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:
3.9.2 Recommendations
for
immunisations
and
malaria
chemoprophylaxis
(see
later
chapters
for
general
health
precautions)
FOR
ALL
COUNTRIES
Check
routine
immunisations
including
tetanus.
Immunisation
against
poliomyelitis,
hepatitis
A
and
typhoid.
For
longer
term
travellers,
check
BCG
status,
and
consider
immunisation
against
diphtheria,
hepatitis
B
and
rabies.
For
rural
travel,
usually
for
more
than
one
month,
particularly
during
and
just
after
the
rainy
seasons,
consider
immunisation
against
Japanese
encephalitis
(see
individual
countries
for
risk).
The
vaccine
is
not
necessary
for
the
majority
of
travellers
to
the
Indian
subcontinent.
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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.
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