Evaluation of Cost-Effective Strategies for Rabies Post-Exposure Vaccination in Low-Income Countries

Background: Prompt post-exposure prophylaxis (PEP) is essential in preventing the fatal onset of disease in persons exposed to rabies. Unfortunately, life-saving rabies vaccines and biologicals are often neither accessible nor affordable, particularly to the poorest sectors of society who are most at risk and upon whom the largest burden of rabies falls. Increasing accessibility, reducing costs and preventing delays in delivery of PEP should therefore be prioritized. Methodology/Principal Findings: We analyzed different PEP vaccination regimens and evaluated their relative costs and benefits to bite victims and healthcare providers. We found PEP vaccination to be an extremely cost-effective intervention (from $200 to less than $60/death averted). Switching from intramuscular (IM) administration of PEP to equally efficacious intradermal (ID) regimens was shown to result in significant savings in the volume of vaccine required to treat the same number of patients, which could mitigate vaccine shortages, and would dramatically reduce the costs of implementing PEP. We present financing mechanisms that would make PEP more affordable and accessible, could help subsidize the cost for those most in need, and could even support new and existing rabies control and prevention programs. Conclusions/Significance: We conclude that a universal switch to ID delivery would improve the affordability and accessibility of PEP for bite victims, leading to a likely reduction in human rabies deaths, as well as being economical for healthcare providers. Author Summary: Rapid delivery of post-exposure vaccination is essential for preventing the fatal onset of rabies in persons bitten by rabid animals. But for communities most at risk of exposure to rabies (in resource poor countries where domestic dog rabies is still common), post-exposure vaccines are often not affordable and are only available in limited quantities. Several safe and effective regimens for delivery of these vaccines are recommended by WHO, but these are inconsistently implemented and there are no clear recommendations as to which is the best regimen for specific settings. We developed a framework for comparing the cost-effectiveness of different vaccination regimens, including existing approved regimens and new candidates subject to approval, in terms of costs per death averted. We demonstrate that post-exposure vaccination is an extremely cost-effective public health intervention and that changing delivery from intramuscular to intradermal vaccination has considerable benefits. Large savings in the volume of vaccine required to treat the same number of patients could potentially both mitigate vaccine shortages and reduce delays in delivery, enabling wider vaccine distribution, and thus improving the accessibility and affordability of these life-saving vaccines. We also present financing mechanisms that could help subsidize the cost for those most in need, and even support new and existing rabies control and prevention programs, without compromising existing healthcare budgets.