- Email: [email protected]
Currently approved post-exposure rabies prophylaxis regimens
Travel Medicine and Infectious Disease (2012) 10, 162e163
Available online at www.sciencedirect.com
journal homepage: www.elsevierhealth.com/journals/tmid
CORRESPONDENCE
Currently approved post-exposure rabies prophylaxis regimens
Mary Warrell deserves credit as a developer of costbenefit-effective intradermal post-exposure rabies vaccine schedules.1 Her work helped eliminate dangerous poorly immunogenic nerve tissue derived Semple and suckling mouse brain vaccines in Asia. Early intramuscular and intradermal rabies vaccine schedules were encumbered by poor understanding of the immunology and pathophysiology and by fear of rabies by the public and professions. This resulted in lengthy post-exposure vaccination schedules lasting up to 3 month and characterized by poor patients compliance.1 As we understood more concerning the immunology of rabies vaccination, developed highly potent tissue culture vaccines and gained worldwide experience, post-exposure schedules were shortened from 3 to 1 month and now to 2 weeks.2 Two promising studies are now on hand and may shorten vaccination schedules to one week in the future.2 This will be a major topic for discussion at one of the next international WHO expert conferences. Most of us who work with rabies in research and in the field, believe that an effective neutralizing antibody response during the first week after infection determines whether the outcome will be life or death. After full compliance with current WHO recommendations for rabies prophylaxis, only very few well documented post-exposure prophylaxis failures have been reported.4 Even there, it is likely that undetected errors such as not injecting all wounds with immunoglobulin or inoculating virus directly into an immune protected peripheral nerve may be responsible for failure.4 There are now only three WHO approved post-exposure vaccination schedules with the likely future addition of the “One week” four site intradermal method now undergoing additional promising international studies in two additional countries.3 Continuing the confusion concerning outdated schedules is confusing and counterproductive. It diverts from pressing issues such as the need for immunoglobulins that are not available in the majority of countries and regions where canine rabies is endemic. This is where most rabies deaths, other than
those due to deviations or total absence of post-exposure treatment, take place. The most recent ongoing rabies epidemic at additional Indonesian islands is now spreading through Maluku. There is, again, disregard of WHO outbreak control recommendations, shortage of animal and human vaccines and almost complete absence of immunoglobulins. Animal and human health authorities are still battling between culling and sustainable mass vaccinating dogs. Much is still lacking in terms of education and using scientific methods that have been clearly defined for decades. Our respected friend and colleague Mary Warrell has published a paper about rabies vaccination which, unfortunately, focuses on a subject that was extensively discussed and virtually unanimously dismissed as outdated at a WHO Expert consultative conference.2 Only three post-exposure schedules are now approved by WHO: the “Gold standard” Essen intramuscular regimen now shortened from one month to 2 weeks, The Zagreb or 2-1-1 intramuscular schedule (used extensively in Europe) and the Thai Red Cross one month intradermal regimen widely used in Asia.2 Only the original 5 shot Essen regimen and the newly shortened twoweek version are approved by the American government. It was also agreed that any modification of WHO rabies vaccine schedules or new rabies biologicals (vaccines or immunoglobulins) must undergo at least two independent WHO level registered trials published in peer review journals before being considered for approval. Mary Warrell’s modified 8/4-site intradermal regimen did not undergo such complete studies. This was one reason why it was not approved by the WHO Expert Consultation Conference.
Conflict of interest None.
References 1. Warrell MJ, Warrell DA, Suntharasamai P, Viravan C, Sinhaseni A, Udomsakdi D, et al. An economical regimen of human diploid cell strain anti-rabies vaccine for post-exposure prophylaxis. Lancet 1983 Aug 6;2(8345):301. 2. WHO. Rabies vaccines position paper. Weekly Rec 2010;85: 309e20.
1477-8939/$ - see front matter ª 2012 Elsevier Ltd. All rights reserved. doi:10.1016/j.tmaid.2012.03.004
Correspondence 3. Khawplod P, Jaijaroensup W, Sawangvaree A, Prakongsri S, Wilde H. One clinic visit for pre-exposure rabies vaccination (a preliminary one year study). Vaccine 2011 Dec 15 [Epub ahead of print]. 4. Shantavasinkul P, Tantawichien T, Wacharapluesadee S, Jeamanukoolkit A, Udomchaisakul P, Chattranukulchai P, et al. Failure of rabies postexposure prophylaxis in patients presenting with unusual manifestations. Clin Infect Dis 2010;50(1):77e9.
163 Henry Wilde* Supaporn Wacharapluesadee Thiravat Hemachudha WHO e Center for Research and Training for Zoonoses, Faculty of Medicine, Chalalongkorn University, Bangkok 10330, Thailand *Corresponding author. E-mail address: [email protected] (H. Wilde)
11 March 2012 Available online 11 May 2012
Available online at www.sciencedirect.com
journal homepage: www.elsevierhealth.com/journals/tmid
CORRESPONDENCE
Currently approved post-exposure rabies prophylaxis regimens
Mary Warrell deserves credit as a developer of costbenefit-effective intradermal post-exposure rabies vaccine schedules.1 Her work helped eliminate dangerous poorly immunogenic nerve tissue derived Semple and suckling mouse brain vaccines in Asia. Early intramuscular and intradermal rabies vaccine schedules were encumbered by poor understanding of the immunology and pathophysiology and by fear of rabies by the public and professions. This resulted in lengthy post-exposure vaccination schedules lasting up to 3 month and characterized by poor patients compliance.1 As we understood more concerning the immunology of rabies vaccination, developed highly potent tissue culture vaccines and gained worldwide experience, post-exposure schedules were shortened from 3 to 1 month and now to 2 weeks.2 Two promising studies are now on hand and may shorten vaccination schedules to one week in the future.2 This will be a major topic for discussion at one of the next international WHO expert conferences. Most of us who work with rabies in research and in the field, believe that an effective neutralizing antibody response during the first week after infection determines whether the outcome will be life or death. After full compliance with current WHO recommendations for rabies prophylaxis, only very few well documented post-exposure prophylaxis failures have been reported.4 Even there, it is likely that undetected errors such as not injecting all wounds with immunoglobulin or inoculating virus directly into an immune protected peripheral nerve may be responsible for failure.4 There are now only three WHO approved post-exposure vaccination schedules with the likely future addition of the “One week” four site intradermal method now undergoing additional promising international studies in two additional countries.3 Continuing the confusion concerning outdated schedules is confusing and counterproductive. It diverts from pressing issues such as the need for immunoglobulins that are not available in the majority of countries and regions where canine rabies is endemic. This is where most rabies deaths, other than
those due to deviations or total absence of post-exposure treatment, take place. The most recent ongoing rabies epidemic at additional Indonesian islands is now spreading through Maluku. There is, again, disregard of WHO outbreak control recommendations, shortage of animal and human vaccines and almost complete absence of immunoglobulins. Animal and human health authorities are still battling between culling and sustainable mass vaccinating dogs. Much is still lacking in terms of education and using scientific methods that have been clearly defined for decades. Our respected friend and colleague Mary Warrell has published a paper about rabies vaccination which, unfortunately, focuses on a subject that was extensively discussed and virtually unanimously dismissed as outdated at a WHO Expert consultative conference.2 Only three post-exposure schedules are now approved by WHO: the “Gold standard” Essen intramuscular regimen now shortened from one month to 2 weeks, The Zagreb or 2-1-1 intramuscular schedule (used extensively in Europe) and the Thai Red Cross one month intradermal regimen widely used in Asia.2 Only the original 5 shot Essen regimen and the newly shortened twoweek version are approved by the American government. It was also agreed that any modification of WHO rabies vaccine schedules or new rabies biologicals (vaccines or immunoglobulins) must undergo at least two independent WHO level registered trials published in peer review journals before being considered for approval. Mary Warrell’s modified 8/4-site intradermal regimen did not undergo such complete studies. This was one reason why it was not approved by the WHO Expert Consultation Conference.
Conflict of interest None.
References 1. Warrell MJ, Warrell DA, Suntharasamai P, Viravan C, Sinhaseni A, Udomsakdi D, et al. An economical regimen of human diploid cell strain anti-rabies vaccine for post-exposure prophylaxis. Lancet 1983 Aug 6;2(8345):301. 2. WHO. Rabies vaccines position paper. Weekly Rec 2010;85: 309e20.
1477-8939/$ - see front matter ª 2012 Elsevier Ltd. All rights reserved. doi:10.1016/j.tmaid.2012.03.004
Correspondence 3. Khawplod P, Jaijaroensup W, Sawangvaree A, Prakongsri S, Wilde H. One clinic visit for pre-exposure rabies vaccination (a preliminary one year study). Vaccine 2011 Dec 15 [Epub ahead of print]. 4. Shantavasinkul P, Tantawichien T, Wacharapluesadee S, Jeamanukoolkit A, Udomchaisakul P, Chattranukulchai P, et al. Failure of rabies postexposure prophylaxis in patients presenting with unusual manifestations. Clin Infect Dis 2010;50(1):77e9.
163 Henry Wilde* Supaporn Wacharapluesadee Thiravat Hemachudha WHO e Center for Research and Training for Zoonoses, Faculty of Medicine, Chalalongkorn University, Bangkok 10330, Thailand *Corresponding author. E-mail address: [email protected] (H. Wilde)
11 March 2012 Available online 11 May 2012