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

Should pretravel rabies vaccination be made compulsory for all travelers to India?
Dr KK Aggarwal,  08 January 2019
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.

New test to detect future risk of type 2 diabetes: One-hour glucose >155 after 75 g OGTT means prediabetes
Dr KK Aggarwal,  08 January 2019
Easy, saves time, cost effective, can be done in GP office 

The one-hour glucose level during an oral glucose-tolerance test (OGTT) improves the early prediction of type 2 diabetes, according to results from the Botnia Prospective Study.

In the study, 1-hour plasma glucose (PG) alone was almost as good as most other multivariate models, especially the combination of HbA1c and 1-hour PG, in predicting type 2 diabetes

One-hour plasma glucose showed the best predictive performance for type 2 diabetes, with 75% sensitivity, 68% specificity and 75% accuracy (by AUC), followed by the 30-min plasma glucose, with 62% sensitivity, 71% specificity and 71% accuracy. Both measures were more accurate than fasting plasma glucose or two-hour plasma glucose.These results are reported online Nov. 15, 2018 in the Journal of Clinical Endocrinology and Metabolism.OGTT is a test commonly employed to screen for and diagnose type 2 diabetes and also to detect persons with prediabetes. It is an important risk factor for future type 2 diabetes. So, it is important to diagnose prediabetes early and also intervene early

to prevent progression to type 2 diabetes.

Conventionally, the results at 2 hours are taken into consideration when determining the risk status of an individual, as has been recommended in guidelines. As per American Diabetes Association (ADA) 2019 Standards of medical care for diabetes, patients with prediabetes are defined by the presence of IFG and/or IGT and/or A1C 5.7–6.4%. IFG is defined as FPG levels between 100 and 125 mg/dL and IGT as 2-h PG during 75-g OGTT levels between 140 and 199 mg/dL).

But, this new study has shown that individuals with 1-hour blood glucose level >155 mg/dL have a very high risk of developing type 2 diabetes and should be subjected to adequate life-style intervention and follow-up.

According to International Diabetes Federation (IDF) Diabetes Atlas (7th Edition), India is second only to China in terms of the number of people with diabetes. China had the largest number of diabetes (11.43 cr.) in 2017, while the corresponding number was 7.29 cr. in India.

Identification of people at risk of type 2 diabetes at an even earlier time than what is routinely followed is the need of the hour to check the rising burden of type 2 diabetes in India.

An article in the December 2018 issue of Diabetes Research and Clinical Practice has strongly advocated redefining current diagnostic criteria for prediabetes with the elevated 1-h blood glucose level (Diabetes Res Clin Pract. 2018 Dec;146:18-33). It states: “The 1-hour postload blood glucose  ≥ 155 mg/dl in those with normal glucose tolerance (NGT) during OGTT is highly predictive for detecting progression to type 2 diabetes,  micro- and macrovascular complications and mortality in individuals at increased risk.”

The STOP DIABETES Study also showed that progression to type 2 diabetes in people at high risk of diabetes – those with NGT and a 1-h PG ≥ 155 mg/dl (8·6 mmol/L) – can be reduced by effective interventions (Lancet Diabetes Endocrinol. 2018 Oct;6(10):781-9).

What these studies tell us is that shortening the standard 75-g OGTT to one hour improves the predictive value as well as clinical utility, especially in patients in whom the A1c, fasting blood sugar and the 2-hour OGTT are normal.