Rabies vaccination

There is currently only one licensed rabies vaccine for intramuscular use in the UK. This is a purified chick embryo cell (PCEC, 2.5 IU/ml) rabies vaccine, known as Rabipur. (1)

This vaccine is inactivated, does not contain live organisms and cannot cause rabies. When given as a primary pre-exposure immunisation, 3 doses of the vaccine (2.5 IU; one vial) should be given intramuscularly on days 0, 7 and 28. (The third dose can be given from day 21 if there is insufficient time before travel.)

Other WHO approved cell culture-derived vaccines are available in other countries and may contain different concentrations of rabies antigen. The UK licensed products contain 2.5IU rabies antigen in a 1ml dose; other products should be used as recommended by the manufacturer.

Post-exposure prophylaxis

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• schedule depends on assessment of risk and immunisation status of individual (consult Green Book for details)
• for example if
  • if bite for area where rabies risk is low risk
    • if unimmunised/incompletely immunised individual
      • five doses (each 1.0 ml) on days 0 3, 7, 14 and 30
    • if fully immunised individual
      • two doses (each 1.0ml) on days 0 and 3

Reactions to these vaccines are not common.

Pre-exposure prophylaxis

The World Health Organization recommends pre-exposure prophylaxis (PrEP) for people at high risk of rabies virus exposure (including sub-populations in highly endemic settings with limited access to timely and adequate post-exposure prophylaxis), people at occupational risk, and travellers who may be at risk of exposure. (2)

Two different dose schedules are recommended;

An intradermal dose (2-site) on days 0 and 7, or;

An intramuscular dose (1-site) on days 0 and 7 (deltoid muscle for adults and anterolateral area of thigh in children <2 years).

(In the US, the Centers for Disease Control and Prevention (CDC) recommends a 2-dose intramuscular regimen (days 0 and 7). Further recommendations depend on the person’s specific risk for being exposed to rabies) (3)

The Joint Committee on Vaccination and Immunisation recommends the intramuscular rather than the intradermal route for pre-exposure prophylaxis use of rabies vaccine. The committee also recommends that only the intramuscular route (or deep subcutaneous route for those with bleeding disorders) is used for post-exposure treatment (1).

Human rabies immunoglobulin (HRIG)

• obtained from the plasma of immunised and screened human donors. Because of a theoretical risk of transmission of vCJD from plasma products, HRIG used in the UK is prepared from plasma sourced from outside the UK. All donors are screened for HIV and hepatitis B and C

Check up to date details in the The Green Book before prescribing/administering a rabies vaccination.

Check the Summary of Product Characteristics (SPC) before prescribing/administering a rabies vaccine.

References;

1. Rabies: the green book, chapter 27; UK Health Security Agency.
2. World Health Organization. Weekly epidemiological record. Rabies vaccines: WHO position paper. April 2018 [internet publication]
3. Centers for Disease Control and Prevention. Use of a modified pre exposure prophylaxis vaccination schedule to prevent human rabies: recommendations of the Advisory Committee on Immunization Practices - United States, 2022. May 2022 [internet publication].