Indian Subcontinent

3.9  Indian Subcontinent

(Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, Sri Lanka)

3.9.1  Disease Risks

Food and water-borne diseases including cholera and other watery diarrhoeas, the dysenteries, typhoid fever, giardia and helminth infections. Hepatitis A very common. Large outbreaks of hepatitis E can occur.

Malaria present in all countries, except virtually eradicated from the Maldives.

Other arthropod-borne diseases endemic (see Chapter 7):

•   Filariasis - common in Bangladesh, India and SW coastal belt of Sri Lanka

   

•   Sandfly fever - increasing.

   

•   Visceral leishmaniasis - sharp increase in Bangladesh, India and Nepal; also present in north Pakistan (Baltistan).

   

•   Cutaneous leishmaniasis - India (Rajasthan) and Pakistan.

   

•   Dengue - epidemics in Bangladesh, India (haemorrhagic in East), Pakistan and Sri Lanka (also haemorrhagic form).

   

•   Japanese encephalitis occurs in much of the subcontinent. The risk is highest during and just after the rainy season.

   

•   Plague - some natural foci in the area.

   

•   Tick-borne and louse-borne relapsing fever and scrub typhus reported from India.

Diseases of close association:

•   Polio eradication activities are as yet incomplete. Polio should still be assumed to be a risk to travellers.

   

•   Meningococcal meningitis - outbreaks have occurred in Nepal.

   

•   Tuberculosis incidence high.

   

•   Trachoma in India, Nepal and Pakistan.

Sexually transmitted and blood-borne infections:

Hepatitis B of intermediate prevalence; HIV becoming more widespread.

Other hazards could include:

•   Snakes.

   

•   Rabies.

3.9.2  Recommendations for immunisations and malaria chemoprophylaxis (see later chapters for general health precautions)
 

3.9.3  Country by country variations and malaria chemoprophylaxis:

Bangladesh

Yellow fever - any person (including infants) who arrives by air or sea without a yellow fever certificate is detained in isolation for a period of up to six days if arriving within six days of departure from an infected area or having been in transit in such an area, or having come by an aircraft that has been in an infected area and has not been disinsected in accordance with the procedure and formulation laid down in Schedule VI of the Bangladesh Aircraft (Public Health) Rules 1977 (First Amendment) or those recommended by WHO.

The following countries and areas are regarded as infected:

•   Africa: Angola, Benin, Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Congo, Democratic Republic of Congo, Equatorial Guinea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Ivory Coast, Kenya, Liberia, Malawi, Mali, Mauritania, Niger, Nigeria, Rwanda, Sao Tome and Principe, Senegal, Sierra Leone, Somalia, Sudan (south of 15ºN), Tanzania, Togo, Uganda, Zambia.

   

•   America: Belize, Bolivia, Brazil, Colombia, Costa Rica, Ecuador, French Guiana, Guatemala, Guyana, Honduras, Nicaragua, Panama, Peru, Surinam, Trinidad and Tobago, Venezuela.

Note: when a case of yellow fever is reported from any country, that country is regarded by the Government of Bangladesh as infected with yellow fever and is added to the above list.

Japanese encephalitis probably widespread but few data are available.

Malaria risk throughout the year in the whole country excluding Dhaka city. Risk highest along the northern and eastern borders and in the South East (Chittagong Hill Tracts). P.falciparum highly resistant to chloroquine reported in the south-east and resistant to sulphadoxine-pyrimethamine reported from these latter areas.

Recommended prophylaxis: chloroquine plus proguanil; mefloquine (or doxycycline or atovaquone/proguanil) is appropriate for anyone visiting forested areas in the south east (including the Chittagong Hill Tracts).

Bhutan

Yellow fever vaccination certificate required from travellers coming from infected areas.

Meningococcal A&C vaccine recommended for all visits longer than a few days.

Japanese encephalitis may occur in the south, but few data are available.

Malaria risk throughout the year in the southern belt of five districts: Chirang, Gaylegphug, Samchi, Samdrupjongkhar and Shemgang. P.falciparum resistant to chloroquine and sulphadoxine-pyrimethamine reported.

Recommended prophylaxis: for risk areas in the southern districts, chloroquine plus proguanil.

India

Yellow fever - anyone (except infants up to the age of six months) arriving by air or sea without a yellow fever certificate is detained in isolation for up to six days if that person

• (i)   arrives within six days of departure from an infected area, or

  (ii)   has been in such an area in transit (excepting those passengers and members of crew who, while in transit through an airport situated in an infected area, remained within the airport premises during their entire stay and the Health Officer agrees to such exemption), or

  (iii) has come on a ship that started from or touched at any port in a yellow fever infected area up to 30 days before its arrival in India, unless such a ship has been disinsected in accordance with the procedure laid down by WHO, or

  (iv) has come by an aircraft which has been in an infected area and has not been disinsected in accordance with the provisions laid down in the Indian Aircraft Public Health Rules, 1954, or those recommended by WHO.

The following countries and areas are regarded as infected:

•   Africa: Angola, Benin, Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Congo, Democratic Republic of Congo, Equatorial Guinea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Ivory Coast, Kenya, Liberia, Mali, Niger, Nigeria, Rwanda, Sao Tome and Principe, Senegal, Sierra Leone, Somalia, Sudan, Tanzania, Togo, Uganda, Zambia.

   

•   America: Bolivia, Brazil, Colombia, Ecuador, French Guiana, Guyana, Panama, Peru, Surinam, Trinidad and Tobago, Venezuela.

Note: when a case of yellow fever is reported from any country, that country is regarded by the Government of India as infected with yellow fever and is added to the above list.

Japanese encephalitis risk highest in central and north east India in the summer and autumn and in parts of the rural south all year round (see recommendations for all countries above).

Malaria risk throughout the year in the whole country below 2,000m. Urban transmission occurs. No transmission in certain parts of the states of Himachal Pradesh, Jammu and Kashmir, and Sikkim. Predominantly P.vivax, but P.falciparum is also important and mixed infections often occur. Highly chloroquine resistant P.falciparum reported.

Recommended prophylaxis: chloroquine plus proguanil except in mountain areas.

Maldives

Yellow fever vaccination certificate required from travellers coming from infected areas.

Malaria prophylaxis: none - malaria eradicated.

Nepal

Yellow fever vaccination certificate required from travellers coming from infected areas.

Meningococcal A&C vaccine recommended for all visits longer than a few days.

Japanese encephalitis occurs in the lowlands only, usually July-December (see recommendations for all countries).

Malaria risk, predominantly P.vivax, throughout the year in rural areas of the Terai districts (incl. forested hills and forest areas) of Dhanukha, Mahotari, Sarlahi, Rautahat, Bara, Parsa, Rupendehi, Kapilvastu, and especially along the Indian border. These are the lowland and foothill areas towards the southern border of the country and include the Chitwan National Park. No risk in Kathmandu. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: in risk areas, chloroquine plus proguanil.

Pakistan

Yellow fever vaccination certificate required from travellers coming from any part of a country in which yellow fever is endemic; infants under six months of age are exempt if the mother's vaccination certificate shows that she was vaccinated before the birth of the child. The countries and areas included in the endemic zones are considered as infected areas.

Japanese encephalitis may occur in the central area and outside Karachi, but few data available.

Malaria risk throughout the year in the whole country below 2,000m. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: chloroquine plus proguanil.

Sri Lanka

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas.

Japanese encephalitis can occur in lowland areas, especially northern and central provinces, usually October-January, but possibly also May-June (see 3.9.2).

Malaria risk, predominantly P.vivax, throughout the year in the whole country excluding the districts of Colombo, Kalutara and Nuwara Eliya. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: chloroquine plus proguanil. None in Colombo and districts listed.