Why don't we have a long-term vaccination for rabies?
September 28, 2014 8:42 PM   Subscribe

I went down a rabies rabbit hole a couple of days ago after listening to this Radiolab episode (and today is, coincidentally, World Rabies Day), and I still don't understand why we don't have a long-term vaccine for it like we do for polio or smallpox.

Five people an hour die a nightmarish rabies death. If we can vaccinate pets, why can't we vaccinate people? Why isn't Bill Gates all over this?

I know this is a rather open-ended question, but I can't find a good answer anywhere else, so maybe I can find one here.
posted by Camofrog to Health & Fitness (25 answers total) 3 users marked this as a favorite
I'd suppose that the vaccine that we do have is a long term vaccine, but that the costs and / or risks of universal administration outweigh the costs and risks of not giving the vaccine. Five people a day die tragically, but this is a tiny toll in the context of public health.
posted by wotsac at 8:47 PM on September 28, 2014

I misread hour as day. Still - the answer is almost certainly that it is more effective, if not more cost effective, to address the problem in a different way.
posted by wotsac at 8:59 PM on September 28, 2014

Because "modern day prophylaxis has proven nearly 100% successful", so there's less demand to develop something else.
posted by unknowncommand at 9:05 PM on September 28, 2014 [3 favorites]

I still don't understand why we don't have a long-term vaccine for it like we do for polio or smallpox.

Five people an hour die a nightmarish rabies death. If we can vaccinate pets, why can't we vaccinate people? Why isn't Bill Gates all over this?

We do have a vaccine. If you go through a course and then get a one-year booster you're good for the next 10 years. That's pretty good, from a vaccination perspective.

We don't have the same push towards universal vaccination because there are a heck of a lot more deadly and pressing public health concerns than rabies. This is not to say a death by rabies isn't a tragedy, it is. But 4,000 children per day die from lack of clean water and poor sanitation. In 2012, 1.6 million people died from AIDS-related diseases. 1.3 million people died from tuberculosis, and drug-resistant tuberculosis is popping up in more and more places. Rabies is terrifying, but the money one could spend towards mass vaccination is far better spent on other, more imminent public health threats.
posted by schroedinger at 9:09 PM on September 28, 2014 [12 favorites]

Also: please take Radiolab with a large grain of salt. Their presence on NPR gives them a veneer of credibility, but their purpose is entertainment first, objective analysis and facts second.
posted by schroedinger at 9:11 PM on September 28, 2014 [8 favorites]

If something goes wrong and your pet suffers real harm from a rabies vaccine, it's tragic but ultimately not a huge deal. If something goes wrong and your baby suffers real harm from a rabies vaccine, there's an international outcry and pharmaceutical companies start going out of business.

Especially when you consider how few humans die of rabies.

(I'm also wondering about frequency and location of rabies infections in humans; sadly, the fact that this is likely not happening in the affluent West is probably a part of the reason cheap rabies vaccines aren't ubiquitous. Malaria and HIV are much more prevalent than human rabies cases.)
posted by Sara C. at 9:30 PM on September 28, 2014 [1 favorite]

I agree with Sara C's parenthetical speculation above, unfortunately. According to the CDC website,"The number of rabies-related human deaths in the United States has declined from more than 100 annually at the turn of the century to one or two per year in the 1990's. Modern day prophylaxis has proven nearly 100% successful." Unfortunately, rabies outbreaks in remote or poor or indigenous regions, like this 2008 case in Venezuela, sometimes take longer to receive public health action than they might have in more politically and economically central populations.
posted by third rail at 9:47 PM on September 28, 2014 [1 favorite]

It also occurs to me that the population at significant risk of rabies doesn't overlap significantly with the population likely to be up to date on vaccines. When rabies breaks out in a remote part of Venezuela, how likely is it that the people affected are fully vaccinated against it, even if the rabies vaccine was ubiquitous?
posted by Sara C. at 9:58 PM on September 28, 2014

I understand that other diseases kill at far greater rates, but it's the way rabies kills that makes me think we'd be much more focused on eradication.
posted by Camofrog at 10:01 PM on September 28, 2014

The rabies vaccine for humans has a much higher rate of moderate and severe complications that most/all vaccines routinely given in the US and other developed countries. Ask someone who has had it ... It is a terribly unpleasant series of shots. It requires four closely and precisely spaced shots plus an immune globulin shot. There are significant side effects in cats and dogs as well, and a community of pet owners who therefore reject the vaccine as unnecessarily cruel (who need to be slapped repeatedly and with great force).

In the 1980s the vaccination regime after exposure was still 20-30 shots ... Not 4. It's improved a lot but it's still pretty sucky by routine vaccination standards. It's also pretty expensive in humans though presumably governments could reduce that as desired.

In the West, most people who have been potentially exposed know they have been potentially exposed, excluding pre-verbal children and drunks who sleep through a bat bite. I got to learn alllllll about this when my pre-verbal child was potentially exposed ... Its pretty unusual for people to NOT know they may have been exposed to rabies in the US. Although I did ask my vet, if I dressed my kids in dog costumes, would he vaccinate them prophylactically? (No.)
posted by Eyebrows McGee at 10:04 PM on September 28, 2014 [7 favorites]

Why do humans need a whole series of shots while dogs only need one every three years?
posted by Camofrog at 10:08 PM on September 28, 2014

And why is the vaccine so ineffective? Because the virus hides out in the nervous system?
posted by Camofrog at 10:10 PM on September 28, 2014

Regarding eradication, since it basically never passes human to human, you would have to eradicate it in bats (and other mammals - in the US, skunks, raccoons, and foxes), which would be essentially impossible. (The UK was rabies free for ONE HUNDRED YEARS until a Scottish guy got himself bit by a surprise rabid bat.) Vaccination of human-adjacent pets and livestock NEARLY removes the risks for humans and wild animal scratches and bites can otherwise be reported. Even if it's eradicated from humans, we'd stop vaccinating when the risk fell to essentially zero (as we have with smallpox), but the infection vector would never disappear.

Maybe if the vaccine continues to improve we will widely vaccinate against it in countries where it's endemic one day.
posted by Eyebrows McGee at 10:15 PM on September 28, 2014 [7 favorites]

True, but I still think, sadly, there's a component of global privilege. American travelers going to places with high rates of human rabies routinely receive a prophylactic vaccine (not as intense as the post-exposure vaccines) that most locals don't get; and vets, and others who work with animals, commonly are pre-vaccinated as well. There are nations/regions with high enough human rabies rates that might warrant emphasis on development of better prophylactic vaccines...
posted by third rail at 10:26 PM on September 28, 2014

Pets are routinely boostered, and humans getting rabies boosters require fewer shots, just like pets. I think humans get two for the booster; dogs and cats get one. (Also, the three year vaccine for cats and dogs is pretty new ... Just this last decade in wide use. Before that it was yearly boosters.) Time between boosters may have to do with body size - we learned that mattered during our exciting rabies adventure, smaller animals die of it faster and show symptoms sooner - but I'm just guessing. It may just be we worry less about adverse reactions in pets and more about possible human exposure.

If your cat or dog is exposed to rabies, they will ALMOST CERTAINLY have blood drawn for "titers" to show how many rabies antibodies are in their blood from their most recent vaccination and whether it's enough. (If it isn't they can either give boosters and isolate the animals for a period of time, or destroy it.) Rabies vaccines protect your pet, but since rabies is not for fucking around, they will still double check if there is an actual exposure and there will still be needles. My cats who met the baby-stalking bat were, luckily*, up to date on their shots and after the vet checked them for bites and scratches (none) were declared free to go as there was no evidence of direct exposure AND their titers were good.

*and by "luckily" I mean "because I'm a responsible pet owner, yo, there is no luck involved here"
posted by Eyebrows McGee at 10:34 PM on September 28, 2014 [3 favorites]

I think unknowncommand has it. If you have a robust health care system, then post exposure prophylaxis is generally more cost effective. If you don't, then there are probably more pressing public health concerns (like water and sanitation) to take care of first.

By the way, modern rabies vaccines have much lower rates of adverse reactions that older types, and can be administered very cost effectively. There are many WHO publications/guidelines/fact sheets on this if you want to learn more.
posted by yonglin at 10:52 PM on September 28, 2014

Refrigeration may also be an issue. Countries without modern transportation, electrical, and refrigeration systems may have difficulty distributing the vaccine simply because of storage requirements. (At least some rabies vaccines require constant refrigeration but no freezing. Don't know if they all do.) Public health can hinge on really mundane questions of road infrastructure.
posted by Eyebrows McGee at 11:03 PM on September 28, 2014 [1 favorite]

Rabies vaccines are quite expensive, I see someone mentioned they're not as expensive above, but the last few times I've dealt with it the price tag was 1,000-1,200$.

At that price range, someone in charge of public health apparently decided that it's cheaper to kill the animal hosts.

As far as vaccine effectiveness, it's extremely effective. In fact, since rabies progresses so slowly, it's the only vaccine I know of that you can give post-exposure without adjuvant globulin and it still prevents disease.

Nearly all vaccines have their effectiveness dramatically fade over time. Ten years is pretty good.
posted by hobo gitano de queretaro at 12:40 AM on September 29, 2014

By way of anecdote, about 4 years ago my (British) daughter was required to get a Rabies vaccination before she could attend an American school in Tunisia. The vaccination required 3 shots over the space of about a month. I don't remember the shots being any more traumatic than any of the other vaccines she was required to get around the same time. The protection is meant to be valid for 10 years.

This was done on the NHS, so there was no cost to us. The NHS guidelines are that they don't generally provide the vaccine unless you are going to be in a place where there is a particular risk of rabies (I presume for the reasons given above).
posted by oclipa at 12:56 AM on September 29, 2014

I'm pretty sure that if you get the full series (even post-exposure prophylaxis) of rabies vaccine, you should be protected for 10 years. At least that's what the hospital told me when I got my series of shots.

Ask someone who has had it ... It is a terribly unpleasant series of shots. It requires four closely and precisely spaced shots plus an immune globulin shot.

Actually, as someone who's received these shots (minus immunoglobulin, but I'll get to that in a second), they were not traumatic at all. I had to get a tetanus booster because I couldn't remember when was the last time I got that one. The tetanus shot definitely left me more sore than the rabies ones. Yes, I had to be sure that I was in the hospital on specific days to get the next shot, but that's far from traumatic. I only paid $400HK for my shots, which was basically $100HK per hospital trip.

I luckily did not have to get the immunoglobulin since I was nipped by a "stray" dog (he adopted people but wasn't really officially a pet nor did he have his shots). Because Hong Kong has been rabies free for quite a while, the hospital didn't give me the immunoglobulin.

On the other hand, a friend of mine was bitten by a monkey in Bali. Since rabies is an actual concern, the hospital she went to there gave her the immunoglobulin. The imunoglobulin is administered strictly by weight (the nurse weighed my friend 5 times on 2 scales before she received the immunoglobulin). She ended up paying a couple of thousand US (the exact amount escapes me) for her rabies immunoglobulin, 1st dose, antibiotics, and anti-viral pills (apparently simian herpes is a thing).
posted by astapasta24 at 1:47 AM on September 29, 2014

Fwiw, my colleagues who study bats are all up to date on their rabies vaccines. If exposure is likely you get the shots. Otherwise it is not necessary. Vaccines are used for common illnesses because they are cheaper and easier than dealing with an epidemic, but rabies is not an epidemic disease.

Rabies death sucks. But death sucks. Dying of cholera? Dysentery? Frickin awful. Don't let radio lab scare you into thinking that death from rabies is just the god awfullest.
posted by Made of Star Stuff at 4:21 AM on September 29, 2014 [2 favorites]

>Ask someone who has had it ... It is a terribly unpleasant series of shots.

*raises hand* The only unpleasantness was going in on Halloween and getting a shot in the ass by a clown. They don't do them in your stomach anymore. However, patient compliance being what it is, "get one shot per week for the next month and be covered for a very unlikely occurrence for 10 years" just doesn't fly unless you are in a higher-risk population like an exotics vet. 40,000 deaths per year worldwide means that a human dying from rabies is incredibly rare, and presumably that money is better spent on diseases that cause more deaths.

On the other hand, I can tell you that "get one shot per week for the next month because you got nipped by a rabid pony and this is better than rabies" is a pretty effective strategy for patient compliance, even for the needle- (and clown-) phobic. For those of us lucky enough to be in close proximity to good medical care, prophylaxis works great.
posted by tchemgrrl at 7:50 AM on September 29, 2014 [3 favorites]

I've had the old fashion series of shots. The WHO has clinics in many nations where you can get it for free. I was bit by a wild dog and had to endure 12 shots, one a day. Then a week off, then 2 shots over two days, a week off and then another shot. The shot was to the abdomen, hurt like hell and left a welt that burned with each breath all day long. After a languid day of painful breathing I'd retire for a night of fever dreams.

I suspect that the modern treatment has patent protection and the old treatment does not. Was this discused in the radiolab show?
posted by bdc34 at 8:41 AM on September 29, 2014

Radiolab did not go into patent law.
posted by Camofrog at 9:06 AM on September 29, 2014

I work in vaccine policy/regulatory affairs, albeit on the animal side. When you ask why we don't have a long-term eradication plan for rabies, you are asking a question that is both a scientific one, as well as one of public policy. Most the discussion above deals with the scientific side - something I could go on all day about, but I'll try to limit my answer to the less addressed one.

We have, to date, only eradicated two infectious diseases: smallpox and rinderpest. The reason we could do that was because we could treat a sufficient number of the at-risk population, had good vaccines, could limit transmission between "free" and "not-free" geographies, and killed a ton of people/animals.

The rabies vaccines we have are very difficult to administer to people en mass because they take a series of shots over time. Small pox could be immunized against with a single shot that was freeze dried to free it from the cold-chain.

Rabies is a virus that infects many different species, some of which - bats - fly. Smallpox was only transmitted between humans, whose travel between countries could be limited. It was also very easy to see who had been treated, because they had a visible scar.

Between routine vaccination of domestic animals and an effective post-exposure treatment regime, we have decreased the number of deaths significantly. This makes an eradication program a difficult expense to justify, especially considering all the other complicating factors involved.
posted by gagoumot at 2:52 PM on September 29, 2014 [2 favorites]

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