Failure of the temperature-controlled supply chain, or “cold chain”, is suspected in the death of a six-year-old girl who was bitten by a rabid dog last month in the northern Indian town of Mani Majra. Despite the rapid response of healthcare providers, the victim ultimately died from rabies.
Rabies is a vaccine-preventable viral disease that causes tens of thousands of deaths each year. The disease disproportionately affects poor, low-resource communities in Asia and Africa. Dog bites are the cause of the vast majority of rabies cases.
Virtually every rabies infection resulted in death prior to 1885, the year Louis Pasteur and Émile Roux developed the first rabies vaccination. Their vaccine consisted of virus harvested from infected rabbits, which was weakened by allowing it to dry for several days.
Today, manufacturers use an attenuated strain of the virus, which is given to an estimated 15 million people each year. Often combined with human rabies immune globulin (“HRIG”), which provides antibodies immediately following exposure for the most severe bites, a rabies prophylaxis regimen is believed to prevent hundreds of thousands of deaths annually.
While the dog-bite victim in India received appropriate wound care, as well as the rabies vaccine and HRIG within 10 to 12 hours of the attack, she ultimately succumbed to the disease. Dr. Vivek Lal and Dr. Atul Prashar, who attended to the victim, suspect vaccine failure, citing the normally high cure rate and the speed at which their team responded.
Dr. Lal, in his three decades of practice, had never seen a patient develop rabies after administering HRIG within the recommended treatment window. Similarly, Dr. Prashar had never seen a case in which rabies developed within 12 hours of being bitten.
Manufacturers recommend that HRIG be stored in a refrigerator between 2° and 8° Celsius and that batches that have been accidentally frozen should be discarded. If these guidelines were not followed in this case, it may have resulted in reduced potency.
There are occasional human rabies cases reported despite post-exposure treatment. In this case, because the victim suffered deep wounds to her face and scalp, the rabies virus may have been able to more quickly reach the victim’s brain. However, most rabies deaths have been reported due to delayed vaccination or non-use of HRIG for deep wounds, or incomplete course of vaccination.