Recommended vaccines for international travelers to India

Abstract

India's tourism industry generated 6.6% of the nation's Gross Domestic Product (GDP) during 2012. International travel to India is predicted to grow at an average annual rate of ∼8% over the next decade. The number of foreign tourists has increased by 9% to 5.8 million. Approximately 8% of travelers to developing countries require medical care during or after travel; the main diagnoses are vaccine-preventable diseases. Travelers to India can be exposed to various infectious diseases; water-borne, water-related, and zoonotic diseases may be imported to India where the disease is not endemic. The World Health Organization (WHO) emphasizes that all international travelers should be up to date with routine vaccinations. The recommended vaccinations for travelers to India vary according to the traveler's age, immunization history, existing medical conditions, duration, legal requirements for entry into countries being visited, travelers preferences, and values. Travelers should consult with a doctor so that there is sufficient time for completion of optimal vaccination schedules. No matter where traveling, one should be aware of potential exposure to certain organisms that can cause severely illnesses, even death. There is no doubt that vaccines have reduced or virtually eliminated many diseases that killed or severely disabled children and adults just a few generations ago. Thus, travelers must take recommended vaccines per schedule before traveling to India.

Keywords:

• traveler
• disease
• immunizations
• disability
• vaccines

International travel to India has grown dramatically over the last decade, which supports the economically important and rapidly growing tourism industry. The World Travel and Tourism Council reported that Indian tourism generated 6.6% of the nation's GDP during 2012. International travel to India is predicted to grow at an average annual rate of ∼8% for 2013–23,¹ which gives India the third rank among countries with the fastest growing tourism industries.²

India's large medical tourism sector is expected to grow at an annual rate of ∼30% to reach ∼95 billion Rupee by 2015. According to provisional statistics, India received 6.3 million tourists in 2011, an increase of 9% from 2010, thus ranking as the 38th country in terms of foreign tourist arrivals. Domestic tourist visits to all states and Union Territories numbered 1036 billion in 2012, an increase of 17% from 2011.³

Approximately 8% of travelers to developing countries require medical care during or after travel, with the main diagnoses being vaccine-preventable diseases.⁴ Travelers to India can be exposed to infectious diseases including water-borne diseases (diarrhea, enteric fever, acute viral hepatitis), water-related diseases (malaria, dengue, Japanese encephalitis), zoonotic diseases (rabies), and imported non-endemic diseases (yellow fever). Importation of vaccine-preventable diseases has been recognized as an important travel-related problem. Vaccination for travelers can be life-saving and is a cornerstone of health protection during travel.

The WHO emphasizes that all international travelers should be up to date with routine vaccinations, which vary according to the traveler's age, immunization history; existing medical conditions, duration, legal requirements for entry into countries being visited, travelers own preferences, and values. Travelers should consult with physicians at least 4–6 wk prior to travel in India so that there is sufficient time for completion of optimal vaccination schedules.

WHO Recommends These Vaccinations for Travelers to India (As Well as Being Up to Date with Measles, Mumps, and Rubella Vaccinations)

Adult diphtheria and tetanus vaccine

Single booster recommended if none in the previous 10 y. Side effects include mild pain at injection site and fever.

Hepatitis A vaccine

Efficacy is almost 100% for up to 1 y; a booster after 12 mo provides at least another 20 y of protection. Mild side effects such as headache and sore arm occur in 5–10% of people.⁵

Hepatitis B vaccine

Now considered routine for most travelers. This vaccine given at 0, 3, and at 6 mo. A rapid schedule is also available as a combined vaccination with Hepatitis A. Side effects are uncommon and mild, usually headache and mild pain at the injection site. Efficacy of is ∼95%.⁶

Oral polio vaccine (OPV)

From January 2014, this vaccine is a mandated requirement for all travelers visiting India from Afghanistan, Ethiopia, Israel, Kenya, Nigeria, Pakistan, and Somalia to receive OPV at least 6 wk before departure for India. OPV is valid for 1 y from the date of its administration. This country list goes beyond the 3 WHO-designated endemic countries. Any adult who received the recommended childhood immunizations but never received a booster as an adult should be given a single dose of inactivated polio vaccine. All children should be up-to-date in their polio vaccinations, and any adult who never completed the initial series of vaccinations should do so before departure.⁷

Typhoid vaccine

Typhoid fever is a life-threatening illness. Typhoid vaccine is recommended for all travelers to India, even if visiting only urban areas. This single-shot vaccine offers ∼70% protection, lasts for 2–3 y. Tablets also are available for administration to an empty stomach in 3 doses is on alternate days. However, injection is usually recommended in that is has fewer side effects. The injectable vaccine is preferable to oral vaccine in pregnant and immuno-compromised travelers.⁸

Varicella vaccine

This vaccine recommended for any international traveler over 1 y of age who does not have either a history of documented chickenpox or a blood test showing immunity. Many people who believe they never had chickenpox show immunity when tested and do not need the vaccine. Varicella vaccine should not be given to pregnant or immuno-compromised individuals. The varicella vaccine is also recommended for long-term travelers (more than 1 mo) or those at special risk.⁹

Japanese encephalitis vaccine

This vaccine is recommended for long-term (>1 mo) travelers to rural areas or travelers who may engage in extensive unprotected outdoor activities in rural areas, especially in the evening, during shorter trips. For age >16, the recommended vaccine is Cell Culture Derived Live SA-14–14–2 Vaccine given as 0.5 mL subcutaneously for all ages, followed by a second dose 28 d later. The series should be completed at least 1 wk before travel. The most common side effects are headaches, muscle aches, and pain and tenderness at the injection site. Safety has not been established in pregnant women, nursing mothers, or children age <17.^10-12

Meningococcal vaccine

This vaccine is given as a single injection. The quadrivalent vaccine gives 2–3 y protection.^10,11

Rabies vaccine

Rabies is a deadly viral infection. The disease is rare in travelers, but risk increases with extended travel and any likelihood of animal contact. The vaccine is recommended for travelers spending a lot of time outdoors, travelers at high risk for animal bites (veterinarians and animal handlers), long-term travelers and expatriates, and travelers involved in any activities that might bring them into direct contact with animals. Children are considered at higher risk because they tend to play with animals, may receive more severe bites, or may not report bites. Dog bites account for most cases of rabies in India, while bites from cats, tigers, camels, and the Indian civet also may transmit rabies. Any animal bite or scratch should be thoroughly cleaned with large amounts of soap and water, and local health authorities should be contacted immediately for possible post-exposure treatment whether or not the person has been immunized against rabies. A complete pre-exposure series consists of 3 doses injected into the deltoid muscle on days 0, 7, and 21 or 28. Side-effects may include pain at the injection site, headache, nausea, abdominal pain, muscle aches, dizziness, or allergic reactions.¹³

Yellow fever (YF) vaccine

Many countries require an ‘international certificate of vaccination or prophylaxis’ signed by a medical provider for YF vaccine for travelers from an infected area. Indian health regulations may ask for evidence of YF vaccination if one is arriving from Africa or South America or other YF areas. Proof of vaccination will be required only if one has visited a country in the YF zone within 6 d prior to entering India. Any person (except infants up to the age of 6 mo) arriving without a certificate within 6 d of departure from or transit through an infected area, or arriving on a ship that started from or touched at any port in an area with risk of YF transmission up to 30 d before its arrival in India, unless such a ship has been disinfected in accordance with the procedure recommended by WHO, will be isolated for up to 6 d. YF vaccine must be administered at an approved YF vaccination center, which will give each vaccinee a fully validated International Certificate of Vaccination. YF vaccine should not be given to those younger than 9 mo, pregnant, immuno-compromised, or allergic to eggs. It also should not be given to those with a history of thymus disease or thymectomy. Vaccine is not recommended or required for travelers arriving directly from North America, Europe, Australia, or other Asian countries.⁹

No matter where traveling, one should know that exposure to certain microorganisms can result in severe illness, even death. There is no doubt that vaccines have reduced or virtually eliminated many diseases that killed or severely disabled children and adults just a few generations ago. Thus, travelers must take recommended vaccines per schedule before travel to India.

Disclosure of Potential Conflicts of Interest

No potential conflicts of interest were disclosed.