People with potential category II or III rabies virus exposure are recommended to receive rabies vaccine as post-exposure prophylaxis
After managing the wound, give rabies vaccine with or without HRIG (human rabies immunoglobulin), depending on the category and source of exposure. See:
- Table. Vaccinated people: post-exposure rabies prophylaxis based on immune status and exposure category
- Table. Unvaccinated people: post-exposure rabies prophylaxis based on immune status and exposure category
- Figure. Rabies post-exposure prophylaxis: terrestrial animal exposures
- Figure. Rabies post-exposure prophylaxis: bat exposures
If a person’s vaccination status is uncertain because documentation showing a full course of rabies vaccine is not available, give the full post-exposure prophylaxis regimen.
Vaccine given intradermally for pre- or post-exposure prophylaxis can be considered previous vaccination.
Vaccinated people have evidence of a completed recommended pre-exposure or post-exposure prophylaxis regimen at any time in the past, or have a documented VNAb (rabies virus neutralising antibody) titre of >0.5 IU per mL at any time in the past. For those with a history of partial immunisation, see Incomplete pre-exposure prophylaxis schedule.
| Immune status | Exposure category | HRIG | Dose 1 (day 0) | Dose 2 (day 3) | Dose 3 (day 7) | Dose 4 (day 14) | Dose 5 (day 28) |
|---|---|---|---|---|---|---|---|
| Immunocompetent | Any category II or III | Not needed | Yes | Yes | Not needed | Not needed | Not needed |
| Mildly or moderately immunocompromised | Any category II or III | Not needed | Yes | Yes | Not needed | Not needed | Not needed |
| Severely immunocompromised | Any category II or III | Not needed | Yes | Yes | Yes | Yes | Yes |
|
HRIG = human rabies immunoglobulin Deviations of a few days from this schedule are probably unimportant.27 For defining the level of immunocompromise, see Definitions and Table. Types of medical conditions and immunosuppressive therapy and associated levels of immunocompromise in Vaccination for people who are immunocompromised. |
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| Immune status | Exposure category | HRIG | Dose 1 (day 0) | Dose 2 (day 3) | Dose 3 (day 7) | Dose 4 (day 14) | Dose 5 (day 28) |
|---|---|---|---|---|---|---|---|
| Immunocompetent | Category II terrestrial animals | Not needed | Yes | Yes | Yes | Yes | Not needed |
| Category II bats and any category III | Yes | Yes | Yes | Yes | Yes | Not needed | |
| Mildly or moderately immunocompromised | Any category II or III | Yes | Yes | Yes | Yes | Yes | Yes |
| Severely immunocompromised | Any category II or III | Yes | Yes | Yes | Yes | Yes | Yes |
|
HRIG = human rabies immunoglobulin Deviations of a few days from this schedule are probably unimportant.27 For defining the level of immunocompromise, see Definitions and Table. Types of medical conditions and immunosuppressive therapy and associated levels of immunocompromise in Vaccination for people who are immunocompromised. |
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Administration of rabies vaccine for post-exposure prophylaxis by the intradermal route is not recommended.
No clinical trial has assessed the efficacy of rabies vaccine, but the rationale supporting a 4-dose schedule in immunocompetent people is based on numerous studies.27-29 There have been no reported cases in Australia or internationally of vaccine failure in people who have been potentially exposed and have received a complete course of post-exposure prophylaxis.30
Incomplete pre-exposure prophylaxis schedule
Incomplete pre-exposure prophylaxis schedule
People who have only received 1 dose previously as pre-exposure prophylaxis require 4 doses as post-exposure prophylaxis (similar to those who are unvaccinated):
- If the single dose was given intramuscularly within the 12 months before exposure, no HRIG is required.
- If the single dose was given more than 12 months before exposure, HRIG is required.
- If the single dose was given intradermally, HRIG is required, regardless of when it was given.
People with any level of immunocompromise who received an incomplete pre-exposure prophylaxis schedule should receive post-exposure prophylaxis as for unvaccinated people, including HRIG.
People who are immunocompromised
People who are immunocompromised
Where possible, stop any immunosuppressive therapy (including corticosteroids) while giving post-exposure prophylaxis. Such treatment may interfere with the development of a protective response from the vaccine. Consult the person’s treating specialist to discuss the feasibility of this.
Measure the VNAb titre 2–4 weeks after the last dose. If the titre is <0.5 IU per mL, give another dose. Repeat the serological testing 2–4 weeks after this dose. If the titre is still <0.5 IU per mL, seek advice via state or territory health authorities.
People who are severely immunocompromised should always receive a dose of rabies immunoglobulin in addition to rabies vaccine as post-exposure prophylaxis, even if they have previously received rabies vaccine.
For defining the level of immunocompromise, see Definitions and Table. Types of medical conditions and immunosuppressive therapy and associated levels of immunocompromise in Vaccination for people who are immunocompromised.
Repeat rabies exposure
Repeat rabies exposure
People with a repeat exposure within 3 months of completing previous post-exposure prophylaxis do not need any further vaccine doses, HRIG and only need wound management (regardless of immune status).
Use of human rabies immunoglobulin
Use of human rabies immunoglobulin
Some people with a potential exposure to rabies virus or other lyssaviruses are recommended to receive HRIG in addition to rabies vaccine as post-exposure prophylaxis. See:
- Table. Lyssavirus exposure categories
- Table. Vaccinated people: post-exposure rabies prophylaxis based on immune status and exposure category
- Table. Unvaccinated people: post-exposure rabies prophylaxis based on immune status and exposure category
- Figure. Rabies post-exposure prophylaxis: terrestrial animal exposures
- Figure. Rabies post-exposure prophylaxis: bat exposures
Where indicated, give a dose of HRIG as soon as possible, and within 7 days (168 hours), after the 1st vaccine dose. Do not give HRIG if more than 7 days (168 hours) have passed since the 1st vaccine dose.
HRIG provides localised anti-rabies antibody protection while the person responds to the rabies vaccine. For information on how to administer HRIG, see Vaccines, dosage and administration.
HRIG is not recommended in people who:
- received the 1st dose of vaccine more than 7 days (168 hours) before presenting for HRIG — that is, more than 7 days (168 hours) have passed since they received the 1st dose of vaccine
- present for medical care more than 12 months after the potential exposure
- have a documented history of at least 2 doses of rabies vaccine from either pre- or post-exposure prophylaxis, as this may suppress the memory response and circulating VNAb; this excludes people who are severely immunocompromised, who always need HRIG (see Table. Vaccinated people: post-exposure rabies prophylaxis based on immune status and exposure category, and Table. Unvaccinated people: post-exposure rabies prophylaxis based on immune status and exposure category)
- have a documented history of 1 dose of rabies vaccine given by the intramuscular route, within the 12 months before exposure
- have documented evidence of VNAb titres >0.5 IU per mL at any time in the past
These people should receive rabies vaccine only.
Data are limited on the effectiveness of rabies vaccine and HRIG as post-exposure prophylaxis against infection with lyssaviruses other than classical rabies virus. However, the available animal data and clinical experience support their use.32-37