Rabies PEP is nearly 100% effective at preventing disease before symptom onset, but once symptoms appear, rabies is almost always fatal. Immediate medical evaluation after any potential exposure is essential.
Rabies is an acute, progressive, and almost universally fatal viral encephalitis caused by rabies lyssavirus. It is most often transmitted through the bite of an infected mammal. While all mammals can carry rabies, dogs and bats are the major global reservoirs, with terrestrial carnivores (e.g., foxes, raccoons, skunks) also contributing to transmission.
Those at highest risk include:
Rabies remains a significant global public health concern, particularly in countries with high numbers of rabid dogs and limited medical infrastructure.
Rabies virus is transmitted when infected saliva enters broken skin or mucous membranes, most commonly through:
Rarely, transmission occurs through organ transplantation.
Following exposure, symptoms begin after an incubation period averaging 1–3 months, but may range from several days to years depending on wound location, viral load, and host immunity.
Rabies symptoms progress through two phases:
This phase is nonspecific and lasts several days.
Once symptoms begin, rabies progresses rapidly over 2–10 days and leads to coma and death.
There is no effective treatment once symptoms begin. Rabies is almost always fatal after clinical onset.
Therefore, prevention is essential, and post-exposure prophylaxis (PEP) must be administered as soon as possible after a potential exposure.
PEP for unvaccinated individuals includes:
For individuals previously vaccinated, RIG is not needed—only two booster vaccine doses are required.
Properly administered PEP is nearly 100% effective at preventing rabies.
Rabies vaccination is used for pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP), based on ACIP/CDC guidance.
Recommended for individuals at ongoing risk:
Protection lasts at least 3 years for immunocompetent individuals.
ACIP recommends two approaches to maintaining immunity:
Examples: workers handling live virus, diagnostic lab staff
Examples: bat handlers, necropsy personnel
Examples: veterinarians, wildlife biologists, animal control officers, selected travellers
Two equivalent options:
Examples: short-term travellers, temporary field workers
Evidence shows:
Completion of PEP provides robust immunity.
Rabies vaccines are highly safe. Common side effects include injection-site pain, mild fever, headache, and myalgia. Serious reactions are rare.
ACIP offers two options to maintain long-term immunity:
Goal: maintain RVNA titers ≥0.5 IU/mL, indicating strong protection.
Both approaches are supported by evidence demonstrating reliable immunogenicity for ≥3 years.
The two-dose PrEP regimen provides durable immunity for ≥3 years, but no studies directly measure anamnestic response beyond 3 years. ACIP therefore recommends:
Both ensure long-term protection.
If titers fall below 0.5 IU/mL, one booster restores immunity and routine post-booster titers are not required for immunocompetent individuals.
Although direct studies on the 2-dose schedule beyond 3 years are lacking, evidence from 3-dose and accelerated schedules shows:
Thus, duration beyond 3 years is inferred from established long-term immunity data.
