CALL BACK STUDY
118 VOLUNTEER SUBJECTS, PREVIOUS PEP OR PREP WITH ANY
TISSUE CULTURE VACCINE 5 – 21 YEARS PREVIOUSLY
METHOD
COLLECT SERUM DAYS 0, 5, 7, 14 FOR NEUTRALIZING ANTIBODY
BOOSTERS VERORAB ID 0.1 mL DAYS 0 AND 3
RESULTS
VACCINE 5- 10 YEARS PREVIOUSLY (PEP,PREP)
VACCINE 10-21 YEARS PREVIOUSLY (PEP.PREP)
65
53
DETECTABLE TITERS ON DAY 0
ANAMNESTIC RESPONSE ON DAY 5
HIGH TITERS ON DAYS 7 AND 14
118
118
118
(Suwansrinon K, Wilde H, Benjavongkulchai M, et al. Vaccine 2006;24: 3878-80)
CALL BACK STUDY DATA
(NABs done by RFFIT test at QSMI. Cut off: > 0.03 )
Group
IU/mL
Day 0
Day 5
Day 7
Day 14
PREP 5-10 Y
GMT
0.64
0.92
3.72
23.48
Range
0.03-8.00
0.04-12.34
0.50-20.89
4.82-67.72
-------------------------------------------------------------------------------------------------------------PEP 5-10 Y
GMT
1.22
1.77
5.42
15.67
Range
0.18-25.94
0.25-30.84
1.25-54.18
4.00-73.85
-------------------------------------------------------------------------------------------------------------PREP 10-21 Y
GMT
1.64
2.40
6.39
20.76
Range
0.07-11.97
0.16-19.15
0.81-24.84
3.26-383.09
---------------------------------------------------------------------------------------------------------------PEP 10-20 Y
GMT
1.30
2.30
6.57
21.29
Range
0.08-16.71
0.11-30.84
0.48-35.12
3.54-135.44
---------------------------------------------------------------------------------------------------------------
PEP FAILURE, MANAGEMENT ERROR
1985
•
DAY 0: THAI MALE 41 YEARS,
•
DOG BITE UPPER LIP DEEP
•
Day 0: WOUND CARE, HDCV IM gluteus
•
DAY 2: HRIG IM INTO GLUTEAL REGION. WOUND NOT INFILTRATED
HDCV 1 AMP IM DELTOID
•
DAY 4: HDCV IM
•
DAY 7: HDCV IM
•
DAY 14 HEADACHE, FEVER, HDCV GIVEN AT 8 SITES 0.1 Ml ID
•
DAY 15: PROGRESSION TO HYDROPHOBIA, AEROPHOBIA, SPASMS
•
DAY 16: DEATH. NO AUTOPSY.
•
ERRORS: CAT III, WOUND NOT INJECTED. HDCV GLUTEUS
FROM QSMI COLLECTION
PEP FAILURE, MANAGEMENT ERROR
1987
•
THAI MALE 53 Y (BANGKOK)
•
•
•
•
•
•
•
•
•
•
•
•
•
•
DAY 0: BITTEN BY DOG WHICH DIED 4 DAYS LATER AND FAT
POSITIVE FOR RABIES. DEEP WOUNDS BOTH HANDS
AND FINGERS. APPROPRIATE WOUND CARE GIVEN.
DAY 6: DOG FAT POS. START PVRV ID. ERIG PASTEUR INTO WOUNDS
REST IM ( GLUTEUS)
DAY 9: PVRV ID 0.1 Ml x 2
Day 12: PVRV ID 0.1 Ml x 2
Day 26: FEVER, HEADACHE, NUMBNESS OF RT ARM AND
SHOULDER, LATER WEAKNESS OF HAND AND
DYSARTHRIA.
DAY 27: STILL COHERENT. NOW DYSEASTHESIA OF LT ARM.
ADMISSION TO CUH. START PHOBIC SPASMS,
AEROPHOBIA, SEIZURES, AND RAPID PROGRESSION.
DAY 28: DEATH. FAT POSITIVE
ERROR: CAT III. DELAY 6 DAYS
QSMI COLLECTION
PEP FAILURE, MANAGEMENT ERROR
1994
• THAI GIRL AGE 2.5 (BANGKOK )
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
DAY 0: BITTEN BY STREET DOG
MULTIPLE DEEP WOUNDS FACE.
APPROPRIAT WOUND CARE
SUTURES UNDER KETAMINE ANESTHESIA
PCEC VACCINE BY TRC ID REGIMEN
DAY 1: ERIG (BERNA) 40 IU/KG HALF INTO WOUNDS AND
REST IM ( GLUTEUS). NOT ALL WOUNDS INJECTED
DAY 3: PCEC ID 0.1 X 2
DAY 7: PCEC ID 0.1 X 2
DAY 10: ONSET OF TYPICAL FURIOUS RABIES WITH PHOBIC
SPASMA, AEROPHOBIA, HYDROPHOBIA.
HOSPITALIZED FOR COMFORT CARE.
DAY 17: DIED. NO AUTOPSY.
ERROR: CAT III, SUTURE OF WOUNDS BEFORE RIG
QSMI COLLECTION
PEP FAILURE, MANAGEMENT ERROR
1987
• THAI BOY AGE 9 Y (CHACHINGSAO)
•
•
•
•
•
•
•
•
•
•
•
DAY 0: BITTEN BY STREET DOG. SEVERE WOUNDS AT 12 SITES OF FACE,
HEAD, ARM. APPROPRIATE WOUND CARE
NOT ALL WOUND INJECTED WITH 4.2 mL ERIG (BERNA) UNDILUTED
PVRV ( PASTEUR MERIEUX) 1 mL IM DELTOID
DAY 3: PVRV IM
DAY 7: PVRV IM
DAY 14: PVRV IM
DAY 21: ONSET OF ENCEPHALITIC RABIES
DAY 25: DEATH. AUTOPSY POSITIVE FOR RABIES
ERROR: CAT III, NOT ALL WOUNDS INJECTED WITH ERIG
QSMI COLLECTION
PEP FAILURE, MANAGEMENT ERROR
2000
2000
•
•
•
•
•
Day 0:
THAI GIRL 7 YR, CHACHINGSAO
DOG BITE : FACE LEFT CHEEK, EYE BROW, ARM
WOUND CARE,
STARTED PET WITH 8-SITE ID REGIMEN (PCEC –CHIRON)
NO RIG AVAILABE
•
DAY 7:
4-SITE ID GIVEN. CHILD WELL
•
DAY 12: HEADACHE, FEVER, PAIN OVER LEFT EAR, HOSPITALIZED
•
•
•
DAY 13: WORSE, CONFUSED, AEROPHOBIA, SPASMS, AGGITATED,
ENT NEG, CT NEG, ROUTINE LAB, SPINAL FLUID
UNREMARKABLE.
•
DAY 14: COMATOUS, INTUBATED
•
DAY 15: DIED, NO AUTOPSY .
•
•
ERROR: CAT III, 8-SITE IN PLACE OF RIG
SRIAROON C. VACCINE 2003
PEP FAILURE, MANAGEMENT ERROR
2005
DAY 0: BURMESE FEMALE AGE 44, NORMAL HOST, DOG BITE IN BURMA, LACERATIONS
FACE INCLUDING NOSE. WOUND CARE IN BURMA WITH SUTURE. TRANSFER
TO THAI SIDE SAME DAY. WOUND INJECTED WITH ERIG (THAI RED CROSS
PEPSIN DIGESTED). STARTED ON PCEC IM DELTOID
DAY 3: PCEC IM
DAY 7: PCEC IM
DAY 14:PCEC IM
DAY 15: ONSET OF FURIOUS RABIES SYMTOMS
DAY 17: DEATH
(Potencies of vaccine and ERIG checked at US-CDC, all meet standards)
ERROR: CAT III, SUTURE BEFORE RIG INJECTION
QSMI COLLECTION
PEP FAILURE
1997
•
THAI FEMALE 72 Y (BANGKOK)
•
•
•
•
DAY 0: BITTEN BY UNKNOWN DOG. SMALL DEEP WOUND CHEEK
IMMEDIATE WOUND CARE.
WOUND INJECTED WITH ERIG (PASTEUR ) REST DELTOID
PVRV (PASTEUR-MERIEUX) IM DELTOID
•
DAY 3: PCEC (CHIRON) IM DELTOID
•
DAY 7: PCEC (CHIRON) IM
•
DAY 14: PCEC (CHIRON) IM
•
•
•
DAY 20: ONSET OF PARALYTIC RABIES. FULL ICU CARE
•
DAY 31: DEATH. AUTOPSY POSITIVE FOR RABIES
•
DAY 29: (SERUM ANTIBODIES 27 IU SERUM AND DETECTABLE IN CNS
T. HEMACHUDHA ET AL. CID. 1999; 28: 143-44
PEP FAILURE
1997
•
THAI BOY 9 (BANGKOK )
•
•
•
•
•
DAY 0: DOG BITE. SUPERFICIAL BLEEDING
SCRATCH OF NOSE AND CHEEK WITHOUT BLEEDING.
APPROPRIATE WOUND CARE .
WOUNDS INFILTRATED WITH ERIG PASTEUR REST IM.
PCEC CHIRON IM DELTOID.
•
DAY 3: PCEC IM DELTOID
•
DAY 7: PCEC IM DELTOID
•
DAY 14: PCEC IM DELTOID
•
DAY 30: ONSET OF FURIOUS RABIES
•
DAY 37: DEATH. AUTOPSY POSITIVE FOR RABIES
T. HEMACHUDHA ET AL. CID. 1999; 28: 143-44
WHY PEP FAILURES?
POOR OR NO WOUND CARE
VACCINE OF POOR QUALITY
RIG OF POOR QUALITY
NO RIG GIVEN AT ALL
NOT ALL BITE WOUNDS INJECTED
EXCEPTIONALLY LARGE VIRAL LOAD
VIRUS CLOSE TO NERVE
0R RAPIDLY NVASIVE VIRUS STRAIN
UNRELIABLE REPORTING
Child face
Hand bites
WHAT ARE WE MISSING?
Old data indicate as much as 40% rabies infection
rate can be avoided by energetic wound cleaning [1].
Wound cleaning and antisepsis is enshrined in WHO guidelines [2]
3 rabies PEP centers in India and Pakistan were visited
Each treated over 100 animal bites daily.
None had facility to clean wounds
We may many PEP failures by just washing wounds
•
1) Kaplan MM, Cohen D, Koprowski H, et al Studies on the local treatment of wounds for the
prevention of rabies. Bull WHO 1962;26:765-75.
•
2) WHO. Expert Committee on Rabies, Technical Report Series 824. Geneva 1992.
AN ARGUMENT FOR PREP
• IN RABIES HYPERENDEMIC REGIONS
WHERE DOG CONTROL IS FAILING
• FOR CHILDREN WHERE PEP NOT
READILY AVAILABLE OR WHO LIKELY
NOT REPORT EXPOSURES
• CAN BE DONE USING ID METHOD AND
MULTIPLE DOSE VIALS.