The challenge to provide affordable rabies post-exposure treatment

Abstract

Treatment with Semple or suckling mouse brain rabies vaccines persists in many countries of Asia, Africa and South America. Its replacement depends on the immediate accessibility of effective affordable alternative treatment with tissue culture vaccines (TCVs). The use of the expensive European TCVs has been possible in Asia by means of economical intradermal (ID) post-exposure vaccine regimens. Implementation of this effective economical treatment has been delayed by the complexity and inconvenience of the regimens, and the reluctance to change prophylaxis against a fatal disease. Up to now, the ID regimens have been used only where passive immunisation with rabies immune globulin (RIG) is usually available. Rabies deaths despite optimal vaccine treatment have been attributed to lack of RIG. The ID regimens might soon be promoted in areas where RIG is not even available for severe exposure. It is therefore vital that economical vaccine regimens should be used which induce protective immunity rapidly. Improvements in rabies PET in developing countries could be made by: (i) publicising the urgency and efficacy of wound cleaning; (ii) facilitating the replacement of nervous tissue vaccines by economical ID treatment with TCVs; (iii) using an ID regimen with a large dose of vaccine on the first day of treatment especially when no RIG is available; and (iv) promoting pre-exposure prophylaxis to eliminate the need for RIG and provide better rabies prophylaxis.