Improving the provision of rabies post-exposure prophylaxis
Authors: Simon Cauchemez, Hervé Bourhy
Journal: The Lancet Infectious Diseases (2018)

In 2015, WHO and its partners set the ambitious objective1WHOGlobal framework for the elimination of dog-mediated human rabies.http://www.who.int/rabies/control/Poster_Global_framework_for_the_elimination_of_dog-mediated_human_rabies.pdfDate accessed: October 26, 2018Google Scholar to reach zero human deaths from dog-mediated rabies by 2030, after the concept of effective One Health interventions.2Cleaveland S Sharp J Abela-Ridder B et al.One Health contributions towards more effective and equitable approaches to health in low- and middle-income countries.Philos Trans R Soc Lond B Biol Sci. 2017; 372: 20160168Crossref PubMed Scopus (78) Google Scholar Mass dog vaccination is expected to be an important part of any successful strategy.3Abela-Ridder B Knopf L Martin S Taylor L Torres G De Balogh K 2016: the beginning of the end of rabies?.Lancet Glob Health. 2016; 4: e780-e781Summary Full Text Full Text PDF PubMed Scopus (43) Google Scholar, 4Zinsstag J Lechenne M Laager M et al.Vaccination of dogs in an African city interrupts rabies transmission and reduces human exposure.Sci Transl Med. 2017; 9: eaaf6984Crossref PubMed Scopus (58) Google Scholar In The Lancet Infectious Diseases, the WHO Rabies Modelling Consortium5WHO Rabies Modelling ConsortiumThe potential impact of provision of rabies postexposure prophylaxis in Gavi-eligible countries: a modelling study.Lancet Infect Dis. 2018; (published online Nov 21.)http://dx.doi.org/10.1016/S1473-3099(18)30512-7Google Scholar reminds us that effective and timely post-exposure prophylaxis, administered to humans bitten by rabid dogs to prevent the fatal onset of rabies, is another essential tool for success.5WHO Rabies Modelling ConsortiumThe potential impact of provision of rabies postexposure prophylaxis in Gavi-eligible countries: a modelling study.Lancet Infect Dis. 2018; (published online Nov 21.)http://dx.doi.org/10.1016/S1473-3099(18)30512-7Google Scholar Through the analysis of a wide range of data collected in multiple countries and the use of multilayer mathematical models, the authors show that increased investment in post-exposure prophylaxis by Gavi, the Vaccine Alliance, would be extremely cost-effective and could substantially reduce disease burden. The study is particularly timely because Gavi is currently reconsidering rabies vaccine investment. Preparation of such assessment required the Consortium5WHO Rabies Modelling ConsortiumThe potential impact of provision of rabies postexposure prophylaxis in Gavi-eligible countries: a modelling study.Lancet Infect Dis. 2018; (published online Nov 21.)http://dx.doi.org/10.1016/S1473-3099(18)30512-7Google Scholar to overcome several major challenges. First, any assessment of post-exposure prophylaxis needs to account for a very diverse set of factors.6Hampson K Cleaveland S Briggs D Evaluation of cost-effective strategies for rabies post-exposure vaccination in low-income countries.PLoS Negl Trop Dis. 2011; 5: e982Crossref PubMed Scopus (91) Google Scholar For example, it must be based on a good understanding of dog populations, how they are structured, how they interact with humans, how they can be affected by the spread of rabies, and how that spread might be mitigated by dog vaccination.7Lembo T Hampson K Kaare MT et al.The feasibility of canine rabies elimination in Africa: dispelling doubts with data.PLoS Negl Trop Dis. 2010; 4: e626Crossref PubMed Scopus (249) Google Scholar Furthermore, the likelihood that a bitten person will seek, obtain access to, and complete post-exposure prophylaxis treatment depends on cultural, economic, geographical, and logistical factors (eg, awareness in the population, accessibility to post-exposure prophylaxis centres, direct and indirect costs, effective stockpiling, and delivery of vaccines). Several of these factors have historically been poorly characterised and might exhibit strong spatial heterogeneities. A major strength of the analysis5WHO Rabies Modelling ConsortiumThe potential impact of provision of rabies postexposure prophylaxis in Gavi-eligible countries: a modelling study.Lancet Infect Dis. 2018; (published online Nov 21.)http://dx.doi.org/10.1016/S1473-3099(18)30512-7Google Scholar is that it benefited from tremendous efforts by Gavi to reduce some of these knowledge gaps by supporting rabies field studies. Consequently, the diversity of data the authors used to build their assessment is quite impressive, both in terms of data type and geographical coverage. A second achievement of the paper is that the authors developed a multidisciplinary modelling framework in which these data could be integrated in a coherent way, making it possible to generate rabies incidence dynamics in dogs and the associated human exposures under various epidemiological scenarios, while also capturing economic, behavioural, and logistical aspects.5WHO Rabies Modelling ConsortiumThe potential impact of provision of rabies postexposure prophylaxis in Gavi-eligible countries: a modelling study.Lancet Infect Dis. 2018; (published online Nov 21.)http://dx.doi.org/10.1016/S1473-3099(18)30512-7Google Scholar The new data and modelling framework therefore constitute an important improvement to past studies; future iterations of the work are likely to lead to additional refinements. Of course, still too many countries have little or no data available, and more field studies targeting these places are needed. Some aspects of the assessment could also be improved further. For example, in some circumstances, free provision alone might be insufficient to increase health-care seeking and accessibility. Indeed, the lack of infrastructure might make it impossible for exposed populations (especially those living in rural remote areas) to travel to clinics and access post-exposure prophylaxis,8Tarantola A Blanchi S Cappelle J et al.Rabies postexposure prophylaxis non-completion after dog bites: estimating the unseen to meet the needs of the underserved.Am J Epidemiol. 2018; 187: 306-315Crossref PubMed Scopus (19) Google Scholar even if vaccines are freely available. To this regard, further investments are needed to improve the accessibility to post-exposure prophylaxis via point-of-care and decentralised integrated dog bite management centres (IDBCs).9Amparo ACB Jayme SI Roces MCR et al.The evaluation of animal bite treatment centers in the Philippines from a patient perspective.PLoS One. 2018; 13: e0200873PubMed Google Scholar The geographical distribution of these IDBCs is a crucial issue in many developing countries and will require important efforts from national authorities.8Tarantola A Blanchi S Cappelle J et al.Rabies postexposure prophylaxis non-completion after dog bites: estimating the unseen to meet the needs of the underserved.Am J Epidemiol. 2018; 187: 306-315Crossref PubMed Scopus (19) Google Scholar The education of populations to increase awareness and perception of the risks related to dog bite exposure and rabies is another complex issue that is starting to be addressed by stakeholders but should be promoted further.10Hasanov E Zeynalova S Geleishvili M et al.Assessing the impact of public education on a preventable zoonotic disease: rabies.Epidemiol Infect. 2018; 146: 227-235Crossref PubMed Scopus (28) Google Scholar Hopefully, Gavi and other national and international stakeholders and donors will keep on supporting field studies so that all these aspects can be better characterised and accounted for in future assessments of rabies control strategies. HB reports grants from Santé Publique France during the conduct of the study and non-financial support from Humabs BioMed SA outside of the submitted work. HB also has a US provisional patent application (62/404,435; Oct 5, 2016) for phtazolinone derivatives used in the treatment and prevention of rabies; patents for antibodies that potentially neutralize rabies virus and other lyssaviruses and uses thereof (PCT/EP2014/003076; Nov 18, 2014); and for antibodies and methods for treatment of lyssavirus infection (PCT/EP2018/078751; Oct 19, 2018). SC declares no competing interests. The potential effect of improved provision of rabies post-exposure prophylaxis in Gavi-eligible countries: a modelling studyInvesting 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. Full-Text PDF Open Access