Advancing Rabies Post-Exposure Prophylaxis: The Role of Monoclonal Antibodies in Pediatric and Neonatal Care

Rabies remains a critical global public health concern due to its high fatality rate and potential for rapid transmission, necessitating vigilant preventive and post-exposure strategies. Worldwide, rabies is responsible for an estimated 59,000 human deaths annually. Children are particularly vulnerable to rabies exposure, primarily because of their natural curiosity and limited capacity to avoid potentially infected animals. In India alone, children accounted for approximately 40% of rabies-related deaths and over 50% of exposure cases between 2016 and 2018 (1,2,). Almost all human rabies cases are caused by animal bites, and inadequate wound care combined with the failure to receive appropriate post-exposure prophylaxis (PEP) significantly increases mortality. According to the World Health Organization (WHO), animal bite exposures are categorized into three groups—Category I, II, and III—based on the severity of the wound and the level of risk. Category III exposures, which include single or multiple transdermal bites or scratches from suspected rabid animals, require urgent administration of rabies biologics (1–4).

The cornerstone of rabies prevention following exposure is timely and comprehensive PEP. This includes immediate and thorough wound cleaning, administration of rabies immunoglobulin (RIG) or monoclonal antibodies (mAbs) for passive immunization, and completion of an anti-rabies vaccine (ARV) regimen. WHO-endorsed biologics such as human rabies immunoglobulin (HRIG), equine rabies immunoglobulin (ERIG), and rabies monoclonal antibodies (RmAbs) have been clinically validated for their effectiveness in neutralizing the rabies virus. For example, a study by Hobart-Porter et al. demonstrated the safety and efficacy of HRIG in pediatric populations, highlighting its essential role in preventing rabies in children following suspected exposure (2,5).

In India, modern cell culture-based rabies vaccines such as the Vero cell rabies vaccine (VCRV) and purified chick embryo cell vaccine (PCECV) are the standard for PEP, often administered in combination with RIG. These vaccines have demonstrated significant improvements in both safety and immunogenicity (6). Recent research, including a prospective randomized trial by Natesan et al., has emphasized the enhanced immune response and reduced adverse effects associated with cell culture-derived vaccines, reinforcing their effectiveness even in cases of severe exposure (7). In our study, rabies monoclonal antibodies (RmAb) were administered in 67% of cases, while human rabies immunoglobulin (HRIG) was used in only 3%. This pattern aligns with findings from Ravish et al. , who demonstrated the safety and efficacy of RmAb as part of post-exposure prophylaxis (PEP) across various age groups, including pediatric populations. Although HRIG remains a WHO-recommended option for passive immunization, its limited availability and higher cost may contribute to its lower utilization. Nonetheless, evidence from Hobart-Porter et al. confirmed the safety of HRIG in children, with no serious adverse events reported, supporting its continued use where accessible (6).

A case reported by Rajesh K et al. described a newborn who was brought to the hospital after being found abandoned. On admission, the infant was moderately hypothermic, with a body temperature of 33.5°C. The blood glucose level was 60 mg/dL, and oxygen saturation was 96% on room air. The baby weighed 1821 grams and was estimated to be between 32 and 34 weeks of gestation.

Physical examination revealed a muscle-deep wound measuring 5 cm × 4 cm × 1 cm on the left upper thigh, a bite mark measuring 2 cm × 1 cm × 1 cm on the left shoulder, and multiple superficial abrasions. Given the clear evidence of dog bite injuries, immediate rabies post-exposure prophylaxis (PEP) was initiated. The infant received intravenous fluids and antibiotics as part of the initial management. For rabies PEP, monoclonal rabies antibody (Rabishield) was administered at a dose of 3.3 IU/kg and locally infiltrated around the wound sites. The injection was well tolerated, with no observed local or systemic adverse effects. In addition, the infant was started on a course of purified Vero cell rabies vaccine. Routine blood investigations were within normal limits, although the C-reactive protein (CRP) level was elevated at 14 mg/dL. Blood and wound cultures were sterile, and antibiotics were discontinued on day three. Regular wound care and dressings were performed. To assess immunogenic response, a rapid fluorescent focus inhibition test (RFFIT) was conducted to measure rabies virus neutralizing antibodies (RVNA). The results showed a titer of 64 IU/mL, indicating adequate seroprotection. Thus, monoclonal rabies antibody represents a safe, cost-effective, and scalable alternative to traditional blood-derived RIG making it a valuable tool, especially in resource-limited settings (8).

References:

1.         Radhakrishnan S, Vanak AT, Nouvellet P, Donnelly CA. Rabies as a Public Health Concern in India—A Historical Perspective. Trop Med Infect Dis. 2020 Oct 21;5(4):162.

2.         Fotedar N, Ravish HS. A prospective study on safety and clinical efficacy of rabies biologicals in paediatric patients with category III animal exposure. Clin Exp Vaccine Res. 2025 Jan;14(1):59–66.

3.         Current status of rabies and prospects for elimination - The Lancet [Internet]. [cited 2025 May 30]. Available from: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)62707-5/fulltext

4.         Ichhpujani RL, Chhabra M, Mittal V, Bhattacharya D, Singh J, Lal S. Knowledge, attitude and practices about animal bites and rabies in general community--a multi-centric study. J Commun Dis. 2006 Dec;38(4):355–61.

5.         Hobart-Porter N, Stein ,Michal, Toh ,Naveh, Amega ,Novinyo, Nguyen ,Huy-Binh, and Linakis J. Safety and efficacy of rabies immunoglobulin in pediatric patients with suspected exposure. Hum Vaccines Immunother. 2021 Jul 3;17(7):2090–6.

6.         Fotedar N, Ravish HS. A prospective study on safety and clinical efficacy of rabies biologicals in paediatric patients with category III animal exposure. Clin Exp Vaccine Res. 2025 Jan;14(1):59–66.

7.         Natesan K, Isloor S, Vinayagamurthy B, Ramakrishnaiah S, Doddamane R, Fooks AR. Developments in Rabies Vaccines: The Path Traversed from Pasteur to the Modern Era of Immunization. Vaccines. 2023 Apr;11(4):756.

8.         Kulkarni R, Khwaja TA, Badgujar G, Patil V, Ambike D. Use of Rabies Monoclonal Antibodies in an Abandoned Newborn. Indian J Pediatr. 2025 May 1;92(5):557–557.