The potential effect of improved provision of rabies post-exposure prophylaxis in Gavi-eligible countries: a modelling study

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.

Behavioral and structural barriers to accessing human post-exposure prophylaxis and other preventive practices in Arequipa, Peru, during a canine rabies epidemic

“…Those who do initiate PEP swiftly often do not complete it [12,13]. In other countries, various factors contributed to limited or delayed treatment seeking, including the lack of perceived need for immediate treatment after exposure [14], preference for traditional medicine, giving priority to earning a livelihood over seeking care [15], limited supply at health facilities [16] and increasingly, vaccine hesitancy [17,18]. Some people reported that rabies vaccine injections were painful and difficult to tolerate [19]; parents reported desperation when they see their children in pain because of a vaccine [17].…”

Quantifying the risk of rabies in biting dogs in Haiti

“…Global elimination of dog-mediated human rabies deaths is likely to require improved access and adherence to human rabies vaccines. Increasing access to human rabies vaccine is thought to be much more feasible on a global scale under the context of an IBCM-strategy [20]. This study has shown that IBCM can be successful enacted in a resource limited setting and has the potential to significantly reduce human rabies vaccine costs; costs that will ideally be re-allocated to dog vaccination activities to achieve permanent canine rabies elimination.…”

“…Globally, tens of thousands of people die each year from rabies virus infection due to lack of appropriate post-exposure prophylaxis after a bite from a rabid dog. Increased access to PEP has been proposed as one means of reducing human rabies deaths, particularly when used in combination with mass dog vaccination strategies 20 . However, given that dog bites are a relatively common event in many countries, and the cause of dog bites is rarely because the animal is rabid, unfettered use of rabies PEP in the absence of a risk-based approach may lead to very high program costs and frequent supply shortages 10 .…”

Cost Savings of Using Updated Thai Red Cross Intradermal Regimen in a High-Throughput Anti-Rabies Clinic in New Delhi, India

“…Progressively switching over to cost-effective WHO-recommended intradermal PEP regimens, improving PEP availability and accessibility, scaled-up mass canine vaccination, and heightened public awareness of rabies PEP are suggested as central policies for eliminating human deaths from dog-mediated rabies [10,12,13]. Economic gains made by healthcare providers via the reduction of procurement costs is a major driver for policy makers for implementing effective policies [10,13].…”

“…On the basis of new clinical evidence and public health needs, WHO recently recommended the dose-sparing abridged one-week intradermal regimen for rabies PEP [11,12]. A study utilizing epidemiological and economic models projected that a switchover to the dose-sparing abridged one-week intradermal regimen along with Gavi (The Vaccine Alliance) investment for improving PEP accessibility and free provision would cost-effectively reduce the disease burden without much change in the vaccine requirement [13]. However, the dose-sparing abridged one-week intradermal regimen is yet to be approved by the DCGI for routine use in India.…”