Primary prevention
Rabies is 100% preventable through prompt medical care. Dogs are the most important global source of rabies in humans; therefore, vaccination of pets and reducing pet exposure to wildlife in rabies-endemic countries is recommended. Children are often at risk of dog bites, so education about avoiding stray or unknown dogs (as well as other wildlife) is important. Wild animals should also be avoided, particularly bats. Animal control should be contacted to remove bats from homes. Travellers to enzootic areas should avoid contact with all wild or domestic animals including stray dogs or cats.
Rabies vaccination is recommended for pre-exposure or post-exposure prophylaxis. Two modern cell culture vaccines are generally available in most countries: a human diploid cell vaccine, and a purified chick embryo cell vaccine. Embryonated egg-based rabies vaccines may also be available. Choice of vaccine depends on local availability.
Pre-exposure prophylaxis (PrEP)
Pre-exposure rabies immunisation is generally reserved for people at increased risk of contracting rabies.
Vaccine dose schedules and recommendations for who should receive PrEP may vary, and local guidelines should be consulted.
The World Health Organization (WHO) recommends PrEP for people at high risk of rabies virus exposure (including sub-populations in highly endemic settings with limited access to timely and adequate post-exposure prophylaxis), people at occupational risk, and travellers who may be at risk of exposure. PrEP should also be considered in populations living in rabies endemic areas where the dog bite incidence is >5% per year or vampire bat rabies is known to be present. Two different dose schedules are recommended:[34]
An intradermal dose (2-site) on days 0 and 7; or
An intramuscular dose (1-site) on days 0 and 7 (deltoid muscle for adults and anterolateral area of thigh in children <2 years).
In the US, the Centers for Disease Control and Prevention (CDC) recommends a 2-dose intramuscular regimen (days 0 and 7). Further recommendations depend on the person’s specific risk for being exposed to rabies.[35]
Risk category 1 (highest risk; people who work with live rabies virus in research or vaccine production facilities, or people who perform testing for rabies in diagnostic laboratories): 2-dose schedule (days 0 and 7), then check rabies antibody titre every 6 months (give booster if titre <0.5 IU/mL).
Risk category 2 (people who frequently handle or have contact with bats, enter high-density bat environments such as caves, or perform animal necropsies): 2-dose schedule (days 0 and 7), then check rabies antibody titre every 2 years (give booster if titre <0.5 IU/mL).
Risk category 3 (risk duration >3 years after they receive primary 2-dose PrEP vaccination series and: people who interact with animals that could be rabid such as veterinarians, technicians, animal control officers; people who handle wildlife reservoir species; spelunkers; and selected travellers): 2-dose schedule (days 0 and 7) plus either: a one-time rabies antibody titre check after 1 year and up to 3 years following the vaccination series (give booster if titre <0.5 IU/mL); or a one-time booster dose between 3 weeks and 3 years following the first vaccination series.
Risk category 4 (same population as category 3 above, but risk duration ≤3 years after they receive primary 2-dose PrEP vaccination series): 2-dose schedule (days 0 and 7).
Risk category 5 (lowest risk; general population): none.
In the UK, the UK Health Security Agency (UKHSA) recommends a 3-dose intramuscular regimen (days 0, 7, and 28). The third dose can be given from day 21 if there is insufficient time before travel. An accelerated regimen may be given if there is insufficient time to complete the 21-28 day course, with 3 doses given on days 0, 3, and 7 and an additional dose at one year if they continue to travel to high-risk areas. PrEP is recommended in the following people:[36]
Laboratory staff routinely working with rabies virus
Workers at DEFRA-authorised quarantine premises and carriers
Those who regularly handle bats (including on a voluntary basis) in the UK
Veterinary and technical staff who encounter enhanced risk
Travellers to rabies enzootic areas, especially if post-exposure medical care and rabies biologics are lacking or are in short supply at the destination, or the person is undertaking higher-risk activities (e.g., cycling, running), or they are living/staying in the area for ≥1 month
Animal control and wildlife workers, veterinary staff, or zoologists who regularly work in rabies enzootic areas.
Response to vaccination may be sub-optimal in immunocompromised people.
The WHO recommends that immunocompromised people should be assessed on a case-by-case basis and receive an additional third dose between days 21 to 28.[34]
The CDC recommends checking that the person’s rabies antibody titre is >0.5 IU/mL at least 1 week (preferably 2 to 4 weeks) after completion of the vaccine series and all booster doses. If the titre is <0.5 IU/mL, a booster dose should be administered, followed by a subsequent titre check. If two booster doses fail to elicit an acceptable antibody titre, local public health authorities should be consulted. If the patient has a temporary immunocompromising condition, vaccination can be delayed until after the condition has resolved or immunosuppressive medications can be withheld.[35]
Concomitant administration of chloroquine or hydroxychloroquine (commonly used antimalarial drugs) may result in a significant reduction in rabies antibody titre.
The WHO recommends that while there is no contraindication to vaccination for people receiving treatment with chloroquine or hydroxychloroquine, PrEP should be completed before chloroquine or hydroxychloroquine treatment is initiated, if possible.[34]
The CDC recommends considering avoiding the use of chloroquine when rabies vaccine is being administered, or if it cannot be avoided, confirming the patient’s rabies antibody titre is >0.5 IU/mL at least 1 week (preferably 2 to 4 weeks) after completion of the vaccine series.[35]
PrEP Has been shown to be safe and immunogenic.[37]
Post-exposure prophylaxis (PEP)
Consists of an effective rabies vaccine and administration of rabies immunoglobulin (if necessary) after cleaning and disinfection of the wound. It is highly effective and should be given to any asymptomatic patient with a documented or likely exposure, regardless of the time that has elapsed since the exposure.
PEP protocols vary; see Treatment algorithm.
Secondary prevention
Rabies is a notifiable disease in many countries. Cases should be reported immediately to local health authorities. Centers for Disease Control and Prevention laboratory confirmation is required for antemortem or postmortem suspected cases in the US. No cases of person-to-person spread to hospital or autopsy personnel have ever been reported. However, relatives, healthcare workers, and others who may have been exposed to direct contact to saliva or body fluids of the patient should be assessed for rabies risk to determine need for rabies post-exposure prophylaxis.
Use of this content is subject to our disclaimer