An ethical dilemma in rabies immunisation.

Rabies continues to be an important public health problem in India and many other developing countries. In India, annually some 700,000 persons are given post-exposure vaccine prophylaxis using Semple (sheep brain) vaccine. It is manufactured by government institutions and given free to the public. It is presumed to be cheap, although the actual cost of production may not be low. However, it is not a safe vaccine as it causes demyelinating central or peripheral nervous system side-effects in 1/3000-7000 persons vaccinated; this adverse reaction is occasionally fatal. Cell culture rabies vaccines are also available in India; unlike the Semple vaccine they are safe and can be used for pre-exposure vaccination, but they are more expensive. The dilemma is whether it is ethically acceptable to continue to use the Semple vaccine in humans while safer products are available. What is urgently needed is a decision tree which would enable economical use of cell culture vaccines together with the backing of professional bodies in medical practice, who will declare that cost is not the only factor in choosing a rabies vaccine-safety is also of paramount importance. We must also strive to reduce the cost of cell culture vaccines.