• Clinical Info

Uses

Prevention of Rabies

Prevention of rabies in children, adolescents, and adults exposed to or at risk of exposure to rabies disease or virus.

Rabies is a viral infection transmitted by saliva of infected mammals, most commonly wild, terrestrial carnivores (e.g., skunks, raccoons, foxes, coyotes) or bats. In the US, the greatest risk for naturally acquired rabies is from contact with and bites from insectivorous bats. Following exposure and infection, rabies virus usually moves along a neural pathway and enters the CNS. After entrance into the CNS, the virus is unlikely to be affected by antirabies antibodies and encephalomyelitis usually develops and is almost always fatal. In the US, approximately 16,000–39,000 individuals receive rabies postexposure prophylaxis each year. Between 1990 and 2004, there were 47 rabies-related deaths in the US. Worldwide, rabies is much more common and about 40,000–100,000 rabies-related deaths occur each year.

USPHS Advisory Committee on Immunization Practices (ACIP) and AAP recommend preexposure vaccination with rabies vaccine (series of 3 doses with booster doses when indicated) in children, adolescents, and adults who are or will be at risk of exposure to the virus. (See Preexposure Vaccination Against Rabies in High-risk Groups under Uses.)

Postexposure prophylaxis with a combined regimen of rabies vaccine (series of 5 doses) and a single dose of rabies immune globulin (RIG) is recommend for previously unvaccinated children, adolescents, and adults following potential rabies exposure. Postexposure prophylaxis with a series of 2 booster doses of rabies vaccine (without RIG) is recommended for previously vaccinated children, adolescents, and adults following potential rabies exposure. (See Postexposure Prophylaxis of Rabies under Uses.)

Preexposure Vaccination Against Rabies in High-risk Groups

Preexposure vaccination in children, adolescents, and adults who are or will be at risk of exposure to rabies virus.

Preexposure vaccination does not eliminate the need for prompt postexposure prophylaxis if an exposure to rabies occurs. (See Postexposure Prophylaxis of Rabies under Uses.)

Need for rabies preexposure vaccination depends on the nature of risk and associated level of potential exposure. Consider preexposure vaccination for individuals whose risk of rabies exposure is greater than that of the general population (e.g., veterinarians and their staff, animal-control and wildlife workers, field biologists, spelunkers, missionaries, rabies researchers, certain laboratory workers). Also consider preexposure vaccination for individuals whose activities bring them into frequent contact with rabies virus or potentially rabid bats, raccoons, skunks, cats, dogs, or other species at risk for having rabies. (For ACIP definitions of risk categories and recommendations regarding preexposure vaccination for each category, see the table.)

Travelers to areas where rabies is endemic may be at risk, especially if they are likely to come in contact with animals in areas where dog or other animal rabies is enzootic and immediate access to appropriate medical care (including rabies vaccine and RIG) is unlikely. CDC recommends preexposure vaccination based on local incidence of rabies in the country to be visited, availability of appropriate agents for rabies postexposure prophylaxis, and intended activity and duration of stay. Immunization against rabies is not a requirement for entry into any country.

Postexposure Prophylaxis of Rabies

Postexposure prophylaxis of rabies in previously vaccinated and unvaccinated children, adolescents, and adults following potential exposure to rabies disease or virus.

History of previous vaccination against rabies simplifies the postexposure prophylaxis regimen, but does not eliminate the need for prompt postexposure prophylaxis if an exposure to rabies occurs.

Following possible exposure to rabies, base decisions regarding need for postexposure prophylaxis on vaccination status of exposed individual, type of exposure (bite, nonbite), information about the animal involved (type, vaccination status, condition at time of attack), and rabies epidemiology in the specific geographic region. Whenever possible, consult local or state public health officials regarding the need for postexposure prophylaxis.

Bite exposures include any skin penetration by teeth; all bite exposures from an animal known or suspected to be rabid, regardless of bite location, pose a potential risk of rabies transmission and require postexposure prophylaxis. Risk of transmission varies in part based on species of biting animal, anatomic site of bite, and severity of wound. Rabies transmission can occur from bites of some animals (e.g., bats) that inflict rather minor injury and wounds that are difficult to detect.

Any potential exposure to a bat requires thorough evaluation. If possible, the bat should be submitted for rabies diagnosis. Postexposure prophylaxis is not necessary if the individual can be reasonably certain a bite, scratch, or mucous membrane exposure did not occur or if the bat is available for testing and is negative for rabies virus. Situations that might qualify as exposures include finding a bat in the same room as a person who might be unaware that a bite or direct contact occurred (e.g., a deeply sleeping individual awakened to find a bat in the room or an adult observes a bat in the room with a previously unattended child, mentally disabled person, or intoxicated person). Other household members who do not have direct contact with the bat or were awake and aware when in the room with the bat should not be considered as having exposure to rabies.

Nonbite exposures include contamination of preexisting open wounds, abrasions, mucous membranes, or scratches with saliva or other potentially infectious material (e.g., neural tissue) from an animal known or suspected to be rabid. Although nonbite exposures only rarely cause rabies, such exposures require assessment to determine if sufficient reasons exist to consider postexposure prophylaxis. Nonbite exposures of highest risk occur in surgical recipients of corneas, solid organs, and vascular tissue transplanted from patients who died of rabies and individuals exposed to large amounts of aerosolized rabies virus.

Other forms of contact in the absence of a bite or nonbite exposure (e.g., petting a rabid animal or contact with blood, urine, or feces of a rabid animal, contact of saliva with intact skin) are not considered exposure and postexposure prophylaxis is not necessary.

In health-care personnel, routine delivery of health care to a patient with rabies is not an indication for postexposure rabies prophylaxis, unless there was exposure of mucous membranes or nonintact skin to potentially infectious body fluids.

Regardless of immunization status, ACIP and AAP recommend local wound treatment as an essential initial step in rabies postexposure prophylaxis in all individuals. (See General under Dosage and Administration.)

In previously unvaccinated children, adolescents, and adults following potential rabies exposure, a combined regimen of active immunization with a 5-dose regimen of rabies vaccine and passive immunization with a single dose of RIG is recommended as soon as possible.

In previously vaccinated children, adolescents, and adults following potential rabies exposure, a 2-dose booster regimen of rabies vaccine (without RIG) is recommended as soon as possible.

For ACIP recommendations regarding rabies postexposure prophylaxis in the US based on the type and status of the animal involved, see the table.

Because the rabies incubation period can range from 5 days to >1 year, initiate rabies postexposure prophylaxis (regardless of the length of delay) if a documented or likely exposure has occurred and clinical signs of rabies have not appeared in the exposed individual.

Postexposure prophylaxis failures have not been reported in the US when recommended immunization regimens and wound management procedures were followed using commercially available rabies vaccines and RIG. Rare reports of failures in other countries usually involved some deviation from recommended procedures (e.g., failure to adequately cleanse wounds, IM injection into the gluteal rather than deltoid region, failure to passively immunize with RIG by infiltrating the wound site, use of less than the recommended dose of RIG).

Travelers with potential rabies exposure should immediately contact local health authorities for advice regarding postexposure prophylaxis and should also contact their personal clinician or state health department as soon as possible. Travelers in other countries may receive postexposure prophylaxis with regimens and/or preparations not currently recommended by ACIP resulting in the need for additional therapy following return to the US. Consider serologic testing in these travelers to verify efficacy of the regimen used and to ensure an adequate immune response. (See Pre- and Postvaccination Serologic Testing under Cautions.)