The vital role of vaccines in SA’s rabies outbreak

100% increase in human rabies cases compared to 2020

The last few months have seen an increase in the number of human rabies cases.1,2 This is particularly worrying as with a 99.9% fatality rate, rabies is the deadliest disease on earth.3

 

As of 9 November, there have been 14 confirmed human rabies cases in South Africa (six in the Eastern Cape, four in KwaZulu-Natal, and four in Limpopo) and a further three probable cases in Kwa-Zulu Natal, according to Medical Scientist at NICD Dr Jacqueline Weyer. Added together, that’s a 100% increase compared to the 7 cases reported in 2020.1

 

Unlike most other vaccine-preventable diseases, rabies vaccines can be given both pre- and post-exposure to rabies. Pre-exposure prophylaxis (PrEP) rabies vaccination is recommended for travellers at risk of exposure, those in high-risk occupations, as well as children residing in or visiting, rabies-endemic areas4,5 – the Eastern Cape, KwaZulu-Natal, Limpopo.2,6

In South Africa, dog-transmitted rabies is an ongoing problem,2 the use of post-exposure prophylaxis is vital in exposed human rabies cases.4,5

“Almost always fatal once clinical symptoms manifest,3,5 adhering to post-exposure prophylaxis regimen is essential after someone has potentially been exposed to rabies,” said Thinus Marais, Sanofi Medical Head: Africa Zone & Algeria. “This includes thorough wound washing, followed by the appropriate use of rabies vaccine and rabies immunoglobulin.”7

 

Sanofi Verorab is an inactivated vaccine used for the prevention of rabies in individuals at risk of infection and for treatment after confirmed or possible infection with rabies virus.8

 

Dosing schedule

Verorab is registered for use as pre- and post-exposure prophylaxis.

Pre-exposure prophylaxis: After the primary pre-exposure immunisation course of injections is spread out over 21 or 28 days, an additional booster injection 1 year later and a subsequent booster injection every 5 years thereafter are recommended.8

Post-exposure prophylaxis: Post-exposure prophylaxis should be started as soon as possible after exposure and treatment must be adapted according to the type of contact and the immunisation status of the patient.8

 

The effectiveness of Verorab has been evaluated during several studies conducted in both children and adults and using the recommended WHO schedules. Subjects bitten by confirmed rabid animals were given Verorab and immunoglobulin as appropriate. None of these subjects developed the disease.8

 

Ingredients8

Each 0.5 ml dose of reconstituted vaccine contains:

Active substances

Rabies virus (WISTAR Rabies PM/WI 38 1503-3M strain) produced on Vero cell lines and inactivated with beta-propiolactone ≥ 2,5 IU, Maltose 52.5 mg, Human albumin 2.5 mg, BME medium (Basal medium eagle: a mixture of mineral salts, vitamins, and amino-acids including L-Phenylalanine) qs Water for injections qs 0.5 ml.

Diluent solution

Sodium chloride 2 mg, water for injections qs 0.5 ml.

 

Don’t underestimate rabies

While the increase in the number of dog rabies cases has hit the Eastern Cape and KwaZulu-Natal hardest, to date, outbreaks have also been reported in Limpopo and Gauteng.2,6 “The Eastern Cape dog rabies outbreak is disastrous and one of the largest dog rabies outbreaks we have seen in South Africa for decades,” said Dr Weyer.

 

Highlighting a lack of awareness, the Technical Lead for rabies in sub-Saharan Africa for the Global Alliance for Rabies Control (GARC) Dr Andre Coetzer said that speaking to a large cohort of people in South Africa, including general practitioners, “they will hear I work on rabies and then go ‘Oh, is that still a problem in South Africa?’, and that’s a huge concern. Furthermore, people don’t consider rabies something that occurs in an urban or metropolitan setting. They falsely believe it’s only a problem in rural areas.”

 

Dr Weyer described South Africans as having the misconception that “Rabies is not my problem!”, saying the situation in the Western Cape illustrated this perfectly: “Dog rabies has not been reported in the Western Cape for decades, but due to raging epidemics in other parts of the country, and low dog rabies vaccination coverage, the disease spilt over from the affected areas in the country to parts of the Western Cape. You just need one rabid dog to come into contact with an unvaccinated dog to set off a new outbreak.”

 

Education is vital in the fight to eliminate rabies and you have a key role to play in ensuring your patients are empowered with the knowledge they need to make informed decisions.

 

“In 2015 the WHO called for action by setting a goal of zero human rabies deaths by 2030.9 We all have a part to play in achieving this goal,” concluded Marais.

 

 

References
  1. NICD Zoonotic and vector-Borne Diseases. An update on rabies in SA. January 2021, Vol.20(1). Available from: https://www.nicd.ac.za/wp-content/uploads/2021/01/An-update-on-rabies-in-South-Africa.pdf. Accessed 15 Nov 2021.
  2. NICD Zoonotic and vector-Borne Diseases. An update on rabies in SA. October 2021;20:(10). Available from: https://www.nicd.ac.za/wp-content/uploads/2021/02/An-update-on-rabies-in-South-Africa.pdf. Accessed 15 Nov 2021
  3. Global Alliance for Rabies Control. Rabies FAQs – Treatment and prevention. Available from: https://rabiesalliance.org/resources/search?type=912#teaser-6020. Accessed 15 Nov 2021
  4. World Health Organization. WHO Expert Consultation on Rabies. Second Report. Available from:  https://apps.who.int/iris/bitstream/handle/10665/85346/9789240690943_eng.pdf?sequence=1&isAllowed=y. Accessed 15 Nov 2021
  5. World Health Organization. Rabies. Available from https://www.who.int/news-room/fact-sheets/detail/rabies. Accessed 15 Nov 2021
  6. NICD Zoonotic and vector-Borne Diseases. An update on rabies in SA. July 2021;20(7). Available from: https://www.nicd.ac.za/wp-content/uploads/2021/07/An-update-on-rabies-in-South-Africa-2.pdf. Accessed 15 Nov 2021
  7. Weyer J, Blumberg L. Management of rabies. South African Family Practice. 2019;61(3):63-66.
  8. Verorab Package Insert, South Africa, July 2013.
  9. The World Health Organization. New global strategic plan to eliminate dog-mediated rabies by 2030. August 2018. Available from: https://www.who.int/news-room/commentaries/detail/new-global-strategic-plan-to-eliminate-dog-mediated-rabies-by-2030. Accessed 15 Nov 2021.