Rabies virus vaccine (verorab) in humans

The rabies vaccine is an inactivated vaccine that induces antibodies production resulting in active immunity. It is used as a postexposure or preexposure prophylaxis for the prevention of rabies infection.


The following factors should be considered prior to administer the postexposure prophylaxis rabies vaccine:

  • Species of the biting animal
  • Circumstances (provoked or unprovoked bite)
  • Type of exposure [(bite, lick (non-bite)]
  • Vaccination status of the biting animal
  • Rabies prevalence in the area

Preexposure prophylaxis is recommended in the following situations:

    • Individuals with a continuous risk of infection:
      • Rabies research laboratory & biologics production workers.
    • Individuals with a frequent risk of infection
      • Rabies diagnostic laboratory workers
      • Cavers
      • Veterinarians and their staff
      • Animal control and wildlife workers
      • Persons who frequently handle bats
    • Persons with an infrequent risk of infection:
      • Veterinarians
      • Animal control staff working with animals in areas where rabies infection is not common
      • Veterinary students
      • Travelers visiting areas where rabies is enzootic

Which animals can transmit rabies?

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Preexposure vaccination:

    • A total of three doses administered intramuscular, 1 mL each, on days 0, 7, and 21 or 28.

Booster vaccination for individuals with continuous or frequent risk of infection:

    • 1 mL administered intramuscular based on antibody titers

Postexposure vaccination:

  • Immunocompetent individuals:

    • 4 doses administered intramuscular (1 mL each) on days 0, 3, 7, and 14.
  • Immunocompromised individuals:

    • 5 doses administered intramuscular(1 mL each) on days 0, 3, 7, 14, and 28.

Note:

  • All patients should receive rabies immune globulin with the first dose of the vaccine.
  • Rabies immunoglobulins are not recommended and only two doses of the vaccine should be administered on days 0 and 3 in the following groups of patients:
    • Individuals who have received postexposure or preexposure prophylaxis previously.
    • Individuals with a documented rabies antibody titers that are adequate.

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Preexposure vaccination:

  • Infants, Children, and Adolescents:
    • 1 mL/dose administered intramuscular for three doses, on days 0, 7, and 21 or 28.

Booster vaccination (for individuals with a frequent or continuous risk of infection):

  • Infants, Children, and Adolescents:
    • 1 mL/dose intramuscular based on the antibody titers

Postexposure vaccination:

  • Note:
    • The vaccine should be administered as soon as possible.
    • Patients not previously vaccinated should also be advised the rabies immunoglobulins.
    • The wound should be cleaned with soap, water, and iodine-pyodine solution.
  • Immunocompetent:
    • The four-dose regimen:
      • 1 mL/dose Intramuscular for 4 doses on days 0, 3, 7, and 14 after exposure.
  • Immunocompromised:
    • The five dose regimen:
      • 1 mL/dose intramuscular for a total of five doses.
      • The dose should be administered on days 0, 3, 7, 14, and 28 after exposure.
      • Individuals previously vaccinated should be given only two doses on days 0 and 3. Rabies immunoglobulins are not recommended in these patients.

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Pregnancy Risk Factor C

  •  
    • Rabies vaccine for postexposure prophylaxis is not contraindicated in pregnant women.
    • Adverse fetal effects have not been observed in pregnant patients administered the inactivated rabies vaccine.

Breastfeeding Considerations

    • Excretion of the vaccine into breastmilk is not known.
    • The manufacturer recommends using it with caution in lactating women.

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[bg_collapse view="button-blue" color="#f7f2f2" icon="arrow" expand_text="Renal Dose" collapse_text="Renal Dose" ] Adjustment in the dose has not been recommended by the manufacturer in patients with renal disease. [/bg_collapse] [bg_collapse view="button-blue" color="#f7f2f2" icon="arrow" expand_text="Dose in Liver disease" collapse_text="Dose in Liver disease" ] Adjustment in the dose has not been recommended by the manufacturer in patients with liver disease. [/bg_collapse] [bg_collapse view="button-blue" color="#f7f2f2" icon="arrow" expand_text="Side effects" collapse_text="Side effects" ]

Common Side Effects of Rabies virus vaccine Include:

  • Central nervous system:
    • Dizziness
    • Headache
    • Malaise
  • Dermatologic:
    • Injection site pruritus
  • Gastrointestinal:
    • Abdominal pain
    • Nausea
  • Hematologic & oncologic:
    • Lymphadenopathy
  • Local:
    • Erythema at the injection site
    • Pain at the injection site
    • Swelling at the injection site
  • Neuromuscular & skeletal:
  • Myalgia

Frequency not defined:

  • Cardiovascular:
    • Cardiovascular toxicity
    • Edema
    • Palpitations
    • Swelling of the injected limb
  • Central nervous system:
    • Chills
    • Encephalitis
    • Fatigue
    • Guillain-Barre syndrome
    • Meningitis
    • Neuropathy
    • Paralysis
    • Paresthesia
    • Retrobulbar neuritis
    • Seizure
    • Vertigo
  • Dermatologic:
    • Pruritus
    • Urticaria
  • Endocrine & metabolic:
    • Hot flash
  • Gastrointestinal:
    • Diarrhea
    • Vomiting
  • Hematologic & oncologic:
    • Adenopathy
  • Hypersensitivity:
    • Anaphylaxis
    • Hypersensitivity reaction
    • Serum sickness
  • Local:
    • Hematoma at the injection site
  • Neuromuscular & skeletal:
    • Arthralgia
    • Arthritis
    • Limb pain
    • Multiple sclerosis
    • Myelitis
    • Weakness
  • Ophthalmic:
    • Visual disturbance
  • Respiratory:
    • Bronchospasm
    • Dyspnea
    • Wheezing
  • Miscellaneous:
    • Fever of more than 38°C (100°F)

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Contraindication to Rabies virus vaccine Include:

  • Preexposure prophylaxis:
    • Serious allergic reactions to the vaccine or any component of the formulation may occur that may be life-threatening.
  • Postexposure prophylaxis:
    • No contraindications have been listed in the manufacturer's labeling.

Warnings & Precautions

  • Hypersensitivity reactions:
    • Anaphylactic reactions may occur with its use.
    • Epinephrine should be available if an anaphylactic reaction occurs.
    • Postexposure prophylaxis should be continued if mild adverse effects are noted.
  • Immune complex-like reactions (serum sickness):
    • Patients may develop arthralgia, fever, arthritis, urticaria, angioedema, malaise, nausea, and vomiting as a result of an immune complex reaction (usually within 2 - 21 days following booster doses of HDCV).
  • Neurologic reactions:
    • Like other vaccinations, cases of Guillain-Barre syndrome that resolve in 12 weeks, encephalitis, meningitis, myelitis, transient paralysis, retrobulbar neuritis, and multiple sclerosis have been reported with rabies vaccination.
  • Syncope:
    • Patients may develop hypotension and syncope resulting in fall and injury.
    • Patients should be seated or lie down during and for at least 15 minutes following the injection.
  • Bleeding disorders:
    • Patients with a bleeding disorder should be advised intramuscular injection with caution.
    • Platelets, Factor VIII, or Fresh Frozen Plasma should be administered if indicated followed by the intramuscular injection.

Rabies virus vaccine: Drug Interaction

Risk Factor C (Monitor therapy)

Chloroquine

May diminish the therapeutic effect of Rabies Vaccine.

Venetoclax

May diminish the therapeutic effect of Vaccines (Inactivated).

Risk Factor D (Consider therapy modification)

Belimumab

May diminish the therapeutic effect of Vaccines (Inactivated). Management: Patients should receive inactivated vaccines prior to initiation of belimumab therapy whenever possible, due to the risk for an impaired response to the vaccine during belimumab therapy.

Fingolimod

May diminish the therapeutic effect of Vaccines (Inactivated). Management: Vaccine efficacy may be reduced. Complete all age-appropriate vaccinations at least 2 weeks prior to starting fingolimod. If vaccinated during fingolimod therapy, revaccinate 2 to 3 months after fingolimod discontinuation.

Immunosuppressants

May diminish the therapeutic effect of Vaccines (Inactivated). Management: Vaccine efficacy may be reduced. Complete all age-appropriate vaccinations at least 2 weeks prior to starting an immunosuppressant. If vaccinated during immunosuppressant therapy, revaccinate at least 3 months after immunosuppressant discontinuation. Exceptions: Cytarabine (Liposomal).

Rabies Immune Globulin (Human)

May diminish the therapeutic effect of Rabies Vaccine. Management: Do not administer additional or repeated doses of rabies immune globulin once rabies vaccine has been administered. The rabies immune globulin should also not be administered in the same site as the vaccine.

Siponimod

May diminish the therapeutic effect of Vaccines (Inactivated). Management: Avoid administration of vaccines (inactivated) during treatment with siponimod and for 1 month after discontinuation due to potential decreased vaccine efficacy.

 

Monitor:

  • Allergic reaction and anaphylaxis for 15 minutes following its administration
  • Patients should be monitored for hypotension and syncope. If syncope develops, the patient should be made to lie in a supine or Trendelenburg position.
  • Serologic testing may be advised at 6 months interval to high-risk patients like hunters and those at continued risk of infection prior to administering the booster dose.
  • Other patients who should have a serologic test done include those at frequent risk of infection (every 2 years) and immunocompromised patients who have completed a preexposure or postexposure prophylaxis series.

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How to administer the Rabies virus vaccine?

  • Intramuscular:
    • It should not be administered intradermally or subcutaneously.
    • The intramuscular injection should be administered as a deep injection in the deltoid muscle.
    • Administration into the gluteal area may result in lower antibody response and should, therefore, be avoided.
    • Postexposure prophylaxis should be initiated after cleansing the wound with water, soap, and povidone-iodine solution.
    • Rabies vaccine and human rabies immune globulin should not be mixed in the same syringe and should not be administered in the same anatomical site.
    • It should not be mixed with other vaccines or injections.
    • The patient should be seated or made to lie down to prevent vaccine-related syncope and hypotension during vaccine administration.
    • Patients at risk of bleeding at the injection site, a fine needle of 23 gauge or smaller should be used for vaccination followed by applying firm pressure for at least two minutes.
    • Hemophilia patients should be administered the vaccine shortly after administration of Factor VIII.

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Mechanism of action of Rabies virus vaccine:

The rabies vaccine is an inactivated virus vaccine that promotes active immunity by inducing the development of antibodies against the virus components. The antibodies response is generally seen in about 7 - 10 days. Rabies vaccine prevents subsequent infections. Rabies immunoglobulins should, therefore, be given in conjunction with rabies vaccine to prevent the disease from developing. The onset of action (production of rabies antibodies) after intramuscular injection is about 7 - 10 days. The peak effect is seen in about 30 to 60 days and the duration of action lasts for more than one year.    

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International Brands:

  • Abhayrab
  • Berrab P
  • Imovax Rabbia
  • Imovax Rabia
  • Imovax Rabies
  • Lyssavac N
  • Berna
  • Rabies MIRV Vaccine
  • Rabies-Imovax
  • Rabiesvax
  • Rabipur
  • Rabivax
  • Rabix-VC
  • Speeda
  • Verorab

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Rabies Virus Vaccine in Pakistan:

Rabies Virus Vaccine [Inj 2.5 Iu/Ml]

Lyssavac-N Hakintramuscularsons Intramuscularpex (Pvt) Ltd.
Rabipur Novartis Pharma (Pak) Ltd
Verorab Sanofi Aventis (Pakistan) Ltd.

Rabies Virus Vaccine [Inj 200 Iu/Ml]

Rabies Antiserum Hakintramuscularsons Intramuscularpex (Pvt) Ltd.

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