Emergency Medicine Executive Summary

Rabies is a zoonotic disease positioned as one of the most lethal viral infections; mortality approaches 100%. It is also preventable in nearly 100% of expositions when vaccination (+/- rabies immunoglobulin) has been properly administered.

Adult vaccination dose for post-exposure prophylaxis (PEP)

  • No prior immunization:
    5 doses IM, days 0-3-7-14-28

  • Prior immunization*:
    2 doses IM, days 0 and 3

*Complete 5 doses of PEP scheme or 3 doses of PrEP (pre-exposure prophylaxis).

About rabies

  • It is a zoonotic disease caused by RNA viruses in the Family Rhabdoviridae that is typically present in the saliva of clinically ill mammals (dogs contribute 99% of all transmissions to humans), and is transmitted through a bite.

  • After an incubation period of an average of 1-3 months (days to years) it enters the central nervous system causing an acute, progressively catastrophic encephalomyelitis (3). Up to 2022 there’ve been only 30 reported survivors worldwide (5, 6) and all but one of them received post-exposure prophylaxis before the onset of symptoms.

Vaccination and Immunoglobulin

Vaccination of rabies was pioneered in 1885 (1) and is now is globally recommended for pre-exposure and post-exposure prophylaxis (PrEP and PEP respectively)(3, 4, 5), for it is extremely successful in preventing the disease, being one of the most effective vaccines ever invented (5). It has an achievable cost-effectiveness when appropriately indicated (3, 5).

  • Rabies vaccines and immunoglobulin are periodically in short supply, it is important to follow current guidelines considering local epidemiology and individual risk in order to achieve public health goals.

  • There are different rabies vaccines depending on the production method, but dosing schemes are the same for all of them. Since 1984, the World Health Organization (WHO) has strongly recommended “discontinuation of production and use of nerve tissue vaccines and their replacement by modern, concentrated, purified cell culture and embryonated egg-based rabies vaccines (CCEEVs). Nerve tissue vaccines can induce severe adverse reactions more frequently and are less immunogenic than CCEEVs” (4).

  • For optimal immunogenic response it must be administered in the deltoid muscle, not in the gluteal area as it leads to lower antibody titers (2, 4, 5).

  • Two inactive virus vaccines (non nerve-tissue-based) are currently licensed by the US-FDA: RabAvert® and Imovax® (7). Other vaccines are widely authorized for their use in Eurasia, Latinamerica and Africa such as Verorab® (8).

Rabies Immunoglobulin (RIG)

Different management strategies have been proposed for RIG.

  • The US-CDC recommends it to be given routinely in all cases when vaccination is indicated for PEP with the only exception of individuals that have already received PrEP or complete PEP (day 0, with first dose of vaccine)(3).

  • WHO guidelines and other countries recommend RIG administration in selected cases, such as exposure to confirmed rabid dogs, bleeding bites to high innervated areas, and exposure to bites of high risk animals like bats. (4).

Note: every bite injury must be properly managed based upon local standard wound care, tetanus and rabies protocols.

Adult and Pediatric dose

Rabies Vaccination for Post-Exposure Prophylaxis (PEP)

  • No prior immunization:
    5 doses IM, days 0-3-7-14-28

  • Prior immunization*:
    2 doses IM, days 0 and 3


For adults and older children, the vaccine should be injected into the deltoid muscle (2, 4, 5). In infants and small children, the anterolateral aspect of the thigh may be preferable, depending on age and body mass.

References

  1. Pasteur L: Méthode pour prévenir la rage après morsure. Comptes Rendus 1885.
    Academie-Sciences

  2. Fishbein DB, Sawyer LA, Reid-Sanden FL, Weir EH. Administration of human diploid-cell rabies vaccine in the gluteal area. N Engl J Med. 1988;318(2):124-125. doi:10.1056/NEJM198801143180219.
    Pubmed

  3. Manning SE, Rupprecht CE, Fishbein D, et al. Human rabies prevention, United States, 2008: recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep. 2008;57(RR-3):1-28
    Pubmed

  4. World Health Organization. Rabies vaccines: WHO position paper, April 2018 - Recommendations. Vaccine. 2018;36(37):5500-5503. doi:10.1016/j.vaccine.2018.06.061.
    Pubmed

  5. Fooks AR, Jackson AC. Rabies. Fourth Edition. Academic Press; 2020.
    Elsevier

  6. Jackson AC. Rabies and Other Rhabdovirus Infections. In: Loscalzo J, Fauci A, Kasper D, Hauser S, Longo D, Jameson J. Harrison's Principles of Internal Medicine. 21th Edition. McGraw Hill; 2022.
    McGraw-Hill

  7. US-FDA (United States Food and Drug Administration) Purple Book, Database of Licensed Biological Products. Search: “Rabies Vaccine”, accessed May 2022.
    US-FDA Purple Book

  8. EMA (European Medicines Agency), List of nationally authorised medicinal products, Active substance: rabies vaccine, Procedure no.: PSUSA/00009277/202103. 28 October 2021, accessed May 2022.
    EMA

2021 EMDrugs. All rights reserved.

contact@emdrugs.com

DISCLAIMER

This website provides general information and discussion about medications, health, and related subjects. The words and other con­tent pro­vided in this website, and in any linked mate­ri­als, are not intended and should not be con­strued as med­ical advice. If the reader or any other per­son has a med­ical con­cern, he or she should con­sult with an appropriately-licensed physi­cian or other legally accredited health care worker in the country that resides or is visiting.

Please do not delay your medical concerns and potential health emergencies by searching information in this website, instead look out for medical opinion in the services that exist with that specific purpose and work under the respective local health-care regulations.

The views expressed on this blog and web­site have no rela­tion to those of any academic, hospital, practice or other insti­tu­tion with which the authors are affiliated.

For other instances, the authors of this website do not have any conflict of interest with any institution or pharmaceutical company in particular, and do not receive any compensation about any licenced drug mentioned in the website. In the same matter, the website is not intended to recommend any specific patented medication.


EMDrugs Team