The death of a young girl of rabies at Pathanamthitta, despite having been administered the anti-rabies vaccine and immunoglobulin serum, reiterates the importance of pre-exposure prophylaxis (PrEP) vaccination for rabies, at least for children and vulnerable population like tribes, in a rabies-endemic State like Kerala.
Currently, only veterinarians and animal handlers, whose occupation frequently puts them at risk of animal bites, are being administered PrEP (rabies vaccination ahead of possible animal exposure or bite). However, the risk of a random animal bite turning fatal can be reduced if PrEP is adopted as a public health strategy.
Vaccine economics
In fact, given the increasing incidence of animal bites and the amount that the State spends on purchasing vaccine and immunoglobulin serum, the State should be conducting a proper assessment on the economics of rabies vaccination, whether pre-exposure prophylaxis vaccination for rabies can turn out to be more cost-effective as well as beneficial for the State.
In many of the human rabies deaths, it was the nature of the wound (deep wounds and wounds directly on nerve fibres) and the possible delays in the administration of immunoglobulin serum which proved to be crucial.
In Category III bites, a person will have to be normally administered eight shots of vaccine and the immunoglobulin serum (a drug which is administered directly to the wound site to neutralise the virus and provide passive immunity till the time vaccine-induced antibodies are produced in the body).
In PrEP, just two shots of vaccine are enough to give immunogenicity. If the person who has had PrEP sustains an animal bite, he only needs to take two booster vaccine shots. Immunoglobulin serum will not be required. This saves a lot of money because immunoglobulin serum, especially human rabies immunoglobulin serum, is prohibitively expensive.
No uniform protocol
“It is a fact that there is no uniform animal exposure management protocol in Kerala. While WHO’s technical report and national guidelines are followed, there is no explicit uniform protocol for the State for managing animal bites. That being the case, improper wound management - not washing the wound with soap and water, delay in administering immunoglobulin, inadequate dose of or technique in giving immunoglobulin, lower quality or potency of immunoglobulin - can be dangerous,” says T.S. Anish, a public health expert.
“There should be a written protocol for animal wound management. It should also be assessed continuously whether the protocols are being followed uniformly and the knowledge and skill levels of doctors and nurses should be updated,” he says.
The genetic angle
Public health experts point out the need for a detailed epidemiological analysis of human rabies as well as an analysis of the trends and pattern in animal rabies. They also point out that if human rabies cases have been happening despite vaccination (assuming that the vaccine quality is stellar), then the State should also be undertaking a genetic analysis of the rabies virus to ensure that there has not been any changes in the virus.
