Rabies Vaccination, Simplified Schedules

Introduction

Current Global Situation

• Rabies remains endemic in many regions, particularly across Africa, Asia, and parts of Latin America.
• According to the World Health Organization (WHO), an estimated 59,000 people die from rabies each year, with the majority of cases resulting from dog bites.

Vaccination Efforts

• Vaccination of domestic animals—especially dogs—is the cornerstone of rabies prevention and control.
• Several countries have successfully implemented mass dog vaccination campaigns, demonstrating measurable reductions in human and animal rabies cases.

Public Awareness and Education

• Public awareness initiatives play a critical role in educating communities about rabies prevention and the importance of timely vaccination.
• Health organizations continue to promote responsible pet ownership and emphasize the need for immediate medical evaluation after any potential exposure.
• Both pre-exposure prophylaxis (PrEP) for high-risk populations and post-exposure prophylaxis (PEP) following suspected rabies exposure are essential, life-saving interventions. PEP includes administration of human rabies immune globulin (HRIG), followed immediately by a complete course of rabies vaccination.

Challenges

• Limited availability and accessibility of PEP, particularly in rural and underserved areas, remain major obstacles to effective rabies control.
• Cultural beliefs, lack of awareness, and underreporting further hinder vaccination uptake and timely treatment.

Future Outlook

• Achieving global rabies elimination requires sustained collaboration, funding, and political commitment.
• The WHO has set the ambitious target of eliminating dog-mediated rabies by 2030, a goal dependent on expanded vaccination coverage, improved access to PEP, and strengthened public health initiatives.
• As new research and resources emerge, strategies will need to be adapted to ensure long-term success in rabies prevention and control.

Pre-exposure prophylaxis (PrEP)

• PrEP vaccination is recommended for people who work directly with animals that could have rabies.
• Those who travel to parts of the world where rabies is common and access to medical care is limited also may consider pre-exposure prophylaxis.
• A two-dose PrEP schedule has replaced the three-dose PrEP schedule to protect people from rabies for up to three years. 
• The minimum acceptable laboratory value (antibody titer) used to determine whether rabies vaccine booster doses are needed was revised and standardized.
• Many people for whom serial titers were recommended every two years now require only a one-time titer (and booster if below a certain level) OR a one-time booster.
• Risk categories have been redefined into five risk groups:

Risk categories

Risk category 1

People who work with live or concentrated rabies virus in laboratories

• 2 doses, days 0 and 7.
• Check titer every 6 months.

Risk category 2

People who frequently do at least one of the following: handle bats, have contact with bats, enter high-density bat environments like caves, or perform animal necropsies.

• 2 doses, days 0 and 7
• Check titer every 2 years

Risk category 3

People who interact with, or are at higher risk to interact, with mammals other than bats that could be rabid, for a period longer than three years after they receive PrEP.

This group includes:

• Most veterinarians, veterinary technicians, animal control officers, wildlife biologists, rehabilitators, trappers, and spelunkers (cave explorers).
• Certain travelers to regions outside of the United States where rabies in dogs is commonly found.

2 doses, days 0 and 7, plus:

• Either a one-time titer check after 1 year or up to 3 years following the first 2-dose vaccination.

Or

• 1-dose booster between 3 weeks and 3 years following the first vaccine in the 2-dose vaccination

Risk category 4

Same population as in risk category 3, but at a higher risk for ≤ three years after they receive PrEP.

• 2 doses, days 0 and 7

Risk category 5

General population

• No vaccination.

Post-exposure prophylaxis (PEP)

Key points

• Rabies PEP includes wound care, human rabies immune globulin (HRIG), and a four-dose vaccine series.
• PEP recommendations differ for people depending on previous rabies vaccine status, and for those who are immunocompromised.
• Never administer the first vaccine dose in the same syringe or in the same anatomical site as HRIG.

Clinical assessment for rabies post-exposure prophylaxis

Following a potential rabies exposure, public health professionals should perform a risk assessment to determine if rabies PEP is needed.

The recommendations consist of:

• Wound care
• A dose of HRIG.
• Rabies vaccine given at the time of the first medical visit, and a dose of vaccine given again on days 3, 7, and 14 after the first dose.

Regardless of rabies risk, bite wounds can result in serious complications, including nerve or tendon lacerations and secondary bacterial infections. For many types of bite wounds, immediate and thorough irrigation—using clean water or a dilute povidone–iodine solution—significantly reduces the risk of infection.

Wound cleansing is also a critical step in rabies prevention. Experimental animal studies have demonstrated that meticulous wound cleansing alone, even in the absence of additional medical interventions such as vaccination, can substantially decrease the likelihood of rabies transmission.

Decisions regarding the use of antibiotics and primary wound closure should be made collaboratively with the patient, considering the type, location, and severity of the injury.

Human rabies immune globulin (HRIG)

People who have been previously vaccinated or are receiving PrEP for rabies should not HRIG.

HRIG is administered only once at the beginning of the PEP course. HRIG provides immediate antibodies until rabies vaccination provides immunogenicity.

HRIG should never be administered in the same syringe or in the same anatomical site as the first vaccine dose, however, subsequent doses of vaccine in the four-dose series can be administered in the same anatomic location where the HRIG dose was administered.

Rabies vaccine

-For people who have never been vaccinated against rabies, PEP should always include the administration of HRIG and rabies vaccine. The combination of HRIG and vaccine is recommended for both bite and non-bite exposures, regardless of the interval between exposure and initiation of treatment, so long as the patient is not showing signs consistent with rabies.

Administer 1.0 mL of Human Diploid Cell Rabies Vaccine (HDCV) or Purified Chick Embryo Cell Vaccine (PCECV) intramuscularly in the deltoid area (for children, anterolateral aspect of the thigh is acceptable).

Do not administer rabies vaccines in the gluteal area.

One injection each on days 0, 3, 7, and 14.

For those with immune disorders, administer a fifth dose on day 28.

-For people who have previously been vaccinated against rabies, PEP consists of two doses of vaccine three days apart.

HDCV or PCECV 1.0 mL, intramuscularly in the deltoid area (for children anterolateral aspect of the thigh is acceptable).

One each on days 0 and 3.

Precautions and contraindications for rabies vaccination

There are no known contraindications for rabies vaccination. Pregnancy is not a contraindication for rabies PEP, and exposure to rabies or a rabies diagnosis in the mother does not require pregnancy termination.

PEP is suitable for all age groups including infants and children.

For immunosuppressed or immunocompromised individuals, rabies PEP should be administered using a 5-dose vaccine regimen, which includes one dose of vaccine on days 0, 3, 7, 14, and 28. Help patients understand that their immune response may be inadequate.

Avoid immunosuppressive agents during rabies PEP unless essential for treating other conditions. Patients on immunosuppressive medications should consult with their healthcare providers about the possibility of delaying these treatments during PEP.

After completing the vaccine series, test the patient for rabies virus neutralizing antibody. The patient’s physician and public health officials should guide further management.

Vaccine administration – intradermal (ID) vs intramuscular (IM):

As detailed in the guidance on PEP administration, WHO recommends moving from intramuscular  to intradermal administration of human rabies vaccines.

Intradermal administration reduces the amount of necessary vaccine and number of doses, therefore reducing costs by 60–80%, without compromising safety or efficacy.

Fewer doses also promote patient compliance with the recommended regimen.

WHO response:

Rabies is included in WHO’s 2021–2030 Roadmap for the global control of NTDs, which sets regional, progressive targets for the global strategic plan to end human deaths from dog-mediated rabies by 2030. This entails:

• Improving access to human rabies vaccines through the efforts of the WHO and its partners, Gavi, the Vaccine Alliance, which had included human rabies vaccines in its Vaccine Investment Strategy for 2021–2025. Despite pandemic-related delays, WHO now collaborates with Gavi to implement the program in 2024.
• Providing technical guidance to countries in developing and implementing their national rabies elimination plans, focusing on strengthening surveillance and reporting.
• Encouraging countries to build the capacity of their One Health workforce by using rabies elimination programs as a platform for multisectoral collaborations.
• Encouraging the use of United Against Rabies (UAR) multi-stakeholder forum, which was launched in collaboration with WHO, Food and Agriculture Organization (FAO) and World Organization for Animal Health (WOAH, formerly OIE), to advocate for action and investment in rabies control.

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