Rabies Biologics

Available biologics in the United States

Rabies biologics for pre- and post-exposure prophylaxis include vaccine and immunoglobulins.

Human rabies vaccine

Single-dose vials of rabies vaccine should be reconstituted with accompanying sterile diluent to a final volume of 1mL before administration. Administer rabies vaccine intramuscularly for adults in the deltoid area, or for children in the deltoid or the anterolateral aspect, or in the thigh. Do not administer vaccines in the buttocks or gluteal area.

Human rabies immune globulin

Post-exposure prophylaxis with human rabies immune globulin (HRIG) is indicated ONLY for people who did not receive ACIP-recommended 1) pre-exposure prophylaxis (PrEP) or 2) post-exposure prophylaxis (PEP) for rabies.

• The recommended dose of HRIG is 20 IU/kg body weight for all age groups, including children.
• If the wound is small and on a distal extremity (e.g., finger, toe), use clinical judgment to decide how much HRIG to inject to avoid complications (e.g., ischemia) due to localized swelling of the finger or fingers.
• Deliver any remaining dose intramuscularly at a site distant from where the vaccine was given.
• If wounds are extensive, do not exceed the dose-appropriate volume of HRIG.
• If the indicated volume is inadequate to inject all wounds, you can dilute the HRIG with normal saline to ensure sufficient volume to inject all wounds.

HyperRab dilution

The one exception is the newer and more concentrated version of HRIG, HyperRab 300 IU/ml, which requires using dextrose 5% in water (D5W) as the diluent. HRIG dilution is particularly important in children whose body weight might be small in relation to the size and number of wounds.

¹ Note: HyperRab^® immunoglobulin product has a different concentration compared to all other rabies immunoglobulins (including the very similarly named HyperRab™S/D), requiring lower volumes to administer the recommended dose of 20 IU/kg; take care to ensure the correct dose of immunoglobulin is administered to allow adequate immune response

Rabies biologics training and resources

• Knowing common errors when administering rabies biologics can help clinicians avoid them
• Rabies PEP administration training videos to assist clinicians with error-free rabies PEP administration
• Rabies PEP training modules to educate healthcare providers and public health professionals about rabies, rabies exposure assessments, and PEP administration
• Rabies PEP calculator uses ACIP recommendations to help with an initial PEP schedule and clinical decisionmaking if a patient has deviated from that schedule

Managing adverse reactions to rabies biologics

Don't interrupt rabies PEP if there are mild reactions to the treatment; manage them with anti-inflammatory drugs like ibuprofen or acetaminophen.

Ideally, the same vaccine should be used throughout the series (either HDCV or PCEC). However, if severe allergic reactions occur, you may need to switch to an alternate vaccine to complete the series.

Have antihistamines and epinephrine ready to counteract anaphylactic reactions in patients with a history of strong allergic or inflammatory reactions to vaccines. Closely monitor patients after vaccination.

Serious reactions to rabies vaccines are rare and require careful consideration before discontinuing vaccination. Healthcare providers should seek advice from local or state health departments for managing serious reactions.

Patient assistance programs for rabies biologics

Manufacturers' patient assistance programs that provide rabies medication to uninsured or underinsured patients may be available for qualified patients. For more information on these programs, including eligibility requirements, please contact the manufacturers directly.

Rabies vaccine

Sanofi Pasteur–Imovax^®
Phone: 1-800-822-2463
www.sanofipasteur.us

Bavarian Nordic–Rabavert^®
Phone: 1-844-422-8274
https://bnvaccines.com

Human rabies immune globulin

Grifols–HyperRab^®
Phone: 1-833-504-9983
www.hypermunes.com/en/hcp

Kedrion–KEDRAB^®
Phone: 1-866-234-3732
https://mykedrab.medmonk.com