Evaluation of cost-effective strategies for rabies post-exposure vaccination in low-income countries

<b>Background:</b> Prompt post-exposure prophylaxis (PEP) is essential in preventing the fatal onset of disease in persons exposed to rabies. Unfortunately, life-saving rabies vaccines and biologicals are often neither accessible nor affordable, particularly to the poorest sectors of society who are most at risk and upon whom the largest burden of rabies falls. Increasing accessibility, reducing costs and preventing delays in delivery of PEP should therefore be prioritized.<p></p> <b>Methodology/Principal Findings:</b> We analyzed different PEP vaccination regimens and evaluated their relative costs and benefits to bite victims and healthcare providers. We found PEP vaccination to be an extremely cost-effective intervention (from $200 to less than$60/death averted). Switching from intramuscular (IM) administration of PEP to equally efficacious intradermal (ID) regimens was shown to result in significant savings in the volume of vaccine required to treat the same number of patients, which could mitigate vaccine shortages, and would dramatically reduce the costs of implementing PEP. We present financing mechanisms that would make PEP more affordable and accessible, could help subsidize the cost for those most in need, and could even support new and existing rabies control and prevention programs.<p></p> <b>Conclusions/Significance:</b> We conclude that a universal switch to ID delivery would improve the affordability and accessibility of PEP for bite victims, leading to a likely reduction in human rabies deaths, as well as being economical for healthcare providers.<p></p&gt

Rabies

International audienceRabies is a zoonotic disease caused by viruses of the Lyssavirus genus (in the family Rhabdoviridae of the order Mononegavirales) that was first described in the 4th century BC 1. Rabies virus (RABV), the proto type virus of the Lyssavirus genus (TABLE 1), is by far the most common causative agent of rabies 2 and is most readily transmitted by the bite of an infected mammal (FIG. 1). Dogtransmitted rabies causes >99% of the human cases reported. Both animal and human rabies are entirely preventable through vaccination, and the first efficacious rabies vaccines for human use were developed in the 19th century. However, in the 21st century, the virus is still enzootic (that is, endemic in animals) in many regions of the world, and human rabies remains one of the most serious and distressing diseases and an important threat to public health 3. Indeed, when an individual with rabies develops symptoms, the disease is nearly always fatal 4. Rabies is often considered a disease of poverty, ignorance and, in some circumstances, misinformation 5. RABV enters peripheral nerves at the synapse level at the site of the bite and is transported to neurons in the central nervous system (CNS); the virus then replicates and causes cerebral damage. Rabies can manifest in two classical forms (furious and paralytic) with a range of symptoms, but ultimately leads to coma and death. The priority for reducing the burden of human rabies is con trolling dog rabies, especially in freeroaming commu nity dogs 6-9. Rabies elimination was achieved in domesti