People who work with bats, laboratory workers who work with live lyssaviruses and some people who travel to rabies-enzootic areas are recommended to receive rabies vaccine as pre-exposure prophylaxis
Pre-exposure prophylaxis with rabies vaccine is recommended for:
- people who may receive bites or scratches from bats — these include bat handlers; veterinarians and veterinary nurses; wildlife officers, wildlife carers and zookeepers; wildlife researchers; and others who come into direct contact with bats in any country, including Australia
- research laboratory workers working with any live lyssavirus
- people who will be travelling to, or living in, rabies-enzootic areas — give pre-exposure prophylaxis after a risk assessment that considers the likelihood that the person will interact with animals and their access to emergency medical attention
Rabies vaccines can be given by the intramuscular or intradermal route. The intradermal route uses 0.1mL per dose of all vaccines. The intramuscular route uses 0.5mL for Verorab and 1.0mL for Rabipur.
The intradermal route may only be used by suitably qualified and experienced providers (eg travel medicine clinics). See Administration of vaccines. This route is only to be used for pre-exposure vaccination of immunocompetent people.
The intradermal route is an unlicensed (‘off-label’) route of administration. If intradermal rabies pre-exposure prophylaxis is considered, it is essential that:
- it is given by immunisation providers who have expertise in, and regularly practise, the intradermal technique, because incorrect administration may mean the person being vaccinated is not adequately protected
- it is not given to people who are immunocompromised, as the immune response may not be adequate1,2,3
- it is not given to people taking chloroquine, or other antimalarials that are structurally related to chloroquine (such as mefloquine or hydroxychloroquine), at the time of vaccination or within 1 month after vaccination, as this can reduce the immune response to intradermal rabies vaccine4
- the immunisation provider follows procedures for the use of a multidose vial and discards any remaining vaccine after 8 hours or at the end of the vaccination session, whichever occurs first
There are 4 options for administering pre-exposure prophylaxis, varying by schedule length, number of doses and route of administration. There is no preferential recommendation for choosing a schedule and route of administration. Consideration should include a person’s circumstance and personal preferences.
3-visit schedules
3-visit schedules
The recommended 3-visit pre-exposure prophylaxis schedule comprises 3 vaccine doses, given at days 0, 7 and 21–28. These can be given by either the intramuscular or intradermal route.
2-visit schedules
2-visit schedules
The recommended 2-visit pre-exposure prophylaxis schedule given by the intramuscular route comprises 2 vaccine doses, given as follows:
- 1 injection (1.0mL for Mérieux and Rabipur, 0.5mL for Verorab) on day 0
- 1 injection (1.0mL for Mérieux and Rabipur, 0.5mL for Verorab) on day 7
The recommended 2-visit pre-exposure prophylaxis schedule given by the intradermal route comprises 4 vaccine doses, given as follows:
- 2 x 0.1 mL injections given at different sites on day 0
- 2 x 0.1 mL injections given at different sites on day 7
Do not use 2-visit schedules in people who are immunocompromised, as the immune response may not be adequate.5
Do not use this 2-visit intradermal schedule in adults >50 years of age, because studies show that seroconversion is less likely to occur in this age group than in younger people.6,7
These 2-visit schedules provide short-term protection, particularly beneficial for travel to rabies-enzootic areas. If further protection is required after 1 year, antibody levels may no longer be adequate.8-10 A single intramuscular booster dose should be given 1 year after the 1st dose of pre-exposure prophylaxis, regardless of the administration route for the original pre-exposure prophylaxis course. An intramuscular booster dose of rabies vaccine should still provide adequate protection even if given more than 1 year after the 1st dose of pre-exposure prophylaxis.9,11,12,13
Booster doses
Booster doses
Booster doses of rabies vaccine are recommended for immunised people who have ongoing occupational exposure to lyssaviruses in Australia or overseas. See People with ongoing occupational exposure to lyssaviruses are recommended to receive booster doses of rabies vaccine.
Serological testing for people who received pre-exposure prophylaxis by the intradermal route
Serological testing for people who received pre-exposure prophylaxis by the intradermal route
If pre-exposure prophylaxis was received by the intradermal route, rabies antibody level should ideally be checked 2–4 weeks after finishing the pre-exposure course to ensure that VNAb (rabies virus neutralising antibody) levels are ≥0.5 IU per mL. Seek expert advice via state or territory health authorities or specialist immunisation clinics if the titre is <0.5 IU per mL.
If there will be insufficient time before travel for serological testing to be performed, the intramuscular route for vaccination should be preferred.
Serological testing for people who are immunocompromised
Serological testing for people who are immunocompromised
People who are immunocompromised should have their VNAb titres checked 2–4 weeks after the 3rd intramuscular dose of vaccine in a 3-visit 21-28 day pre-exposure prophylaxis schedule. Give a further dose if the titre is <0.5 IU per mL, and repeat serological testing. If the titre remains <0.5 IU per mL, seek advice via state or territory health authorities or specialist immunisation clinics.
Rationale for pre-exposure prophylaxis
Rationale for pre-exposure prophylaxis
Pre-exposure prophylaxis simplifies how a potential subsequent exposure to rabies virus or Australian bat lyssavirus is managed because:
- the person needs fewer doses of rabies vaccine in the post-exposure phase
- the person does not need RIG (rabies immunoglobulin) unless they are severely immunocompromised
This is particularly important because RIG — either human (HRIG), equine (ERIG) or monoclonal RIG — can be difficult to obtain and is expensive, and its safety cannot be guaranteed in many rabies-enzootic developing countries. See also Vaccination after potential exposure to rabies virus or other lyssaviruses (post-exposure prophylaxis).