Should pretravel rabies vaccination be made compulsory for all travelers to India?

The Jan. 4, 2019 issue of CDC’s Morbidity and Mortality Weekly Report (MMWR) reported the case of a US citizen, who was bitten by a puppy while traveling in India in 2017 during a Yoga camp. The patient did not seek rabies medical treatment (postexposure prophylaxis), although she cleaned the wound. Upon his return to the US, the patient developed rabies and died during hospitalization despite aggressive treatment. A total of 250 health care workers were assessed for exposure to the patient, 72 of whom were advised to initiate postexposure prophylaxis (PEP). The patient had no record of a pretravel health screening, did not receive rabies preexposure vaccination before the trip, nor had she ever been vaccinated against rabies.

This case highlights the importance of pretravel preparation, including medical guidance, for international travelers.

India is a favorite travel destination not only for tourists, it is also growing in popularity as a hub for medical tourism. Also, many people come to India to learn yoga and meditate. Often, these purposes necessitate long stay in the country.

India is endemic for rabies accounting for 36% of the world’s human rabies deaths with 18,000-20,000 rabies deaths occurring every year. About 30-60% of reported rabies cases and deaths in India occur in children under the age of 15 years as bites that occur in children often go unrecognized and unreported. Majority of human rabies cases are due to dog bites (SEARO).

CDC guideline for rabies vaccination for travelers recommends pre-exposure rabies vaccination (3 doses given on days 0, 7 and 21 or 28) before travel, especially for those who will be involved in outdoor activities (such as camping, hiking, biking, adventure travel, caving) or those who come for yoga retreats and so are likely to stay longer in the country. But, if bitten or scratched by an animal, prompt post-exposure prophylaxis should be sought, even if pre-exposure vaccination has been taken.

Despite these guidelines, most people do not take pretravel consultation, including for recommended vaccinations, particularly when visiting countries with high incidence of emerging or zoonotic pathogens.

Rabies is a 100% preventable disease, but is almost always fatal once symptoms appear.

Pretravel rabies vaccination should be a valid option for all international travelers, especially those traveling rabies endemic countries and are likely to stay for long durations in the said country with outdoor activities.

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