical advice on which treatment is right for you. In addition, resistance to established antimalarial drugs is growing alarmingly – none of the following provides complete protection, so avoiding being bitten in the first place remains important. Chloroquine- and proguanil-resistant strains of malaria are particularly prevalent in Assam and the northeast; travellers to this region might consider taking a course of malarone, doxycycline or mefloquine instead.
The most established regime – widely prescribed in Europe, but not in North America – is a combination of chloroquine (trade names Nivaquin or Avloclor) taken weekly either on its own or in conjunction with a daily dose of proguanil (Paludrine). You need to start this regime a week before arriving in a malarial area and continue it for four weeks after leaving. In India chloroquine is easy to come by but proguanil isn’t, so stock up before you arrive. Mefloquine (Lariam) is a newer and stronger treatment. As a prophylactic, you need take just one tablet weekly, starting two weeks before entering a risk area and continuing for four weeks after leaving. Mefloquine is a very powerful and effective antimalarial, though there have been widely reported concerns about its side effects, including psychological problems.
Doxycycline is often prescribed in Australasia. One tablet is taken daily, starting a day or two before entering a malarial zone and continuing for four weeks after leaving. It’s not suitable for children under ten and it can cause thrush in women, while three percent of users develop a sensitivity to light, causing a rash, so it’s not ideal for beach holidays. It also interferes with the effectiveness of the contraceptive pill. Malarone (a combination of atovaquone and proguanil) is the most recent drug to come on the market. The bonus is that you only have to start taking it two days before you enter a malarial zone and continue for just a week after leaving, meaning that, although it’s expensive, it can prove economical for short trips.
The first signs of malaria are remarkably similar to a severe flu, and may take months to appear: if you suspect anything go to a hospital or clinic for a blood test immediately. The shivering, burning fever and headaches come in waves, usually in the early evening. Malaria is not infectious, but some strains are dangerous and occasionally even fatal when not treated promptly, in particular, the chloroquine-resistant cerebral malaria. This virulent and lethal strain of the disease, which affects the brain, is treatable, but has to be diagnosed early. Erratic body temperature, lack of energy and aches are the first key signs.
Preventing mosquito bites
The best way of combating malaria is, of course, to avoid getting bitten: malarial mosquitoes are active from dusk until dawn and during this time you should use mosquito repellent and take all necessary precautions. Sleep under a mosquito net if possible, burn mosquito coils (widely available in India, but easy to break in transit) or electrically heated repellents such as All Out. An Indian brand of repellent called Odomos is widely available and very effective, though most travellers bring their own from home, usually one containing the noxious but effective compound DEET. DEET can cause rashes and a strength of more than thirty percent is not advised for those with sensitive skin. A natural alternative is citronella or, in the UK, Mosiguard Natural, made from a blend of eucalyptus oils; those with sensitive skin should still use DEET on clothes and nets. Mosquito “buzzers” – plug-in contraptions that smoulder tablets of DEET compounds slowly overnight – are pretty useless, but wrist and ankle bands are as effective as spray and a good alternative for sensitive skin. Though active all night, female Anopheles mosquitoes prefer to bite in the evening, so be especially careful at that time. Wear long sleeves, skirts and trousers, avoid dark colours, which attract mosquitoes, and put repellent on all exposed skin.
Dengue fever and Japanese encephalitis
Another illness spread by mosquito bites is dengue fever, whose symptoms are similar to those of malaria, plus aching bones. There is no vaccine available and the only treatment is complete rest, with drugs to assuage the fever. Japanese encephalitis, a mosquito-borne viral infection causing fever, muscle pains and headaches, is most prevalent in wet, rural rice-growing areas. However, it only rarely affects travellers, and the vaccine isn’t usually recommended unless you plan to spend much time around paddy fields during and immediately after the monsoons.
Diarrhoea is the most common bane of travellers. When mild and not accompanied by other major symptoms, it may just be your stomach reacting to unfamiliar food. Accompanied by cramps and vomiting, it could well be food poisoning. In either case, it will probably pass of its own accord in 24–48 hours without treatment. In the meantime, it is essential to replace the fluids and salts you’re losing, so take lots of water with oral rehydration salts (commonly referred to as ORS, or called Electrolyte in India). If you can’t get ORS, use half a teaspoon of salt and eight of sugar in a litre of water, and if you are too ill to drink, seek medical help immediately. Travel clinics and pharmacies sell double-ended moulded plastic spoons with the exact ratio of sugar to salt.
While you are suffering, it’s a good idea to avoid greasy food, heavy spices, caffeine and most fruit and dairy products. Some say bananas and pawpaws are good, as are kitchri (a simple dhal and rice preparation) and rice soup and coconut water, while curd or a soup made from Marmite or Vegemite (if you happen to have some with you) are forms of protein that can be easily absorbed by your body when you have the runs. Drugs like Lomotil or Imodium simply plug you up – undermining the body’s efforts to rid itself of infection – though they can be useful if you have to travel. If symptoms persist for more than a few days, a course of antibiotics may be necessary; this should be seen as a last resort, following medical advice.
Sordid though it may seem, it’s a good idea to look at what comes out when you go to the toilet. If your diarrhoea contains blood or mucus and if you are suffering other symptoms including rotten-egg belches and farts, the cause may be dysentery or giardia. With a fever, it could well be caused by bacillic dysentery, and may clear up without treatment. If you’re sure you need it, a course of antibiotics such as tetracycline should sort you out, but they also destroy gut flora in your intestines (which help protect you – curd can replenish them to some extent). If you start a course, be sure to finish it, even after the symptoms have gone. Similar symptoms, without fever, indicate amoebic dysentery, which is much more serious, and can damage your gut if untreated. The usual cure is a course of Metronidazole (Flagyl) or Fasigyn, both antibiotics which may themselves make you feel ill, and must not be taken with alcohol. Symptoms of giardia are similar – including frothy stools, nausea and constant fatigue – for which the treatment is again Metronidazole. If you suspect that you have either of these, seek medical help, and only start on the Metronidazole (750mg three times daily for a week for adults) if there is definitely blood in your diarrhoea and it is impossible to see a doctor.
Finally, bear in mind that oral drugs, such as malaria pills and the Pill, are likely to be largely ineffective if taken while suffering from diarrhoea.
Bites and creepy crawlies
Worms may enter your body through skin (especially the soles of your feet) or food. An itchy anus is a common symptom, and you may even see them in your stools. They are easy to treat: if you suspect you have them, get some worming tablets such as Mebendazole (Vermox) from any pharmacy.
Biting insects and similar animals other than mosquitoes may also aggravate you. The obvious suspects are bed bugs – look for signs of squashed ones around beds in cheap hotels. An infested mattress can be left in the hot sun all day to get rid of them, but they often live in the frame or even in walls or floors. Head and body lice can also be a nuisance, but medicated soap and shampoo (preferably brought with you from home) usually see them off. Avoid scratching bites, which can lead to infection. Bites from ticks and lice can spread typhus, characterized by fever, muscle aches, headaches and, later, red eyes and a measles-like rash. If you think you have it, seek treatment (tetracycline is usually prescribed).
Snakes are unlikely to bite unless accidentally disturbed, and most are harmless in any case. To see one at all, you need to search stealthily – walk heavily and they usually oblige by disappearing. If you do get bitten, remember what the snake looked like (kill it if you can), try not to move the affected part, and seek medical help: antivenins are available in most hospitals. A few spiders have poisonous bites too. Remove leeches, which may attach themselves to you in jungle areas, with salt or a lit cigarette: never just pull them off.
At high altitudes, you may develop symptoms of acute mountain sickness (AMS). Just about everyone who ascends to around 4000m or higher experiences mild symptoms, but serious cases are rare. The simple cure – descent – almost always brings immediate recovery.
AMS is caused by the fact that at high elevations there is not only less oxygen, but also lower atmospheric pressure. This can have all sorts of weird effects on the body: it can cause the brain to swell and the lungs to fill with fluid, and even bring on uncontrollable farting. The syndrome varies from one person to the next but symptoms include breathlessness, headaches and dizziness, nausea, difficulty sleeping and appetite loss. More extreme cases may involve disorientation and loss of balance, and the coughing up of pink frothy phlegm.
AMS strikes without regard for fitness – in fact, young people seem to be more susceptible, possibly because they’re more reluctant to admit they feel sick and they dart about more energetically. Most people are capable of acclimatizing to very high altitudes but the process takes time and must be done in stages. The golden rule is not to go too high, too fast; or if you do, spend the night at a lower height (“Climb High, Sleep Low”). Above 3000m, you should not ascend more than 500m per day; take mandatory acclimatization days at 3500m and 4000m – more if you feel unwell – and try to spend these days day-hiking to higher altitudes.
The general symptoms of AMS can be treated with the drug acetazolamide (Diamox) but this is not advised as it will block the early signs of severe AMS, which can be fatal. It is better to stay put for a day or two, eat a high-carbohydrate diet, drink plenty of water (three litres a day is recommended), take paracetamol or aspirin for the headaches, and descend if the AMS persists or worsens. If you fly direct to a high-altitude destination such as Leh, be especially careful to acclimatize (plan for three days of initial rest); you’ll certainly want to avoid doing anything strenuous at first.
Other precautions to take at high altitudes include avoiding alcohol and sleeping pills, drinking more liquid, and protecting your skin against UV solar glare.
HIV and AIDS
HIV/AIDS is as much of a risk in India as anywhere else, despite the government’s reluctance to admit it. As yet only NGOs and foreign agencies such as the WHO have embarked on awareness and prevention campaigns. As elsewhere in the world, high-risk groups include prostitutes and intravenous drug users. It is extremely unwise to contemplate casual sex without a condom – carry some with you (preferably brought from home as Indian ones may be less reliable) and insist upon using them.
Should you need an injection or a transfusion in India, make sure that new, sterile equipment is used; any blood you receive should be from voluntary rather than commercial donor banks. If you have a shave from a barber, make sure he uses a clean blade and don’t undergo processes such as ear-piercing, acupuncture or tattooing unless you can be sure that the equipment is sterile.
Getting medical help
Pharmacies can usually advise on minor medical problems, and most doctors in India speak English. Also, many hotels keep a doctor on call; if you do get ill and need medical assistance, take advice as to the best facilities around. Basic medications are made to Indian Pharmacopoea (IP) standards, and most medicines are available without prescription, but always check the sell-by date. Hospitals have variable standards: private clinics and mission hospitals are often better than state-run ones but may not have the same facilities. Hospitals in big cities, including university or medical-school hospitals, are generally pretty good, and cities such as Delhi, Mumbai and Bengaluru boast state-of-the-art medical facilities but at a price. Many hospitals require patients (even emergency cases) to buy necessities such as medicines, plaster casts and vaccines, and to pay for X-rays, before procedures are carried out. Remember to keep receipts for insurance reimbursements.
However, government hospitals provide all surgical and after-care services free of charge and in most other state medical institutions charges are usually so low that for minor treatment the expense may well be lower than the initial “excess” on your insurance. You will, however, need a companion to stay, or you’ll have to come to an arrangement with one of the hospital cleaners, to help you out in hospital – relatives are expected to wash, feed and generally take care of the patient. Beware of scams by private clinics in tourist towns such as Agra where there have been reports of overcharging and misdiagnosis by doctors to claim insurance money.