” Vaccine is then administered alone with delay before seeking further

medical care. This may be too late as injected immunoglobulin will then interfere Epigenetic activity inhibition with the native immune response generated by vaccine administered more than 7 days earlier. This increases the risk of treatment failure.[3] A recent study from Switzerland brought this issue to our attention.[4] Original WHO guidelines stressed the production of long-lasting antibody levels at the expense of reaching the highest possible early immune response capable of killing the virus at the inoculation sites. This, before it attaches itself to nerve endings and starts to ascend centrally. Once the virus enters the nerves, it is in a partly immune-protected environment. In the early 1970s, there were at least four postexposure prophylaxis vaccination schedules in use worldwide. These treatment methods continued the tradition of lengthy injection schedules dating back to days of poorly immunogenic brain-tissue-derived Semple vaccines. Initially, these 3-month treatments also required six clinic visits to be completed.[5] Lack of better understanding of the pathophysiology and immunology of rabies were the reasons for

Ganetespib clinical trial continuing these lengthy regimens. This, even though Dean and Baer had already shown, in animal studies in 1963, that neutralizing the virus at the inoculation sites is possible and can save additional lives.[6] At the turn of the century,

it became apparent that modern tissue and avian culture rabies vaccines are potent BCKDHB and result in long-lasting immune memory.[7] Bitten subjects, even when administered potent vaccines in a timely manner, may still require additional passive immunity (rabies immunoglobulin) to cover the “window period” before vaccine-generated virus-killing antibody appears in circulation. This is not before at least 7 days after start of a vaccine series.[3] Treatment failures, in patients who received vaccine alone or were given immunoglobulin that was not injected into all bite wounds, are still being reported.[8] Vaccination alone is effective in most rabies-exposed subjects. This is due to the fact that only some bites result in early virus invasion into nerves. Virus excretion in saliva varies in rabid dogs and cats and the viral inoculum may range from none to very high levels. We cannot predict which patient will succumb without wound injection and which one might survive with vaccination alone. Many less advanced rabies-endemic countries, being aware of this, have not provided costly immunoglobulins for the public sector. This was documented in the recent Bali rabies epidemic.[9] Risk factors for rabies postexposure treatment failures are high viral load, bite site near peripheral nerve endings, immunocompromised host, and more virulent virus strain.