Different routes of administration of cell culture rabies vaccines.

Sir,

Kudos to the team of Asma Rahim for highlighting the economic advantages of using intradermal regimen in antirabies treatment in resource-starved countries like ours.(1) It is true that it also reduces the indirect cost involved in terms of man hour cost, travel time, and expenses for one extra visit in intramuscular regimen. I would like to highlight the problem faced by medical institutions while delivering antirabies prophylaxis services.

The Drug Controller General of India approved the use of intradermal route of administration of cell culture vaccines from February 2006.(2) But its use is still in infancy. ID regimen is being used in public health (primary and secondary care centers) while IM regimen is being used in medical institutions (tertiary care centers) for antirabies management in Maharashtra. At times the patient has to change the healthcare facility for continuation of ongoing treatment due to various reasons like stock not available at the center, shift of residence or other social causes. In such cases it is impractical to change the route of administration between an ongoing regimen. Hence a new schedule/regimen with different route of administration has to be started. This results in wastage of resources which are already scarce in government settings.

In a vast nation like India, health is a state issue. Thus, each state has its own policies.(3) The intradermal route for antirabies vaccination is followed in few states like Karnataka, Uttar Pradesh, and Orissa. For the proper prevention of the fatal disease, rabies, it is necessary that national guidelines should be put down to be followed alike by all states. Thus it is recommended that a similar line of treatment (the ID regimen) should be followed in all states, at all levels of healthcare delivery system, including private practitioners, all over India. This cost-effective intervention, which is expected to reduce the burden of human rabies in India, if coupled with suitable supportive canine population and rabies control activities, would make plausible the prospects of “Rabies Free India by 2020.”(4)