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 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.13 Severely immunocompromised refers to people for whom live vaccines are contraindicated. See 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 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.13 Severely immunocompromised refers to people for whom live vaccines are contraindicated. See 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.18-20 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.31
Incomplete pre-exposure prophylaxis schedule
Incomplete pre-exposure prophylaxis schedule
People who are immunocompetent and have previously received an incomplete pre-exposure prophylaxis schedule of 2 doses can receive the 2-dose post-exposure prophylaxis schedule described above.
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 (that is, people for whom live vaccines are contraindicated) 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.
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 and only need wound management.
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.36-41