Vaccines: Rabies

Specific vaccination recommendations vary among countries or even within a given country. Local or country-specific guidelines should be consulted.

1. Vaccine and immunoglobulin: Rabies vaccines contain inactivated rabies virus. Rabies immunoglobulin (RabIG) is derived from pooled human plasma of donors that have been immunized against the rabies virus.

2. Indications: Rabies vaccination is recommended in persons traveling to endemic areas (travel-specific recommendations: see Immunization Prior to Travel to Endemic Areas) as well as in all individuals bitten by wild or domestic animals suspected of carrying rabies (see below). It is also indicated in persons at risk of occupational or recreational exposure to sick animals (eg, forestry workers, hunters, veterinarians, laboratory technicians, speleologists). There is limited pregnancy safety data. In the case of administering preexposure prophylaxis to immunocompromised patients, the antibody titer after the vaccine series should be measured to confirm antibody production.

3. Contraindications to preexposure prophylaxis include general contraindications for inactivated vaccines. Given the near-universal mortality associated with untreated rabies virus infection, there are no contraindications to postexposure prophylaxis.

4. Preexposure prophylaxis: Preexposure prophylaxis consists of 3 vaccine doses administered IM on days 0, 7, and 28. Those with ongoing high-risk occupational exposures should be vaccinated again if antirabies IgG titers are <0.5 IU/mL.

5. Postexposure prophylaxis must be considered immediately in cases of suspected exposure, in conjunction with infectious disease specialists and a local public health unit. A number of factors are necessary to appropriately risk stratify a potential exposure, including the species of animal involved, whether the animal was wild or domesticated, vaccination status of the animal involved, type of exposure (bite vs nonbite), and whether the exposure was provoked or unprovoked. Postexposure prophylaxis is not indicated when a patient has had indirect contact with a potentially rabid animal or when the exposure consisted of saliva on the patient’s intact skin. In all cases where the epithelial barrier is not fully intact (eg, saliva on an open wound, animal bite), postexposure prophylaxis should be given.

In cases where the potential exposure was from direct contact with a bat, it is often difficult to ascertain whether a bite has occurred. Where the bat is available for testing, the presence of the rabies virus should be excluded. If the bat is unavailable for veterinary observation or testing, postexposure prophylaxis should always be administered.

1) Unvaccinated persons with a probable exposure: 4 IM doses of rabies vaccine on days 0, 3, 7, and 14. In immunocompromised patients a fifth IM dose of rabies vaccine should be administered on day 28. In addition, patients should receive 20 IU/kg of RabIG on day 0. Vaccination and RabIG should be administered at distant sites from each other (opposite limbs) but can be given at the same time.

2) Previously vaccinated persons with a probable exposure: 2 IM doses of rabies vaccine on days 0 and 3. RabIG is not required in a patient who has completed preexposure prophylaxis.

6. Adverse events: Systemic anaphylactic reactions have been reported in 1/10,000 doses, occurring more frequently in those receiving booster doses than the primary series.