What is the recommended pre-exposure prophylaxis (pre-exposure prevention) for rabies?

Rabies Pre-Exposure Prophylaxis Recommendations

The recommended pre-exposure prophylaxis for rabies consists of three 1.0-mL injections of human diploid cell vaccine (HDCV) or purified chick embryo cell vaccine (PCECV) administered intramuscularly in the deltoid area on days 0,7, and 21 or 28. 1, 2

Who Should Receive Pre-Exposure Prophylaxis

Pre-exposure vaccination should be offered to individuals at risk of rabies exposure:

• High risk (continuous exposure): Rabies laboratory workers, rabies biologics production workers
• Frequent risk: Veterinarians and staff, animal control officers, wildlife workers in rabies-endemic areas, cavers, rabies diagnostic laboratory workers, individuals who frequently handle bats
• Infrequent risk: Veterinary students, travelers to rabies-endemic areas with limited access to medical care
• General population: No vaccination necessary 3, 1, 2

Vaccination Protocol

Primary Vaccination

1. Administer three 1.0-mL doses of HDCV or PCECV intramuscularly in the deltoid area
2. Follow schedule: days 0,7, and 21 or 28
3. In children, the anterolateral thigh may be used depending on age and body mass 3, 1, 2

Important Administration Considerations

• Always use the deltoid area in adults (never gluteal region, which results in lower antibody response)
• If taking chloroquine or other antimalarials, complete vaccination at least 1 month before starting antimalarial therapy or use the IM route exclusively 3, 1
• For immunosuppressed individuals, consider antibody testing after vaccination and additional doses if response is inadequate 2

Follow-up and Booster Doses

Follow-up depends on risk category:

1. Continuous risk (laboratory workers handling rabies virus):

   • Check antibody titers every 6 months
   • Administer booster if titer falls below complete neutralization at 1:5 serum dilution by RFFIT

2. Frequent risk (veterinarians, animal handlers in endemic areas):

   • Check antibody titers every 2 years
   • Administer booster if titer falls below complete neutralization at 1:5 serum dilution by RFFIT

3. Infrequent risk (veterinarians in low-rabies areas, travelers):

   • No routine serologic testing or boosters required 3, 1, 2

Recent evidence suggests that a single booster dose after primary vaccination may confer long-term immunity in nearly all individuals, potentially alleviating the need for frequent antibody monitoring 4.

Benefits of Pre-Exposure Prophylaxis

Pre-exposure vaccination provides several advantages:

1. Eliminates need for rabies immune globulin (RIG) if exposure occurs
2. Reduces number of vaccine doses needed for post-exposure prophylaxis (only 2 doses on days 0 and 3)
3. Provides partial protection when post-exposure prophylaxis is delayed
4. Offers protection against unrecognized exposures 3, 1, 2

Post-Exposure Management for Previously Vaccinated Individuals

If a previously vaccinated person is exposed to rabies:

• Only 2 IM doses (1.0 mL each) of vaccine are required on days 0 and 3
• No rabies immune globulin is needed
• Thorough wound cleansing remains essential 3, 1

Common Pitfalls to Avoid

• Incorrect administration site: Using gluteal region instead of deltoid area
• Incomplete vaccination series: All three doses are necessary for protection
• Assuming permanent immunity: Follow-up testing is required based on risk category
• Delayed boosters: Maintaining appropriate follow-up based on exposure risk is crucial
• Inappropriate use in low-risk travelers: Pre-exposure prophylaxis is not routinely recommended for general travelers to areas where rabies is not endemic 1, 2

While pre-exposure prophylaxis is beneficial for high-risk individuals, it should not replace efforts to control rabies in animal reservoirs, provide post-exposure prophylaxis, or educate communities about rabies awareness 5.