Consult the medical resource doctors trust

UpToDate is one of the most respected medical information resources in the world, used by over 360,000 doctors and thousands of patients to find answers to medical questions.

  • Content written by a faculty of over 4,000 physicians from leading medical institutions
  • Unbiased: free of advertising or pharmaceutical funding
  • Evidence-based treatment recommendations
  • Continuously updated to incorporate new medical findings

Rabies immune globulin and vaccine

INTRODUCTION

More than 3.3 billion people worldwide live in areas where rabies is enzootic [1]. Human mortality from endemic canine rabies in Africa and Asia is estimated to be 55,000 deaths/year. In the United States, there has been an average of two fatal human rabies cases annually since 1980, the majority associated with exposure to bats.

Rabies is virtually always fatal, but infection can be prevented with proper wound care and postexposure prophylaxis. Although the incidence of human rabies is very low in the United States, approximately 16,000 to 39,000 cases with contact to potentially rabid animals receive rabies postexposure prophylaxis annually [2]. The estimated annual expenditure for rabies prevention is $584 million; the cost of postexposure prophylaxis with rabies immune globulin and vaccine accounts for almost half of this expenditure [3].

The safety, efficacy, and administration of rabies immune globulin and rabies vaccine will be reviewed here. Clinical decision-making regarding the necessity for rabies prophylaxis can be complex. This issue and the clinical presentation, diagnosis, and care of the patient with suspected rabies are discussed elsewhere. (See "When to use rabies prophylaxis" and "Clinical manifestations, diagnosis, and treatment of rabies".)

GENERAL PRINCIPLES

The general principles guiding rabies prophylaxis, as derived from the Advisory Committee on Immunization Practices (ACIP) guidelines of the US Centers for Disease Control and Prevention (CDC), are discussed below [3]. The full set of guidelines can be accessed at: http://www.cdc.gov/mmwr/pdf/rr/rr57e507.pdf.

Timing of prophylaxis — Rabies postexposure prophylaxis is a medical urgency and should begin as soon as possible after the presumed exposure.
To continue reading this article you need to subscribe.

Read the rest of this article and others like it

The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use (click here) ©2010 UpToDate, Inc.
References Top
  1. Rabies vaccines. WHO position paper. Wkly Epidemiol Rec 2007; 82:425.
  2. 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; 57:1.
  3. Knobel, DL, Cleaveland, S, Coleman, PG, et al. Re-evaluting the burden of rabies in Africa and Asia. Bull World Health Organ 2005; 83:360.
  4. Dean, DJ, Baer, GM, Thompson, WR. Studies on the local treatment of rabies-infected wounds. Bull World Health Organ 1963; 28:477.
  5. Cabasso, VJ, Loofbourow, JC, Roby, RE, Anuskiewicz, W. Rabies immune globulin of human origin: preparation and dosage determination in non-exposed volunteer subjects. Bull World Health Organ 1971; 45:303.
  6. Wilde, H, Tipkong, P, Khawplod, P. Economic issues in postexposure rabies treatment. J Travel Med 1999; 6:238.
  7. Chantanakajornfung, A, Naraporn, N, Khumphai, W, et al. A study of human rabies immune globulin manufactured by the Thai Red Cross. Vaccine 1999; 17:979.
  8. Wilde, H, Khawplod, P, Hemachudha, T, Sitprija, V. Postexposure treatment of rabies infection: can it be done without immunoglobulin?. Clin Infect Dis 2002; 34:477.
  9. Anderson, LJ, Sikes, RK, Langkop, CW, et al. Postexposure trial of a human diploid cell strain rabies vaccine. J Infect Dis 1980; 142:133.
  10. Strady, A, Lang, J, Lienard, M et al. Antibody persistence following preexposure regimens of cell-culture rabies vaccines: 10 year follow up and proposal for a new booster policy. J Infect Dis 1998; 177:1290.
  11. Hemachudha, T, Phanuphak, P, Johnson, RT, et al. Neurologic complications of semple-type rabies vaccine: clinical and immunologic studies. Neurology 1987; 37:550.
  12. Bahmanyar, M, Fayat, A, Nour-Salehi, S, et al. Successful protection of humans exposed to rabies infection. Postexposure treatment with the new human diploid cell rabies vaccine and antirabies serum. JAMA 1976; 236:2751.
  13. Navarrete-Navarro, S, Aguilar-Setien, A, Avila-Figueroa, C, et al. Improved serological response to human diploid cell rabies vaccine when given simultaneously with antirabies hyperimmune globulin. Arch Med Res 1999; 30:332.
  14. Bijok, U, Vodopija, I, Smerdel, S, et al. Purified chick embryo cell (PCEC) rabies vaccine for human use: clinical trials. Behring Inst Mitt 1984; :155.
  15. Wang, XJ, Lang, J, Tao, XR, et al. Immunogenicity and safety of purified Vero-cell rabies vaccine in severely rabies-exposed patients in China. Southeast Asian J Trop Med Public Health 2000; 31:287.
  16. Harverson, G, Wasi, C. Use of post-exposure intradermal rabies vaccination in a rural mission hospital. Lancet 1984; 2:313.
  17. Warrell, MJ, Nicholson, KG, Warrell, DA, et al. Economical multiplesite intradermal immunization with human diploid cell-strain vaccine is effective for postexposure rabies prophylaxis. Lancet 1985; 1:1059.
  18. Chutivongse, S, Wilde, H, Supich, C, et al. Postexposure prophylaxis for rabies with antiserum and intradermal vaccination. Lancet 1990; 335:896.
  19. Quiambao, BP, Dimaano, EM, Ambas, C, et al. Reducing the cost of post-exposure rabies prophylaxis: efficacy of 0.1 ml PCEC rabies vaccine administered intradermally using the Thai Red Cross post-exposure regimen in patients severely exposed to laboratory-confirmed rabid animals. Vaccine 2005; 23:1709.
  20. Brookes, SM, Parsons, G, Johnson, N, et al. Rabies human diploid cell vaccine elicits cross-neutralising and cross-protecting immune responses against European and Australian bat lyssaviruses. Vaccine 2005; 23:4101.
  21. Lodmell, DL, Ewalt, LC. Rabies vaccination: comparison of neutralizing antibody responses after priming and boosting with different combinations of DNA, inactivated virus, or recombinant vaccinia virus vaccines. Vaccine 2000; 18:2394.
  22. Fishbein, DB, Bernard, KW, Miller, KD et al. The early kinetics of the neutralizing antibody response after booster immunizations with human diploid cell rabies vaccine. Am J Trop Med Hyg 1986; 35:663.
  23. Sabchareon, A, Lang, J, Attanath, P, et al. A new Vero cell rabies vaccine: results of a comparative trial with human diploid cell rabies vaccine in children. Clin Infect Dis 1999; 29:141.
  24. Nicholson, K, Farrow, PR, Bijok, U, Barth, R. Pre-exposure studies with purified chick embryo cell culture rabies vaccine and human diploid cell vaccine: serological and clinical responses in man. Vaccine 1987; 5:208.
  25. Lang, J, Gravenstein, S, Briggs, D, et al. Evaluation of the safety and immunogenicity of a new heat-treated human rabies immune globulin using a sham, post-exposure prophylaxis of rabies. Biologicals 1998; 26:7.
  26. Suwansrinon, K, Jaijareonsup, W, Wilde, H. et al. Sex-and age-related differences in rabies immunoglobulin hypersensitivity. Trans R Soc Trop Med Hyg 2007; 101:206.
  27. Fishbein, DB, Dreesen, DW, Holmes, DF, et al. Human diploid cell rabies vaccine purified by zonal centrifugation: a controlled study of antibody response and side effects following primary and booster pre-exposure immunizations. Vaccine 1989; 7:437.
  28. Fishbein, DB, Yenne, KM, Dreesen, DW, et al. Risk factors for systemic hypersensitivity reactions after booster vaccinations with human diploid cell rabies vaccine: a nationwide prospective study. Vaccine 1993; 11:1390.
  29. Systemic allergic reactions following immunization with human diploid cell rabies vaccine. MMWR Morb Mortal Wkly Rep 1984; 33:185.
  30. Dreesen, D, Fishbein, DB, Kemp, DT, Brown, J. Two-year comparative trial on the immunogenicity and adverse effects of purified chick embryo cell rabies vaccine for pre-exposure immunization. Vaccine 1989; 7:397.
  31. Dobardzic, A, Izurieta, H, Woo, EJ, et al. Safety review of the purified chick embryo cell rabies vaccine: Data from the Vaccine Adverse Event Reporting System (VAERS), 1997-2005. Vaccine 2007; 25:4244.
  32. Fishbein, DB, Sawyer, LA, Reid Sanden, FL, et al. Administration of human diploid cell rabies vaccine in the gluteal area. N Engl J Med 1988; 318:124.
  33. http://www.cdc.gov/vaccines/recs/provisional/downloads/rabies-July2009-508.pdf.
  34. Human rabies prevention--United States, 1999. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 1999; 48:1.
  35. Smith, JS, Fishbein, DB, Rupprecht, CE, et al. Unexplained rabies in three immigrants in the United States: a virologic investigation. N Engl J Med 1991; 324:205.
  36. Rupprecht, CE, Gibbons, RV. Clinical practice. Prophylaxis against rabies. N Engl J Med 2004; 351:2626.
  37. Briggs, DJ, Dreesen, DW, Nicolay, U, et al. Purified Chick Embryo Cell Culture Rabies Vaccine: interchangeability with Human Diploid Cell Culture Rabies Vaccine and comparison of one versus two-dose post-exposure booster regimen for previously immunized persons. Vaccine 2000; 19:1055.
  38. Chutivongse, S, Wilde, H, Benjavongkulchai, M, et al. Postexposure rabies vaccination during pregnancy: effect on 202 women and their infants. Clin Infect Dis 1995; 20:818.
  39. Varner, MW, McGuinness, GA, Galask, RP. Rabies vaccination in pregnancy. Am J Obstet Gynecol 1982; 143:717.
  40. Pappaioanou, M, Fishbein, DB, Dreesen, DW, et al. Antibody response to preexposure human diploid-cell rabies vaccine given concurrently with chloroquine. N Engl J Med 1986; 314:280.
  41. Bernard, KW, Fishbein, DB, Miller, KD et al. Preexposure rabies immunization with human diploid cell vaccine: decreased antibody responses in persons immunized in developing countries. Am J Trop Med Hyg 1985; 34:633.
  42. Enright, JB, Franti, CE, Frye, FL, et al. The effects of corticosteroids on rabies in mice. Can J Microbiol 1970; 16:667.
  43. Deshpande, A, Briggs, DJ, Dietzschold, B et al. Immune response to purified chick embryo cell vaccine (PCECV) in HIV-infected individuals in Mumbai India using a simulated rabies post-exposure regimen. In: Proceedings of the IX International Meeting on Research Advances and Rabies Control in the Americas, Puerto Vallarta Mexico, December 1998.
  44. Goudsmit, J, Marissen, WE, Weldon, WC, et al. Comparison of an anti-rabies human monoclonal antibody combination with human polyclonal anti-rabies immune globulin. J Infect Dis 2006; 193:796.
  45. Bakker, AB, Python, C, Kissling, CJ, et al. First administration to humans of a monoclonal antibody cocktail against rabies virus: safety, tolerability, and neutralizing activity. Vaccine 2008; doi:10.1016/j.vaccine.2008.08.050.
white circle LOG IN
white circle DEMO