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Bote et al. One Health Implement Res 2023;3:11-5 https://dx.doi.org/10.20517/ohir.2022.46 Page 13

Considering that less vaccine is needed per injection and fewer visits are required due to the shortened
vaccination schedule, ID vaccination has been proven cost-effective even in low-throughput clinics. As
throughput increases, ID regimens become increasingly cost-effective, saving up to 85% of the available
[9]
vaccine . This increases the number of available vaccines, preventing shortages due to supply issues or
financial constraints in the healthcare system. Following the recommendations for ID vaccination would
[10]
hence not only avert additional deaths but also be highly cost-effective . Additionally, it would make
vaccination more affordable for patients, which is one of the main obstacles to timely PEP-seeking in
[11]
countries where the healthcare system does not provide PEP for free . Increasing the affordability of PEP
not only saves lives but is also in line with the United Nations’ Sustainable Development Goals. In
particular, it ensures good health (Goal 3), reduces inequalities (Goal 10), and when vaccination is not
covered by government policies, it decreases out-of-pocket spending in communities that are often already
stricken by poverty (Goal 1).

However, despite the described advantages, most countries have not yet adopted the shortened ID
vaccination schedule and the information leaflets of most rabies vaccines have not been updated to include
the 3-visit ID regimen. Switching to ID vaccination would offer countries an important chance to tackle
PEP-related challenges in times of crisis, for example, when vaccine supply or adequate logistics are
insufficient, such as during acute outbreaks with many dog rabies cases or events like the COVID-19
[11]
pandemic when health systems are under extreme stress , but also in normal times. Seeking PEP not only
comes with the cost of the treatment itself but further includes the cost of travelling to the healthcare facility
and the loss of time and income. Patients living in rural areas, who have to travel long distances to reach a
healthcare facility, may easily feel discouraged by long vaccination schedules. In underserved areas, public
transportation is often the only option available, but the length of such travel, coupled with reduced
financial means, may prevent people from starting or completing PEP. The shortened vaccination regimen
increases the likelihood of patients receiving all the doses of vaccine they need.

Misinformation about rabies vaccination is an additional obstacle and can create vaccine hesitancy, refusal
and scepticism. Healthcare workers need to be trained to communicate with the public about safety and
[4]
concerns . A shortened vaccination schedule with fewer visits decreases the patient load in high-
throughput clinics and allows healthcare workers to treat and inform their patients with less stress and more
time.

Adopting the recommended ID vaccination schedule further assists countries in their efforts to include
rabies in routine vaccination programmes because, especially in the initial phase of any programme, vaccine
demand can increase due to augmented awareness. Using dose-sparing ID regimens would assist in
ensuring the vaccine supply and preventing shortages. Countries could then focus on stable vaccine
procurement, especially of WHO pre-qualified rabies vaccines that make up only 14% of the total share .
[12]
The upcoming Gavi, the Vaccine Alliance’s support focused on ID vaccination is expected to attract
[13]
additional attention and accelerate the shift to ID administration .
In combination with mass dog vaccination, investment in human PEP using the WHO’s recommended 3-
visit ID vaccination schedule will drive progress towards the stated aim of zero human deaths from dog-
mediated rabies by 2030. It should now be a matter of urgency for Health Ministries in rabies-endemic
settings to adopt this beneficial regimen and ensure appropriate medical training and healthcare service
delivery to improve PEP, enabling underserved populations to access affordable, life-saving rabies vaccines.
The “Guide to introducing human rabies vaccine into national immunization programmes” supports
Health Ministries in their policy discussions and 6-step operational planning towards this goal .
[4]