What are the guidelines for rabies (Rabies virus) management?

From the Guidelines

Rabies post-exposure prophylaxis should be initiated immediately after a potential exposure to the rabies virus, with a regimen that includes thorough wound cleansing, administration of rabies immune globulin (RIG), and a series of four doses of rabies vaccine on days 0,3,7, and 14. This recommendation is based on the most recent and highest quality study available, which suggests that a 4-dose vaccination regimen is sufficient for previously unvaccinated individuals 1. The use of RIG and vaccine has been shown to be highly effective in preventing human rabies, and prompt treatment is critical due to the almost universally fatal nature of the disease once clinical symptoms appear.

Key Components of Rabies Post-Exposure Prophylaxis

• Thorough wound cleansing with soap and water
• Administration of RIG, with 20 IU/kg body weight infiltrated around the wound and any remaining volume given intramuscularly at a site distant from the vaccine
• A series of four doses of rabies vaccine on days 0,3,7, and 14 for previously unvaccinated individuals
• For individuals who have previously received a complete vaccination series, a 2-dose PEP vaccination series is recommended
• For immunocompromised individuals, a 5-dose vaccination regimen with 1 dose of RIG is recommended

Pre-Exposure Prophylaxis

Pre-exposure prophylaxis is recommended for high-risk individuals, such as those who work with animals or travel to areas where rabies is common. The regimen consists of three doses of rabies vaccine given on days 0,7, and 21 or 28.

Importance of Prompt Treatment

Rabies is almost universally fatal once clinical symptoms appear, which is why immediate prophylaxis is critical. The virus travels through peripheral nerves to the central nervous system, causing encephalitis. The incubation period typically ranges from 1-3 months but can vary from days to years, making prompt treatment essential even for exposures that occurred weeks earlier.

From the FDA Drug Label

Rabies Postexposure Prophylaxis The following recommendations are only a guide. In applying them, take into account the animal species involved, the circumstances of the bite or other exposure, the vaccination status of the animal, and presence of rabies in the region. Local Treatment of Wounds: Immediate and thorough washing of all bite wounds and scratches with soap and water is perhaps the most effective measure for preventing rabies. Active Immunization: Active immunization should be initiated as soon as possible after exposure (within 24 hours). Passive Immunization: A combination of active and passive immunization (vaccine and immune globulin) is considered the acceptable postexposure prophylaxis except for those persons who have been previously immunized with rabies vaccine and who have documented adequate rabies antibody titer.

The rabies guideline recommends that postexposure prophylaxis should be initiated as soon as possible after exposure to a potentially rabid animal. This includes:

• Immediate and thorough washing of all bite wounds and scratches with soap and water
• Active immunization with a rabies vaccine, initiated within 24 hours of exposure
• Passive immunization with rabies immune globulin, given in conjunction with the vaccine, except for individuals who have been previously immunized and have a documented adequate rabies antibody titer. It is essential to consider the animal species involved, circumstances of the bite or other exposure, vaccination status of the animal, and presence of rabies in the region when determining the need for postexposure prophylaxis 2.

From the Research

Rabies Guideline Overview

• Rabies is a fatal zoonotic disease that can be prevented through timely and adequate post-exposure prophylaxis (PEP) 3
• The World Health Organization (WHO) recommends PEP schedules that include wound washing and antisepsis, a series of intradermal (ID) or intramuscular (IM) rabies vaccinations, and rabies immunoglobulin in WHO category III exposures 3

Post-Exposure Prophylaxis (PEP) Schedules

• Abridged PEP schedules with reduced doses have the potential to save costs, increase patient compliance, and improve equitable access to life-saving PEP for at-risk populations 3
• The 1-week, 2-site ID PEP schedule is considered the most advantageous, as it is safe, immunogenic, and involves the least direct costs compared to other schedules 3
• Changes in the rabies vaccine product and/or the route of administration during PEP are possible, and evidence suggests that this does not affect the safety and immunogenicity of the vaccine 4

Safety and Immunogenicity of PEP

• Studies have shown that PEP is safe and immunogenic, even when there are changes in the route of administration or brand/type of rabies vaccine 4
• The rabies virus neutralizing antibody titers were assessed in one study, and all vaccinees had titers ≥0.5 IU per mL on day 14, which is considered adequate for protection against rabies 4
• Administering rabies vaccines during pregnancy is safe and effective, according to available data 3

Rabies Immunoglobulin (IG) Administration

• The administration of rabies IG is generally recommended in conjunction with the first dose of the rabies vaccine 5
• A study evaluated adherence to Centers of Disease Control and Prevention (CDC) recommendations for rabies IG patient selection, dosing, timing, and anatomical site of administration, and found high adherence to guideline recommendations for rabies IG patient selection, dosing, and timing 6
• However, only 56% of eligible patients received rabies IG infiltration at wound sites as recommended by guidelines 6

Pre-Exposure Prophylaxis (PreEP)

• Rabies pre-exposure immunisation is recommended for those individuals at risk of exposure to the virus 5
• Pre-exposure prophylaxis consists of 3 doses of an approved rabies vaccine administered either intramuscularly or intradermally on days 0,7, and 21 or 28, with periodic booster doses or titre determination depending on the level of risk of potential exposure to the virus 5