We are grateful to the New York State Department of Health Wadsworth Center for supporting this project.

The following protocol has been approved for the ethical use of human samples by the New York State Department of Health Wadsworth Center for assay development, protocol approval number #03-019.
1. Safety
<ol>
	<li>Don personal protective equipment (PPE), at minimum eye protection (glasses or face shield), a surgical mask, and non-latex gloves.</li>
	<li>Ensure personnel are vaccinated for rabies and that a titer of &#8805;0.5 IU/mL has been demonstrated within the past 6 months.</li>
</ol>
2. Antigen slide preparation
NOTE: Perform all virus, CSF, and serum manipulations in a biosafety cabinet (BSC) using universal precautions.
<ol>
	<li>Prepare 20 mL of mouse neuroblastoma or BHK-21 cells to a concentration of 3.0 x 105 cells/mL in Eagle&#39;s minimum essential media supplemented with 10% fetal bovine serum (EGM) and keep cold until use.</li>
	<li>Prepare CVS-11 virus by diluting in EGM to a working dilution of 1.0 x 106.5 50% tissue culture infectious dose (TCID50) per milliliter and keep cold until ready for use. 
	NOTE: TCID50 is determined by the Reed and Muench method published previously5.</li>
	<li>Clean a humidity slide chamber and polytetrafluoroethylene (PTFE)-coated well-microscope slides with 70% ethanol and allow to air-dry in the BSC.</li>
	<li>Add distilled water (dH2O) to strips of absorbent paper in the slide chamber to ensure the humidity remains constant throughout the procedure.</li>
	<li>Using a pencil, label each slide to be used with the lot number, date, cell type, and any other identifying information required for storage, and place in the slide chamber. 
	NOTE: Most markers, pens, or labels will not withstand the future acetone fixation step (step 2.9).</li>
	<li>Apply 50 &#181;L of virus dilution to each well on the microscope slides with a repeating pipette. Then, apply 50 &#181;L of cell dilution to each well, being careful not to contaminate the pipette tip with the virus already on the well.</li>
	<li>Close the humidity slide chamber and place it in the humid incubator at 34-36 &#176;C. Assess the cell infectivity after 24 h. 
	NOTE: Perform steps 2.8-2.12 on only one slide.</li>
	<li>Remove the slide from the humidity chamber and carefully aspirate the supernatant. Wash the slide in a phosphate-buffered saline (PBS)-filled Coplin jar for 2 min, then allow the slide to air-dry.</li>
	<li>Place the slide in the Coplin jar and fix the slide in cold acetone for a minimum of 1 h in a -20 &#176;C freezer approved for flammable materials. Perform all acetone pouring and air-drying procedures in a fume hood.</li>
	<li>Allow the acetone to flash off and slide to dry. Apply rabies direct fluorescent antibody (DFA) conjugate prepared according to the manufacturer&#39;s instructions to the wells of the slide and incubate for 30 min in a 34-36 &#176;C humid incubator.</li>
	<li>Wash the slide in Coplin jars of PBS twice for 2 min each. Air-dry the slide.</li>
	<li>Mount a coverslip with 0.05 M Tris, 0.15 M NaCl (pH 9.0), and 20% glycerol mountant, and read the slide using a fluorescent microscope at 200x magnification to assess the infectivity. If the cells are not approximately 50% infected, repeat steps 2.7-2.12 the following day until the desired infectivity is reached. 
	NOTE: Cell infectivity is approximated based on visually assessing the ratio of negative cells to rabies-positive cells on the slide well. Negative cells appear red in color, while positive cells show green fluorescent staining.</li>
	<li>Remove the remaining slides from the incubator and humidity chamber. Carefully aspirate the supernatant from each well, then place the slides in a Coplin jar(s) with PBS for 1-2 min. Air-dry the slides for approximately 30 min. Store the slides at -80 &#176;C until ready for use.</li>
</ol>
3. Sample preparation
<ol>
	<li>Prepare patient serum or CSF sample dilutions for testing. Prepare the necessary conjugate for a proper working concentration diluted in PBS with 0.05% Evans blue. 
	&#8203;NOTE: Keep the conjugate in the dark to maintain the fluorophore integrity prior to application</li>
</ol>
4. IFA procedure
<ol>
	<li>Remove the necessary number of prepared antigen slides needed for each assay and allow the slides to defrost and dry completely.</li>
	<li>Place the slides in a Coplin jar(s) and fix the slides in cold acetone for between 2 h to overnight in a -20 &#176;C freezer approved for flammable materials. Remove the slides from the acetone and allow to air-dry.</li>
	<li>Place the slides in a humidity chamber box inside the BSC with dH2O-soaked absorbent strips to maintain humidity. Apply 50 &#181;L of each sample dilution, control sample, or PBS to the pre-determined well. 
	NOTE: Each slide must contain an appropriate number of patient sample wells, positive control, negative control, and PBS cell control well.</li>
	<li>Place the closed humidity slide chamber in a 37 &#176;C, 5% CO2 humid incubator. Incubate the slides for 30 min, then remove the humidity slide chamber from the incubator and place it into a BSC.</li>
	<li>Use an aspirator tip to carefully aspirate the supernatant from each well, ensuring not to disturb the cell monolayer. Use a sterile dropper pipette to apply one drop of PBS to each well.</li>
	<li>Repeat careful aspiration, then place each slide in a PBS-filled Coplin jar and wash twice for a total of 15 min.</li>
	<li>Place the slides back in the humidity chamber box and apply 50 &#181;L of appropriate anti-human antibody conjugate to each well. Repeat steps 4.4 to 4.6.</li>
	<li>Allow the slides to air-dry, mount a coverslip with mounting media, and read the slides under fluorescent microscope.</li>
</ol>
5. Slide analysis
<ol>
	<li>Grade samples based on the staining pattern and fluorescence intensity compared to positive control samples with confirmed high anti-rabies antibody titer.</li>
	<li>Grade the samples on a scale of negative, 1+, 2+, 3+, and 4+, with a negative result showing no fluorescent staining and 4+ representing a bright green apple color fluorescence with a staining pattern similar to positive control samples1. 
	NOTE: The green apple color applies only to FITC-labeled antibodies; the color varies depending on fluorophore selection.</li>
	<li>Assign the samples an end point value represented by the dilution factor at which the sample displays a 1-2+ grade. Test the samples at a higher dilution factor if the end point is not reached in the initial assay.</li>
</ol>

Quick and Early Detection of Rabies Antibodies to Evaluate the Immune Response in a Patient

<ol>
	<li>Rupprecht, C. E., Fooks, A. R., Abela-Ridder, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laboratory+Techniques+in+Rabies.+Volume+1.">Laboratory Techniques in Rabies. Volume 1.</a> World Health Organization. , 232-245 (2018).</li><li>Moore, S. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Challenges+of+rabies+serology:+defining+context+of+interpretation.">Challenges of rabies serology: defining context of interpretation.</a> Viruses. 13 (8), 1516 (2021).</li><li>Zajac, M. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Development+and+evaluation+of+a+rabies+enzyme-linked+immunosorbent+assay+(ELISA)+targeting+IgM+and+IgG+in+human+sera.">Development and evaluation of a rabies enzyme-linked immunosorbent assay (ELISA) targeting IgM and IgG in human sera.</a> Viruses. , 40-49 (2019).</li><li>Mills, D. J., Lau, C. L., Mills, C., Furuya-Kanamori, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Long-term+persistence+of+antibodies+and+boostability+after+rabies+intradermal+pre-exposure+prophylaxis.">Long-term persistence of antibodies and boostability after rabies intradermal pre-exposure prophylaxis.</a> Journal of Travel Medicine. 29 (2), (2022).</li><li>Ramakrishnan, M. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Determination+of+50%+endpoint+titer+using+a+simple+formula.">Determination of 50% endpoint titer using a simple formula.</a> World Journal of Virology. 5 (2), 85-86 (2016).</li><li>Rudd, R. J., Appler, K. A., Wong, S. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Presence+of+cross-reactions+with+other+viral+encephalitides+in+the+indirect+fluorescent-antibody+test+for+diagnosis+of+rabies.">Presence of cross-reactions with other viral encephalitides in the indirect fluorescent-antibody test for diagnosis of rabies.</a> Journal of Clinical Microbiology. 51 (12), 4079-4082 (2013).</li><li>Fooks, A. R., Jackson, A. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Rabies: scientific basis of the disease and its management. , (2020).</li><li>Paldanius, M., Bloigu, A., Leinonen, M., Saikku, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Measurement+of+Chlamydia+pneumoniae-specific+immunoglobulin+A+(IgA)+antibodies+by+the+microimmunofluorescence+(MIF)+method:+comparison+of+seven+fluorescein-labeled+anti-human+IgA+conjugates+in+an+in-house+MIF+test+using+one+commercial+MIF+and+one+enzyme+immunoassay+kit.">Measurement of Chlamydia pneumoniae-specific immunoglobulin A (IgA) antibodies by the microimmunofluorescence (MIF) method: comparison of seven fluorescein-labeled anti-human IgA conjugates in an in-house MIF test using one commercial MIF and one enzyme immunoassay kit.</a> Clinical and Diagnostic Laboratory Immunology. 10 (1), 8-12 (2003).</li><li>Rodriguez, M. C., Fontana, D., Garay, E., Prieto, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Detection+and+quantification+of+anti-rabies+glycoprotein+antibodies:+current+state+and+perspectives.">Detection and quantification of anti-rabies glycoprotein antibodies: current state and perspectives.</a> Applied Microbiology and Biotechnology. 105 (18), 6547-6557 (2021).</li><li>Katz, I. S. S., Guedes, F., Fernandes, E. R., Dos Ramos Silva, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Immunological+aspects+of+rabies:+a+literature+review.">Immunological aspects of rabies: a literature review.</a> Archives of Virology. 162 (1), 3251-3268 (2017).</li><li>Moore, S. M., Hanlon, C. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Rabies-specific+antibodies:+measuring+surrogates+of+protection+against+a+fatal+disease.">Rabies-specific antibodies: measuring surrogates of protection against a fatal disease.</a> PLoS Neglected Tropical Diseases. 4 (3), 595 (2010).</li></ol>

The authors have nothing to disclose.

The IFA test takes advantage of an antigen-antibody complex, allowing for a labeling site to visualize rabies-specific antibodies. Neuroblastoma or BHK cells are seeded on multi-well PTFE-coated microscope slides and inoculated with rabies virus lab strain CVS-11. Once the monolayer is confluent and the cells reach the desired infectivity of approximately 50%, the slides are stored until ready for use6.
Patient serum or CSF is applied to the infected cell monolayer and ...

The rabies indirect fluorescent antibody (IFA) test is used to detect various rabies-specific antibody isotypes in sera or cerebral spinal fluid. It is one of an arsenal of tests available for monitoring an antemortem rabies patient. It is especially useful for the early detection of antibodies to evaluate a patient's immune response to rabies infection. When used in conjunction with other tests, case history, and the patient's vaccination status, the IFA test can assist in determining exposure to rabies virus or a vaccine1. As the IFA test measures IgM and/or IgG, the values of the specific antibody can indicate an approximate time frame from exposure to the antigen1. This test may be useful in the listed applications or others not yet explored.
There are several rabies serological assays available. The rapid fluorescent focus inhibition test (RFFIT), fluorescent antibody virus neutralization (FAVN) test, or modifications of these are the primary methods for measuring rabies virus neutralizing antibodies (RVNAs)1. However, these tests do not differentiate IgM and IgG antibodies. When differentiating antibody isotype is important in monitoring the rabies immune response, the rabies IFA and the rabies enzyme-linked immunosorbent assay (ELISA) tests are used, but they do not measure RVNAs. Although the IFA and ELISA tests can be used to determine the presence of rabies-specific antibodies in a sample, there are some differences in how they are executed. The IFA test utilizes a cell-cultured live virus as its antigen substrate, whereas a typical ELISA for rabies detection uses one or more of the viral proteins. In a laboratory setting where the rabies virus can be cultured, the IFA test may be more easily performed instead of purchasing or cultivating individual viral proteins for the ELISA. The purpose of testing and the information garnered from the results of any rabies serological assay should be considered when determining which to choose2.
IgM is the first to respond, increasing until class switching is observed at around day 28, at which point IgG becomes the predominant circulating antibody3. Hence, IgM would only be expected for a limited amount of time following exposure to rabies virus or vaccination. Testing both serum and cerebrospinal fluid (CSF) can indicate if the exposure was through vaccination, in which antibodies would be seen only in sera, or from a viral infection, which would potentially show antibodies in CSF1.
It has been established that rabies antibodies persist for several years following pre-exposure prophylaxis (PrEP)4. The IFA test can be a useful tool to demonstrate this at different time points following vaccination or exposure.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>25x55mm glass cover slips</td>
			<td>Any</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Acetone</td>
			<td>Any</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Anti-Human IgG Labeled Conjugate</td>
			<td>Sigma-Aldrich</td>
			<td>F9512</td>
			<td></td>
		</tr>
		<tr>
			<td>Anti-Human IgM Labeled Conjugate</td>
			<td>SeraCare</td>
			<td>5230-0286</td>
			<td></td>
		</tr>
		<tr>
			<td>Aspirating pipette tip</td>
			<td>Any</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>BHK-21 Cells</td>
			<td>ATCC</td>
			<td>CCL-10</td>
			<td></td>
		</tr>
		<tr>
			<td>BION IFA Diluent</td>
			<td>MBL BION</td>
			<td>DIL-9993</td>
			<td></td>
		</tr>
		<tr>
			<td>Cell Culture water</td>
			<td>Sigma-Aldrich</td>
			<td>W3500</td>
			<td>EGM</td>
		</tr>
		<tr>
			<td>Coplin Jars</td>
			<td>Any</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Fetal Bovine Serum&#160;</td>
			<td>Sigma-Aldrich</td>
			<td>F2442</td>
			<td>EGM</td>
		</tr>
		<tr>
			<td>Fluorescent microscope with FITC filter</td>
			<td>Any</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Glycerol</td>
			<td>Sigma-Aldrich</td>
			<td>G7893</td>
			<td>Mountant</td>
		</tr>
		<tr>
			<td>Gullsorb IgM inactivation reagent</td>
			<td>Fisher Scientific</td>
			<td>23-043-158</td>
			<td>IgG Inactivation Reagent</td>
		</tr>
		<tr>
			<td>L-Glutamine</td>
			<td>Sigma-Aldrich</td>
			<td>G-7513</td>
			<td>EGM</td>
		</tr>
		<tr>
			<td>Minimum Essential Media Eagle &#8211; w/Earle&#8217;s salts, L-glutamine, and non-essential amino acids, w/o sodium bicarbonate</td>
			<td>Sigma-Aldrich</td>
			<td>M0643</td>
			<td>EGM</td>
		</tr>
		<tr>
			<td>Mouse Neuroblastoma Cells</td>
			<td>ATCC</td>
			<td>CCL-131</td>
			<td></td>
		</tr>
		<tr>
			<td>Multi-well Teflon coating glass slides</td>
			<td>Any</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>PBS</td>
			<td>Any</td>
			<td></td>
			<td>pH 7.6&#160;</td>
		</tr>
		<tr>
			<td>Penicillin</td>
			<td>Sigma</td>
			<td>P-3032</td>
			<td>EGM</td>
		</tr>
		<tr>
			<td>Rabies Direct Fluorescent Antibody Conjugate</td>
			<td>Millipore Sigma</td>
			<td>5100, 5500 or 6500</td>
			<td></td>
		</tr>
		<tr>
			<td>Sodium bicarbonate</td>
			<td>Sigma-Aldrich</td>
			<td>S-5761</td>
			<td>EGM</td>
		</tr>
		<tr>
			<td>Sodium Chloride crystals</td>
			<td>Sigma-Aldrich</td>
			<td>S5886</td>
			<td>Mountant</td>
		</tr>
		<tr>
			<td>Sterile dropper</td>
			<td>Any</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Streptomycin sulfate salt</td>
			<td>Sigma</td>
			<td>S9137</td>
			<td>EGM</td>
		</tr>
		<tr>
			<td>Trizma pre-set crystals pH 9.0</td>
			<td>Sigma-Aldrich</td>
			<td>S9693</td>
			<td>Mountant</td>
		</tr>
		<tr>
			<td>Tryptose Phosphate Broth</td>
			<td>BD</td>
			<td>260300</td>
			<td>EGM</td>
		</tr>
		<tr>
			<td>Vitamin mix</td>
			<td>Sigma-Aldrich</td>
			<td>M6895</td>
			<td>EGM</td>
		</tr>
	</tbody>
</table>

detection of rabies igg and igm antibodies using the rabies indirect fluorescent antibody test

The rabies indirect fluorescent antibody (IFA) test was developed to detect various rabies-specific antibody isotypes in sera or cerebral spinal fluid. This test provides rapid results and can be used to detect rabies antibodies in several different scenarios. The rabies IFA test is especially useful for the quick and early detection of antibodies to evaluate the immune response in a patient who has developed rabies. Although other methods for antemortem rabies diagnosis take precedence, this test may be utilized to demonstrate recent rabies virus exposure through antibody detection. The IFA test does not provide a virus-neutralizing antibody (VNA) titer, but the pre-exposure prophylaxis (PrEP) response can be evaluated through positive or negative antibody presence. This test can be utilized in various situations and can provide results for a number of different targets. In this study, we used several paired serum samples from individuals who received PrEP and demonstrated their rabies antibody presence over time using the IFA test.

Author Spotlight: Rabies-Specific Antibody Isotypes Detection in Sera or Cerebral Spinal Fluid Using an IFA Test 

Detection of Rabies IgG and IgM Antibodies Using the Rabies Indirect Fluorescent Antibody Test

The IFA test assesses antibody response during rabies infection or evaluates the immune response from vaccines. It can be used to establish antibody presence in a sample and distinguish which antibody isotypes are present. Neutralizing antibody assays are the gold standard for rabies antibody detection to assess antibody titer in a person who has received pre or post-exposure prophylaxis.Although an IFA test may yield different results than a neutralizing antibody assay, it can still provide valuable information when used as an alternative. Typically, assays that measure rabies neutralizing antibodies evaluate immune response. However, these tests take multiple days, requiring virus and live cell culture.The IFA test allows advanced preparation of antigen slides for testing with results in a few hours compared to days. Using the IFA tests in human rabies cases may lead to more answers about how an individual's immune system responds to rabies infection. There is great variation amongst cases, and this test can provide results in a real-time manner during the disease.

All serum samples were collected from the patients at approximately the same time frames following PrEP. The samples were tested from five different patients at the following time points: 2 weeks after the final rabies vaccine inoculation, 6 months after the rabies vaccine series, and 18 months after the rabies vaccine series. Each serum sample was diluted in series and graded for both IgM and IgG presence, as described in protocol steps 5.2 and 5.3. The antibody value assigned represents the dilution factor where the sa...

Watch this Scientific Journal Video about Rabies-Specific Antibody Isotypes Detection in Sera or Cerebral Spinal Fluid Using an IFA Test at JoVE.com

The aim of this manuscript is to examine the use of the rabies indirect fluorescent antibody test for the detection of rabies-specific IgG and IgM antibodies.

The rabies indirect fluorescent antibody (IFA) test was developed to detect various rabies-specific antibody isotypes in sera or cerebral spinal fluid. ...

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Research

JoVE Journal

Immunology and Infection

Preparing Slides of CVS-11 Virus Antigen for Detecting Rabies-Specific Antibodies

Indirect Fluorescent Antibody (IFA) Test to Detect Rabies-Specific Antibody Isotypes in Sera or Cerebral Spinal Fluid

1.3K Views.  New York State Department of Health.  The aim of this manuscript is to examine the use of the rabies indirect fluorescent antibody test for the detection of rabies-specific IgG and IgM antibodies.

Quick and Early Detection of Rabies Antibodies to Evaluate the Immune Response in a Patient

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