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. Travelers 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 postexposure 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 immunization 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 subpopulations in highly endemic settings with limited access to timely and adequate postexposure prophylaxis), people at occupational risk, and travelers 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:[33]
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.[34]
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 titer every 6 months (give booster if titer <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 titer every 2 years (give booster if titer <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 travelers): 2-dose schedule (days 0 and 7) plus either: a one-time rabies antibody titer check after 1 year and up to 3 years following the vaccination series (give booster if titer <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.
Response to vaccination may be suboptimal 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.[33]
The CDC recommends checking that the person’s rabies antibody titer 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 titer is <0.5 IU/mL, a booster dose should be administered, followed by a subsequent titer check. If two booster doses fail to elicit an acceptable antibody titer, 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.[34]
Concomitant administration of chloroquine or hydroxychloroquine (commonly used antimalarial drugs) may result in a significant reduction in rabies antibody titer.
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.[33]
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 titer is >0.5 IU/mL at least 1 week (preferably 2 to 4 weeks) after completion of the vaccine series.[34]
PrEP has been shown to be safe and immunogenic.[35]
Postexposure prophylaxis (PEP)
Consists of an effective rabies vaccine and administration of rabies immune globulin (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.
The table that follows summarizes recommendations for primary prevention of rabies taken from the CDC Yellow Book.[32]
Note that an individual patient may fall into more than one group and so interventions might be additive; please review all population and subpopulation groups to assess all that apply.
Traveler to rabies-enzootic country
All
Intervention
Avoid bites
Counsel patients pre-travel to stay away from all free-roaming mammals, including puppies and kittens, and to avoid contact with bats and other wildlife.
Goal
Prevent transmission
Avoiding bites is the most important prevention measure.
With planned activities that increase risk of exposure to potentially rabid animals; uncertain access to postexposure prophylaxis; and duration of risk >3 years after primary 2-dose PrEP vaccine series
Intervention
Rabies vaccination; 2-dose schedule; first dose given on day 0
A 2-dose intramuscular schedule given on days 0 and 7 is recommended.
Goal
Immunity against rabies infection
A 2-dose schedule alone is not enough to assume protection for >3 years. To provide ongoing immunity either:
perform a one-time rabies antibody titer check >1 year and ≤3 years following the vaccination series; give booster if titer <0.5 IU/mL; or
give a one-time booster dose >3 weeks and ≤ 3 years after the first vaccination series.
With planned activities that increase risk of exposure to potentially rabid animals; uncertain access to postexposure prophylaxis; and duration of risk ≤3 years after primary 2-dose PrEP vaccine series
Intervention
Rabies vaccination; 2-dose schedule; first dose given on day 0
A 2-dose intramuscular schedule given on days 0 and 7 is recommended.
Goal
Immunity against rabies infection
Protection against rabies for the duration of risk is assumed following completion of the vaccination series.
Person who works with live rabies virus or performs diagnostic testing for rabies
All
Intervention
Rabies vaccination; 2-dose schedule; first dose given on day 0
A 2-dose intramuscular schedule given on days 0 and 7 is recommended.
Goal
Immunity against rabies infection
A 2-dose schedule alone is not enough to assume ongoing protection. To ensure immunity whilst the individual is still working in these high-risk environments:
check rabies antibody titer every 6 months; and
give booster if titer <0.5 IU/mL.
Person who has contact with bats, enters high-density bat environments such as caves, or performs animal necropsies
All
Intervention
Rabies vaccination; 2-dose schedule; first dose given on day 0
A 2-dose intramuscular schedule given on days 0 and 7 is recommended.
Goal
Immunity against rabies infection
A 2-dose schedule alone is not enough to assume ongoing protection. To ensure immunity whilst the individual remains in this risk group:
check rabies antibody titer every 2 years; and
give booster if titer <0.5 IU/mL.
Person whose occupational or recreational activities involve contact with potentially rabid animals
Includes veterinarians, technicians, animal control officers, and their students or trainees; people who handle wildlife reservoir species (e.g., wildlife biologists, rehabilitators, and trappers); and spelunkers
Duration of risk >3 years after primary 2-dose PrEP vaccine series
Intervention
Rabies vaccination; 2-dose schedule; first dose given on day 0
A 2-dose intramuscular schedule given on days 0 and 7 is recommended.
Goal
Immunity against rabies infection
A 2-dose schedule alone is not enough to assume protection for >3 years. To provide ongoing immunity either:
perform a one-time rabies antibody titer check >1 year and ≤3 years following the vaccination series; give booster if titer <0.5 IU/mL; or
give a one-time booster dose >3 weeks and ≤3 years after the first vaccination series.
Duration of risk ≤3 years after primary 2-dose PrEP vaccine series
Intervention
Rabies vaccination; 2-dose schedule; first dose given on day 0
A 2-dose intramuscular schedule given on days 0 and 7 is recommended.
Goal
Immunity against rabies infection
Protection against rabies for the duration of risk is assumed following completion of the vaccination series.
Secondary prevention
Rabies is a notifiable disease in the US and many other countries. Cases should be reported immediately to the local and state health department. CDC 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 postexposure prophylaxis.
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