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Banović P, Mijatović D, Simin V, Vranješ N, Meletis E, Kostoulas P, Obregon D, Cabezas-Cruz A. Real-world evidence of rabies post-exposure prophylaxis in Serbia: Nation-wide observational study (2017-2019). Travel Med Infect Dis 2024; 58:102697. [PMID: 38369074 DOI: 10.1016/j.tmaid.2024.102697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 02/04/2024] [Accepted: 02/12/2024] [Indexed: 02/20/2024]
Abstract
BACKGROUND Rabies remains a deadly zoonotic disease, primarily prevalent in Eastern European countries, with a significant global burden in Asia and Africa. Post-exposure prophylaxis (PEP) is critical to prevent clinical rabies. Serbia, a country with a relatively low animal rabies incidence, has been implementing a 4-dose Essen PEP regimen for 13 years. This real-world study aimed to assess the effectiveness of the 4-dose Essen regimen, considering demographic and clinical factors, after WHO Category III exposure. METHOD The study included 601 patients who received the 4-dose Essen PEP and 79 who received an additional 5th dose. RESULTS Age emerged as a critical factor influencing seroconversion rates after the 4-dose regimen, with older individuals exhibiting lower RVNA titers. Logistic regression indicated a 3.18% decrease in seroconversion odds for each added year of age. The Cox proportional hazards mixed model highlighted age-related risks, with age groups 45-60 and 75-92 at the highest risk of non-seroconversion. Human Rabies Immune Globulin (HRIG) administration was associated with lower RVNA values after the 4-dose regimen, suggesting interference with vaccine immunogenicity among people who received larger doses of HRIG. CONCLUSIONS This study provides valuable real-world evidence for rabies PEP in a non-homogeneous population with potential comorbidities. The results underscore the importance of optimizing PEP strategies, particularly in older individuals, and reconsidering HRIG dosing to improve seroconversion rates.
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Affiliation(s)
- Pavle Banović
- Department for Prevention of Rabies and Other Infectious Diseases, Pasteur Institute Novi Sad, Novi Sad 21000, Serbia; Department of Microbiology with Parasitology and Immunology, Faculty of Medicine, University of Novi Sad, Novi Sad 21000, Serbia.
| | - Dragana Mijatović
- Department for Research & Monitoring of Rabies & Other Zoonoses, Pasteur Institute Novi Sad, 21000 Novi Sad, Serbia
| | - Verica Simin
- Department of Microbiology, Pasteur Institute Novi Sad, 21000 Novi Sad, Serbia
| | - Nenad Vranješ
- Department for Research & Monitoring of Rabies & Other Zoonoses, Pasteur Institute Novi Sad, 21000 Novi Sad, Serbia
| | - Eleftherios Meletis
- Faculty of Public and One Health, School of Health Sciences, University of Thessaly, 24410 Karditsa, Greece
| | - Polychronis Kostoulas
- Faculty of Public and One Health, School of Health Sciences, University of Thessaly, 24410 Karditsa, Greece
| | - Dasiel Obregon
- School of Environmental Sciences University of Guelph, Guelph, Ontario N1G 2W1, Canada
| | - Alejandro Cabezas-Cruz
- ANSES, INRAE, Ecole Nationale Vétérinaire d'Alfort, UMR BIPAR, Laboratoire de Santé Animale, Maisons-Alfort F-94700, France
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Akter F, Shamimuzzaman M. Potency, immunogenicity, and efficacy of rabies vaccine: In vitro and in vivo approach. Immun Inflamm Dis 2024; 12:e1198. [PMID: 38411335 PMCID: PMC10898210 DOI: 10.1002/iid3.1198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 01/12/2024] [Accepted: 02/07/2024] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND Rabies, a potentially lethal virus, affects more than 150 countries. Although the rabies vaccine and immunoglobulin have been available since 1908, Bangladesh is new to vaccine manufacturing. We checked the quality of the local manufacturing rabies vaccine for substandard. METHODS The potency and immunogenicity of 20 vaccines were analyzed by three in vivo and in vitro methods from March 2020 to May 2023. Single radial immunodiffusion, fluorescent antibody virus neutralization, and national institutes of health tests were carried out to evaluate the vaccine's efficacy to provide sufficient protection against the rabies virus. RESULTS The potency of the rabies vaccine was determined by the in vitro SRID method by measuring glycoprotein content. An average of 16 articles from each batch was calculated. The minimum and maximum average mean values of the 20 batches were 5.058 and 5.346, respectively. The variance was calculated at 0.00566. We found a coefficient of variation (CV) between 9.36% and 14.80%. The 100% sample was satisfactory, as these samples had a potency of over 2.5 IU/mL. To observe immunogenicity, we applied the FAVN method for determining antibody titers. An average of 16 articles from every batch were counted to quantify antibody titers. The mean quantity of antibody titers ranged from 2.389 to 3.3875. The CV was slightly lower because of the dispersion of the data. At last, we performed an in vivo method, the NIH test method, to determine potency based on mortality rate. We found a mean value of 4.777 IU/SHD with a standard deviation of 1.13 IU/SHD. All 20 batches were found 100% satisfactory in the NIH test. CONCLUSION The study implies that the rabies human vaccines manufactured in Bangladesh are potent enough to provide sufficient immunogenicity. Our research is warranted testimony for healthcare providers who work to extirpate rabies.
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Affiliation(s)
- Fahima Akter
- Department of Microbiology and Hygiene, Bangladesh Agricultural University, Mymensingh, Bangladesh
| | - Md Shamimuzzaman
- Department of Microbiology, Jashore University of Science and Technology, Jashore, Bangladesh
- Directorate General of Drug Administration, Ministry of Health and Family Welfare, Dhaka, Bangladesh
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H S R, Khobragade A, Satapathy D, Gupta M, Kumar S, Bhomia V, V R, Desai M, Agrawal AD. Safety and Immunogenicity of a novel three-dose recombinant nanoparticle rabies G protein vaccine administered as simulated post exposure immunization: A randomized, comparator controlled, multicenter, phase III clinical study. Hum Vaccin Immunother 2021; 17:4239-4245. [PMID: 34499574 DOI: 10.1080/21645515.2021.1957413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Rabies vaccines are lifesaving in human post animal exposure. However, the compliance to the complete course of vaccine is found to be only 60%. Hence, there is a need for safe and immunogenic, shorter course vaccine that can enhance the compliance and effectively prevent the disease. OBJECTIVES To establish a noninferiority of a novel three-dose recombinant rabies G protein vaccine to be administered as simulated postexposure prophylaxis when compared to five-dose WHO prequalified vaccine for better safety and immunogenicity. METHODS A multi-centric, open label, assessor blind, center-specific block randomized, parallel design, phase III clinical study was conducted among 800 subjects. The eligible subjects were randomized in 2:1 ratio for recombinant rabies G protein vaccine and the reference vaccine. Subjects in recombinant rabies G protein vaccine arm received three doses of vaccine on days 0, 3, and 7, while subjects in reference vaccine arm received five doses of WHO prequalified vaccine on days 0, 3, 7, 14, and 28. RESULTS The socio-demographic characteristics of the two arms were comparable. About 9.9% subjects in recombinant rabies G protein vaccine arm and 17.2% subjects in reference arm reported adverse events. The sero-protection on day 14 was found to be 99.24% and 97.72% in recombinant rabies G protein vaccine arm and reference vaccine arm respectively and the difference was statistically nonsignificant. CONCLUSION The novel three-dose recombinant rabies G protein vaccine administered as simulated postexposure prophylaxis was noninferior to five dose WHO prequalified vaccine in terms of safety and immunogenicity.
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Affiliation(s)
- Ravish H S
- Department of Community Medicine, Kempegowda Institute of Medical Science, Bengaluru, India
| | | | - Durga Satapathy
- Department of Community Medicine, VSS Institute of Medical Science and Research, Sambalpur, India
| | - Monica Gupta
- Consultant Physician, Samvedna Hospital, Varanasi, India
| | - Surendra Kumar
- Department of Community Medicine, S P Medical College and A.G Hospitals, Bikaner, India
| | - Vinay Bhomia
- Consultant Physician, Sanjivani Superspeciality Hospital Pvt. Ltd, Ahmedabad, India
| | - Ramasubramanian V
- Senior Consultant, Infectious Diseases and Tropical Medicine, Apollo Hospital, Chennai, India
| | - Maharshi Desai
- Senior Consultant, Infectious Diseases, Apollo Hospitals International Ltd, Gandhinagar, India
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Briggs DJ, Moore SM. The Route of Administration of Rabies Vaccines: Comparing the Data. Viruses 2021; 13:v13071252. [PMID: 34199111 PMCID: PMC8310204 DOI: 10.3390/v13071252] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 06/24/2021] [Accepted: 06/25/2021] [Indexed: 11/16/2022] Open
Abstract
Cell culture rabies vaccines were initially licensed in the 1980s and are essential in the prevention of human rabies. The first post-exposure prophylaxis (PEP) vaccination regimen recommended by the World Health Organization (WHO) was administered intramuscularly over a lengthy three-month period. In efforts to reduce the cost of PEP without impinging on safety, additional research on two strategies was encouraged by the WHO including the development of less expensive production methods for CCVs and the administration of reduced volumes of CCVs via the intradermal (ID) route. Numerous clinical trials have provided sufficient data to support a reduction in the number of doses, a shorter timeline required for PEP, and the approval of the intradermal route of administration for PEP and pre-exposure prophylaxis (PreP). However, the plethora of data that have been published since the development of CCVs can be overwhelming for public health officials wishing to review and make a decision as to the most appropriate PEP and PreP regimen for their region. In this review, we examine three critical benchmarks that can serve as guidance for health officials when reviewing data to implement new PEP and PreP regimens for their region including: evidence of immunogenicity after vaccination; proof of efficacy against development of disease; and confirmation that the regimen being considered elicits a rapid anamnestic response after booster vaccination.
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Leboux RJT, Schipper P, van Capel TMM, Kong L, van der Maaden K, Kros A, Jiskoot W, de Jong EC, Bouwstra JA. Antigen Uptake After Intradermal Microinjection Depends on Antigen Nature and Formulation, but Not on Injection Depth. FRONTIERS IN ALLERGY 2021; 2:642788. [PMID: 35386985 PMCID: PMC8974696 DOI: 10.3389/falgy.2021.642788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 03/01/2021] [Indexed: 12/12/2022] Open
Abstract
The skin is an attractive alternative administration route for allergy vaccination, as the skin is rich in dendritic cells (DCs) and is easily accessible. In the skin multiple subsets of DCs with distinct roles reside at different depths. In this study antigen (=allergen for allergy) formulations were injected in ex vivo human skin in a depth-controlled manner by using a hollow microneedle injection system. Biopsies were harvested at the injection site, which were then cultured for 72 h. Subsequently, the crawled-out cells were collected from the medium and analyzed with flow cytometry. Intradermal administration of ovalbumin (OVA, model antigen) solution at various depths in the skin did not affect the migration and maturation of DCs. OVA was taken up efficiently by the DCs, and this was not affected by the injection depth. In contrast, Bet v 1, the major allergen in birch pollen allergy, was barely taken up by dermal DCs (dDCs). Antigens were more efficiently taken up by CD14+ dDCs than CD1a+ dDCs, which in turn were more efficient at taken up antigen than Langerhans cells. Subsequently, both OVA and Bet v 1 were formulated in cationic and anionic liposomes, which altered antigen uptake drastically following intradermal microinjection. While OVA uptake was reduced by formulation in liposomes, Bet v 1 uptake in dDCs was increased by encapsulation in both cationic and anionic liposomes. This highlights the potential use of liposomes as adjuvant in intradermal allergy vaccine delivery. In conclusion, we observed that antigen uptake after intradermal injection was not affected by injection depth, but varied between different antigens and formulation.
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Affiliation(s)
- Romain J. T. Leboux
- Division of BioTherapeutics, Leiden Academic Centre for Drug Research, Leiden University, Leiden, Netherlands
| | - Pim Schipper
- Division of BioTherapeutics, Leiden Academic Centre for Drug Research, Leiden University, Leiden, Netherlands
| | - Toni M. M. van Capel
- Department of Experimental Immunology, Academic Medical Center, Amsterdam, Netherlands
| | - Lily Kong
- Division of Supramolecular Chemistry, Leiden Institute of Chemistry, Leiden University, Leiden, Netherlands
- Tongji School of Pharmacy, HuaZhong University of Science and Technology, Wuhan, China
| | - Koen van der Maaden
- Tumor Immunology Group, Department of Immunology, Leiden University Medical Center, Leiden, Netherlands
- TECO Development GmbH, Rheinbach, Germany
| | - Alexander Kros
- Division of Supramolecular Chemistry, Leiden Institute of Chemistry, Leiden University, Leiden, Netherlands
| | - Wim Jiskoot
- Division of BioTherapeutics, Leiden Academic Centre for Drug Research, Leiden University, Leiden, Netherlands
| | - Esther C. de Jong
- Department of Experimental Immunology, Academic Medical Center, Amsterdam, Netherlands
- Esther C. de Jong
| | - Joke A. Bouwstra
- Division of BioTherapeutics, Leiden Academic Centre for Drug Research, Leiden University, Leiden, Netherlands
- *Correspondence: Joke A. Bouwstra
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Moulenat T, Petit C, Bosch Castells V, Houillon G. Purified Vero Cell Rabies Vaccine (PVRV, Verorab ®): A Systematic Review of Intradermal Use Between 1985 and 2019. Trop Med Infect Dis 2020; 5:E40. [PMID: 32156005 PMCID: PMC7157209 DOI: 10.3390/tropicalmed5010040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 01/31/2020] [Accepted: 03/02/2020] [Indexed: 12/25/2022] Open
Abstract
The purified Vero cell rabies vaccine (PVRV; Verorab®, Sanofi Pasteur) has been used in rabies prevention since 1985. Evolving rabies vaccination trends, including shorter intradermal (ID) regimens with reduced volume, along with WHO recommendation for ID administration has driven recent ID PVRV regimen assessments. Thus, a consolidated review comparing immunogenicity of PVRV ID regimens during pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) is timely and beneficial in identifying gaps in current research. A search of seven databases for studies published from 1985 to November 2019 identified 35 studies. PrEP was assessed in 10 studies (n = 926) with 1-3-site, 1-3-visit regimens of up to 3-months duration. Seroconversion (rabies virus neutralizing antibodies [RVNA] ≥ 0.5 IU/mL) rates of 90-100% were reported within weeks, irrespective of regimen, with robust booster responses at 1 year (100% seroconversion rates by day 14 post-booster). However, data are lacking for the current WHO-recommended, 2-site, 1-week ID PrEP regimen. PEP was assessed in 25 studies (n = 2136) across regimens of 1-week to 90-day duration. All ID PEP regimens assessed induced ≥ 99% seroconversion rates (except in HIV participants) by day 14-28. This review confirms ID PVRV suitability for rabies prophylaxis and highlights the heterogeneity of use in the field.
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Affiliation(s)
- Thomas Moulenat
- Université Claude Bernard Lyon 1, Institut des Sciences Pharmaceutiques et Biologiques (ISPB)—Faculté de Pharmacie de Lyon, 69008 Lyon, France;
| | - Céline Petit
- Sanofi Pasteur, 14 Espace Henry Vallée, 69007 Lyon, France; (C.P.); (V.B.C.)
| | | | - Guy Houillon
- Sanofi Pasteur, 14 Espace Henry Vallée, 69007 Lyon, France; (C.P.); (V.B.C.)
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7
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Warrell MJ. Simplification of Rabies Postexposure Prophylaxis: A New 2-Visit Intradermal Vaccine Regimen. Am J Trop Med Hyg 2019; 101:1199-1201. [PMID: 31392953 PMCID: PMC6896873 DOI: 10.4269/ajtmh.19-0252] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 06/24/2019] [Indexed: 11/24/2022] Open
Abstract
A 2-visit multiple-site intradermal (ID) vaccine protocol would be the most economical, immunogenic, and practicable regimen for postexposure rabies prophylaxis (PEP) in clinics seeing few patients a month. This regimen with an additional day 28 dose is now recommended by the WHO. The difficulties surrounding ID rabies vaccination have hindered progress in provision of prophylaxis, especially in rural Asia and Africa. Although the latest WHO recommendations include 1-week ID postexposure vaccine regimens, these are unlikely to prove economical where rabies vaccination is presently unavailable. The new protocol uses a whole vial of vaccine divided between 4-sites ID on the first day and half a vial at 2-sites ID on day 7. Gavi has recently approved support for rabies PEP. This 2-visit 4-site ID regimen, with or without a day 28 dose, should be considered for implementation in this remarkable new initiative.
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Affiliation(s)
- Mary J. Warrell
- Oxford Vaccine Group, University of Oxford, Oxford, United Kingdom
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9
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Warrell MJ. Rabies post-exposure vaccination in 2 visits within a week: A 4-site intradermal regimen. Vaccine 2019; 37:1131-1136. [PMID: 30691982 DOI: 10.1016/j.vaccine.2019.01.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 01/09/2019] [Accepted: 01/11/2019] [Indexed: 12/25/2022]
Abstract
Rabies is fatal in all unvaccinated patients bitten by dogs, and so post-exposure vaccine regimens must be robust enough to ensure their survival under all conditions. Treatment tends to be excessive for most people, but there is justified anxiety about reducing vaccine dosage and shortening regimens. Recently, World Health Organisation (WHO) recommended one week primary post-exposure intradermal regimens requiring 3 clinic visits, but these are unlikely to prove economical where rabies vaccination is most needed, in deprived rural areas of Africa and Asia. A highly immunogenic regimen involving two doses of intradermal vaccine given one week apart has advantages over other regimens. Anyone exposed to a possibly rabid animal would be given intradermal (ID) injections at 4 sites using a whole vial of vaccine. Those who had not been previously vaccinated would be given 2-site ID injections using half a vial one week later. Those who might be immunosuppressed could be given an optional single ID dose on day 28. The rationale for this regimen is discussed in the context of the recently revised WHO recommendations for rabies prophylaxis.
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Affiliation(s)
- M J Warrell
- Oxford Vaccine Group, University of Oxford, Centre for Clinical Vaccinology & Tropical Medicine, Churchill Hospital, Old Rd, Headington, Oxford OX3 7LE, United Kingdom.
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Kessels J, Tarantola A, Salahuddin N, Blumberg L, Knopf L. Rabies post-exposure prophylaxis: A systematic review on abridged vaccination schedules and the effect of changing administration routes during a single course. Vaccine 2019; 37 Suppl 1:A107-A117. [PMID: 30737043 DOI: 10.1016/j.vaccine.2019.01.041] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Revised: 01/18/2019] [Accepted: 01/21/2019] [Indexed: 12/25/2022]
Abstract
Rabies is a fatal zoonotic disease preventable through timely and adequate post-exposure prophylaxis (PEP) to potentially exposed persons i.e. wound washing and antisepsis, a series of intradermal (ID) or intramuscular (IM) rabies vaccinations, and rabies immunoglobulin in WHO category III exposures. The 2010 WHO position on rabies vaccines recommended PEP schedules requiring up to 5 clinic visits over the course of approximately one month. Abridged schedules with less doses have potential to save costs, increase patient compliance, and thereby improve equitable access to life-saving PEP for at-risk populations. We systematically reviewed new evidence since that considered for the 2010 position paper to evaluate (i) the immunogenicity and effectiveness of PEP schedules of reduced dose and duration; (ii) new evidence on effective PEP protocols for special populations; and (iii) the effect of changing routes of administration (ID or IM) during a single course of PEP. Our search identified a total of 14 relevant studies. The identified studies supported a reduction in dose or duration of rabies PEP schedules. The 1-week, 2-site ID PEP schedule was found to be most advantageous, as it was safe, immunogenic, supported by clinical outcome data and involved the least direct costs (i.e. cost of vaccine) compared to other schedules. To supplement this evidence, as yet unpublished additional data were reviewed to support the strength of the recommendations. Evidence suggests that changes in the rabies vaccine product and/or the route of administration during PEP is possible. Few studies have evaluated PEP schedules in persons with suspect or confirmed rabies exposures. Gaps exist in understanding the safety and immunogenicity of novel PEP schedules in special populations such as infants and immunocompromised individuals. Available data indicate that administering rabies vaccines during pregnancy is safe and effective.
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Affiliation(s)
- Joss Kessels
- Department of the Control of Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland
| | - Arnaud Tarantola
- Unité d'Epidémiologie, Institut Pasteur de Nouvelle-Calédonie, Nouméa, New Caledonia; Unité d'Epidémiologie et de Santé Publique, Institut Pasteur du Cambodge, Phnom Penh, Cambodia
| | | | - Lucille Blumberg
- National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | - Lea Knopf
- Department of the Control of Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland.
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Denis M, Knezevic I, Wilde H, Hemachudha T, Briggs D, Knopf L. An overview of the immunogenicity and effectiveness of current human rabies vaccines administered by intradermal route. Vaccine 2018; 37 Suppl 1:A99-A106. [PMID: 30551985 DOI: 10.1016/j.vaccine.2018.11.072] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 11/16/2018] [Accepted: 11/26/2018] [Indexed: 12/01/2022]
Abstract
Pre- as well as post-exposure prophylaxis plays an important role in controlling the number of deaths associated with human rabies. Rabies vaccines, classically injected intramuscularly, are now also administered by intradermal (ID) route. Vaccines to be administered by the ID route should meet the same quality, safety and efficacy specifications as vaccines for intramuscular (IM) use. The aim of this paper is to provide information based on publicly available data regarding the ID use of rabies vaccines and to identify potential needs for further analysis of the potency, immunogenicity and effectiveness of rabies vaccines administered by this route. A first literature search, focused on the immunogenicity of rabies vaccines given by ID route, identified 338 publications in the period 1997-2018, 40 of which were included in our analyses. A second search investigating the effectiveness of ID vaccination resulted in 371 hits for the period 2007-2018, of which 13 suitable publications were retained. The immunogenicity of current rabies vaccines was analyzed in 3 ways: proportion of subjects reaching the antibody threshold of 0.5 IU/ml after ID vaccination, relationship between potency and immunogenicity of the vaccine given intradermally, and comparison of antibody responses after IM or ID vaccination. Overall, vaccines administered intradermally were found immunogenic. Post-exposure prophylaxis by ID route appeared at least as immunogenic as by IM regimens. By contrast, ID pre-exposure prophylaxis trended towards lower antibody titers than IM vaccination, but the observation was not associated with any clinical relevance. Vaccine effectiveness was assessed by investigating survival after exposure. Data from more than 30,000 patients who sought rabies post-exposure prophylaxis did not indicate that current vaccines administered by ID route lack efficacy. These results support current recommendations for ID vaccination against rabies. However, published data on ID performance were associated with significant weaknesses that future research should better address.
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Affiliation(s)
| | - Ivana Knezevic
- Department of Essential Medicines and Health Products, Norms and Standards for Biologicals, World Health Organization, Geneva, Switzerland
| | - Henry Wilde
- Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Thiravat Hemachudha
- World Health Organization Collaborating Centre for Research and Training on Viral Zoonoses, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Deborah Briggs
- Kansas State University, College of Veterinary Medicine Manhattan, USA
| | - Lea Knopf
- Neglected Zoonotic Diseases, Department of Control of Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland
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Preiss S, Chanthavanich P, Chen LH, Marano C, Buchy P, van Hoorn R, Vonk Noordegraaf M, Mukherjee P. Post-exposure prophylaxis (PEP) for rabies with purified chick embryo cell vaccine: a systematic literature review and meta-analysis. Expert Rev Vaccines 2018; 17:525-545. [PMID: 29939085 DOI: 10.1080/14760584.2018.1473765] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Fifteen million people each year receive post-exposure prophylaxis (PEP) to prevent rabies, yet the disease remains neglected and highly under-reported. AREAS COVERED In this systematic literature review, we assessed the immunogenicity, efficacy, and safety of a purified chick embryo cell-culture rabies vaccine (PCECV) for PEP against rabies by intramuscular (IM) or intradermal (ID) administration. We performed meta-analyses to compare immunogenicity according to the route of vaccine administration, study population, and PEP regimen, such as number of doses, and concomitant rabies immunoglobulin. EXPERT COMMENTARY There were 54 estimates of immune responses to vaccination, which showed that in the overall population, after starting PEP with PCECV by the IM or ID route (≥2.5 IU per dose), almost all individuals had rabies virus neutralizing antibody (RVNA) titers above the World Health Organization (WHO) recommended serological threshold for an adequate immune response to vaccination (RVNA ≥0.5 IU/ml by day 14). In the overall population, PCECV had an acceptable safety profile. However, given that there are 59,000 human rabies deaths reported annually, the challenge is to improve access to PCECV for PEP against human rabies.
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Affiliation(s)
| | - Pornthep Chanthavanich
- b Department of Tropical Pediatrics, Faculty of Tropical Medicine , Mahidol University , Bangkok , Thailand
| | - Lin H Chen
- c Travel Medicine Center, Division of Infectious Diseases and Travel Medicine , Mount Auburn Hospital , Cambridge , MA , USA.,d Harvard Medical School , Boston , MA , USA
| | | | | | - Rosa van Hoorn
- f Pallas Health Research and Consultancy , Rotterdam , The Netherlands
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Kerdpanich P, Chanthavanich P, De Los Reyes MR, Lim J, Yu D, Ama MC, Mojares Z, Casula D, Arora AK, Pellegrini M. Shortening intradermal rabies post-exposure prophylaxis regimens to 1 week: Results from a phase III clinical trial in children, adolescents and adults. PLoS Negl Trop Dis 2018; 12:e0006340. [PMID: 29874228 PMCID: PMC6005579 DOI: 10.1371/journal.pntd.0006340] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 06/18/2018] [Accepted: 02/23/2018] [Indexed: 11/18/2022] Open
Abstract
Background This phase III clinical trial compared the immunogenicity and safety of a purified chick-embryo cell rabies vaccine (PCECV) administered according to a shortened post-exposure prophylaxis (PEP) 4-site/1-week intradermal regimen, compared with the currently recommended 2-site/Thai Red Cross (TRC) regimen. Methodology/Principal findings This controlled, open-label, multi-center study (NCT02177032) enrolled healthy individuals ≥1 year of age, randomized into 4 groups to receive intradermal PCECV according to one of the 2 regimens, with or without human rabies immunoglobulin (HRIG) administration at first visit (in adults only). Rabies virus neutralizing antibody (RVNA) concentrations and percentages of participants with RVNA concentrations ≥0.5 IU/mL (considered as adequate concentrations following PEP) were assessed up to day (D) 365 post-first vaccination. Non-inferiority of the 4-site/1-week regimen to the 2-site/TRC regimen was demonstrated if at D49, the lower limit of the 95% confidence interval (CI) for the difference between groups in the percentage of participants with adequate RVNA concentrations was >-5%. Of the 443 participants receiving the 4-site/1-week regimen, 88 adults received HRIG; 442 participants received the 2-site/TRC regimen (88 with HRIG). All participants achieved adequate RVNA concentrations by D14. At D49, the difference in percentage of participants with adequate RVNA concentrations between the 4-site/1-week and the 2-site/TRC groups was -1 (95%CI: -2.4–0.0); thus, non-inferiority was concluded. RVNA geometric mean concentrations were 18 IU/mL in 4-site/1-week groups and 12 IU/mL in 2-site/TRC groups at D14, and subsequently declined in all groups. RVNA concentrations were consistently lower in adults with HRIG administration than in those without. The 2 regimens had similar safety profiles. Of the 15 serious adverse events reported in 4-site/1-week groups and 19 in 2-site/TRC groups, none were vaccination-related. Significance The data suggest that the 4-site/1-week regimen might be an alternative to current recommendations, with potential benefits in terms of improved cost-efficiency and compliance to vaccination. Rabies is a deadly, but vaccine-preventable disease which still causes tens of thousands of deaths yearly, mostly in Asia and Africa. Rabies virus is spread via the saliva of infected mammals to humans, usually through bites or contamination of open wounds. Access to measures like wound cleansing with soap and rabies vaccination immediately after contact with a suspected rabid animal (exposure) can be life-saving. The post-exposure vaccination schedule currently recommended by the World Health Organization for intradermal injection is the Thai Red Cross regimen, requiring 4 clinic visits in one month, with 2 injections given at each visit on days (D) 0 (day of the contact), 3, 7, and 28. In this study, we evaluated the antibody responses and the safety profile of a new shortened schedule, requiring 3 clinic visits and only 1 week to complete, consisting of 4 intradermal injections given at each visit on D0, 3, and 7 (the 4-site/1-week regimen). The study was conducted in the Philippines and Thailand which enrolled 885 healthy volunteers, at least 1 year of age, with no real exposure to rabies. The two schedules induced adequate antibody responses in similar proportion of volunteers at day 49. The vaccine administration according to both schedules was well tolerated.
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Affiliation(s)
- Phirangkul Kerdpanich
- Department of Pediatrics, Division of Infectious Diseases, Phramongkutklao Hospital, Bangkok, Thailand
| | - Pornthep Chanthavanich
- Department of Tropical Pediatrics, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Mari Rose De Los Reyes
- Research Institute for Tropical Medicine, Filinvest Corporate City, Alabang Muntinlupa City, the Philippines
| | - Jodor Lim
- Asian Hospital and Medical Center, Filinvest Corporate City, Alabang Muntinlupa City, the Philippines
| | - Delia Yu
- De La Salle Health Sciences Institute-Congressional Road, Dasmarinas City, Cavite, the Philippines
| | - Ma. Cecilia Ama
- Research Institute for Tropical Medicine, Filinvest Corporate City, Alabang Muntinlupa City, the Philippines
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A single center, open label study of intradermal administration of an inactivated purified chick embryo cell culture rabies virus vaccine in adults. Vaccine 2017; 35:4315-4320. [PMID: 28688782 DOI: 10.1016/j.vaccine.2017.06.083] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 06/24/2017] [Accepted: 06/26/2017] [Indexed: 11/22/2022]
Abstract
In the USA, rabies vaccines (RVs) are licensed for intramuscular (IM) use only, although RVs are licensed for use by the intradermal (ID) route in many other countries. Recent limitations in supplies of RV in the USA reopened discussions on the more efficient use of available biologics, including utilization of more stringent risk assessments, and potential ID RV administration. A clinical trial was designed to compare the immunogenic and adverse effects of a purified chicken embryo cell (PCEC) RV administered ID or IM. Enrollment was designed in four arms, ID Pre-Exposure Prophylaxis (Pre-EP), IM Pre-EP, ID Booster, and IM Booster vaccination. Enrollment included 130 adult volunteers. The arms with IM administration received vaccine according to the current ACIP recommendations: Pre-EP, three 1mL (2.5 I.U.) RV doses, each on day 0, 7, and 21; or a routine Booster, one 1ml dose. The ID groups received the same schedule, but doses administered were in a volume of 0.1mL (0.25 I.U.). The rate of increase in rabies virus neutralizing antibody titers 14-21days after vaccination were similar in the ID and correspondent IM groups. The GMT values for ID vaccination were slightly lower than those for IM vaccination, for both naïve and booster groups, and these differences were statistically significant by t-test. Fourteen days after completing vaccination, all individuals developed RV neutralizing antibody titers over the minimum arbitrary value obtained with the rapid fluorescent focus inhibition test (RFFIT). Antibodies were over the set threshold until the end of the trial, 160days after completed vaccination. No serious adverse reactions were reported. Most frequent adverse reactions were erythema, induration and tenderness, localized at the site of injection. Multi use of 1mL rabies vaccine vials for ID doses of 0.1 was demonstrated to be both safe and inmunogenic.
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Mpolya EA, Lembo T, Lushasi K, Mancy R, Mbunda EM, Makungu S, Maziku M, Sikana L, Jaswant G, Townsend S, Meslin FX, Abela-Ridder B, Ngeleja C, Changalucha J, Mtema Z, Sambo M, Mchau G, Rysava K, Nanai A, Kazwala R, Cleaveland S, Hampson K. Toward Elimination of Dog-Mediated Human Rabies: Experiences from Implementing a Large-scale Demonstration Project in Southern Tanzania. Front Vet Sci 2017; 4:21. [PMID: 28321400 PMCID: PMC5337520 DOI: 10.3389/fvets.2017.00021] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 02/08/2017] [Indexed: 12/25/2022] Open
Abstract
A Rabies Elimination Demonstration Project was implemented in Tanzania from 2010 through to 2015, bringing together government ministries from the health and veterinary sectors, the World Health Organization, and national and international research institutions. Detailed data on mass dog vaccination campaigns, bite exposures, use of post-exposure prophylaxis (PEP), and human rabies deaths were collected throughout the project duration and project areas. Despite no previous experience in dog vaccination within the project areas, district veterinary officers were able to implement district-wide vaccination campaigns that, for most part, progressively increased the numbers of dogs vaccinated with each phase of the project. Bite exposures declined, particularly in the southernmost districts with the smallest dog populations, and health workers successfully transitioned from primarily intramuscular administration of PEP to intradermal administration, resulting in major cost savings. However, even with improved PEP provision, vaccine shortages still occurred in some districts. In laboratory diagnosis, there were several logistical challenges in sample handling and submission but compared to the situation before the project started, there was a moderate increase in the number of laboratory samples submitted and tested for rabies in the project areas with a decrease in the proportion of rabies-positive samples over time. The project had a major impact on public health policy and practice with the formation of a One Health Coordination Unit at the Prime Minister's Office and development of the Tanzania National Rabies Control Strategy, which lays a roadmap for elimination of rabies in Tanzania by 2030 by following the Stepwise Approach towards Rabies Elimination (SARE). Overall, the project generated many important lessons relevant to rabies prevention and control in particular and disease surveillance in general. Lessons include the need for (1) a specific unit in the government for managing disease surveillance; (2) application of innovative data collection and management approaches such as the use of mobile phones; (3) close cooperation and effective communication among all key sectors and stakeholders; and (4) flexible and adaptive programs that can incorporate new information to improve their delivery, and overcome challenges of logistics and procurement.
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Affiliation(s)
- Emmanuel Abraham Mpolya
- Global Health and Biomedical Sciences, School of Life Sciences and Bioengineering, Nelson Mandela African Institution of Science and Technology, Arusha, Tanzania
- Institute of Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, Glasgow, UK
- Paul G. Allen School for Global Animal Health, Washington State University, Pullman, WA, USA
| | - Tiziana Lembo
- Institute of Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, Glasgow, UK
| | - Kennedy Lushasi
- Institute of Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, Glasgow, UK
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Rebecca Mancy
- Institute of Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, Glasgow, UK
| | - Eberhard M. Mbunda
- Department of Epidemiology, Ministry of Agriculture, Livestock and Fisheries, Dar es Salaam, Tanzania
| | - Selemani Makungu
- Department of Epidemiology, Ministry of Agriculture, Livestock and Fisheries, Dar es Salaam, Tanzania
| | - Matthew Maziku
- Department of Epidemiology, Ministry of Agriculture, Livestock and Fisheries, Dar es Salaam, Tanzania
| | | | - Gurdeep Jaswant
- Preventive Veterinary Medicine, Sokoine University of Agriculture (SUA), Morogoro, Tanzania
| | - Sunny Townsend
- Institute of Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, Glasgow, UK
| | - François-Xavier Meslin
- Food Safety Zoonoses and Food-Borne Diseases, World Health Organization (former WO staff), Geneva, Switzerland
| | | | - Chanasa Ngeleja
- Tanzania Veterinary Laboratory Agency (TVLA), Ministry of Agriculture, Livestock and Fisheries, Dar es Salaam, Tanzania
| | - Joel Changalucha
- Institute of Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, Glasgow, UK
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | | | - Maganga Sambo
- Institute of Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, Glasgow, UK
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Geofrey Mchau
- Department of Epidemiology, Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC), Dar es Salaam, Tanzania
| | - Kristyna Rysava
- Institute of Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, Glasgow, UK
| | - Alphoncina Nanai
- Department of Neglected Tropical Diseases, World Health Organization – Country Office of Tanzania, Dar es Salaam, Tanzania
| | - Rudovick Kazwala
- Preventive Veterinary Medicine, Sokoine University of Agriculture (SUA), Morogoro, Tanzania
| | - Sarah Cleaveland
- Institute of Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, Glasgow, UK
| | - Katie Hampson
- Institute of Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, Glasgow, UK
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Salahuddin N, Gohar MA, Baig-Ansari N. Reducing Cost of Rabies Post Exposure Prophylaxis: Experience of a Tertiary Care Hospital in Pakistan. PLoS Negl Trop Dis 2016; 10:e0004448. [PMID: 26919606 PMCID: PMC4769324 DOI: 10.1371/journal.pntd.0004448] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 01/20/2016] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Rabies is a uniformly fatal disease, but preventable by timely and correct use of post exposure prophylaxis (PEP). Unfortunately, many health care facilities in Pakistan do not carry modern life-saving vaccines and rabies immunoglobulin (RIG), assuming them to be prohibitively expensive and unsafe. Consequently, Emergency Department (ED) health care professionals remain untrained in its application and refer patients out to other hospitals. The conventional Essen regimen requires five vials of cell culture vaccine (CCV) per patient, whereas Thai Red Cross intradermal (TRC-id) regimen requires only one vial per patient, and gives equal seroconversion as compared with Essen regimen. METHODOLOGY/PRINCIPAL FINDINGS This study documents the cost savings in using the Thai Red Cross intradermal regimen with cell culture vaccine instead of the customary 5-dose Essen intramuscular regimen for eligible bite victims. All patients presenting to the Indus Hospital ED between July 2013 to June 2014 with animal bites received WHO recommended PEP. WHO Category 2 bites received intradermal vaccine alone, while Category 3 victims received vaccine plus wound infiltration with Equine RIG. Patients were counseled, and subsequent doses of the vaccine administered on days 3, 7 and 28. Throughput of cases, consumption utilization of vaccine and ERIG and the cost per patient were recorded. CONCLUSIONS/SIGNIFICANCE Government hospitals in Pakistan are generally underfinanced and cannot afford treatment of the enormous burden of dog bite victims. Hence, patients are either not treated at all, or asked to purchase their own vaccine, which most cannot afford, resulting in neglect and high incidence of rabies deaths. TRC-id regimen reduced the cost of vaccine to 1/5th of Essen regimen and is strongly recommended for institutions with large throughput. Training ED staff would save lives through a safe, effective and affordable technique.
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Affiliation(s)
- Naseem Salahuddin
- Infectious Disease Division, Department of Medicine, The Indus Hospital, Karachi, Pakistan
| | - M. Aftab Gohar
- Emergency Department, The Indus Hospital, Karachi, Pakistan
| | - Naila Baig-Ansari
- Indus Hospital Research Center, The Indus Hospital, Karachi, Pakistan
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Malerczyk C, Freuling C, Gniel D, Giesen A, Selhorst T, Müller T. Cross-neutralization of antibodies induced by vaccination with Purified Chick Embryo Cell Vaccine (PCECV) against different Lyssavirus species. Hum Vaccin Immunother 2015; 10:2799-804. [PMID: 25483634 PMCID: PMC5443070 DOI: 10.4161/21645515.2014.972741] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background: Rabies is a neglected zoonotic disease caused by viruses belonging to the genus lyssavirus. In endemic countries of Asia and Africa, where the majority of the estimated 60,000 human rabies deaths occur, it is mainly caused by the classical rabies virus (RABV) transmitted by dogs. Over the last decade new species within the genus lyssavirus have been identified. Meanwhile 15 (proposed or classified) species exist, including Australian bat lyssavirus (ABLV), European bat lyssavirus (EBLV-1 and -2), Duvenhage virus (DUVV), as well as Lagos bat virus (LBV) and Mokola virus (MOKV) and recently identified novel species like Bokeloh bat lyssavirus (BBLV), Ikoma bat lyssavirus (IKOV) or Lleida bat lyssavirus (LLBV). The majority of these lyssavirus species are found in bat reservoirs and some have caused human infection and deaths. Previous work has demonstrated that Purified Chick Embryo Cell Rabies Vaccine (PCECV) not only induces immune responses against classical RABV, but also elicits cross-neutralizing antibodies against ABLV, EBLV-1 and EBLV-2. Material & Methods: Using the same serum samples as in our previous study, this study extension investigated cross-neutralizing activities of serum antibodies measured by rapid fluorescent focus inhibition test (RFFIT) against selected other non-classical lyssavirus species of interest, namely DUVV and BBLV, as well as MOKV and LBV. Results: Antibodies developed after vaccination with PCECV have neutralizing capability against BBLV and DUVV in the same range as against ABLV and EBLV-1 and -2. As expected, for the phylogenetically more distant species LBV no cross-neutralizing activity was found. Interestingly, 15 of 94 serum samples (16%) with a positive neutralizing antibody titer against RABV displayed specific cross-neutralizing activity (65-fold lower than against RABV) against one specific MOKV strain (Ethiopia isolate), which was not seen against a different strain (Nigeria isolate). Conclusion: Cross-neutralizing activities partly correlate with the phylogenetic distance of the virus species. Cross-neutralizing activities against the species BBLV and DUVV of phylogroup 1 were demonstrated, in line with previous results of cross-neutralizing activities against ABLV and EBLV-1 and -2. Potential partial cross-neutralizing activities against more distant lyssavirus species like selected MOKV strains need further research.
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Giesen A, Gniel D, Malerczyk C. 30 years of rabies vaccination with Rabipur: a summary of clinical data and global experience. Expert Rev Vaccines 2015; 14:351-67. [DOI: 10.1586/14760584.2015.1011134] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Alexandra Giesen
- 1 Novartis Vaccines and Diagnostics GmbH, Global Medical Affairs, Emil-von-Behring-Strasse 76, 35041 Marburg, Germany
| | - Dieter Gniel
- 2 Novartis Vaccines and Diagnostics GmbH, Global Medical Affairs, Marburg, Germany
| | - Claudius Malerczyk
- 3 Novartis Vaccines and Diagnostics GmbH, Medical Affairs Region Europe & International, Marburg, Germany
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Narayana A, Manoharan A, Narayan MS, Kalappa SM, Biligumba G, Haradanahalli R, Anand AM. Comparison of safety and immunogenicity of 2 WHO prequalified rabies vaccines administered by one week, 4 site intra dermal regimen (4-4-4-0-0) in animal bite cases. Hum Vaccin Immunother 2015; 11:1748-53. [PMID: 26083005 PMCID: PMC4517453 DOI: 10.1080/21645515.2015.1048938] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Revised: 04/15/2015] [Accepted: 05/02/2015] [Indexed: 12/25/2022] Open
Abstract
The currently advocated rabies post-exposure prophylaxis regimens are of one month duration with reduced patient compliance. WHO recommended research on shortened vaccination regimens which have a practical and economic advantage over the existing regimens. Hence, the present study was undertaken to assess the safety and immunogenicity of 2 WHO prequalified rabies vaccines administered by one week, 4 site intra dermal regimen (4-4-4-0-0) in animal bite cases. This study was a comparative, open label, phase III, randomized clinical trial conducted at Anti rabies clinic, KIMS Hospital, Bangalore, India. The study was registered in Clinical Trials Registry of India (CTRI) bearing the registration number CTRI/2012/12/003230. Ninety subjects with category II/III animal bites/exposures were enrolled. Equine rabies immunoglobulin was administered to all category III exposures. 0.1 mL of either purified chick embryo cell vaccine (Rabipur) or purified verocell rabies vaccine (Verorab) was administered intradermally into 4 sites on days 0, 3 and 7 to all the study subjects. Serum of subjects collected on day 0, 14, 90 and 365 were analyzed for rabies virus neutralizing antibody (RVNA) concentration. The incidence of ADR in Rabipur and Verorab group was 2.96% and 1.14% respectively. In Rabipur group, geometric mean concentration (95% confidence interval) of RVNA was 14.5 (13.50, 15.57), 11.78 (11.27, 12.31) and 5.95 (5.50, 6.44) IU/mL on days 14, 90 and 365 respectively; In Verorab group geometric mean concentration (95% confidence interval) of RVNA was 14.43 (13.41, 15.53), 11.93 (11.47, 12.40) and 5.67 (5.29, 6.08) IU/mL on days 14, 90 and 365 respectively. In conclusion, Rabipur and Verorab were found to be safe, immunogenic and comparable with each other, when administered using one week, 4 site intradermal regimen (4-4-4-0-0) in animal bite cases.
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Affiliation(s)
- Ashwath Narayana
- Community Medicine; Kempegowda Institute of Medical Sciences; Bangalore, Karnataka, India
| | - Aravind Manoharan
- Community Medicine; Kempegowda Institute of Medical Sciences; Bangalore, Karnataka, India
| | - Madhusudana Shampur Narayan
- Department of Neurovirology; National Institute of Mental health and Neurosciences (NIMHANS); Bangalore, Karnataka, India
| | - Sudarshan Mysore Kalappa
- Rajiv Gandhi Institute of Public Health and Center for Disease Control; Bangalore, Karnataka, India
| | - Gangaboraiah Biligumba
- Community Medicine; Kempegowda Institute of Medical Sciences; Bangalore, Karnataka, India
| | - Ravish Haradanahalli
- Community Medicine; Kempegowda Institute of Medical Sciences; Bangalore, Karnataka, India
| | - Ashwini Manoor Anand
- Department of Neurovirology; National Institute of Mental health and Neurosciences (NIMHANS); Bangalore, Karnataka, India
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Li R, Li Y, Wen S, Wen H, Nong Y, Mo Z, Xie F, Pellegrini M. Immunogenicity and safety of purified chick-embryo cell rabies vaccine under Zagreb 2-1-1 or 5-dose Essen regimen in Chinese children 6 to 17 years old and adults over 50 years: a randomized open-label study. Hum Vaccin Immunother 2015; 11:435-42. [PMID: 25692350 PMCID: PMC4514244 DOI: 10.4161/21645515.2014.994460] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 10/03/2014] [Accepted: 10/12/2014] [Indexed: 11/19/2022] Open
Abstract
The aim of this Phase IIIb, open-label, randomized study was to demonstrate the non-inferiority of immune responses and to assess the safety of a purified chick-embryo cell rabies vaccine (PCECV) in healthy Chinese children (6 to 17 years) and older adults (≥51 years) following 2 alternative intramuscular (IM) simulated post-exposure prophylaxis (PEP) regimens: 4-dose Zagreb or 5-dose Essen regimen. Serum samples were collected prior to vaccination on Days 1 and 15 and on day 43 to assess immune response by rabies virus neutralizing antibody (RVNA) concentrations. Solicited adverse events (AEs) were recorded for up to 7 days following each vaccine dose, and unsolicited AEs throughout the entire study period. PCECV vaccination induced a strong immune response at Day 15, and the non-inferiority in immune response of the Zagreb vs. the Essen regimen was demonstrated in children and older adults. At Day 15,100% of children (N = 224), and 99% of subjects ≥51 years of age (N = 376) developed adequate RVNA concentrations (≥0.5 IU/mL); at Day 43 all subjects achieved RVNA concentrations ≥0.5 IU/mL, for both PEP regimens. The well-known tolerability and safety profile of the PCECV was again observed in this study following either Zagreb or Essen regimens. Rabies PEP vaccination with PCECV following a Zagreb regimen induced immune responses non-inferior to those of the Essen regimen, and had a similar safety and tolerability profile to the Essen regimen in Chinese children, adolescents, and adults over 51 years. ClinicalTrials.gov identifier: NCT01680016.
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Key Words
- AE, adverse event
- CI, confidence interval
- Essen regimen
- GMC, geometric mean concentration
- IM, intramuscular
- NIFDC, National Institutes for Food and Drug Control
- PCECV, purified chick-embryo cell rabies vaccine
- PEP, post-exposure prophylaxis
- PPS, per-protocol set
- RFFIT, Rapid Fluorescent Focus Inhibition Test
- RVNA, rabies virus neutralizing antibody
- Zagreb regimen
- immunogenicity
- intramuscular post-exposure prophylaxis; purified chick-embryo cell rabies vaccine
- rabies
- rabies virus neutralizing antibody
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Affiliation(s)
- RongCheng Li
- Guangxi Center for Disease Prevention and Control; Guangxi, China
| | - YanPing Li
- Guangxi Center for Disease Prevention and Control; Guangxi, China
| | - ShuQing Wen
- Mengshan Center for Disease Prevention and Control; Mengshan, Guangxi, China
| | - HuiChun Wen
- Mengshan Center for Disease Prevention and Control; Mengshan, Guangxi, China
| | - Yi Nong
- Guangxi Center for Disease Prevention and Control; Guangxi, China
| | - Zhaojun Mo
- Guangxi Center for Disease Prevention and Control; Guangxi, China
| | - Fang Xie
- Novartis Vaccines & Diagnostics Inc.; Cambridge, MA USA
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Madhusudana SN, Mani RS. Intradermal vaccination for rabies prophylaxis: conceptualization, evolution, present status and future. Expert Rev Vaccines 2014; 13:641-55. [DOI: 10.1586/14760584.2014.901893] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Shampur Narayan Madhusudana
- Department of Neurovirology, WHO Collaborating Centre for Reference and Research on Rabies, National Institute of Mental Health and Neurosciences (NIMHANS),
Bangalore, Karnataka 560029, India
| | - Reeta Subramaniam Mani
- Department of Neurovirology, WHO Collaborating Centre for Reference and Research on Rabies, National Institute of Mental Health and Neurosciences (NIMHANS),
Bangalore, Karnataka 560029, India
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Trend of human rabies prophylaxis in developing countries: Toward optimal rabies immunization. Vaccine 2014; 32:1421-2. [DOI: 10.1016/j.vaccine.2013.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Revised: 11/05/2013] [Accepted: 11/07/2013] [Indexed: 12/25/2022]
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Sudarshan MK, Narayana DHA, Madhusudana SN, Holla R, Ashwin BY, Gangaboraiah B, Ravish HS. Evaluation of a one week intradermal regimen for rabies post-exposure prophylaxis: results of a randomized, open label, active-controlled trial in healthy adult volunteers in India. Hum Vaccin Immunother 2012; 8:1077-81. [PMID: 22699446 PMCID: PMC3551879 DOI: 10.4161/hv.20471] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
The currently recommended intradermal regimen for post-exposure prophylaxis spreads over a month period which many times lead to low compliance from the patients. There is a need to introduce and evaluate short course regimens to overcome this problem. This study was conducted to evaluate the immunogenicity and safety of a "new one week intradermal regimen" for rabies post-exposure prophylaxis. A total of 80 healthy adult volunteers were enrolled and allocated randomly either to purified chick embryo cell (PCECV) rabies vaccine or purified verocell rabies vaccine (PVRV), 40 in each group. Each subject received intradermally one of the vaccines , using the one week regimen (4-4-4). Blood samples were collected on Days 0, 7, 14, 28,180 and 365 for estimation of rabies virus neutralizing antibody (RVNA) concentration. The sera samples were analyzed by rapid fluorescent focus inhibition test (RFFIT). All subjects in both the groups had adequate RVNA concentration of 0.5 IU/mL from day 14 to till day 180 and the difference of geometric mean concentrations between the two groups was not significant (P > 0.606). Further to assess the immunological memory produced by this new regimen, a "single visit four site" intradermal booster vaccination was given to those who did not have adequate RVNA concentration on day 365. This resulted in a quick and enhanced RVNA concentration in these subjects thus denoting a successful anamnestic response. The incidence of adverse events was 8.3% in PCECV group and 1.6% in PVRV group (P=0.001) and the regimen was well tolerated without any dropouts. In conclusion, the new "one week intradermal regimen" is immunogenic and safe for rabies post-exposure prophylaxis and needs to be further evaluated in persons exposed to rabies.
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Affiliation(s)
- Mysore Kalappa Sudarshan
- Anti-Rabies Clinic and Rabies Epidemiology Unit; Department of Community Medicine; Kempegowda Institute of Medical Sciences; Bangalore, India
| | | | - Shampur Narayan Madhusudana
- Department of Neurovirology; WHO Collaborating Center for Research and Reference on Rabies; National Institute of Mental Health and Neurosciences; Bangalore, India
| | - Ramesh Holla
- Anti-Rabies Clinic and Rabies Epidemiology Unit; Department of Community Medicine; Kempegowda Institute of Medical Sciences; Bangalore, India
| | - Belludi Yajaman Ashwin
- Department of Neurovirology; WHO Collaborating Center for Research and Reference on Rabies; National Institute of Mental Health and Neurosciences; Bangalore, India
| | - Bilagumba Gangaboraiah
- Anti-Rabies Clinic and Rabies Epidemiology Unit; Department of Community Medicine; Kempegowda Institute of Medical Sciences; Bangalore, India
| | - Haradanahalli S. Ravish
- Anti-Rabies Clinic and Rabies Epidemiology Unit; Department of Community Medicine; Kempegowda Institute of Medical Sciences; Bangalore, India
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Warrell M. Current rabies vaccines and prophylaxis schedules: Preventing rabies before and after exposure. Travel Med Infect Dis 2012; 10:1-15. [DOI: 10.1016/j.tmaid.2011.12.005] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2011] [Accepted: 12/21/2011] [Indexed: 02/07/2023]
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Kamoltham T, Thinyounyong W, Khawplod P, Phraisuwan P, Phongchamnaphai P, Anders G, Malerczyk C. Immunogenicity of Simulated PCECV Postexposure Booster Doses 1, 3, and 5 Years after 2-Dose and 3-Dose Primary Rabies Vaccination in Schoolchildren. Adv Prev Med 2011; 2011:403201. [PMID: 21991438 PMCID: PMC3170734 DOI: 10.4061/2011/403201] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2011] [Accepted: 05/13/2011] [Indexed: 11/28/2022] Open
Abstract
Objectives. To assess the immunogenicity of intradermal (ID) booster doses of Purified Chick Embryo Cell rabies vaccine (PCECV, Rabipur) administered to Thai schoolchildren one, three and five years after a primary ID pre-exposure (PrEP) vaccination series. Methods. In this follow-up study of a randomized, open-label, phase II clinical trial, two simulated post-exposure booster doses of PCECV were administered on days 0 and 3 intradermally to 703 healthy schoolchildren, one, three or five years after primary vaccination with either two or three ID doses of 0.1 mL PCECV. Blood was drawn immediately before and 7, 14 and 365 days after the first booster dose to determine rabies virus neutralizing antibody (RVNA) concentrations. Results. An anamnestic response of approximately 30-fold increase in RVNA concentrations was demonstrated within 14 days after booster. All children (100%) developed adequate RVNA concentrations above 0.5 IU/mL. No vaccine related serious adverse events were seen in any of the vaccinees. Conclusion. ID rabies PrEP with PCECV is safe and immunogenic in schoolchildren and the anamnestic response to a two booster dose vaccination series was found to be adequate one, three, and five years after a two- or three-dose primary PrEP vaccination series.
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Affiliation(s)
| | - Wiravan Thinyounyong
- Provincial Health Office of Phetchabun, Ministry of Health, Phetchabun 67160, Thailand
| | - Pakamatz Khawplod
- Queen Saovabha Memorial Institute, Thai Red Cross Society and Department of Medicine, Chulalongkorn Hospital, 1871 Rama 4 Road, Bangkok 10330, Thailand
| | - Phran Phraisuwan
- Provincial Health Office of Phetchabun, Ministry of Health, Phetchabun 67160, Thailand
| | - Phana Phongchamnaphai
- Provincial Health Office of Phetchabun, Ministry of Health, Phetchabun 67160, Thailand
| | - Gerlind Anders
- Novartis Vaccines and Diagnostics GmbH, Medical Affairs, Emil-von-Behring-Str. 76, Marburg 35041, Germany
| | - Claudius Malerczyk
- Novartis Vaccines and Diagnostics GmbH, Medical Affairs, Emil-von-Behring-Str. 76, Marburg 35041, Germany
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Hampson 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:e982. [PMID: 21408121 PMCID: PMC3050908 DOI: 10.1371/journal.pntd.0000982] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2010] [Accepted: 02/09/2011] [Indexed: 12/20/2022] Open
Abstract
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.
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Affiliation(s)
- Katie Hampson
- Boyd Orr Centre for Population and Ecosystem Health, Institute for Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, Glasgow, United Kingdom.
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Intradermal rabies vaccination: the evolution and future of pre- and post-exposure prophylaxis. Curr Top Microbiol Immunol 2011; 351:139-57. [PMID: 21267707 DOI: 10.1007/82_2010_121] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Inactivated rabies vaccines have been used to pioneer the immunological and economical advantages of intradermal (ID) administration over 35 years. Vaccine shortages or its prohibitive cost stimulated studies of various doses, frequency and sites of injection. An economical regimen for pre-exposure prophylaxis requires one-tenth of an intramuscular dose, but the early popularity of the method has been stifled by pharmaceutical regulations. There has also been reluctance to use multiple-site post-exposure ID regimens, except in a very few Asian counties. A new four-site ID regimen could overcome many of the problems encountered to date. The time is ripe to make dramatic progress towards efficient use of the current excellent vaccines globally, wherever there is a shortage of vaccine or funds.
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Warrell M. Rabies and African bat lyssavirus encephalitis and its prevention. Int J Antimicrob Agents 2010; 36 Suppl 1:S47-52. [PMID: 20801003 DOI: 10.1016/j.ijantimicag.2010.06.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Unlike any other human infection, encephalitis caused by dog rabies virus is always fatal. Rabies and other lyssaviruses have been found in unexpected places, and human disease, especially paralytic rabies, has gone unrecognised. Evidence is emerging that rabies-related bat lyssaviruses are enzootic across Europe, Africa, Asia and Australia, but none has been detected in the Americas. The epidemiology and origins of African lyssaviruses are discussed. Ideal rabies prophylaxis (pre-exposure immunisation followed by post-exposure booster vaccination) has proved 100% effective; hence all human deaths result from failure of prevention. Rabies vaccines of known quality are unaffordable for the majority in Africa. Although intradermal regimens requiring <40% of the usual vaccine dose are economical and are recommended by the World Health Organization, several problems have inhibited their use. A new, simplified, economical post-exposure vaccine regimen that uses an initial dose of intradermal injections at four sites overcomes many of the difficulties of the previous methods: it is at least as immunogenic as the standard intramuscular course of tissue-culture vaccine; is safer in inexperienced hands; requires fewer than two ampoules of vaccine and only three instead of five clinic visits. Recent data should increase the confidence of physicians to use the World Health Organization-accredited rabies vaccines more efficiently and at lower cost.
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Affiliation(s)
- Mary Warrell
- Oxford Vaccine Group, University of Oxford, Centre for Clinical Vaccinology and Tropical Medicine, Churchill Hospital, Headington, Oxford, UK.
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Sudarshan MK, Gangaboraiah B, Ravish HS, Narayana DHA. Assessing the relationship between antigenicity and immunogenicity of human rabies vaccines when administered by intradermal route: results of a metaanalysis. HUMAN VACCINES 2010; 6:562-5. [PMID: 20523131 PMCID: PMC3322518 DOI: 10.4161/hv.6.7.11934] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2009] [Revised: 03/10/2010] [Accepted: 03/28/2010] [Indexed: 11/19/2022]
Abstract
The metadata of 10 published studies and 3 vaccine trial reports comprising of 19 vaccine cohorts from four countries conducted over a period of 23 years (1986 - 2009) was used for metaanalysis. The vaccines studied were purified chick embryo cell vaccine (Rabipur, India & Germany), purified vero cell rabies vaccine (Verorab, France; Indirab, India) & human diploid cell vaccine (MIRV, France).The potency of these vaccines varied from 0.55 IU to 2.32 IU per intradermal dose of 0.1 ml per site. The vaccines were administered to 1,011 subjects comprising of 19 cohorts and using five different ID regimens. The immunogenicity was measured by assays of rabies virus neutralizing antibody (RVNA) titres using rapid fluorescent focus inhibition test (RFFIT) [15 cohorts] and mouse neutralization test (MNT) [4 cohorts]. The statistical analysis of the data was done by Karl Pearson's correlation coefficient to measure the relationship between antigenicity and immunogenicity. It was revealed that, there was no significant linear relationship between antigenicity and immunogenicity of rabies vaccines when administered by intradermal route. (p> 0.230 and p>0.568).
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Affiliation(s)
- Mysore K Sudarshan
- Department of Community Medicine, Kempegowda Institute of Medical Sciences, Bangalore, India.
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Abstract
Rabies is a widely distributed zoonotic disease of major public-health importance. While canine rabies has been controlled throughout most of the developed world, it remains a significant burden in developing countries, particularly in Africa and Asia. Owing to the effectiveness of local rabies control in industrialized countries, the lack of familiarity with rabies may place certain travelers to countries with a higher prevalence of rabies at higher risk for potential contact with rabid animals, requiring rabies postexposure prophylaxis. Where necessary, some travelers may need to consider rabies pre-exposure vaccination, depending on planned activities and duration of travel within a given country. Education regarding behavior around unfamiliar animals and general familiarity with local rabies epidemiology is often sufficient to reduce a person's risk of exposure. Travelers to countries where rabies is prevalent should balance the cost and inconvenience of immunization to the benefits of rabies pre-exposure vaccination.
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Affiliation(s)
- Jesse D Blanton
- Poxvirus and Rabies Branch, Division of Viral and Rickettsial Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30333, USA.
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Warrell MJ, Riddell A, Yu LM, Phipps J, Diggle L, Bourhy H, Deeks JJ, Fooks AR, Audry L, Brookes SM, Meslin FX, Moxon R, Pollard AJ, Warrell DA. A simplified 4-site economical intradermal post-exposure rabies vaccine regimen: a randomised controlled comparison with standard methods. PLoS Negl Trop Dis 2008; 2:e224. [PMID: 18431444 PMCID: PMC2292256 DOI: 10.1371/journal.pntd.0000224] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2007] [Accepted: 03/14/2008] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The need for economical rabies post-exposure prophylaxis (PEP) is increasing in developing countries. Implementation of the two currently approved economical intradermal (ID) vaccine regimens is restricted due to confusion over different vaccines, regimens and dosages, lack of confidence in intradermal technique, and pharmaceutical regulations. We therefore compared a simplified 4-site economical PEP regimen with standard methods. METHODS Two hundred and fifty-four volunteers were randomly allocated to a single blind controlled trial. Each received purified vero cell rabies vaccine by one of four PEP regimens: the currently accepted 2-site ID; the 8-site regimen using 0.05 ml per ID site; a new 4-site ID regimen (on day 0, approximately 0.1 ml at 4 ID sites, using the whole 0.5 ml ampoule of vaccine; on day 7, 0.1 ml ID at 2 sites and at one site on days 28 and 90); or the standard 5-dose intramuscular regimen. All ID regimens required the same total amount of vaccine, 60% less than the intramuscular method. Neutralising antibody responses were measured five times over a year in 229 people, for whom complete data were available. FINDINGS All ID regimens showed similar immunogenicity. The intramuscular regimen gave the lowest geometric mean antibody titres. Using the rapid fluorescent focus inhibition test, some sera had unexpectedly high antibody levels that were not attributable to previous vaccination. The results were confirmed using the fluorescent antibody virus neutralisation method. CONCLUSIONS This 4-site PEP regimen proved as immunogenic as current regimens, and has the advantages of requiring fewer clinic visits, being more practicable, and having a wider margin of safety, especially in inexperienced hands, than the 2-site regimen. It is more convenient than the 8-site method, and can be used economically with vaccines formulated in 1.0 or 0.5 ml ampoules. The 4-site regimen now meets all requirements of immunogenicity for PEP and can be introduced without further studies. TRIAL REGISTRATION Controlled-Trials.com ISRCTN 30087513.
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Affiliation(s)
- Mary J Warrell
- The Oxford Vaccine Group, Centre for Clinical Vaccinology & Tropical Medicine University of Oxford, Churchill Hospital, Oxford, United Kingdom.
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Rabies vaccines. Vaccines (Basel) 2008. [DOI: 10.1016/b978-1-4160-3611-1.50031-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023] Open
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