Abstract
SummaryBackgroundTens of thousands of people die from dog-mediated rabies annually. Deaths can be prevented through post-exposure prophylaxis for people who have been bitten, and the disease eliminated through dog vaccination. Current post-exposure prophylaxis use saves many lives, but availability remains poor in many rabies-endemic countries due to high costs, poor access, and supply.MethodsWe developed epidemiological and economic models to investigate the effect of an investment in post-exposure prophylaxis by Gavi, the Vaccine Alliance. We modelled post-exposure prophylaxis use according to the status quo, with improved access using WHO-recommended intradermal vaccination, with and without rabies immunoglobulin, and with and without dog vaccination. We took the health provider perspective, including only direct costs.FindingsWe predict more than 1 million deaths will occur in the 67 rabies-endemic countries considered from 2020 to 2035, under the status quo. Current post-exposure prophylaxis use prevents approximately 56 000 deaths annually. Expanded access to, and free provision of, post-exposure prophylaxis would prevent an additional 489 000 deaths between 2020 and 2035. Under this switch to efficient intradermal post-exposure prophylaxis regimens, total projected vaccine needs remain similar (about 73 million vials) yet 17·4 million more people are vaccinated, making this an extremely cost-effective method, with costs of US$635 per death averted and $33 per disability-adjusted life-years averted. Scaling up dog vaccination programmes could eliminate dog-mediated rabies over this time period; improved post-exposure prophylaxis access remains cost-effective under this scenario, especially in combination with patient risk assessments to reduce unnecessary post-exposure prophylaxis use.InterpretationInvesting in post-exposure vaccines would be an extremely cost-effective intervention that could substantially reduce disease burden and catalyse dog vaccination efforts to eliminate dog-mediated rabies.FundingWorld Health Organization.
Highlights
Post-exposure prophylaxis prevents the fatal onset of rabies, which causes an estimated 60 000 human deaths each year, mostly in Africa and Asia and among children.[1,2] Domestic dogs are responsible for 99% of human cases.[3]
Mass dog vaccination is required for elimination of dog-mediated rabies, the disease burden could be substantially reduced through improved access to post-exposure prophylaxis
Our analyses suggest that investments should prioritise vaccines for post-exposure prophylaxis rather than rabies immunoglobulin, which is costly and has more marginal health benefits
Summary
Post-exposure prophylaxis prevents the fatal onset of rabies, which causes an estimated 60 000 human deaths each year, mostly in Africa and Asia and among children.[1,2] Domestic dogs are responsible for 99% of human cases.[3] mass dog vaccination is required for elimination of dog-mediated rabies, the disease burden could be substantially reduced through improved access to post-exposure prophylaxis. Intradermal multisite vaccination regimens have been developed, which are more economical than intra-muscular administration because they use reduced vaccine volumes.[4] While the use of post-exposure prophylaxis at current levels saves many lives,[2] access to post-exposure prophylaxis is poor in many parts of the world, rural areas where most rabies exposures occur. Even if people who have been bitten get to a treatment centre and post-exposure prophylaxis is available, its cost is often unaffordable
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