# Rabies - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: ICPC-3 (WONCA International Classification of Primary Care, 3rd edition) class AD14.06 - condition scope only, no dose · No dose - referral pathway, no medicine given in primary care · Rabies - StatPearls - NCBI Bookshelf - https://www.ncbi.nlm.nih.gov/books/NBK448076/ · Rabies - StatPearls - NCBI Bookshelf - disease-level clinical article (rabies-full.txt) · WHO. Rabies vaccines: WHO position paper - April 2018. Wkly Epidemiol Rec. 2018;93(16):201-220 (who-rabies-position-paper-2018.txt), Administration of rabies vaccines and Table 1 Post-exposure prophylaxis (PEP) by category of exposure · WHO. Rabies vaccines: WHO position paper - April 2018. Wkly Epidemiol Rec. 2018;93(16):201-220 (who-rabies-position-paper-2018.txt), Administration of rabies immunoglobulin - Verified date: 2026-08 ## Verified against - No dose - referral pathway, no medicine given in primary care - Rabies - StatPearls - NCBI Bookshelf - disease-level clinical article (rabies-full.txt) - WHO. Rabies vaccines: WHO position paper - April 2018. Wkly Epidemiol Rec. 2018;93(16):201-220 (who-rabies-position-paper-2018.txt), Administration of rabies vaccines and Table 1 Post-exposure prophylaxis (PEP) by category of exposure - WHO. Rabies vaccines: WHO position paper - April 2018. Wkly Epidemiol Rec. 2018;93(16):201-220 (who-rabies-position-paper-2018.txt), Administration of rabies immunoglobulin ## Treatment metadata - Wound care now, then same-day referral (Emergency) - Rabies vaccine — injection - Rabies immune globulin (human) — injection ## Complete treatment card ```text RABIES Sources: ICPC-3 (WONCA International Classification of Primary Care, 3rd edition) class AD14.06 - condition scope only, no dose · No dose - referral pathway, no medicine given in primary care · Rabies - StatPearls - NCBI Bookshelf - https://www.ncbi.nlm.nih.gov/books/NBK448076/ · Rabies - StatPearls - NCBI Bookshelf - disease-level clinical article (rabies-full.txt) · WHO. Rabies vaccines: WHO position paper - April 2018. Wkly Epidemiol Rec. 2018;93(16):201-220 (who-rabies-position-paper-2018.txt), Administration of rabies vaccines and Table 1 Post-exposure prophylaxis (PEP) by category of exposure · WHO. Rabies vaccines: WHO position paper - April 2018. Wkly Epidemiol Rec. 2018;93(16):201-220 (who-rabies- position-paper-2018.txt), Administration of rabies immunoglobulin Review status: REVIEWED against 3 sources listed above (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (5) - Early illness resembles a nonspecific virus - fever, tiredness, muscle aches, GI upset, and headache. [fatigue · fever · headache · muscle pain] - Within roughly two weeks, a neurologic phase brings anxiety, agitation, and confusion. [anxiety · confusion · irritability] - About four in five patients develop the furious form, with severe throat spasms set off by the sight or thought of water, causing fear of drinking or of air. [spasm] - The other fifth instead get a paralytic form, with weakness spreading upward starting from the limb that was bitten. - Tingling, itching, or discomfort at the site of the old wound can be an early clue before more obvious features appear. [itching · tingling] SIGNS - what you find (4) - Brisk reflexes, neck stiffness, and an abnormal Babinski response may turn up on neurologic exam. [hyperreflexia · neck stiffness] - Outside the nervous system, exam can reveal a fast heart rate, fast breathing, and fever. [fever · tachycardia · tachypnoea] - Heart involvement can produce signs of myocarditis, heart block, or failure, including chest pain and arrhythmia. [arrhythmia · chest pain · heart block] - Coma tends to develop within about ten days of the first neurologic signs, with prolonged breathing pauses and floppy paralysis, and death usually follows within a few days. [coma · paralysis] TESTS (7) - Spinal fluid analysis usually shows nonspecific encephalitis changes, such as a raised white cell count and elevated protein. - Brain imaging is usually normal and is mainly used to exclude other diagnoses. - Confirming the diagnosis before death requires four samples together - spinal fluid, saliva, serum, and a skin biopsy from the back of the neck. - The neck skin biopsy must go full thickness and capture at least 10 hair follicles with one nerve at the follicle base. - Saliva is examined using reverse-transcription PCR to detect viral genetic material. - After death, direct detection of virus in cerebellar and brainstem cross-sections is the definitive test. - A positive IgG antibody result can simply reflect prior vaccination or immunoglobulin rather than true infection, so vaccination history matters for interpretation. IF NOT THIS - what else fits (3) - The paralytic form can resemble Guillain-Barre syndrome, delirium tremens, tetanus, botulism, diphtheria, or a tick-borne illness. - Belladonna alkaloid poisoning, cerebral malaria, and meningitis are also part of the differential for a rabies-like picture. - Metabolic causes such as low blood sugar or thiamine deficiency should also be considered. Source StatPearls "Rabies" - disease-level clinical article Status traced to the source above Rx: Main treatment | Post-exposure prophylaxis - start the same day, at an anti-rabies centre | Category III exposure, never previously vaccinated - infiltrated into the wound MAIN TREATMENT 1. WOUND CARE NOW, THEN SAME-DAY REFERRAL (EMERGENCY) [1st line] Adult Wash the wound with soap and running water for at least 15 minutes, cover tetanus, treat the bite as an infected wound if it looks infected, and send the patient the SAME DAY to an anti-rabies centre for vaccine and, for a category III bite, immunoglobulin. Rabies is essentially always fatal once symptoms begin, and prompt prophylaxis is essentially always effective. The regimens the centre will use are on this card. - Same-day referral, with wound care given now Peds Children follow the same pathway: recognise and refer. No primary-care medicine is implied. Source No dose - referral pathway, no medicine given in primary care Why Wash the wound with soap and running water for at least 15 minutes, cover tetanus, treat the bite as an infected wound if it looks infected, and send the patient the SAME DAY to an anti-rabies centre for vaccine and, for a category III bite, immunoglobulin. Rabies is essentially always fatal once symptoms begin, and prompt prophylaxis is essentially always effective. The regimens the centre will use are on this card. Caution Hydrophobia, agitation, hypersalivation, or paralysis in a bitten patient means the disease is already established and essentially untreatable. The prophylaxis itself is given at an anti-rabies centre (VACSERA and the fever hospitals in Egypt), not in the consulting room. The vaccine and immunoglobulin rows on this card exist so that the doctor who sees the bite first knows exactly what the patient is being sent for, how many visits it takes, and what must not be left out - not so that the course is started here. RED FLAG - Any bite, scratch, or lick on broken skin or mucosa from a dog, cat or other mammal must be treated as urgent; do not wait for the animal to seem sick. POST-EXPOSURE PROPHYLAXIS - START THE SAME DAY, AT AN ANTI-RABIES CENTRE 2. RABIES VACCINE [1st line] Adult One intradermal dose is 0.1 mL; one intramuscular dose is the whole vial (0.5 mL or 1.0 mL depending on the product). Never previously vaccinated, category II or III exposure - any ONE of the three WHO regimens: 2-site intradermal on days 0, 3 and 7 (one-week course); OR 1-site IM on days 0, 3, 7 and one dose between day 14 and 28 (4-dose Essen); OR 2-site IM on day 0 then 1-site IM on days 7 and 21 (Zagreb). Previously vaccinated: 1-site intradermal on days 0 and 3, OR 4-site intradermal on day 0, OR 1-site IM on days 0 and 3 - and no immunoglobulin. x 7 days for the intradermal one-week course; 21 to 28 days for the intramuscular regimens. The schedule IS the dose - finish it. Peds Children get the SAME schedule and the SAME volumes as adults - there is no weight-based rabies dose, and WHO writes its regimens for individuals of all age groups. Only the site differs: an intramuscular rabies vaccine goes into the deltoid in an adult, and into either the deltoid or the anterolateral thigh in a child - for the youngest, under 2 years, WHO specifies the anterolateral area of the thigh. Source WHO. Rabies vaccines: WHO position paper - April 2018. Wkly Epidemiol Rec. 2018;93(16):201-220 (who-rabies-position-paper-2018.txt), Administration of rabies vaccines and Table 1 Post-exposure prophylaxis (PEP) by category of exposure Why Stray-dog bites are an everyday Cairo presentation. WHO states the indication and the schedule in one document: post-exposure prophylaxis is the wound washed and flushed thoroughly; then a course of rabies vaccine begun promptly after the exposure; and, where indicated, rabies immunoglobulin infiltrated into and around the wound, again promptly. The volumes and all three regimens are printed. This is still an emergency card: the patient goes to an anti-rabies centre today. The schedule is here so the referring doctor knows what is being started, can tell the patient how many visits it means, and can recognise an interrupted course. Four Egyptian products are registered, from 67.50 EGP. Note that the register files VERORAB under VACCINE RABIES rather than RABIES VACCINE. Caution THIS IS AN EMERGENCY - the patient goes to an anti-rabies centre today, not at the next appointment. WHO's figure for post-exposure prophylaxis given promptly after a severe exposure is 100% prevention. Wash the wound first and for long enough. On animal work, washing under soap and water for 15 minutes or more cuts the risk of rabies by 30%. Follow it, where you have one, with a virucidal irrigation such as povidone-iodine. NEVER into the buttock. The article bars the gluteal site for the vaccine, and WHO says the same - no intramuscular rabies vaccine into the gluteal region. Nor do the vaccine and the human rabies immunoglobulin share a syringe or a site. There is no reason to withhold it. Rabies kills so reliably that no contraindication to the vaccine exists when it is given as post-exposure prophylaxis. Pregnancy and breastfeeding are not reasons to withhold it either: expert opinion worldwide holds the vaccine safe in pregnancy and while breastfeeding, and what data there are show no rise in fetal anomaly, in premature birth, or in miscarriage. Late is not too late. WHO's position is that a recognised category III exposure is always vaccinated, whether the contact was recent or months or years ago. Already vaccinated? Then vaccine only, no immunoglobulin - someone who has had the vaccine before needs the vaccine alone after an exposure judged to carry a rabies risk. Immunoglobulin must NOT be given to them: it gets in the way of the antibody response they would otherwise mount. A repeat exposure inside 3 months of a completed course needs neither. WHO: where the new exposure follows the last one by under 3 months and a full course of post-exposure prophylaxis was completed, treat the wound and stop there - no vaccine, no immunoglobulin. Vaccine quality matters: WHO backs only the vaccines grown in cell culture or in embryonated eggs (CCEEVs), each vial of a potency no lower than 2.5 IU, and advises against the nerve-tissue vaccines altogether. This is prophylaxis, not treatment. Neither the immunoglobulin nor the vaccine has any part in managing rabies once it is established - the clinical studies show that neither changes the course of the illness. Once hydrophobia and encephalitis have started, care is palliative. Egypt RABIES VACCINE (VERO CELL) 2.5I.U./0.5ML FREEZE-DRIED I.M.INJ. CHANGCHU... 67.50 EGP RABIPUR 2.5I.U./VIAL (PCEC RABIES VACCINE FOR HUMAN ) NOVARTIS > RAMCO 70.00 EGP VERORAB 2.5I.U./0.5ML VIAL SANOFI PASTEU... 75.00 EGP RABIES VACCINE VACSERA 198.40 EGP CATEGORY III EXPOSURE, NEVER PREVIOUSLY VACCINATED - INFILTRATED INTO THE WOUND - give alongside 3. RABIES IMMUNE GLOBULIN (HUMAN) [add-on - not a substitute] Adult 20 IU/kg body weight for human rabies immunoglobulin (hRIG); 40 IU/kg for equine (eRIG). Given once, at the start of the course, and infiltrated into and around the wound - not as a routine injection into a distant muscle. If not given on day 0 it may still be given up to day 7 of the vaccine course, and not after that. - A single dose, with the first vaccine dose (or up to day 7, never later) Peds 20 IU/kg for human RIG at any age - the article puts HRIG at 20 IU/kg for every patient, whatever the weight or age, with eRIG at 40 IU/kg. In a small child the calculated volume may be too little to infiltrate several wounds; it may be diluted with saline to make up the volume. Do NOT exceed the calculated dose. Source WHO. Rabies vaccines: WHO position paper - April 2018. Wkly Epidemiol Rec. 2018;93(16):201-220 (who-rabies-position-paper-2018.txt), Administration of rabies immunoglobulin Why WHO recommends giving RIG after a category III exposure in anyone with no previous rabies vaccination, and states the dose in the same section. Three Egyptian products are registered (BERIRAB P 300 IU/2 mL at 480 EGP, 750 IU and 1500 IU), so the volume can be worked out at the bedside. The infiltration instruction is printed word for word because that, not the milligram, is what makes the dose work. Caution INFILTRATE IT INTO THE WOUND. WHO puts the immunoglobulin into the wound and around it, and for a small wound asks for as much as the anatomy will physically take. The article's instruction is the same: get as much of the human rabies immunoglobulin into the wound as you can. The infiltration hazard, from WHO: compartment syndrome, which is what happens when a large volume of immunoglobulin goes into a small part of the body with little tissue to hold it, and it must be avoided. Fingers, toes, ears and the nose are where this happens. Timing, from WHO: it must NOT be given later than day 7 counting from the first dose of vaccine, because by then the patient's own virus-neutralising antibodies are starting to appear. Do NOT withhold the vaccine because immunoglobulin is unavailable. WHO is explicit that a rabies vaccine is never held back for want of immunoglobulin. With no immunoglobulin at all, washing the wound thoroughly and vaccinating at once, then finishing the course, still prevents rabies highly effectively. WHO on closing the wound: hold off suturing until after the immunoglobulin has been infiltrated, and where a suture cannot be avoided, leave it loose. Equine immunoglobulin, where that is what is stocked: 40 IU/kg. The article puts its risk of an adverse reaction at 0.8% to 6% - mostly minor, but above what the human product carries. Be ready to treat anaphylaxis. WHO on the pre-test: do NOT skin-test before equine immunoglobulin, because the test does not predict the reaction reliably. Not for a patient already vaccinated - it blunts the anamnestic response. Neither the immunoglobulin nor the vaccine is indicated where the exposure repeats within 3 months. Egypt BERIRAB P 300I.U./2ML I.M INJ. CSL BEHERING-... 480.00 EGP BERIRAB P 750I.U./5ML I.M INJ. CSL BEHERING-... 1100.00 EGP Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)