Cost comparison of rabies pre-exposure vaccination with post-exposure treatment in Thai children.

Thailand is a canine rabies endemic country with an annual prevalence above 1,000 reported animals diagnosed rabid . Over 345,000 humans are treated for possible rabies exposures annually . Lack of perception of the disease burden, social, cultural and traditional beliefs play an important role in the failure of canine rabies control. It is unfortunate that health care budgets are increasingly allocated to human post-exposure treatment rather than to the eradication of rabies in the canine animal vector. Children under the age of 15 years represent up to one-half of dog bite victims and of human rabies deaths, but accurate data of dog bite prevalence are not available . Large scale pre-exposure immunization of children has been advocated but financial and logistic barriers have hindered implementation. This study analyzes direct medical costs of pre-exposure vaccination (PREP) as a human rabies preventive strategy, against the cost of post-exposure prophylaxis (PEP) in Thai children. Three pre- and post-exposure vaccine regimens are in use and this impacts on cost calculations. It was found that costs of both strategies, PREP of children or PEP of exposed, become equal when the dog bite incidence is 2-30%; depending on which post-exposure treatment regimens (PEP) are used.

Rabies intradermal post-exposure vaccination of humans using reconstituted and stored vaccine.

Thailand's northern Petchabun province is endemic for canine rabies. There were 27 reported human rabies deaths between 1989 and 1998. A rabies control plan was formulated in 1997 between medical and veterinary public health officials. It started an intense education program and an ongoing dog vaccination campaign. Economic constraints and the high cost of biological were the main reasons for inadequate human post-exposure management (PET). It was therefore decided to use the economical Thai Red Cross Intradermal Vaccine Regimen (TRC-ID) throughout the province. The original TRC-ID method is only suitable for clinics that see more than one PET patient daily. TRC-ID was therefore modified by storing the reconstituted vaccine in a refrigerator for the same patient's next two visits. Data on a total of 8157 PET patients were collected. An additional modification of TRC-ID also eliminated the 90 day booster. There were no treatment failures and no human rabies deaths in 1999, 2000 and 2001. The modified TRC-ID method induces adequate levels of neutralizing antibodies, protects humans bitten by rabid dogs and results in significant savings in vaccine and travel costs.

Postexposure treatment of rabies infection: can it be done without immunoglobulin?

The last remaining international manufacturer of equine rabies immunoglobulin (ERIG) discontinued production in 2001. However, ERIG remains an essential biological that has no substitute other than human rabies immunoglobulin (HRIG), which is in short supply and virtually unaffordable in developing countries. Physicians in regions where canine rabies is endemic and neither ERIG nor HRIG is available are providing less-than-optimal treatment to patients exposed to rabies. If no immunoglobulin is available, they have only 1 therapy option: use of a vaccine schedule that produces the highest and, hopefully, earliest neutralizing antibody response. However, treatment failures must still be expected. Early, aggressive wound cleansing and more intensive efforts at canine control and are ever more important. Countries that have the resources to manufacture their own rabies immunoglobulins must be encouraged to do so.

Use of rabies vaccines after reconstitution and storage.

Storing freshly reconstituted purified chick embryo rabies vaccine at 4 degrees C for 1 week allowed use of <1 ampoule of 1.0 mL for 1 patient for day 0, 3, and 7 immunizations, representing considerable savings in vaccine and also possibly allowing use of this cost-saving regimen in centers that see <1 rabies-exposed patient daily. The 90-day booster dose mandated in the current intradermal regimen may not be necessary if the day 28 dose is doubled, eliminating 1 clinic visit at no additional cost in vaccine.