Foreign visitors to India are unaware of rabies riskBMJ 2005; 331 doi: https://doi.org/10.1136/bmj.331.7511.255 (Published 28 July 2005) Cite this as: BMJ 2005;331:255
Foreigners visiting India need to be sensitised to the persistence of rabies as a serious public health problem in India, doctors said last week. A British woman died last Saturday of rabies contracted during a trip to Goa earlier this year.
The 39 year old woman from Bury, Greater Manchester, had been bitten by a dog in Goa and became unwell after her return to the United Kingdom. She was diagnosed with rabies and had treatment at the Walton Centre for Neurology in Liverpool.
“There are clear guidelines from the World Health Organization that European and North American travellers to the Indian subcontinent take pre-exposure vaccinations against rabies,” said Shampur Madhusudana, a virologist at the Indian National Institute of Mental Health and Neurosciences.
“Unfortunately, most foreigners visiting India remain oblivious to the risk of rabies even after they've come into contact with animals,” said Mysore Sudarshan, the head of community medicine at the Kempegowda Institute of Medical Sciences in Bangalore.
A community survey by the Association for the Prevention and Control of Rabies, which covers 21 towns across India, two years ago showed that 20 000 people in the country die from rabies each year out of eight million who are bitten by dogs.
India's efforts to eliminate stray dogs received a setback four years ago when animal rights activists influenced the government to pass the Animal Birth Control Rules, which prohibit municipal authorities from killing stray animals.
“Animal officers pick up stray dogs, sterilise them, give them one vaccination, and put them back on streets. There is no mechanism for follow-up and dogs remain a source of infection,” said Mysore Sudarshan, founding president of the association.
He said that people seeking visas to visit India should be advised about the risk of rabies without creating alarm. “Visitors who're likely to stay several weeks and expect to come into contact with street animals need pre-exposure vaccinations,” Dr Sudarshan said.
The UK's National Travel Health Network estimates that, since 1902, there have been 24 deaths from imported classical rabies reported in the UK. All but two resulted from dog bites, and two thirds of patients had been exposed to rabies in the Indian subcontinent.
Last year, German epidemiologists reported that a 51 year old man from Bavaria contracted rabies six weeks after returning from a five month stay in India, during which he had contact with stray dogs and had been bitten once by a monkey.
The man developed hydrophobia, pharyngeal spasms, and respiratory failure and died 20 days after the symptoms emerged. Investigators could not determine whether the exposure was due to the monkey bite or through contact with the saliva of infected dogs.
The updated 2005 version of the UK Department of Health's guidance on immunisation advises pre-exposure vaccine for travellers to endemic areas if away for more than a month or shorter time if they will have ‘limited access to post-exposure medical care’.
Dr Mary Warrell of the Oxford Vaccine Group, University of Oxford, said: “If you are going to India at all you should have pre-exposure treatment as post exposure treatment is never 100 per cent successful. There is always a possibility of a delay in treatment, or failure to find the right treatment. If you are just going to a big city then maybe there is not a big risk, but if you are going to the countryside I would recommend it.”
The Leeds-based private travel clinic, the Medical Advisory Service for Travellers Abroad (MASTA), only recommends pre-exposure vaccination for people likely to be more than 24 hours away from medical treatment, people working with animals, or people on a long visit to India.
“We have never said everyone should have pre-exposure vaccine,” said Linda Bramham, senior nurse advisor. “But it is important travellers know they have to seek advice immediately if they are bitten or scratched.”
She added that it was not yet clear whether the woman who died had received post exposure vaccine when she was in India.
An individual who is licked by a potentially rabid animal may also be at risk if they have any skin wound at that point, said Dr Warrell.
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