Vaccination for safe travel to India

Abstract

Worldwide more than 900 million international journeys are undertaken every year. India is one of the favorite tourist destinations around the world. International travel exposes travelers to a range of health risks. Traveling to India possess a threat to travelers with waterborne diseases like bacterial diarrhea, hepatitis A and E, and typhoid fever; vector borne diseases like dengue fever, Japanese encephalitis, and malaria; animal contact disease like rabies. Furthermore diseases spreading through behavior aspects cannot be ruled out hence posing a risk for hepatitis B, HIV/AIDS, hepatitis C as well. Hence, before travel the travelers are advised about the risk of disease in the country or countries they plan to visit and the steps to be taken to prevent illness. Vaccination offers the possibility of avoiding a number of infectious diseases that may be countered abroad. There is no single vaccination schedule that fits all travelers. Each schedule must be individualized according to the traveler’s previous immunizations, countries to be visited, type and duration of travel, and the amount of time available before departure.

Introduction

Tourism has been recognized as a potent engine for socio-economic development of any nation. Because of its inter-sectorial linkages it possesses the potential to stimulate other economic factors as well. In this rapidly shrinking world, International travel has risen from 25 million international tourists in 1950 to 1.035 million international tourists in 2012 and an estimated increase to 1.8 billion tourists in 2030.¹

Worldwide more than 900 million international journeys are undertaken every year. India is one of the favorite tourist destinations around the world. In comparison to the previous year, there has been substantial growth in foreign tourist arrivals which rose from 6.31 million to 6.65 million accounting to 5.4% and Foreign Exchange Earnings which rose from US $77 591 to US $94 487 crore accounting to 21.8% during the year 2012.²

International travel exposes travelers to a range of health risks. Many of these risks can be minimized by precautions taken before, during and after travel. Hence, before travel the travelers are advised about the risk of disease in the country or countries they plan to visit and the steps to be taken to prevent illness.³

Vaccination offers the possibility of avoiding a number of infectious diseases that may be countered abroad. However, satisfactory vaccines have not yet been developed against several of the most life-threatening infections, including tuberculosis, malaria, dengue and HIV/AIDS. There is no single vaccination schedule that fits all travelers. Each schedule must be individualized according to the traveler’s previous immunizations, countries to be visited, type and duration of travel, and the amount of time available before departure.³

Following vaccination, the immune response of the vaccinated individual varies with the type of vaccine, the number of doses required, and whether the individual has been vaccinated previously against the same disease. For this reason, travelers are advised to consult a travel medicine practitioner or physician 4–8 wk before departure in order to allow sufficient time for optimal immunization schedules to be completed.³

Traveling to India possess a threat to travelers with waterborne diseases like bacterial diarrhea, hepatitis A and E, and typhoid fever; vector borne diseases like dengue fever, Japanese encephalitis, and malaria; animal contact disease like rabies.⁴ Further more diseases spreading through behavior aspects cannot be ruled out hence posing a risk for hepatitis B, HIV/AIDS, hepatitis C as well.

Vaccine Recommendations for Travelers

Numerous international, national, and professional organizations publish guidelines and recommendations that assist travel health providers in giving the best possible advice to prospective travelers. Some of the reasons why guidelines differ include availability of products in different countries, a different cultural perception of risk, lack of evidence (or differing interpretations of the same evidence), and sometimes just honest differences in opinion among experts.⁵

Vaccines Recommended for India Travel⁶

The vaccination recommended for India travel includes yellow fever, hepatitis A, hepatitis B, tetanus-diphtheria, poliomyelitis, measles, mumps, rubella, influenza, pneumococcal, typhoid fever, and some other selective vaccines like cholera, Japanese encephalitis, and rabies (Table 1).

Table 1. The vaccination recommended for India travel.

Vaccine	Recommendations
Yellow fever	There is no risk of yellow fever in India. A vaccination certificate is required only from travelers coming from a country with risk of yellow fever transmission. The vaccination requirement is imposed by this country for protection against the introduction of yellow fever since the vector Aëdes aegypti is present in its territory. A yellow fever certificate is valid for 10 y beginning 10 d after vaccination. The following countries have risk of Yellow Fever transmission: AFRICA – Angola, Benin, Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Republic of the Congo, Côte d’Ivoire, Democratic Republic of the Congo, Equatorial Guinea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Kenya, Liberia, Mali, Mauritania, Niger, Nigeria, Rwanda, Senegal, Sierra Leone, South Sudan, Sudan, Togo, Uganda. AMERICAS—Argentina, Bolivia, Brazil, Colombia, Ecuador, French Guiana, Guyana, Panama, Paraguay, Peru, Suriname, Trinidad and Tobago, Venezuela. A vaccination certificate is required for children over nine months of age. A vaccination certificate is required for travelers coming from, or in transit through, a country with yellow fever transmission 6 d prior to arrival. India does not require a vaccination certificate from Argentina, Mauritania, and Paraguay
Hepatitis A	All travelers should be vaccinated against this viral infection occurring worldwide which is transmitted through contaminated water and food or by the fecal-oral route. Vaccination is recommended for all travelers over one year of age. An anti-HAV antibody test is advised for persons born before 1945 or those born in developing countries to determine immunity. This vaccine is often combined with hepatitis B and provides long-term protection for both viral diseases.
Hepatitis B	Vaccination is now given routinely as a childhood vaccination. The virus is transmitted through infected blood products, sexual intercourse or infected items such as needles or razor blades. Due to high rate hepatitis B carriers in this country, vaccination is recommended for persons on working assignments in the health care field (dentists, physicians, nurses, laboratory technicians) or for those working in close contact with the local population (teachers, aid workers, missionaries), or persons foreseeing sexual relations with locals.
Tetanus-Diphtheria	A single injection booster (tetanus-diphtheria toxoids, adult type) is recommended every 10 y for all adult travelers and children over 7 y of age, regardless of destination. A primary series is required for those not previously vaccinated.
Poliomyelitis	A primary vaccination series is necessary for those not previously or only partially vaccinated. Adults who have been fully vaccinated as children should receive a polio booster once only. If travelers have not received a polio booster as adults, vaccination is recommended for countries where polio is not yet eradicated: Afghanistan, Nigeria, and Pakistan. Some countries in Africa, the Middle East and Central Asia are susceptible to re-introduction of polio.
Measles	Vaccination is not required for persons born before 1957 since they are considered to be immune as a result of previous illness or having had a clinically asymptomatic infection when the virus circulated freely before the vaccine was introduced. Persons immunized before 1980 should receive a booster before traveling. Unvaccinated adolescents and young adults should also be immunized since outbreaks typically occur on university campuses and other congregational places.
Mumps	Vaccination is indicated for adolescents and children approaching puberty. Adults born before 1957 can be considered immune as a result of previous illness or clinically in apparent infections acquired when the virus was widely circulating among the population before availability of the vaccine. Unvaccinated adults should get the vaccine before traveling.
Rubella	Vaccination is recommended for women of childbearing age who are not immune (after blood testing for rubella antibodies) provided they are not pregnant. Women who are vaccinated under these conditions should be advised not to become pregnant for the 30 d following vaccination.
Influenza	Vaccination is recommended for all travelers over 6 mo of age, especially for children, pregnant women, persons over 65, and those with chronic health conditions such as asthma, diabetes, lung disease, heart disease, immune-suppressive disorders, and organ transplant recipients. In the northern hemisphere the flu season typically runs from November to April and from April to October in the southern hemisphere. If the flu vaccine is not available at the time of departure, contact your doctor or travel health clinic regarding influenza anti-viral protection.
Pneumococcal	A one-time only vaccination is recommended for persons over 65 or persons with chronic health conditions such as heart disease, emphysema, asthma, renal disorders, and organ transplant recipients, or person with immuno-suppressive disorders. Pneumonia, ear infections, or meningitis can be more severe for these travelers.
Cholera	The risk of infection to travelers is low and vaccination is advised only for medical and rescue personnel working in endemic areas. The best protection is to avoid potentially contaminated water and food. Meticulous food and water hygiene are essential when traveling in endemic areas. Persons living and working in inadequate sanitary conditions and those with impaired defense mechanisms (deficient production of gastric acid due to surgery for duodenal or gastric ulcers), persons on antacid therapy, and users of cannabis (smoking marijuana reduces acid secretion of the stomach) are more susceptible to cholera infection. The World Health Organization announced in 1991 that cholera vaccination certificates are no longer required by any country or territory.
Japanese encephalitis	Risk is present throughout India except in Dadra and Nagar Haveli, Daman and Diu, Gujarat, Himachal Pradesh, Jammu and Kashmir, Lakshadweep, Meghalaya, Punjab, Rajasthan, and Sikkim. In northern India transmission occurs from May to October, and generally all year in southern India.
Rabies	Rabies is a constant threat; the pre-exposure rabies vaccination (3 shots) is advised for persons undertaking outdoor activities such as camping, hiking, eco-tourism, and cave exploring or on outdoor working assignments such as veterinarians and wildlife researchers. Although this provides adequate initial protection, a person bitten by a potentially rabid animal will require 2 additional post-exposure inoculations. Any animal bite or scratch must be washed repeatedly with copious amounts of soap and water. Seek medical attention immediately.

Conclusion

Travel is a good opportunity for the health care provider to review the immunization status of infants, children, adolescents and adults. Unimmunized or incompletely immunized travelers should be offered vaccination as recommended. A health care provider or travel medicine clinic should be consulted 2 to 3 mo in advance of travel in order to allow sufficient time for optimal immunization schedules to be completed. Vaccination offers the possibility of avoiding a number of infectious diseases that may be countered abroad. But it is important to remember that all health problems faced by international travelers are not preventable by vaccines. It is also important to remember that immunization is not a substitute for safe practices, careful selection and handling of food and water.

10.4161/hv.27234

Disclosure of Potential Conflicts of Interest

No potential conflicts of interest were disclosed.