When to use rabies prophylaxis
- Alfred DeMaria, Jr, MD
Alfred DeMaria, Jr, MD
- Medical Director, Bureau of Infectious Disease
- Massachusetts Department of Public Health and Laboratory Sciences
Rabies is a fatal viral disease primarily acquired from the bite of a rabid animal, with only six cases of documented human survival prior to 2004. However, since that time there have been three documented survivors who had not received any pre-exposure rabies vaccine .
Infection can be prevented with proper post-exposure prophylaxis, as first pioneered by Louis Pasteur in 1885. While 35,000 to 59,000 people worldwide die of rabies every year (40 percent are children younger than 15 years) , only 34 cases of human rabies were diagnosed in the United States from 2003 through 2013 [3,4]. The low rate of human cases in the United States reflects the success of domestic animal control and vaccination programs. The predominant reservoir of rabies in the United States is now wildlife, with most cases occurring in raccoons, skunks, foxes and bats.
The recommendations of the Advisory Committee on Immunization Practices (ACIP) for rabies post-exposure prophylaxis are reviewed here . These guidelines can be accessed through the Centers for Disease Control and Prevention's website at http://www.cdc.gov/rabies/ and should be checked periodically for updates. The use of rabies biologics (vaccine and immunoglobulin) and the clinical features and treatment of human rabies are presented separately. (See "Rabies immune globulin and vaccine" and "Clinical manifestations and diagnosis of rabies".)
Several factors need to be considered in deciding whether to administer post-exposure rabies prophylaxis. These include [5,6]:
●The epidemiology of animal rabies in the region
- Centers for Disease Control and Prevention (CDC). Recovery of a patient from clinical rabies--California, 2011. MMWR Morb Mortal Wkly Rep 2012; 61:61.
- World Health Organization. Rabies. http://www.who.int/rabies (Accessed on October 15, 2015).
- Noah DL, Drenzek CL, Smith JS, et al. Epidemiology of human rabies in the United States, 1980 to 1996. Ann Intern Med 1998; 128:922.
- Dyer JL, Yager P, Orciari L, et al. Rabies surveillance in the United States during 2013. J Am Vet Med Assoc 2014; 245:1111.
- Manning SE, Rupprecht CE, Fishbein D, et al. Human rabies prevention--United States, 2008: recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep 2008; 57:1.
- Rupprecht CE, Gibbons RV. Clinical practice. Prophylaxis against rabies. N Engl J Med 2004; 351:2626.
- Zinsstag J, Schelling E, Roth F, et al. Human benefits of animal interventions for zoonosis control. Emerg Infect Dis 2007; 13:527.
- Boland TA, McGuone D, Jindal J, et al. Phylogenetic and epidemiologic evidence of multiyear incubation in human rabies. Ann Neurol 2014; 75:155.
- Eidson M, Matthews SD, Willsey AL, et al. Rabies virus infection in a pet guinea pig and seven pet rabbits. J Am Vet Med Assoc 2005; 227:932.
- Helmick CG, Tauxe RV, Vernon AA. Is there a risk to contacts of patients with rabies? Rev Infect Dis 1987; 9:511.
- Kan VL, Joyce P, Benator D, et al. Risk assessment for healthcare workers after a sentinel case of rabies and review of the literature. Clin Infect Dis 2015; 60:341.
- Fishbein DB. Rabies in humans. In: The natural history of rabies, Second Edition, Baer GM (Ed), CRC Press, Boca Raton, Florida 1991. p.519.
- Sitthi-Amorn C, Jiratanavattana V, Keoyoo J, Sonpunya N. The diagnostic properties of laboratory tests for rabies. Int J Epidemiol 1987; 16:602.
- Feder HM Jr, Nelson R, Reiher HW. Bat bite? Lancet 1997; 350:1300.
- De Serres G, Skowronski DM, Mimault P, et al. Bats in the bedroom, bats in the belfry: reanalysis of the rationale for rabies postexposure prophylaxis. Clin Infect Dis 2009; 48:1493.
- National Advisory Committee on Immunization (NACI). Recommendations Regarding the Management of Bat Exposures to Prevent Human Rabies. http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/09pdf/acs-dcc-07.pdf (Accessed on March 01, 2010).
- Winkler WG, Fashinell TR, Leffingwell L, et al. Airborne rabies transmission in a laboratory worker. JAMA 1973; 226:1219.
- CDC. Rabies in a laboratory worker--New York. MMWR 1977; 26:183.
- Winkler WG, Baker EF Jr, Hopkins CC. An outbreak of non-bite transmitted rabies in a laboratory animal colony. Am J Epidemiol 1972; 95:267.
- Afshar A. A review of non-bite transmission of rabies virus infection. Br Vet J 1979; 135:142.
- Siegel JD, Rhinehart E, Jackson M, et al. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Health Care Settings. Am J Infect Control 2007; 35:S65.
- Mattner F, Henke-Gendo C, Martens A, et al. Risk of rabies infection and adverse effects of postexposure prophylaxis in healthcare workers and other patient contacts exposed to a rabies virus-infected lung transplant recipient. Infect Control Hosp Epidemiol 2007; 28:513.
- WHO Expert Consultation on rabies. World Health Organ Tech Rep Ser 2005; 931:1.
- Centers for Disease Control (CDC). Human-to-human transmission of rabies via corneal transplant--Thailand. MMWR Morb Mortal Wkly Rep 1981; 30:473.
- Gode GR, Bhide NK. Two rabies deaths after corneal grafts from one donor. Lancet 1988; 2:791.
- CDC . Human to human transmission of rabies via a corneal transplant--France. MMWR Morb Mortal Wkly Rep 1980; 29:25.
- Houff SA, Burton RC, Wilson RW, et al. Human-to-human transmission of rabies virus by corneal transplant. N Engl J Med 1979; 300:603.
- WHO. Two rabies cases following corneal transplantation. Weekly Epidemiol Rec 1994; 69:330.
- Javadi MA, Fayaz A, Mirdehghan SA, Ainollahi B. Transmission of rabies by corneal graft. Cornea 1996; 15:431.
- Centers for Disease Control and Prevention (CDC). Investigation of rabies infections in organ donor and transplant recipients--Alabama, Arkansas, Oklahoma, and Texas, 2004. MMWR Morb Mortal Wkly Rep 2004; 53:586.
- Srinivasan A, Burton EC, Kuehnert MJ, et al. Transmission of rabies virus from an organ donor to four transplant recipients. N Engl J Med 2005; 352:1103.
- Vora NM, Basavaraju SV, Feldman KA, et al. Raccoon rabies virus variant transmission through solid organ transplantation. JAMA 2013; 310:398.
- Hellenbrand W, Meyer C, Rasch G, et al. Cases of rabies in Germany following organ transplantation. Euro Surveill 2005; 10:E050224.6.
- Fekadu M, Endeshaw T, Alemu W, et al. Possible human-to-human transmission of rabies in Ethiopia. Ethiop Med J 1996; 34:123.
- Niezgoda M, Briggs DJ, Shaddock J, et al. Pathogenesis of experimentally induced rabies in domestic ferrets. Am J Vet Res 1997; 58:1327.
- Fitzpatrick MC, Hampson K, Cleaveland S, et al. Cost-effectiveness of canine vaccination to prevent human rabies in rural Tanzania. Ann Intern Med 2014; 160:91.
- National Association of State Public Health Veterinarians, Inc. Compendium of animal rabies prevention and control, 2011. MMWR Recomm Rep 2011; 60:1.
- Jentes ES, Blanton JD, Johnson KJ, et al. The global availability of rabies immune globulin and rabies vaccine in clinics providing direct care to travelers. J Travel Med 2013; 20:148.
- Jentes ES, Blanton JD, Johnson KJ, et al. The global availability of rabies immune globulin and rabies vaccine in clinics providing indirect care to travelers. J Travel Med 2014; 21:62.
- WHO Publication. Rabies vaccines: WHO position paper--recommendations. Vaccine 2010; 28:7140.
- Khawplod P, Wilde H, Chomchey P, et al. What is an acceptable delay in rabies immune globulin administration when vaccine alone had been given previously? Vaccine 1996; 14:389.
- WHO. Recommendations on rabies postexposure treatment and the correct technique of intradermal immunization against rabies. Document EMC.ZOO 96.6. WHO, Geneva 1996.
- Wilde H, Khawplod P, Hemachudha T, Sitprija V. Postexposure treatment of rabies infection: can it be done without immunoglobulin? Clin Infect Dis 2002; 34:477.
- Krebs JW, Smith JS, Rupprecht CE, Childs JE. Rabies surveillance in the United States during 1997. J Am Vet Med Assoc 1998; 213:1713.
- Centers for Disease Control and Prevention (CDC). Human exposures to a rabid bat - Montana, 2008. MMWR Morb Mortal Wkly Rep 2009; 58:557.
- Moran GJ, Talan DA, Mower W, et al. Appropriateness of rabies postexposure prophylaxis treatment for animal exposures. Emergency ID Net Study Group. JAMA 2000; 284:1001.
- GENERAL PRINCIPLES
- ANIMAL RABIES EPIDEMIOLOGY
- Domestic animal rabies
- Wild terrestrial mammals
- TYPES OF EXPOSURE
- Bat exposures
- Non-bite animal exposures
- Human-to-human transmission
- - Risk for health care workers
- - Transplant recipients
- - Bite and non-bite exposures
- ANIMAL OBSERVATION AND TESTING
- VACCINATION STATUS OF DOMESTIC ANIMALS
- PROVOKED VERSUS UNPROVOKED EXPOSURE
- HIGH-RISK GROUPS
- Rationale for pre-exposure prophylaxis
- COUNSELING TRAVELERS
- Post-exposure prophylaxis in resource-limited settings
- DELAYS IN PROPHYLAXIS
- COST OF POST-EXPOSURE PROPHYLAXIS
- HOW SHOULD PROPHYLAXIS BE GIVEN?
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS