Pre-exposure Prophylaxis (PrEP)

The majority of people in the United States have a low risk of coming in contact with the rabies virus. However, a small subset has a higher level of risk, such as those who work directly with animals that could have rabies, or those who travel to parts of the world where rabies is common and access to medical care is limited. These people should receive rabies pre-exposure prophylaxis (PrEP), a series of rabies vaccine doses given before coming into contact with the rabies virus.

The Advisory Committee on Immunization Practices (ACIP) develops the U.S. recommendations about how to use vaccines to prevent disease in the United States, including how to prevent rabies in people. ACIP updated rabies vaccine recommendations in May 2022, which are summarized below:

Updates to the ACIP recommendations to prevent human rabies, 2022
  • A 2-dose PrEP schedule has replaced the 3-dose PrEP schedule to protect for up to 3 years. Options for maintaining protection beyond 3 years are also described.
  • Risk categories have been redefined into 5 risk groups.
  • The minimum acceptable laboratory value (antibody titer) used to determine whether rabies vaccine booster doses are needed was revised and standardized.
  • Many people for whom serial titers were recommended every 2 years now require only a one-time titer (and booster if below a certain level) OR a one-time booster.
  • Clinical guidance for administering PrEP to people with weakened immune systems has been outlined and includes recommendations to confirm that the vaccine was effective.

Risk categories and PrEP recommendations

Risk category

Risk category

Risk category

Who this typically* affects

Who this typically* affects

Who this typically* affects

Recommendations

Recommendations

Recommendations

Risk category 1
Highest risk

Risk category

Risk category 1
Highest risk

People who work with live or concentrated rabies virus in laboratories

Who this typically* affects

People who work with live or concentrated rabies virus in laboratories

2 doses, days 0 and 7
Check titer every 6 months

Recommendations

2 doses, days 0 and 7
Check titer every 6 months

Risk category 2

Risk category

Risk category 2

People who frequently do at least one of the following: handle bats, have contact with bats, enter high-density bat environments like caves, or perform animal necropsies

Who this typically* affects

People who frequently do at least one of the following: handle bats, have contact with bats, enter high-density bat environments like caves, or perform animal necropsies

2 doses, days 0 and 7
Check titer every 2 years

Recommendations

2 doses, days 0 and 7
Check titer every 2 years

Risk category 3

Risk category

Risk category 3

People who interact with, or are at higher risk to interact, with mammals other than bats that could be rabid, for a period longer than three years after they receive PrEP

This group includes:

  • Most veterinarians, veterinary technicians, animal control officers, wildlife biologists, rehabilitators, trappers, and spelunkers (cave explorers)
  • Certain travelers to regions outside of the United States where rabies in dogs is commonly found
Who this typically* affects

People who interact with, or are at higher risk to interact, with mammals other than bats that could be rabid, for a period longer than three years after they receive PrEP

This group includes:

  • Most veterinarians, veterinary technicians, animal control officers, wildlife biologists, rehabilitators, trappers, and spelunkers (cave explorers)
  • Certain travelers to regions outside of the United States where rabies in dogs is commonly found

2 doses, days 0 and 7, plus:

Either a one-time titer check after 1 year and up to 3 years following the first 2-dose vaccination

OR

1-dose booster between 3 weeks and 3 years following the first vaccine in the 2-dose vaccination

Recommendations

2 doses, days 0 and 7, plus:

Either a one-time titer check after 1 year and up to 3 years following the first 2-dose vaccination

OR

1-dose booster between 3 weeks and 3 years following the first vaccine in the 2-dose vaccination

Risk category 4

Risk category

Risk category 4

Same population as risk category 3, but at a higher risk for ≤ three years after they receive PrEP

Who this typically* affects

Same population as risk category 3, but at a higher risk for ≤ three years after they receive PrEP

2 doses, days 0 and 7

Recommendations

2 doses, days 0 and 7

Risk category 5
Lowest risk

Risk category

Risk category 5
Lowest risk

General U.S. population

Who this typically* affects

General U.S. population

None

Recommendations

None

*The typical characteristics described may not include the characteristics of all activities that fall within the described risk group.

For detailed information about these recommendations, please refer to the published MMWR.