Use of a Modified Preexposure Prophylaxis Vaccination Schedule to Prevent Human Rabies

Recommendations of the Advisory Committee on Immunization Practices -- United States, 2022

Agam K. Rao, MD; Deborah Briggs, PhD; Susan M. Moore, PhD; Florence Whitehill, DVM; Doug Campos-Outcalt, MD; Rebecca L. Morgan, PhD; Ryan M. Wallace, DVM; José R. Romero, MD; Lynn Bahta, MPH; Sharon E. Frey, MD; Jesse D. Blanton, DrPH


Morbidity and Mortality Weekly Report. 2022;71(18):619-627. 

In This Article


Transmission of rabies virus occurs when saliva or neural tissue from an infected mammal is introduced into a person or another animal through, for example, a bite or contact with mucous membranes.[1] Worldwide, approximately 59,000 human rabies deaths occur each year.[2] The canine rabies virus variant (CRVV) is the most common source of human rabies infections, accounting for approximately 98% of cases, including some cases among U.S. travellers.[3] In the United States, CRVV has been eliminated,[3] but wildlife rabies remains endemic, accounting for approximately 5,000 reported rabid animals each year.[4] Specific wildlife rabies virus variants (RVVs) associated with mesocarnivores (small to midsized animals whose diet includes 50%–70% meat) are endemic in distinct geographically confined locations in 42 U.S. states and Puerto Rico.[4] In contrast, bat RVVs are widely distributed throughout the United States, with only Hawaii being rabies-free.[3] During January 2000–December 2020, 52 cases of human rabies were diagnosed in the United States, 38 of which were indigenously acquired (i.e., from rabies exposures that occurred in the United States);[4] none were in persons who had previously received PrEP.

In the United States, two modern cell culture vaccines are licensed for rabies PrEP and PEP: human diploid cell vaccine (HDCV; Imovax/Sanofi Pasteur)* and purified chick embryo cell vaccine (PCECV; RabAvert/Bavarian Nordic), respectively; both are packaged for intramuscular (IM) administration.[1] Each IM dose of vaccine consists of 1 mL and should be administered in the deltoid for adults, and in either the deltoid or anterolateral aspect of the thigh for children.