ACIP updates rabies pre-exposure prophylaxis guidelines
The US Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP) have updated their rabies pre-exposure prophylaxis (PrEP) guidelines. PrEP is recommended in certain people who are at high risk for rabies exposure.
Fewer doses are now required in the primary vaccination schedule. ACIP recommends a two-dose intramuscular rabies vaccination series to replace the previously recommended three-dose schedule. Doses should be administered on days 0 and 7. As a consequence of this update, more people who are recommended to receive rabies PrEP might now be vaccinated because the two-dose series is associated with a lower cost and takes less time to complete.
The minimum acceptable rabies antibody titer, used to determine whether rabies vaccination booster doses are required, has been increased to 0.5 IU/mL. Historically, the minimum antibody titer recommended was 0.1 to 0.3 IU/mL. Therefore, when titers are checked, more people may require a booster dose than with the previous titer cut-off.
Recommendations for PrEP depend on the level of a person’s risk for being exposed to rabies. These risk categories have been redefined into 5 risk groups. Many people for whom serial titers were previously recommended every 2 years now require only a one-time titer (and booster if the titer is below a certain level), or a one-time booster. This means less frequent or no antibody titer checks for some risk groups.
Worldwide, approximately 59,000 human rabies deaths occur each year. In the US, 52 cases of human rabies were diagnosed between 2000 to 2020, 28 of which were indigenously acquired.
Rabies is a notifiable disease in the US.
Preventable through prompt medical care. Postexposure prophylaxis with wound cleansing, immunization, and rabies immune globulin is highly effective at preventing the disease when given promptly and properly.
Symptoms begin with a nonspecific prodromal illness. In encephalitic rabies, this is followed by early-onset behavioral changes and late-onset paralysis. In the paralytic form, the behavioral changes are absent.
Almost always fatal following onset of clinical signs. The disease is rapidly progressive, leading to death within 2 weeks in most cases. Some survivors have been reported.
Pre-exposure prophylaxis is recommended for certain people at high risk for exposure.
An acute viral encephalomyelitis caused by the rabies virus and other members of the Lyssavirus genus, which is transmitted by animal bites, mainly dogs in developing countries and bats in other countries including the US.
The World Health Organization (WHO) has set a global goal to achieve no human deaths from dog-transmitted rabies by 2030.
History and exam
Key diagnostic factors
- history of recent scratch or bite from known vector
- limb numbness, pain, and paresthesia
- change in behavior
- agitation and confusion
- signs of autonomic instability
- rapid progression of symptoms
- weakness and paralysis
Other diagnostic factors
- urinary or fecal incontinence
- abdominal pain
- slurred or stuttered speech
- recent scratch or bite from known vector
- travel to/living in rabies-endemic country
- occupational or recreational exposure
- age <15 years
1st investigations to order
- saliva PCR and viral culture
- skin biopsy (neck) with direct fluorescent antibody (DFA) and PCR
- CSF cytology
- CSF biochemistry
- CSF rabies neutralizing antibody
- serum rabies IgM or IgG
- CSF herpes simplex PCR
- CSF enterovirus PCR
- CSF West Nile virus IgM
- serum N-methyl-D-aspartate (NMDA) glutamate receptor antibodies
Investigations to consider
- serum arbovirus antibodies
- serum Bartonella antibodies
- serum Rickettsia antibodies
- head MRI
asymptomatic with recent vector exposure
Sergio Recuenco, MD, MPH, DrPH
Faculty of Medicine Sa Fernando
National University of San Marcos
SR declares that he has no competing interests.
Rodney Willoughby, MD
Medical College of Wisconsin
RW is an author of a number of references cited in this topic.
Dr Sergio Recuenco and Dr Rodney Willoughby would like to gratefully acknowledge Dr Kis Robertson, a previous contributor to this topic.
KR declares that she has no competing interests.
Peter Leggat, MD
School of Public Health
Tropical Medicine and Rehabilitation Sciences
Faculty of Medicine
Health and Molecular Sciences
James Cook University
PL is a member of the Australian Travel Health Advisory Group that is supported by a grant from GlaxoSmithKline. PL has received travel grants from GlaxoSmithKline to attend travel medical conferences in the last 5 years.
Allan Grill, MD, CCFP, MPH
Department of Family and Community Medicine
Dalla Lana School of Public Health
University of Toronto
AG declares that he has no competing interests.
- Herpes simplex virus infection
- Enterovirus meningoencephalitis
- West Nile virus encephalitis
- Use of a modified preexposure prophylaxis vaccination schedule to prevent human rabies
- CDC health information for international travel (The Yellow Book). Chapter 4: infectious diseases related to travel - rabies
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