TITLE:
Breaking the Barriers to Access a Low Cost Intra-Dermal Rabies Vaccine Through Innovative “Pooling Strategy”
AUTHORS:
Omesh K Bharti, Wim Van Damme, Kristof Decoster, Petros Isaakidis, An Appelmans, Vidya Ramachandran, Archana Phull
KEYWORDS:
Intra-Dermal Route For Anti-Rabies Vaccination; Rabies
JOURNAL NAME:
World Journal of Vaccines,
Vol.2 No.3,
August
3,
2012
ABSTRACT: Background: In India every year an estimated 20,000 patients die of Rabies. Major reason for poor compliance to
anti-rabies prophylaxis is the high cost of anti-rabies vaccine being prescribed intramuscularly (IM) as a routine i.e. 44.5 USD per course of five injections. In 1992 WHO recommended low cost intra-dermal rabies vaccination (IDRV),
which costs only 7.5 USD or less per animal bite course. Methods: Interviews with doctors revealed that they were not
prescribing intra-dermal anti rabies vaccination as they were either not aware or were not confident of this route of rabies
vaccination. Also the vaccine vial did not have the label for “intra-dermal use”. These barriers were removed by
advocacy efforts with policy makers & drug companies, credit sharing & team building, which led to starting of first
intra dermal anti-rabies clinic of North India on 2nd August 2008. Results: Within a month of start of intra-dermal rabies
vaccination clinic, i.e. by 2nd September, 2008, there was an increase in the hospital patient load by 2.8 times, and
poor patients load by 3.2 times. In just less than two-year time, 200,000 USD of poor patients were saved and 5769 patients
vaccinated. Each patient was asked to bring one vial on first visit & rest of doses were given “free” by pooling
strategy. Pooling strategy involved distribution of one vial of vaccine among four persons and keep the three vials for
use one by one by all the four patients on subsequent three visits. Another offshoot of the strategy was to prevent wasting
of even few drops of vaccine that used to remain in each vial of 1 ml after distribution among four patients (0.2 mL
or less). Out of more than 5000 vials utilised, every time we would transfer the left out drops of vaccine to the next new
vial and use it immediately on a new pool of patients waiting for vaccination. We would, however, discard the unused
vaccine after eight hours of reconstitution at the end of the day. The vaccine so saved turned to be a stock of more than
100 vials in less than two years that we were able to give free to more than 225 rag pickers, garbage collectors and
newspaper hawkers on World Rabies Day, Sep 28, 2010. Conclusions: With intra-dermal clinic, we were able to successfully
introduce the new cost effective intra-dermal method of rabies vaccination despite all odds & vested interests
of companies & old mindset of doctors that had blocked this technique till now. This will go a long way in reducing the
burden of disease & death due to rabies from India.