Which medications in the drug class Rabies Vaccines (United States) are used in the treatment of Rabies?

Updated: Jun 21, 2019
  • Author: Sandra G Gompf, MD, FACP, FIDSA; Chief Editor: Michael Stuart Bronze, MD  more...
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Rabies Vaccines (United States)

These agents promote immunity by inducing an active immune response. Two types of rabies vaccines have been produced: cell-cultured vaccines and nerve tissue vaccines.

In developing countries worldwide, nerve tissue vaccines have been the most widely used type for prophylaxis of rabies. They are dangerous because they may induce autoimmune CNS disease and may produce neurologic reactions; they also require multiple injections and are not always effective. WHO has advised discontinuation of nerve tissue rabies vaccines. [53]

Two types of nerve tissue vaccine exist: the Semple type (STV) and the suckling mouse brain vaccine (SMBV). STV is obtained from inactivated virus prepared on adult animal nerve tissue. It is inexpensive and relatively easy to produce. In India, 3 million people receive postexposure courses of STV each year. STV may produce neurologic reactions, including postvaccination encephalomyelitis, in up to 1 in 220 courses, with a 3% mortality rate.

SMBV is cultured on immature mouse brain tissue, which contains little myelin. It is the most widely used rabies postexposure vaccine in Vietnam. Rare neurologic reactions occur, with complications in 1 in 27,000 treated people, with a 22% mortality rate.

Because SMBV and STV are widely used throughout the developing world, they are the vaccines that are administered to US travelers exposed to animal bites in some countries. It is advisable that US travelers to endemic areas receive pretravel rabies immunization with a cell-cultured vaccine if the itinerary suggests sufficient risk.

Cell-cultured rabies vaccines benefit from efficacy demonstrated in trials and a high level of immunogenicity; this permits a rational dosing schedule, and cell-cultured vaccines are considered the reference standard. The disadvantage of these vaccines is the cost of production.

In the United States, the CDC recommends rabies postexposure prophylaxis only with IM cell-cultured vaccines; intradermal (ID) formulations are not FDA approved for use in the United States.

Outside the United States, in areas where cost and vaccine supply are limiting factors, alternatives to the IM regimens may be more feasible. In addition, rabies vaccination may be the norm in some countries where rabies is endemic, and anamnestic response may permit effective alternative dosing.

In 1998, WHO released guidelines for ID use of HDCV, purified chick embryo cell vaccine, and purified duck embryo cell vaccine. [36] WHO published updated postexposure prophylaxis guidelines that included ID regimens often used outside the United States. [37]

In previously vaccinated individuals, studies have shown that single-visit, 4-site ID booster regimens offer satisfactory anamnestic response. A retrospective study at The Queen Saovabha Memorial Institute (QSMI) investigated booster regimens in more than 5000 previously immunized individuals who presented with rabies exposures. The study found that the single-visit, 4-site ID booster regimen using cell-cultured vaccine demonstrated superior anamnestic response, more rapid rise in Nab levels, and more persistently high Nab levels 1 year after prophylaxis than did the standard WHO 2-visit booster regimen. [43] Advantages of the single-visit booster also included reduced time and reduced costs from loss of work or from delayed travel, along with enhanced compliance.

Booster immunization is indicated for individuals at continuous or frequent risk of rabies, who should undergo periodic rabies antibody testing and who have serum rabies titer of less than 1:5 dilution based on RFFIT results.

Rabies vaccine (HDCV, Imovax Rabies, Rabies vaccine human diploid cell culture)

Indicated for preexposure and postexposure. Grown in human diploid cell culture. Contains the inactivated virus that promotes immunity by inducing an active immune response. For IM use only.

Rabies vaccine chick embryo cell derived (RabAvert)

Indicated for preexposure or postexposure. Contains the inactivated virus that promotes immunity by inducing an active immune response. For IM injection.

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