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

Reasons for Revisions of Recommendations

ACIP has recommended rabies PrEP since 1969.[5] As safe and effective modern cell culture vaccines have replaced those derived from nerve tissue and duck embryo, and as rabies epidemiology has continued to evolve (e.g., elimination of CRVV, emergence and spread of the racoon RVV, and host shifts of bat RVV to mesocarnivores in the southern United States), changes have been made to ACIP recommendations. Since 2008, when the last ACIP rabies PrEP recommendations were published, barriers affecting adherence to the recommendations have been identified, including out-of-pocket costs of rabies biologics (3-dose PrEP vaccination series is currently estimated at ≥$1,100§), confusion about which activities fall within different risk categories, and noncompliance with recommendations for repeated titer checks.[6] In addition, travel medicine providers have indicated that the largest group for which PrEP is recommended (travelers to regions with endemic CRVV) might often be unable to complete the 3-dose series described in the 2008 ACIP recommendations[1] because at least 21 days are required to complete the series before initiation of travel.[7]

During September 2019–November 2021, the ACIP Rabies Work Group participated in monthly or bimonthly teleconferences and considered evidence-based updates to the 2008 ACIP recommendations. The Work Group comprised experts in diverse disciplines including laboratory, public health, and clinical specialties. Data collected, analyzed, and prepared by the Work Group were deliberated by ACIP during six public meetings. With publication of this report, the recommendations become final and are the official CDC recommendations for rabies PrEP.