After considering the evidence, ACIP recommended all persons for whom rabies PrEP is indicated receive 2 IM doses of HDCV or PCECV on days 0 and 7. In addition, persons in the newly defined risk category 1 should have rabies antibody titers checked every 6 months, and those in the newly defined risk category 2 should have rabies antibody titers checked every 2 years; a booster dose should be administered if titers are <0.5 IU/mL at the time of these titer checks (Table). ACIP recommended persons in risk category 3 either have rabies antibody titers checked during years 1–3 after completion of the 2-dose primary series (and a booster dose if the titer is <0.5 IU/mL) or preemptively receive a one-time IM booster dose of rabies vaccine during day 21–year 3 after completion of the 2-dose primary series (Figure). These recommendations apply both to immunocompetent and immunocompromised persons; however, PrEP administered to immunocompromised persons requires additional considerations as described in the approach to PrEP section under the following Clinical Guidance.
Management of long-term immunogenicity* for hypothetical patients (A–E)†,§,¶ who received the Advisory Committee on Immunization Practices recommended 2-dose rabies preexposure prophylaxis schedule** and have sustained risk for recognized exposures (risk category 3) — Advisory Committee on Immunization Practices, United States, 2022
Abbreviations: ACIP = Advisory Committee on Immunization Practices; IM = intramuscular injection; IU = international units; PEP = postexposure prophylaxis; PrEP = preexposure prophylaxis; RIG = rabies immunoglobulin.
*Long-term immunogenicity is considered a successful anamnestic response (i.e., rapid rise in antibody levels) after an encounter with the rabies virus antigen >3 years after the primary vaccination series.
†Patient A received the recommended booster dose during day 21–year 3 and patients B and C received the recommended one-time titer check during years 1–3. Recommended options for patients A–C include 1) a one-time rabies vaccine booster dose from day 21 to 3 years after the 2-dose primary series (patient A) and 2) a one-time rabies antibody titer check 1–3 years after the 2-dose primary series (patients B and C).
§Patient D did not receive the recommended one-time titer or booster dose but was realigned to the ACIP recommendations before an exposure occurred. Realigning involves checking a titer. If the titer is ≥0.5 IU/mL, no further action is needed, and the patient is considered realigned with the ACIP recommendations. If the titer is <0.5 IU/mL, patient D should receive a booster dose followed by an additional titer no sooner than 1 week later (preferably 2–4 weeks later) to confirm the appropriate response.
¶Patient E did not receive the recommended one-time titer or booster dose and had an exposure before they could be realigned to the ACIP recommendations. This patient should receive RIG and the 4-dose rabies vaccine PEP series indicated for persons not previously vaccinated.
**An acceptable antibody titer (i.e., ≥0.5 IU/mL) should be confirmed after boosters are administered to immunocompromised persons.
Morbidity and Mortality Weekly Report. 2022;71(18):619-627. © 2022 Centers for Disease Control and Prevention (CDC)