Dr A S Vasudev On Rabies Management

Post-exposure treatment of previously vaccinated persons

Local treatment of wounds should always be carried out. On the basis of the information available at the time, the eighth report of the WHO Expert Committee recommended that persons who had previously received full pre- or post-exposure treatment with a potent cell-culture vaccine should be given only two booster doses, either intramuscularly or intradermally, on days 0 and 3, but no rabies immunoglobulin. Persons who have previously received pre- or post-exposure treatment with vaccines of unproven potency, and those who have not demonstrated an acceptable rabies neutralizing antibody titre, should receive a complete post-exposure course, including rabies immunoglobulin if indicated.

source:WHO

Administration of rabies immunoglobulin

Rabies immunoglobulin (RIG) should be given for all category III exposures, irrespective of the interval between exposure and beginning of treatment. Two kinds of rabies antibody preparations may be used: human rabies immunoglobulin (HRIG) and equine rabies immunoglobulin (ERIG). A skin test must be performed prior to the administration of ERIG. As much as possible of the recommended dose (20 IU/kg of body weight of HRIG or 40 IU/kg of body weight of ERIG) should be infiltrated around the wounds if anatomically feasible. The remainder should be administered intramuscularly (into gluteal region) in a single dose and followed by a complete course of vaccine.
Rabies immunoglobulin of human origin (HRIG) is available in some countries; however, it is expensive and only limited amounts are available.
Rabies immunoglobulin of equine origin (ERIG) is available in many countries and is considerably cheaper than HRIG. Most of the currently available preparations of ERIG are highly purified and quite safe; however, a skin test should always be carried out prior to its use.

source: WHO

Preventing rabies with the Verorab vaccine: 1985-2005 Twenty years of clinical experience.

Toovey S.
Burggartenstrasse 32, 4103 Bottmingen, Switzerland. malaria@freesurf.ch
Purified rabies vaccine cultured on Vero cells (Verorab, sanofi pasteur) is WHO-approved for pre- and post-exposure prophylaxis by intradermal and intramuscular routes. During 20 years of use, over 40 million doses of Verorab have been administered in more than 100 countries. No serious adverse event due to Verorab has been reported in clinical trials involving 3937 persons, and Verorab is better tolerated than human diploid cell vaccine (HDCV). Pre-exposure prophylaxis is confirmed immunogenic in 1437 subjects by all routes, with prompt responses following boosting; Verorab boosts effectively subjects pre-immunized with HDCV. Unlike HDCV, Verorab is not associated with post-boosting serum sickness. In the absence of data in immunodeficient/HIV-positive individuals, pre-exposure immunization is urged as early as possible. Essen, Zagreb, Thai Red Cross Intradermal (TRC-ID) and other post-exposure intramuscular and intradermal regimens are documented. Two thousand one hundred and eighty-three subjects received post-exposure prophylaxis, including 874 high risk, severe or confirmed rabid attacks. Co-administration of rabies immune globulin (RIG) does not affect neutralizing antibody levels when Essen or TRC-ID regimens are employed; levels are lower with the Zagreb regimen. Verorab has been administered safely and effectively post-exposure to 251 pregnant women, without any increase in congenital malformations or spontaneous abortions. From a pediatric perspective, safety and efficacy have been demonstrated in 759 children (0-15 years). Intradermal post-exposure Verorab is an effective and inexpensive option for developing countries. Inadvertent subcutaneous administration does not reduce immunogenicity. WHO already strongly recommends the replacement of nerve tissue vaccines with modern vaccines. Extensive clinical experience supports the use of Verorab for intramuscular and intradermal pre- and post-exposure prophylaxis, including in special situations.


Source: PMID: 17983973 [PubMed - indexed for MEDLINE]