India

Destination overview

India is approximately one-third the size of the United States but has 4 times the population—over 1.4 billion people—making it the most populous country in the world. Rich in history, culture, and diversity, India is the birthplace of 4 of the world's religions: Buddhism, Hinduism, Jainism, and Sikhism. India is experiencing rapid urbanization, as noted in the growth of megacities (e.g., Delhi, Mumbai). India's topography is varied, ranging from tropical beaches to deserts, foothills, and the Himalaya Mountains. Northern India has a more temperate climate; the south is more tropical year-round. Many travelers prefer India during the winter (November–March), when temperatures are more agreeable.

Because of India's size, short-term travelers usually select a region of the country to visit for any given trip. Popular tourist destinations in the north include the cities of Agra, Delhi, Varanasi, Ladakh, Rishikesh, and cities in Rajasthan State (e.g., Jaipur [the Pink City], Jaisalmer [desert city], and Udaipur). More southern and western routes might swing through the lakes and lagoons of Kerala, the beaches of Goa, and the cities of Bengaluru (Bangalore) and Mumbai (Bombay). In the east, Kolkata (Calcutta) is considered the cultural capital of the country.

Despite the many and varied itineraries, most health recommendations for travelers to India are similar. The incidence of some illnesses (e.g., those transmitted by mosquitoes) is greater during the monsoon season (June–September), which has high temperatures, heavy rains, and the risk of flooding. Travelers visiting friends and relatives (VFRs) require extra consideration. VFR travelers are at greater risk of many travel-related illnesses because they might stay in rural areas not often visited by tourists or businesspeople, live in private homes, and eat and drink in the homes of their families or friends. Some VFR travelers might not realize that it is necessary to seek pre-travel health advice since they are returning to their land of origin (see Visiting Friends and Relatives: VFR Travel chapter).

Infectious disease risks

All travelers to India should be up to date with routine immunizations. Infants 6–11 months old should get 1 dose of measles-mumps-rubella (MMR) vaccine before travel to India; this dose does not count as part of the routine childhood vaccination series. Vaccination against hepatitis A, hepatitis B, and COVID-19 is recommended for travelers to India; specific guidance varies by age of the traveler (see Hepatitis A and COVID-19 chapters). Additionally, India requires travelers coming from countries reporting cases of polio (endemic or circulating following importation) to show proof of oral polio vaccination; travelers should check with the Ministry of Health to learn if there is a requirement for a dose of polio vaccine prior to entry into India. India also requires proof of yellow fever vaccination for travelers coming from countries with risk of yellow fever (see Yellow Fever Vaccine and Malaria Prevention Information, by Country chapter).

Enteric infections and diseases

Brucellosis

Brucellosis is endemic in livestock systems (e.g., cattle) and imposes high risk to animal handlers and consumers of raw animal products. Symptoms of disease include fever, sweats, joint/muscle pains, or general malaise. Travelers should avoid contact with livestock. There is limited laboratory capacity to test for brucellosis in India.

Cholera

Active cholera transmission has been reported from India in recent years and might be underreported. For current cholera vaccine recommendations for travel to India, refer to the destination page on the Centers for Disease Control and Prevention (CDC) Travelers' Health website (for more information on cholera, see Cholera chapter).

Giardiasis

Giardiasis is a major cause of diarrheal disease and is associated with morbidity in both children and adults in India. Travelers should maintain good hand hygiene, avoid drinking tap or surface water, and exclusively consume boiled, bottled, or filtered water (see Water Disinfection for Travelers chapter).

Hepatitis E

Hepatitis E virus is transmitted through fecally-contaminated water and person-to-person through the fecal-oral route. Highly endemic to India, hepatitis E is a major cause of acute viral hepatitis and acute liver failure. Infection during pregnancy puts women at greater risk of severe disease as well as adverse pregnancy outcomes (e.g., miscarriage, neonatal demise).

Travelers drinking untreated water or going to areas with poor sanitation are at risk of infection. Travelers should maintain good hand hygiene; avoid tap water; drink only boiled, bottled, or filtered water; and eat thoroughly cooked meats (see Food and Water Precautions for Travelers chapter). Travelers immunized against hepatitis A who develop symptomatic hepatitis likely have hepatitis E.

Travelers' diarrhea

Travelers' diarrhea (TD) is acquired through ingestion of contaminated food, water, or beverages, particularly in places where basic hygiene and sanitation infrastructure are poor. Both cooked and uncooked foods are potential vehicles for infection if handled improperly. The risk of TD is high in India; travelers have >60% likelihood of developing TD during a 2-week journey. Consumption of food and beverages obtained from street vendors may increase the risk of illness. In general, fully cooked foods that are served hot and foods that travelers carefully prepare themselves are safest. Discuss self-treatment for diarrheal illness with travelers (see Travelers' Diarrhea and Food and Water Precautions for Travelers chapters).

Typhoid and paratyphoid fever

In the United States, approximately 85% of cases of typhoid fever are in people who traveled to India or other countries in South Asia (see Typhoid and Paratyphoid Fever chapter). Thus, even for short-term travel, typhoid vaccine is recommended. Patients hesitant to be vaccinated might be persuaded by learning that typhoid fever acquired in South Asia is typically multidrug-resistant and, in a growing number of instances, extensively drug-resistant. Remind all travelers to India to also practice good hand hygiene and to follow safe food and water precautions.

Paratyphoid fever, a clinically similar disease caused by Salmonella enterica serotypes Paratyphi A, B, and C, has become increasingly prevalent in South Asia, but typhoid vaccines are not protective against this infection.

Respiratory infections and diseases

Coronavirus disease 2019

All travelers going to India should be up to date with their COVID-19 vaccines.

Histoplasmosis

Histoplasmosis is an uncommon disease in India. A review of case reports from 1994 to 2017, encompassing 144 cases of histoplasmosis, indicated its broad but uneven distribution across the country. The majority of cases were clustered in specific areas of West Bengal and Assam, the Gangetic Plains, and parts of western India, with occasional cases reported from the southern and northern regions of India. In areas where Histoplasma spp. are endemic, occupational and recreational (e.g., bat or birdwatching, cave exploration) activities that disrupt the soil surface can release infectious mold spores into the air. If inhaled, these spores can cause acute pulmonary disease and, more rarely, focal or disseminated extrapulmonary infection.

Influenza

Influenza virus circulation in India is almost year-round because of its sub-tropical location and latitudinal expanse, with the northern part experiencing peak activity after monsoon season (July–November) and a secondary peak during winter (December–February), the southern part having peak activity during monsoon season (November–February), and the rest of India seeing only post-monsoon activity (July–November). The World Health Organization recommends the Southern Hemisphere influenza vaccine for all of India. However, India's national influenza vaccination policy recommends either the Northern or Southern Hemisphere influenza vaccines, and the individual states determine which to use. Short-term travelers (<6 months) to India are recommended to be up to date using the influenza vaccination offered in their home country. For long-term travelers to India, determining the influenza policy of the state they are visiting and obtaining the vaccine in India may be preferred. Even when vaccinated, travelers should continue to observe all necessary behavioral precautions to protect themselves from influenza, including frequent hand washing and respiratory etiquette.

Melioidosis

Cases of melioidosis have been on the rise, although the disease remains largely underreported and undiagnosed due to a lack of diagnostic capacity. The first sign of infection is often pneumonia. Travelers should avoid contact with loose, muddy soil and use potable drinking water.

Tuberculosis

Approximately 25% of all tuberculosis (TB) cases worldwide are reported from India. Travelers planning to work in high-risk settings or in crowded institutions (e.g., homeless shelters, hospitals, medical clinics, prisons) are at risk of exposure. Travelers visiting ill friends, visiting ill relatives, or engaging in congregate activities (e.g., religious gatherings) also can face TB exposure risk.

Discuss the importance of testing before and after travel, and measures that travelers can take to prevent disease. Travelers with anticipated exposure risks should undergo tuberculin skin testing or have an interferon-γ release assay (IGRA) before leaving the United States. If a tuberculin skin test is used, CDC recommends the 2-step method for establishing a baseline. If the pre-departure test results are negative, repeat the same type of test 8–10 weeks after the traveler returns from India.

Use of bacille Calmette-Guérin (BCG) vaccine in healthcare professionals who will have increased risk of exposure during travel has been proposed, although this recommendation remains controversial (see Tuberculosis chapter). U.S. Food and Drug Administration (FDA)-approved BCG formulations are no longer available in the United States.

Sexually transmitted infections and HIV

An estimated 2.4 million people in India live with HIV infection. Although the reported adult HIV prevalence in India is low, prevalence is much greater in specific locations (e.g., in the states of Manipur, Mizoram, Nagaland) and among high-risk populations (e.g., people who inject drugs, men who have sex with men, female sex workers). Condomless sex increases a traveler's risk of HIV and other sexually transmitted infections, including chlamydia, gonorrhea, and syphilis (see Sex and Travel chapter).

The Indian constitution protects the well-being and fundamental rights to life, liberty, and dignity of sex workers. However, Indian law penalizes acts related to prostitution, including running a brothel, soliciting, and trafficking. High-quality condoms and other barrier methods are available for sale in drugstores in India. Homosexuality is not illegal in India.

Skin infections

Superficial dermatophytosis

Superficial dermatophytosis (also known as tinea or ringworm) is one of the most common skin problems affecting returned travelers from any country (see Post-Travel Dermatologic Conditions chapter). For travelers to India, superficial multidrug-resistant dermatophytosis has become a significant issue, largely due to the presence of a widespread fungus, Trichophyton indotineae, that is highly resistant to typical treatments. Indiscriminate use of topical antifungal plus highly potent steroid combination preparations is believed to have contributed to the rise of this fungus. Travelers who develop a rash they think is ringworm should be aware that creams sold widely in drugstores in India can worsen the infection and cause other health problems. Healthcare professionals evaluating returned travelers with a possible infection can receive more guidance from this CDC website.

Soil- and waterborne infections

Helminths

India accounts for 65% of soil-transmitted helminth infections in Southeast Asia and 27% of all cases globally (see Post-Travel Parasitic Disease Including Evaluation of Eosinophilia chapter). Pathogens are found in both urban and rural areas; they include roundworm (Ascaris lumbricoides), hookworm (Ancylostoma duodenale and Necatur americanus), and whipworm (Trichuris trichiura). Symptoms might be non-specific and include abdominal pain, diarrhea (with blood or mucous), fatigue, nausea, vomiting, or weight loss. To reduce the risk of infection, travelers should practice good hand hygiene and safe food and water precautions (see Food and Water Precautions for Travelers chapter) in addition to always wearing shoes outdoors.

Leptospirosis

Leptospirosis (see Leptospirosis chapter) is endemic in India, with regular outbreaks being reported across many states. Travelers should be advised to limit exposure to freshwater, particularly after heavy rainfall or flooding, and drink only potable water. Diagnostic capacity in India is limited, and the disease is often misdiagnosed because its symptoms are similar to that of malaria, dengue, hepatitis, and other bacterial and viral diseases that are also endemic.

Vector-borne diseases

Chikungunya, dengue, and Zika

During the last several years, India has experienced outbreaks of chikungunya, transmitted by infected Aedes species (Aedes aegypti or Aedes albopictus) mosquitoes. Chikungunya symptoms are similar to those of dengue and malaria but often with severe and persistent arthralgia. A vaccine is now available for adults (see Chikungunya chapter).

Dengue is transmitted by infected Aedes species (Ae. aegypti or Ae. albopictus) mosquitoes and is endemic in most parts of India (see Dengue chapter). Large outbreaks can occur, including in many urban areas. Incidence is greatest during the wet summer season, which includes the monsoon season (June–September). Aedes mosquitoes bite both indoors and outdoors. Travelers to India should take measures to protect themselves from mosquito bites (see Mosquitoes, Ticks, and Other Arthropods chapter).

Zika is a risk in India (see Zika chapter). Because of the possibility for birth defects in infants born to mothers infected with Zika during pregnancy, women who are pregnant or trying to become pregnant should review the most recent Zika travel recommendations.

Japanese encephalitis

Japanese encephalitis (JE) virus is present throughout most of the country (see Japanese Encephalitis chapter). The most affected states are Andhra Pradesh, Assam, Bihar, Haryana, Karnataka, Kerala, Maharashtra, Manipur, Odisha, Tamil Nadu, Uttar Pradesh, and West Bengal. JE cases in India often follow a seasonal pattern, with increased transmission during the monsoon and post-monsoon periods when mosquito populations are high. The peak season is May–November, especially in northern India. The transmission season can be extended or year-round in some areas, especially in southern India. The JE virus is transmitted to humans who live and work in rural areas (typically around rice paddies and irrigation systems), primarily by Culex mosquitoes that feed on infected birds, pigs, and other mammals. Symptoms include diarrhea, fever, severe headache, vomiting, general weakness, and neurological symptoms. Vaccination is recommended for people traveling extensively in rural areas, long-term travelers, and people assigned to work in endemic areas.

Leishmaniasis (kala-azar)

Visceral leishmaniasis, transmitted by sand flies (Phlebotomus argentipes), presents with acute fever and splenomegaly (see Leishmaniasis chapter). Travelers to India should take measures to protect themselves from both day- and night-biting sand flies (see Mosquitoes, Ticks, and Other Arthropods chapter).

Lymphatic filariasis

Lymphatic filariasis (LF) is transmitted by several mosquito vectors that bite during day, evening, and night, including Aedes, Anopheles, and Culex mosquito species. LF presents with lymphedema and elephantiasis many years after the infection; in men, LF can present with hydrocele (swelling of the scrotum). In most instances, short-term travelers are at low risk because multiple bites over time are necessary for infection. Long-term travelers and expatriates are at greater risk.

Malaria

Malaria remains a public health problem in India. Both Plasmodium vivax and chloroquine-resistant Plasmodium falciparum are found throughout India, including the cities of Mumbai and New Delhi. Most cases (average of >10,000 per year between 2019 to mid-2023) occur in 7 states: Chhattisgarh, Jharkhand, Maharashtra, Odisha, Tripura, Uttar Pradesh, and West Bengal. Malaria-transmitting mosquitoes bite primarily between dusk and dawn. For recommended prophylaxis and mosquito-bite precautions, see Yellow Fever Vaccine and Malaria Prevention Information, by Country; Mosquitoes, Ticks, and Other Arthropods; and Malaria chapters.

Rickettsial diseases

Rickettsial infections, including outbreaks, are present across India; scrub typhus is the most common (see Rickettsial Diseases chapter). Infection is seasonal (after the rainy season), more prevalent in rural areas, and often presents with non-specific signs and symptoms. Counsel travelers to protect exposed skin with insect repellents and to wear long-sleeved shirts and pants when visiting potential vector (e.g., louse, flea, tick, mite)-infested areas, especially areas with forest and vegetation (see Mosquitoes, Ticks, and Other Arthropods chapter). Counsel travelers to seek prompt medical care for acute fever onset, rash, or eschar (i.e., tan, brown, or black tissue) around an insect bite.

Yellow fever

India has no risk of yellow fever, and CDC has no recommendations for travelers to receive yellow fever vaccine before going to India. The Government of India, however, has strict and carefully defined country entry requirements for proof of vaccination against yellow fever from travelers ≥9 months old (infants <9 months old exempted) arriving from areas with risk of yellow fever virus transmission (for details, see Yellow Fever Vaccine and Malaria Prevention Information, by Country chapter).

Environmental hazards and risks

Air quality

Air pollution is a major public health problem across India, and travelers might encounter high-level exposures to various pollutants in urban, peri-urban, and rural settings. All travelers to India should be aware of local air pollution concerns and any advisories in effect on a day-to-day basis (see Air Quality and Ionizing Radiation During Travel chapter). Vulnerable groups (e.g., children, older people) and people with preexisting health conditions (e.g., asthma, chronic lung disease, coronary artery disease) are particularly at risk of adverse outcomes. When air quality is poor or expected to deteriorate, travelers should avoid outdoor activities and follow local health guidance from the Government of India, Ministry of Environment and Forests, Central Pollution Control Board, and the U.S. Embassy and U.S. Consulates in India. Air quality data are available at IQAIR.

Altitude illness and acute mountain sickness

Popular tourist destinations in India include the high-elevation Himalayas. Inform travelers visiting these areas about the early symptoms of altitude illness and acute mountain sickness, to not ascend to higher elevations when experiencing symptoms, and to descend if symptoms become worse while resting at the same elevation (see High-Altitude Travel and Altitude Illness chapter). Travelers with certain underlying medical problems can be at increased risk of adverse events associated with travel to high elevations and should consult a physician familiar with this topic prior to departure.

Animal bites and rabies

India has the highest burden of rabies in the world; rabid dogs are common (see Rabies chapter). Travelers bitten or scratched by a dog or other mammal in India might have limited access to post-exposure rabies treatment; rabies immune globulin is generally unavailable in India. Encourage travelers to consider purchasing a medical evacuation insurance policy that will cover travel to receive recommended rabies post-exposure prophylaxis (see Travel Insurance, Travel Health Insurance, and Medical Evacuation Insurance chapter). Discuss pre-exposure rabies vaccination with travelers who have high exposure risk, including adventure travelers, campers, cave explorers, children, expatriates, long-term travelers, people for whom there is an occupational exposure risk (e.g., veterinarians, wildlife biologists), and people visiting rural areas.

Animal bites and wounds can transmit diseases other than rabies (see Zoonotic Exposures: Bites, Scratches, and Other Hazards chapter). Cellulitis, fasciitis, and wound infections can result from the scratch or bite of any animal. Potentially fatal to humans, B virus is carried by macaques. These Old World monkeys inhabit many of the temples in India, scatter themselves in many tourist gathering places, and are kept as pets. Macaques can be aggressive and often seek food from people. When visiting temples, travelers should not carry any food in their bags, hands, or pockets. Emphasize to travelers that they should not approach or attempt to handle monkeys or other animals. If bitten, travelers should seek immediate medical care.

Travelers, particularly those going to rural areas, should be aware of the risk of snake bites and should take precautions to wear solid shoes or boots and use a flashlight when walking outside at night. Be aware that prompt access to safe and effective antivenoms may be limited.

Climate and sun exposure

Sun exposure and heat-related illnesses are concerns for travelers in India, particularly during summer months and at high elevations (see Sun Exposure in Travelers and Heat and Cold Illness in Travelers chapters). Travelers should eat and drink regularly, wear loose and lightweight clothing, and limit physical activity at times when temperatures are high.

Natural disasters

Natural disasters, including cyclones, droughts, earthquakes, floods, and landslides, are not uncommon in India. Travelers should become aware of the natural disaster risks at their destination. Encourage U.S. citizens and nationals traveling and living in India to enroll in the U.S. Department of State's Smart Traveler Enrollment Program to receive information on safety conditions and to help the U.S. Embassy in India contact them in an emergency, including during natural disasters.

Safety and security

Crime

Crime does occur in India but rarely is it directed toward foreign travelers; verbal and sometimes physical harassment of female foreign travelers is a concerning exception. Although most victims of harassment are locals, attacks in tourist areas highlight the fact that visitors to India are also at risk and should exercise vigilance and situational awareness. Petty crimes (e.g., pickpocketing, purse snatching) are very common when using public transportation, while out walking, and in heavily populated tourist areas.

Mass gatherings

Drawing tens of millions of people, Kumbh Mela is the largest mass gathering event in the world. Celebrated according to the Hindu calendar, Kumbh Mela occurs 4 times over an approximately 12-year cycle. During each observance of this normally 4-month-long festival, pilgrims ritually bathe in 1 of 4 sacred rivers in India. Mass casualty trauma (e.g., crush injuries, stampedes) and transmission of antimicrobial-resistant organisms and enteric and respiratory pathogens are among the more serious risks to health and safety associated with attendance (see Mass Gatherings chapter).

Political and religious unrest

Demonstrations and general strikes often cause inconvenience. Religious violence occurs occasionally. Travelers should obey curfews and travel restrictions and avoid demonstrations and rallies because of the potential for violence.

Terrorism

India continues to experience terrorist and insurgent activities that can affect U.S. citizens directly or indirectly. Terror attacks have targeted public places (e.g., cinemas, hotels, markets, mosques, restaurants in large urban areas, trains, and train stations), including some places frequented by tourists. Although an attack can occur at any time, they generally take place during the busy evening hours in markets and other crowded places. Travelers should pay attention to U.S. Department of State advisories regarding issues that arise at some borders, religious tensions, or terrorist activities. In times of instability, travelers should seek guidance from the U.S. Embassy or Consulates in India for appropriate action (see Safety and Security Overseas chapter).

Traffic-related injuries

India's roadways are some of the most hazardous in the world and have large numbers of traffic-related deaths, including among pedestrians (see Injury and Death During Travel chapter). Animals, bicycles, overcrowded buses, motor scooters, pedestrians, rickshaws, and trucks all compete for space on streets and roads, increasing the risk of crashes. Travelers should fasten seat belts when riding in cars and wear helmets when riding bicycles or motorbikes. Advise travelers to avoid boarding overcrowded buses and not to travel by bus into the interior of the country or on curving, mountainous roads. Discourage nighttime driving (long-distance travel in particular), even with a hired, paid driver.

Availability and quality of medical care

Strongly encourage travelers to invest in travel health insurance, including medical evacuation insurance (see Travel Insurance, Travel Health Insurance, and Medical Evacuation Insurance chapter). India ranks highly in international quality standards at major private hospitals that employ the bulk of the country's doctors, but the healthcare system is not highly regulated, with the quality of healthcare services varying by provider and location.

Travelers needing medical care while traveling can consult the U.S. Embassy in India website for a list of hospitals and doctors, speak to a hotel concierge, or consult with the National Accreditation Board for Hospitals & Healthcare Providers, Constituent Board of the Quality Council of India. Most major hospitals in large cities accept payment by major credit cards; hospitals and doctors in smaller cities might only accept cash (see What to Do When Sick Abroad chapter).

Medical tourism

Well-trained, English-speaking healthcare professionals and low cost for high-quality treatment make India a healthcare destination for a mix of alternative (ayurveda, homeopathy, yoga), conventional (cosmetic, surgical), and wellness medicine (see Medical Tourism chapter).