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Vaccine. 2018 Dec 7. pii: S0264-410X(18)31519-6. doi: 10.1016/j.vaccine.2018.11.010. [Epub ahead of print]

Modelling to inform prophylaxis regimens to prevent human rabies.

Author information

1
Institute of Biodiversity, Animal Health & Comparative Medicine, University of Glasgow, Glasgow G12 8QQ, UK. Electronic address: katie.hampson@glasgow.ac.uk.
2
Department of the Control of Neglected Tropical Diseases, 1121 Geneva 27, Switzerland. Electronic address: abelab@who.int.
3
State Institute of Health and Family Welfare, Himachal Pradesh, India. Electronic address: bhartiomesh@yahoo.com.
4
Department of the Control of Neglected Tropical Diseases, 1121 Geneva 27, Switzerland. Electronic address: knopfl@who.int.
5
Swiss Tropical & Public Health Institute, PO Box, 4002 Basel, Switzerland, University of Basel, Petersplatz 1, 4003 Basel, Switzerland. Electronic address: Monique.lechenne@swissph.ch.
6
Centre de Support en Sante International (CSSI), N'Djamena, Chad. Electronic address: mrola2002@yahoo.fr.
7
Epidemiology & Public Health Unit, Institut Pasteur du Cambodge, Phnom Penh, Cambodia. Electronic address: atarantola@pasteur.nc.
8
Swiss Tropical & Public Health Institute, PO Box, 4002 Basel, Switzerland, University of Basel, Petersplatz 1, 4003 Basel, Switzerland. Electronic address: jakob.zinsstag@unibas.ch.
9
Disease Dynamics Unit, Department of Veterinary Medicine, University of Cambridge, Madingley Road, Cambridge CB3 0ES, UK. Electronic address: clt56@cam.ac.uk.

Abstract

BACKGROUND:

The Strategic Advisory Group of Experts (SAGE) Working Group on rabies vaccines and immunoglobulins was established in 2016 to develop practical and feasible recommendations for prevention of human rabies. To support the SAGE agenda we developed models to compare the relative costs and potential benefits of rabies prevention strategies.

METHODS:

We examined Post-Exposure Prophylaxis (PEP) regimens, protocols for administration of Rabies Immunoglobulin (RIG) and inclusion of rabies Pre-Exposure Prophylaxis (PrEP) within the Expanded Programme on Immunization (EPI). For different PEP regimens, clinic throughputs and consumables for vaccine administration, we evaluated the cost per patient treated, costs to patients and potential to treat more patients given limited vaccine availability.

RESULTS:

We found that intradermal (ID) vaccination reduces the volume of vaccine used in all settings, is less costly and has potential to mitigate vaccine shortages. Specifically, the abridged 1-week 2-site ID regimen was the most cost-effective PEP regimen, even in settings with low numbers of bite patients presenting to clinics. We found advantages of administering RIG to the wound(s) only, using considerably less product than when the remaining dose is injected intramuscularly distant to the wound(s). We found that PrEP as part of the EPI programme would be substantially more expensive than use of PEP and dog vaccination in prevention of human rabies.

CONCLUSIONS:

These modeling insights inform WHO recommendations for use of human rabies vaccines and biologicals. Specifically, the 1-week 2-site ID regimen is recommended as it is less costly and treats many more patients when vaccine is in short supply. If available, RIG should be administered at the wound only. PrEP is highly unlikely to be an efficient use of resources and should therefore only be considered in extreme circumstances, where the incidence of rabies exposures is extremely high.

KEYWORDS:

Dose-sparing; Expanded program on immunization; Intradermal; Intramuscular; Post-exposure prophylaxis; Pre-exposure prophylaxis; Rabies immunoglobulin; Regimen

PMID:
30528846
DOI:
10.1016/j.vaccine.2018.11.010
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