, Volume 14, Issue 4, pp 365–383 | Cite as

A Review of the Economics of the Prevention and Control of Rabies

Part 1: Global Impact and Rabies in Humans
Review Article


The existing literature on the economics of rabies and its control can be characterised as a poorly documented set of cost estimates with insufficient information to allow replication of the analyses. Most articles have numerous ‘violations’ of the standard recommended procedures for assessing the burden of disease and the cost and benefits of interventions. Per capita costs are often crudely extrapolated from small to large populations without allowing for geographic differences in incidence. Furthermore, most studies do not distinguish between financial charges and true economic costs, and only a few articles contain a multiyear framework, complete with discounting of future costs and benefits.

With the exception of the increase in average incidence of postexposure prophylaxes (PEPs) in Asia, the average incidences of both human-rabies cases and PEPs in Africa, the Americas and Europe have not changed significantly over time. There are, however, large differences between countries within a region and regional averages can conceal notable changes in incidences over time for a given country. The largest number of human-rabies cases occur in developing countries due to the low levels of vaccination among dogs, the high cost of biologicals for PEP and problems of availability.

The costs (1995 values) of PEP range from $US1707 per person in Massachusetts, US, to $US2.50 for a complete series of vaccinations (without immunoglobulin) using sheep-derived vaccines in Karachi, Pakistan. Most studies which reported the cost of PEP, however, provided only direct medical costs and did not consider indirect costs such as lost productivity due to death, permanent disability or time spent while receiving medical care. Given the expense of controlling rabies in dogs and wildlife, there is an urgent need to develop a cheaper humanrabies vaccine or further refine the ‘low-dose’ PEP regimes. PEP is often given unnecessarily, and experience with expert consultations systems and algorithms has shown that the rate, and therefore total cost, of PEP can be significantly reduced. However, because it may be difficult to identify lesions from a bite by a bat, algorithms may be of less value when dealing with possible exposure to bat rabies. Using US prices and values, only 2 individuals per 1000 possible contacts have to be at risk from bat rabies in order for it to be economically justifiable to give PEP to all those potentially exposed to bat rabies. With regard to pre-exposure vaccination, routine use of pre-exposure has generally not been shown to be cost effective.


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  1. 1.
    Baer GM. Rabies: a historical perspective. Infect Agents Dis1994; 3(4): 168–80PubMedGoogle Scholar
  2. 2.
    Baer GM, Neville J, Turner GS. Rabbis and rabies: a pictorialhistory of rabies through the ages. Mexico City: LaboratoriosBaer, S.A. de C.V., 1996Google Scholar
  3. 3.
    Haddix AC, Teutsch SM, Shaffer PA, et al., editors. Preventioneffectiveness: a guide to decision analysis and economic evaluation.New York: Oxford University Press, 1996Google Scholar
  4. 4.
    Gold MR, Siegel JE, Russell LB, et al., editors. Cost-effectivenessin health and medicine. New York: Oxford UniversityPress, 1996Google Scholar
  5. 5.
    Drummond MF, O’Brien B, Stoddart GL, et al. Methods for theeconomic evaluation of health care programmes. 2nd ed. NewYork: Oxford University Press, 1997Google Scholar
  6. 6.
    Kuwert E, Mérieux C, Koprowski H, et al., editors. Rabies inthe tropics. New York: Springer-Verlag, 1985CrossRefGoogle Scholar
  7. 7.
    World Health Organization (WHO). Report of a symposium onrabies control in Asia, 1993 Apr 27-30: Jakarta. Geneva:WHO, 1993. Report no.: WHO/Rab.Res/93.44Google Scholar
  8. 8.
    Baer GM, editor. The natural history of rabies. 2nd ed. BocaRotan (FL): CRC Press, 1991Google Scholar
  9. 9.
    Smith JS. New aspects of rabies with emphasis on epidemiology,diagnosis, and prevention of the disease in the UnitedStates. Clin Microbiol Rev 1996; 9(2): 166–76PubMedGoogle Scholar
  10. 10.
    World Health Organization (WHO). Expert Committee on Rabies:eighth report. Geneva: WHO, 1992. WHO technical reportseries no.: 824Google Scholar
  11. 11.
    World Health Organization (WHO) Working Group. Recommendationsof working group on the epidemiology and controlof rabies. In: Thraenhart O, Koprowski H, Bögel K, et al.Progress in rabies control. Proceedings of the Second InternationalIMVI ESSEN/WHO Symposium on New Developmentsin Rabies Control; 1988 Jul 5–7: Essen. RoyalTunbridge Wells: Well Medical Limited, 1989: 567-68Google Scholar
  12. 12.
    World Bank. World development report 1993. New York: OxfordUniversity Press, 1993Google Scholar
  13. 13.
    Gibbons A. Researchers fret over neglect of 600 million patients[news & comments]. Science 1992; 256: 1135PubMedCrossRefGoogle Scholar
  14. 14.
    World Health Organization (WHO). World survey of rabies no.29 for the year 1993. Geneva: WHO, 1996. Report no.:WHO/EMC/ZOO/96.2Google Scholar
  15. 15.
    World Health Organization (WHO). World survey of rabies no.30 for the year 1994. Geneva: WHO, 1996. Report no.:WHO/EMC/ZOO/96.3Google Scholar
  16. 16.
    Bögel K, Motschwiller E. Incidence of rabies and post-exposuretreatment in developing countries. Bull World HealthOrgan 1986; 64(6): 883–7PubMedGoogle Scholar
  17. 17.
    Larghi OP, Arrosi JC, Nakajata-A J, et al. Control of urbanrabies. In: Campbell JB, Charlton KM, editors. Rabies. Boston: Kluwer Academic press, 1988: 408–22Google Scholar
  18. 18.
    World Bank. World tables, 1987. 4th ed. Washington, D.C.: World Bank, 1988Google Scholar
  19. 19.
    World Health Organization (WHO). World survey of rabies no.27 for the year 1991. plGeneva: WHO, 1993. Report no.:WHO/RABIES/93.209Google Scholar
  20. 20.
    World Health Organization (WHO). World survey of rabies no.28 for the year 1992. Geneva: WHO, 1994. Report no.:WHO/RABIES/94.210Google Scholar
  21. 21.
    World Health Organization (WHO). World survey of rabiesXXI for the years 1982/83. Geneva: WHO, 1984. report no.:WHO/RABIES/84.195Google Scholar
  22. 22.
    Ott L. An introduction to statistical methods and data analysis.North Scituate (MA): Duxbury Press, 1977Google Scholar
  23. 23.
    Zoonoses control: rabies situation and trends in Asia [reportfrom a conference]. Wkly Epidemiol Rec 1997; 72: 266–8Google Scholar
  24. 24.
    Kingnate D, Sagarasaeranee P, Choomkasien P. Rabies controlin Thailand (human side). Proceedings of the Third International Symposium on Rabies Control in Asia; 1996 Sep 11–15:Wuhan, China. Geneva: World Health Organization, 1996.Report no.: WHO/EMC/ZOO/96.8Google Scholar
  25. 25.
    Thraenhart O, Koprowski H, Bögel K, et al. Progress in rabiescontrol. Proceedings of the Second International IMVI ESSEN/WHO Symposium on New Developments in Rabies Control; 1988 Jul 5-7: Essen. Royal Tunbridge Wells: WellMedical Limited, 1989Google Scholar
  26. 26.
    World Health Organization (WHO). Proceedings of the ThirdInternational Symposium on Rabies Control in Asia; 1996Sep 11–15: Wuhan, China. Geneva: WHO, 1996. Report no.:WHO/EMC/ZOO/96.8Google Scholar
  27. 27.
    Müller WW. Review of reported rabies case data in Europe tothe WHO Collaborating Centre Tübingen from 1977 to 1996.Rabies Bull Eur 1996; 20: 11–8Google Scholar
  28. 28.
    Meslin FX, Fishbein DB, Matter HC. Rationale and prospectsfor rabies elimination in developing countries. In: RupprechtCE, Dietzschold B, Koprowski H, editors. Lyssaviruses. NewYork: Springer-Verlag, 1994: 1–26Google Scholar
  29. 29.
    Fishbein DB, Miranda NJ, Merrill, et al. Rabies control in theRepublic of the Philippines: benefits and costs of elimination.Vaccine 1991; 9: 581–7PubMedCrossRefGoogle Scholar
  30. 30.
    Wilde H, Chutivongse S. Rabies in Thailand: economic perspectivesand the intradermal vaccine regimen. In: ThraenhartO, Koprowski H, Bögel K, et al.,. Progress in rabiescontrol. Proceedings of the Second International IMVI ESSEN/WHO Symposium on New Developments in RabiesControl; 1988 Jul 5–7: Essen. Royal Tunbridge Wells: WellMedical Limited, 1989: 529-35Google Scholar
  31. 31.
    Helmick CG. The epidemiology of human rabies post-exposureprophylaxis, 1980-1981. JAMA 1983; 250: 1990–6PubMedCrossRefGoogle Scholar
  32. 32.
    Fischman HR. Rabies. Johns Hopkins Magazine 1984 Aug; 8–15Google Scholar
  33. 33.
    Tinline RR. Persistence of rabies in wildlife. In: Campbell JB,Charlton KM, editors. Rabies. Boston: Kluwer AcademicPublishers, 1988: 301–22CrossRefGoogle Scholar
  34. 34.
    Sherman KM. Rabies control in Florida with special referenceto innovative programs in other states. Florida J Pub Health1990; 2(2): 2–6Google Scholar
  35. 35.
    Fishbein DB, Arcangeli S. Rabies prevention in primary care:a four step approach. Postgrad Med 1987; 82(3): 83–95PubMedGoogle Scholar
  36. 36.
    Uhaa IJ, Dato VM, Sorhage FE, et al. Benefits and costs of usingan orally absorbed vaccine to control rabies in raccoons. J Am Vet Med Assoc 1992; 201(12): 1873–82PubMedGoogle Scholar
  37. 37.
    Bellani L, Gagliardi G, Mantovani A, et al. Epidemiology,socio-economic importance and control of rabies in Italy [inItalian]. Veterinaria Ital 1975; 26: 23–31Google Scholar
  38. 38.
    Curk A. Economic losses due to rabies in Slovenia. Zb Vet Fak Univ Ljubljana 1990; 27 (2): 195–9Google Scholar
  39. 39.
    US Bureau of the Census. Statistical abstract of the UnitedStates: 1996. 116th ed. Washington, D.C.: US Bureau of theCensus, 1996Google Scholar
  40. 40.
    Göpfertová D, Walter G. Economic costs and losses in anti-rabicprophylaxis [in Czech]. Cs Epidemiol 1982; 32(6): 342–8Google Scholar
  41. 41.
    Diaz PT, Nóvoa A, Cliff J. Rabies in Mozambique [in Portuguese].Rev Med Mocambique 1987; 3(2): 17–23Google Scholar
  42. 42.
    Edelsten RM. Epidemiology and control of rabies in Malawi.Trop Anim Health Prod 1995; 27: 155–63PubMedCrossRefGoogle Scholar
  43. 43.
    World Health Organization (WHO). WHO recommendationson rabies post-exposure treatment and the correct technique of intradermal immunization against rabies. Geneva: WHO,1997. Report no.: WHO/EMC/ZOO.96.6Google Scholar
  44. 44.
    Nicholson KG. Modern vaccines: rabies. Lancet 1990; 335:1201–5PubMedCrossRefGoogle Scholar
  45. 45.
    Dupuy JM, Freidel L. Lag between discovery and productionof new vaccines for the developing world [viewpoint]. Lancet1990; 336: 733–4PubMedCrossRefGoogle Scholar
  46. 46.
    Vodopija I, Clark HF. Human vaccination against rabies. In:Baer GM, editor. The natural history of rabies. 2nd ed. BocaRotan (FL): CRC Press, 1991: 571–95Google Scholar
  47. 47.
    Facts and Comparisons, Inc. Drug facts and comparisons. 1996ed. St. Louis (MO): Facts and Comparisons, Inc., 1996Google Scholar
  48. 48.
    Warrell DA, Warrell MJ. Human rabies and its prevention: anoverview. Rev Infect Dis 1988; 10 Suppl. 4: 726S–31SCrossRefGoogle Scholar
  49. 49.
    Morrison AJ, Hunt EH, Atuk NO, et al. Rabies pre-exposureprophylaxis using intradermal human diploid vaccine: immunologicefficacy and cost-effectiveness in a university medicalcenter and a review of selected literature. Am J Med Sci1987; 293(5): 293–7PubMedCrossRefGoogle Scholar
  50. 50.
    Medical Economics Company, Inc. The Red Book, 1996.Montvale (NJ): Medical Economics Company, Inc., 1996Google Scholar
  51. 51.
    Nicholson KG, Warrell MJ, Warrell DA, et al. Economical regimensof human diploid cell strain antirabies vaccine for postexposureprophylaxis. In: Kuwert E, Mérieux C, KoprowskiH, et al., editors. Rabies in the tropics. New York: Springer-Verlag, 1985: 209–20Google Scholar
  52. 52.
    Thraenhart O, Marcus I, Scheiermann N, et al. 3-1 scheme, aregimen of only two clinical visits with optimal antibody andinterferon-induction. In: Thraenhart O, Koprowski H, BögelK, et al. Progress in rabies control. Proceedings of the SecondInternational IMVI ESSEN/WHO Symposium on New Developmentsin Rabies Control; 1988 Jul 5–7: Essen. RoyalTunbridge Wells: Well Medical Limited, 1989: 536-47Google Scholar
  53. 53.
    Swaddiwudhipong W, Prayoonwiwat N, Kunasol P, et al. A highincidence of neurological complications following Sempleanti-rabies vaccine. Southeast Asian J Trop Med PublicHealth 1987; 18 (4): 526–31PubMedGoogle Scholar
  54. 54.
    Greenwood M. Tenth report on data of anti-rabies treatmentssupplied by Pasteur Institutes. Bull World Health Organ 1945;12: 30Google Scholar
  55. 55.
    Sellers TF. Rabies, the physician’s dilemma. Am J Trop MedHyg 1948; 28: 453–6PubMedGoogle Scholar
  56. 56.
    Peck FB, Powell HM, Culbertson CG. A new antirabies vaccinefor human use: clinical and laboratory results using rabiesvaccine made from embryonated duck eggs. J Lab Clin Med 1955; 45: 679–83PubMedGoogle Scholar
  57. 57.
    Swaddiwuthipong W, Weniger BG, Wattanasri S, et al. A highrate of neurological complications following Semple anti-rabiesvaccine. Trans R Soc Trop Med Hyg 1988; 82: 472–5PubMedCrossRefGoogle Scholar
  58. 58.
    Held JR, Lopez-Adaros HL. Neurological disease in man followingadministration of suckling-mouse brain antirabiesvaccine. Bull World Health Organ 1972; 46: 321–7PubMedGoogle Scholar
  59. 59.
    Hemachuda T, Phanuphak P, Johnson RT, et al. Neurologicalcomplications of a Semple-type rabies vaccine: clinical andimmunological studies. Neurology 1987; 37: 550–6CrossRefGoogle Scholar
  60. 60.
    Majchrowicz H.Evaluation of rabies prophylaxis in people ofSzczecin region in the years of 1986-1991 [in Polish]. AnnAcad Med Stetin 1995; 41: 171–82Google Scholar
  61. 61.
    Thraenhart O, Marcus I, Kreuzfelder E. Current and future immunoprophylaxisagainst human rabies: reduction of treatment failures and errors. In: Rupprecht CE, Dietzschold B, Koprowski H, editors. Lyssaviruses. New York: Springer-Verlag,1994: 173–94CrossRefGoogle Scholar
  62. 62.
    Wilde H, Sirikawin S, Sabcharoen A, et al. Failure of post-exposuretreatment of rabies in children. Clin Infect Dis 1996;22: 228–32PubMedCrossRefGoogle Scholar
  63. 63.
    Rupprecht CE, Smith JS, Krebs J, et al. Current issues in rabiesprevention in the United States: health dilemmas, public coffers,private interests. Public Health Rep 1996; 111: 400–7PubMedGoogle Scholar
  64. 64.
    Auslander M, Kaelin C. Rabies post-exposure prophylaxis survey:Kentucky, 1994. Emerg Infect Dis 1997; 3 (2): 199–202PubMedCrossRefGoogle Scholar
  65. 65.
    Mann JM, Burkhart MJ, Rollag OJ. Anti-rabies treatments in New Mexico: impact of a comprehensive consultation-biologicssystem. Am J Public Health 1980; 70 (2): 128–32PubMedCrossRefGoogle Scholar
  66. 66.
    Kriendel SM, McGuill M, Meltzer MI, et al. Rabies postexposureprophylaxis: the Massachusetts experience. Public Health Rep 1998; 113: 247–51Google Scholar
  67. 67.
    Centers for Disease Control and Prevention. Dog-bite-relatedfatalities: United States, 1995-1996. MMWR Morb MortalWkly Rep 1997; 46 (21): 463–7Google Scholar
  68. 68.
    Berzon DR, DeHoff JB. Medical costs and other aspects of dogbites in Baltimore. Public Health Rep1974; 89: 377–81PubMedGoogle Scholar
  69. 69.
    Stephen C, Daly P, Martin M. The public health response tosuspected rabies exposure in British Columbia (1989–1994). Can Vet J 1996; 37: 163–4PubMedGoogle Scholar
  70. 70.
    Lontai I. Human rabies infection is a real danger: possibilitiesof the prevention [in Hungarian]. Magy Állatorvosok Lapja1995; 50: 111–5Google Scholar
  71. 71.
    Noah DL, Smith MG, Gotthardt JC, et al. Mass human exposureto rabies in New Hampshire: exposures, treatment, and costs.Am J Public Health 1996; 86(8):1149–51PubMedCrossRefGoogle Scholar
  72. 72.
    Centers for Disease Control and Prevention. Animal rabies:South Dakota, 1995. MMWR Morb Mortal Wkly Rep 1996;45 (8): 164–6Google Scholar
  73. 73.
    Centers for Disease Control and Prevention. Post-exposure rabiestreatment: Georgia. MMWR Morb Mortal Wkly Rep 1977; 26 (11): 92Google Scholar
  74. 74.
    Centers for Disease Control and Prevention. Human rabies: California,1987. MMWR Morb Mortal Wkly Rep 1988; 37 (19):305–8Google Scholar
  75. 75.
    Woodruff BA, Jones JL, Eng TR. Human exposures to rabiesfrom pet raccoons in South Carolina and West Virginia, 1987through 1988. Am J Public Health 1991; 81 (10): 1328–30PubMedCrossRefGoogle Scholar
  76. 76.
    Centers for Disease Control and Prevention. Rabies post-exposureprophylaxis: Connecticut, 1990-1994. MMWR Morb Mortal Wkly Rep 1996; 45(11): 232–4Google Scholar
  77. 77.
    Meltzer MI, Teutsch SM. Setting priorities for health needs,managing resources. In: Stroup DF, Teutsch SM, editors.Quantitative solutions to public health problems. New York: Oxford University Press, 1998: 123–49Google Scholar
  78. 78.
    Dufour B, Aubert M, Bonnel A, et al. Financial results of bovinerabies prevention program in France in 1987 [in French]. Le Point Vétérinaire 1989; 21 (122): 523–8Google Scholar
  79. 79.
    Wilde H, Thipkong P, Sitprija V, et al. Heterologous antisera andantivenins are essential biologicals: perspectives on a worldwidecrisis. Ann Intern Med 1996; 125: 233–6PubMedGoogle Scholar
  80. 80.
    Dutta JK. Rabies prevention: cost to an Indian laborer [letter].JAMA 1996; 276(1): 32PubMedCrossRefGoogle Scholar
  81. 81.
    Parviz S. Public health perspective of rabies prevention andcontrol in Pakistan. Proceedings of the Third International Symposium on Rabies Control in Asia; 1996 Sep 11-15:Wuhan, China. Geneva: World Health Organization, 1996.Report no.: WHO/EMC/ZOO/96.8Google Scholar
  82. 82.
    Bögel K, Meslin FX. Economics of human and canine rabieselimination: guidelines for programme orientation. Bull World Health Organ 1990; 68(3): 281–91PubMedGoogle Scholar
  83. 83.
    Rodriguez Torres JG, Cuellar AM, Rauda Esquivel J. The costof medical care for persons bitten by dogs in Ciudad Juarez,Mexico [in Spanish]. Bol Oficina Sanit Panam 1983; 95(4):327–32PubMedGoogle Scholar
  84. 84.
    Mann JM. Routine pre-exposure rabies prophylaxis: a reassessment.Am J Public Health 1984; 74(4): 720–2PubMedCrossRefGoogle Scholar
  85. 85.
    LeGuerrier P, Pilon PA, Deshaies D, et al. Pre-exposure rabiesprophylaxis for the international traveler: a decision analysis.Vaccine 1996; 14: 167–76CrossRefGoogle Scholar
  86. 86.
    Bernard KW, Fishbein DB. Pre-exposure rabies prophylaxis fortravellers: are the benefits worth the cost? Vaccine 1991; 9:833–685 Lang 85.PubMedCrossRefGoogle Scholar
  87. 85.
    Lang J, Hoa DQ, Gioi NV, et al. Randomized feasibility trial of pre-exposure rabies vaccination with DTPIPV in infants. Lancet 1997; 349: 1663–5PubMedCrossRefGoogle Scholar
  88. 88.
    Middaugh J, Ritter D. A comprehensive rabies control programin Alaska. Am J Public Health 1982; 72(4): 38–6CrossRefGoogle Scholar
  89. 89.
    Fishbein DB, Robinson LE. Rabies. N Engl J Med 1993; 329(22): 1632–8PubMedCrossRefGoogle Scholar
  90. 90.
    Cantor SB, Clover RD, Thompson RF. A decision-analytic approachto post-exposure rabies prophylaxis. Am J Public Health1994; 84: 1144–8PubMedCrossRefGoogle Scholar
  91. 91.
    Bisseru B. Rabies. London: William Heinemann MedicalBooks, 1972Google Scholar
  92. 92.
    Kaplan C. Rabies: a worldwide disease. In: Bacon PJ, editor.Population dynamics of rabies in wildlife. London: AcademicPress, 1985: 1–22Google Scholar
  93. 93.
    Medicode. Fee and coding standard. Salt Lake City (UT): Medicode, 1997Google Scholar
  94. 94.
    Medicare program: changes to the hospital inpatient prospectivepayment systems and fiscal year 1998 rates. Fed Regist1997; 62(168): 46066–116Google Scholar

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© Adis International Limited 1998

Authors and Affiliations

  1. 1.Office of the DirectorNational Center for Infectious Diseases, Centers for Disease Control and PreventionAtlantaUSA
  2. 2.Rabies Section, Viral and Rickettsial Zoonoses Branch, National Center for Infectious DiseasesCenters for Disease Control and PreventionAtlantaUSA

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