"Pooling" strategy makes ID vaccination work for poor people

In India, all bite victims used to be offered nerve tissue rabies vaccine free of charge. However, following rare, but serious adverse reactions to this, and following WHO advice this vaccine was withdrawn from India. Modern, cell tissue vaccine are available, but at a cost of $44.5 per course (for traditional IM delivery) many poor people were left with no affordable source of vaccine.  Patients are known to have died of rabies as a result, or had to borrow large amounts ofmoney for vaccinations.  The sudden withdrawal of the old vaccine also caused shortages of the modern vaccine amongst those who could pay. The WHO approved Intra-Dermal (ID) route of delivery requires 5-fold less vaccine, and can reduce this cost to $7.50 or less, but it was not being widely  used in India.

A short paper in World Journal of Vaccines, describes how the barriers to more widespread use of the ID route were addressed in setting up the first ID rabies vaccination clinic in North-West India.

One barrier was the lack of knowledge about the new route and training in how to administer vaccine in this way. Another was reluctance to administer vaccine by the ID route when the vial was not labeled “for IMroute”.

The clinic is based in a small referral hospital in Shimla, and vaccination works by a ‘pooling’ strategy.  After wound washing and first aid, all nearby hospitals were asked to refer all patients to one central location for vaccination. Each patient pays for a single vial of vaccine ($7.50) and bringsit to their first vaccination. A group of four patients are assembled and are all vaccinated from one of the vials, and the other three stored for use ‘free’on subsequent visits.  Posters in English and Hindi were developed to help inform the public about the new procedures.

Within a month of the clinic starting this strategy, the number of poor patients receiving vaccination had increased over 3 fold. Within 2 years, the clinic vaccinated 5,769 animal bite victims without any failure,even in cases of proven rabid dog bite victims. Around 12,000 vials of ARV vaccine were given, saving more than US $200,000. The district budget foremergency medicine, previously all spent on rabies vaccine, was then used tofund other emergency medicines for the poor as well.

A further refinement was to transfer any left over drops from the old vial to the new vial, within the allowed 8 hour time frame. The vaccine saved over time amounted to over 100 vials which were used on World Rabies Day 2010 to vaccinate 225 of the most vulnerable members of society –rag pickers, garbage collectors and street sellers, at no cost.

These methods have begun to spread to other clinics in Himachal, and now with more states in India adopting the ID route, there is increasing pressure for vaccine manufacturers to label the vials ‘for IM/IDuse’. The clinic is also advocating to other countries that there is an affordable alternative to the old NTV vaccine.

Research has shown that the ID route could be used for other vaccines, including the injectable polio vaccine, with potential to free up more budgets for the health needs of poor people, and spare doses to avoid scarcity of vaccines. Publications such as this one allow everyone to benefitfrom successful innovations, and do more to help poor people access vital rabies vaccines.

Summarised from the paper “Breaking the Barriers to Access a Low CostIntra-Dermal Rabies Vaccine through Innovative “Pooling Strategy” by Omesh Bharti and colleagues, in World Journal of Vaccines, 2012, 2, A121-124