Vaccinations and health precautions for Sri Lanka - what do I actually need and what is overblown?

I work with travellers arriving in the hill country and I've seen this first-hand. Let me give you what's actually practical.

Malaria: the risk in Sri Lanka has been very low since 2012 when it was declared malaria-free. Some travel clinics still recommend antimalarials for certain regions (northern and eastern provinces) but for standard tourist routes including Colombo, Kandy, Ella, Galle, and the cultural triangle - the risk is negligible. Most travellers skip antimalarials entirely for Sri Lanka now and this is generally considered acceptable. Check your specific country's travel health guidelines as they vary.

Vaccinations most doctors agree are worth having for Sri Lanka:
- Hepatitis A (food and water-borne, real risk)
- Typhoid (especially if eating from street stalls, which you should)
- Tetanus booster if not up to date
- Routine vaccinations (MMR, polio) - make sure these are current

Vaccinations that are more situational:
- Hepatitis B (if you might need medical care or are staying long)
- Rabies (if spending a lot of time outdoors in rural areas, near monkeys or dogs)
- Japanese Encephalitis (rural areas, rice-growing regions, mostly long stays)

Water: don't drink tap water. Bottled water is everywhere and cheap (LKR 60-100 for 1.5L). In good guesthouses and restaurants the water served is filtered. Ice in tourist areas is usually safe. In very local roadside places I'd avoid ice.

Stomach issues: expect at least one rough day, especially in the first week. This is normal exposure to unfamiliar gut bacteria rather than food poisoning. Eat at busy places, avoid pre-cooked food sitting under glass for hours, start with plain rice and curry before moving to more adventurous things. Carry rehydration sachets and basic antidiarrhoeal tablets.

Mosquitoes: real but manageable. Dengue is the main concern, not malaria. Use repellent with DEET in the evenings, especially near standing water. Long sleeves at dusk helps. This is more important in coastal lowland areas than in the hill country.