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Content current as of October 12, 2026. AI-assisted draft; not yet reviewed by a licensed pharmacist. Current CDC schedules: immunization schedules.
- The disease and why it matters
- Video and figures
- Get CE credit
- Products available
- Who should get it
- Dosing and schedule, including catch-up
- Administration
- Storage and handling
- Contraindications and precautions
- Safety and adverse events
- Special populations
- Counseling pearls for the pharmacy counter
- Common patient questions
- References
The disease and why it matters
Rabies virus infects the central nervous system and clinical illness culminates in an acute, fatal encephalitis; signs and symptoms most commonly develop within several weeks to months after exposure, with early pain and paresthesia at the exposure site followed by anxiety, paralysis and other signs of encephalitis (including hydrophobia), then coma and death. [1]
The most successful mode of transmission is via the bite of a rabid animal, and scratches that break skin can be contaminated by rabies-laden saliva and are a potential route; even low-trauma events such as nips from young animals or bites from bats can lead to deaths. [1]
Dog-maintained rabies virus variants remain enzootic in many areas of the world, including Africa, parts of Central and South America, and Asia; the rate of rabies exposures in travelers is an estimate, at best, and might range from 16 to 200 exposures per 100,000 travelers. [1]
Children are at greater risk for exposure and subsequent illness because of their inquisitive nature and inability to read behavioral cues from animals, and the smaller a child's stature, the more likely they are to experience severe bites to the head and face. [1]
Video and figures
Video
Get CE credit
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Products available
Two cell culture rabies vaccines are licensed in the United States: human diploid cell vaccine (HDCV; Imovax Rabies, Sanofi Pasteur) and purified chick embryo cell vaccine (PCEC; RabAvert, Bavarian Nordic). [1]
| Vaccine | Manufacturer (FDA page) | FDA-approved use |
|---|---|---|
| Imovax Rabies (HDCV) | Sanofi Pasteur SA [2] | Prevention of rabies in all age groups; approved for pre-exposure and post-exposure prophylaxis; for intramuscular use, 1 mL per dose [3] |
| RabAvert (PCEC) | Bavarian Nordic A/S [4] | Preexposure vaccination (primary series and booster dose) and postexposure prophylaxis against rabies in all age groups; for intramuscular use only, 1 mL per dose [5] |
The Imovax Rabies label was revised 7/2025 (its recent major changes list the pre-exposure dose and schedule), whereas the RabAvert label posted on FDA's page is an older-format document that still describes a 3-dose pre-exposure series and a 5-dose post-exposure series; the FDA RabAvert page is marked content current as of 10/31/2024. [3] [5] [4]
RabAvert is a freeze-dried vaccine obtained by growing the Flury LEP strain in primary cultures of chicken fibroblasts and contains polygeline (processed bovine gelatin), human serum albumin, potassium glutamate and sodium EDTA; the label advises that patients at risk of severe hypersensitivity to the vaccine or its components should receive an alternative rabies vaccine if a suitable product is available. [5]
Who should get it
Pre-exposure prophylaxis (PrEP) does not eliminate the need for additional medical attention after an exposure, but it simplifies PEP and might provide some protection when an exposure goes unrecognized or PEP is delayed; travelers who complete a recognized PrEP series or receive full PEP are considered previously vaccinated and do not require routine boosters, and routine antibody testing is not recommended for international travelers who do not fall into the frequent or continuous risk categories and have no immunodeficiencies. [1]
| Category | Typical population | Primary PrEP series | Booster |
|---|---|---|---|
| 1 | People working with live rabies virus in research or vaccine production facilities; people performing rabies testing in diagnostic laboratories | Day 0 and day 7 [1] | Check titers every 6 months; booster for titers below 0.5 IU/mL |
| 2 | People with frequent bat contact; people who perform animal necropsies | Day 0 and day 7 [1] | Check titers every 2 years; booster for titers below 0.5 IU/mL |
| 3 | People who interact with animals that could be rabid; people whose occupational or recreational activities typically involve contact with animals; selected travelers (sustained risk for more than 3 years) | Day 0 and day 7 [1] | One-time titer check during years 1 to 3, with booster for titers below 0.5 IU/mL, or a booster at 21 days or more but less than 3 years after the primary series |
| 4 | Same populations as category 3 but risk duration 3 years or less | Day 0 and day 7 [1] | None |
| 5 | Typical resident of the United States (low risk) | Not applicable [1] | None |
For travelers, PrEP considerations include whether the person will take part in occupational or recreational activities that increase risk of exposure to potentially rabid animals (particularly dogs) and whether they will have difficulty getting prompt access to safe PEP, for example in rural areas or destinations where PEP is not readily available; consider PrEP for animal handlers, field biologists, cavers, missionaries, veterinarians and some laboratory workers. [1]
Dosing and schedule, including catch-up
| Source | Primary series | Booster |
|---|---|---|
| CDC Yellow Book (ACIP 2022) | HDCV (Imovax) or PCEC (RabAvert), 1.0 mL IM, 2 doses on days 0 and 7 [1] | Per the Table 4.15.1 risk category: titer checks or a booster; travelers with a sustained risk should have a titer drawn or receive a third dose within 3 years [1] |
| Imovax Rabies label (7/2025) | Three-dose schedule at day 0, 7 and 21 or 28, or two-dose schedule at day 0 and 7 [3] | A single dose; CDC has published clinical guidance on boosters depending on exposure risk and for immunocompromised individuals or those receiving chloroquine [3] |
| RabAvert label (older format) | 3 injections of 1 mL on day 0, day 7 and day 21 or 28 [5] | 1 mL intramuscularly for persons who remain at increased risk [5] |
The Yellow Book says the revised 2-dose schedule is less expensive and easier to complete before travel; data strongly support a 3-year duration of immunity for the 2-dose series, but longer durations are still being evaluated, so travelers with sustained risk should have a titer 1 to 3 years after the primary series or receive a third dose no sooner than day 21 and no later than 3 years. [1]
| Source | Not previously vaccinated | Previously vaccinated |
|---|---|---|
| CDC Yellow Book | RIG 20 IU/kg once on day 0 (infiltrate the wound if possible; remainder IM at a separate site) plus vaccine 1.0 mL IM on days 0, 3, 7 and 14 (and 28 if immunocompromised) [1] | Vaccine 1.0 mL IM, 2 doses on days 0 and 3; RIG is not administered [1] |
| Imovax Rabies label (7/2025) | Vaccine on day 0, 3, 7, 14 and 28 plus HRIG on day 0 per its prescribing information; same regimen for immunosuppressed people irrespective of previous vaccination [3] | One dose immediately after exposure (day 0) and one at day 3 [3] |
| RabAvert label (older format) | HRIG 20 IU/kg once, then 5 injections of 1.0 mL on days 0, 3, 7, 14 and 28 [5] | 2 IM doses on day 0 and day 3; HRIG should not be given [5] |
The CDC schedule (4 doses, with a fifth at day 28 only if immunocompromised) differs from the 5-dose regimen on both posted labels; the Yellow Book says to make every effort to adhere to a recognized ACIP or WHO schedule and that variations of days to weeks are unlikely to diminish the immune response but could delay onset of protection. [1] [3] [5]
RIG: do not give RIG more than 7 days after the first vaccine dose because antibodies from the patient's own immune response should be present; if RIG access is delayed but modern cell culture vaccine is available, start the vaccine series as soon as possible and add RIG within 7 days after the first dose; a previously unimmunized traveler with a bite suspicious for rabies should receive full PEP including RIG even if considerable time has passed. [1]
Human RIG (HRIG) historically contained 150 IU/mL and newer products contain 300 IU/mL, so the clinician must ascertain which product is available to avoid exceeding the total calculated dose; the more concentrated HyperRAB (300 IU/mL) requires D5W as the diluent; for small distal wounds use clinical judgment about how much to inject and give the remainder intramuscularly at a distant site. [1]
Administration
- Vaccines should be delivered intramuscularly into the deltoid area (anterolateral thigh acceptable for children) and never in the gluteal area; the infant and pediatric dose of HDCV or PCEC is the same as for adults. [1]
- Do not inject Imovax Rabies into the gluteal area or intradermally. [3]
- Imovax Rabies is supplied as a lyophilized vaccine vial with a Luer-Lok prefilled syringe of 1 mL Sterile Water diluent and a reconstitution needle; transfer the entire contents of the diluent syringe into the vial; administer immediately after reconstitution. [3]
- RIG should be infiltrated around and into the wounds if anatomically feasible, and should never be given in the same syringe or at the same anatomical site as the vaccine because the two products neutralize each other. [1] [5]
- Wound care: clean all animal bites and scratches with copious amounts of soap and water, povidone iodine, or other products with virucidal activity; for unvaccinated patients delay suturing for a few days, and if suturing is necessary inject RIG into all exposed tissues before closing the wound; local anesthetics are not contraindicated. [1]
- Once initiated, rabies PEP should not be interrupted or discontinued because of local or mild systemic reactions; if an adverse event occurs with one vaccine type, consider switching to the alternative cell culture vaccine; antihistamines or NSAIDs before vaccination can help reduce mild reactions in people with a history of such reactions. [1]
Storage and handling
Contraindications and precautions
| Source | Statement |
|---|---|
| Imovax Rabies label | Pre-exposure prophylaxis: known life-threatening systemic hypersensitivity reaction to any component of the vaccine; post-exposure prophylaxis: no contraindication. [3] |
| RabAvert label | Pre-exposure vaccination: history of anaphylaxis to the vaccine or any of its components; post-exposure prophylaxis: no contraindication, including pregnancy, in view of the almost invariably fatal outcome of rabies. [5] |
| Yellow Book | Pregnancy is not a contraindication to receiving PEP. [1] |
| Precaution (Imovax) | Individuals with altered immunocompetence may have reduced immune response; in individuals who have had anaphylaxis after a dose, the risk of developing rabies must be carefully considered in decisions about discontinuing post-exposure vaccination. [3] |
Chloroquine: the Imovax label notes that CDC has published guidance on rabies vaccination of individuals receiving chloroquine or drugs related to chloroquine. [3]
Safety and adverse events
Travelers might experience local reactions (erythema, itching, pain, swelling) or mild systemic reactions (abdominal pain, dizziness, headache, muscle aches, nausea); approximately 6% of people receiving booster vaccinations with HDCV experience systemic hypersensitivity reactions (malaise, pruritus, urticaria), with less likelihood with PCEC vaccine. [1]
Imovax label: with the two-dose pre-exposure regimen the most commonly reported solicited reactions (10% or more) were injection-site pain (35.4% in participants 18 years and older and 25.7% in participants 2 through 17 years) and headache (21.3% and 13.9%), plus malaise (26.0%) and myalgia (22.8%) in participants 18 and older. [3]
RabAvert label: in a US study of 83 subjects who received RabAvert, the most common adverse reaction was pain at the injection site (84%), and the most common systemic reactions were headache (52%), myalgia (53%) and malaise (20%); anaphylaxis and neuroparalytic events including Guillain-Barré syndrome have been reported temporally associated with its use. [5]
The incidence of adverse events after modern equine-derived RIG is low (0.8% to 6.0%) and most reactions are minor, but such products are not FDA-regulated so their use cannot be recommended unequivocally; brain-derived (nerve tissue) vaccines still used in some low- and middle-income countries, typically a daily 5 mL injection for about 14 to 21 days, should be declined by travelers because of variable potency and risk of severe adverse reactions. [1]
Special populations
Immunocompromised people: those immunocompromised by disease or medications should postpone pre-exposure vaccination and consider avoiding activities for which PrEP is indicated during the period of expected immune compromise, and if that is not possible should have antibody titers checked after vaccination; immunocompromised PEP patients receive a fifth dose at day 28 with antibody monitoring. [1]
Pregnancy and lactation: pregnancy is not a contraindication to PEP; the Imovax label says data on administration to pregnant women are insufficient to inform vaccine-associated risks and that it is not known whether it is excreted in human milk, noting that confirmed rabies infection nearly always results in death. [1] [3]
Vaccines used abroad: purified Vero cell rabies vaccine is an acceptable alternative if available; other vaccines or regimens might require additional prophylaxis or confirmation of adequate antibody titers, so travelers should photograph the PEP products they receive and be conscious of storage conditions and the administration schedule. [1]
Counseling pearls for the pharmacy counter
- Rabies is a serious illness that almost always results in death; people can get rabies from contact with the saliva or neural tissue of an infected animal, for example through a bite or scratch, if they do not receive appropriate medical care including rabies vaccine. [6]
- People at higher risk should receive 2 doses of rabies vaccine given on days 0 and 7; vaccination does not remove the need for medical attention after an exposure. [6] [1]
- Avoid bites: stay away from unfamiliar mammals including puppies and kittens, avoid contact with bats and other wildlife (any contact of a bat with bare skin or hair is grounds for seeking PEP), and do not approach non-human primates. [1]
- If exposed, wash the wound immediately, seek PEP promptly, and encourage the purchase of medical evacuation insurance for areas of high rabies risk. [1]
Common patient questions
A traveler was bitten by a dog in a rabies-endemic country, has never been vaccinated and has no RIG available locally. What now?
Start the cell culture vaccine series as soon as possible and add RIG within 7 days after the first vaccine dose if it becomes available; after day 7 RIG is unlikely to benefit. [1]
A veterinarian received a 2-dose PrEP series 4 years ago and is now exposed. Does she need RIG?
No. RIG should not be administered to previously vaccinated people because it can diminish the immune response; PEP is vaccine on days 0 and 3. [1]
How many PEP doses for an unvaccinated immunocompetent patient: 4 or 5?
CDC's Yellow Book lists 4 doses (days 0, 3, 7, 14) plus RIG, with a fifth dose at day 28 for immunocompromised patients, while the Imovax and RabAvert labels list 5 doses (days 0, 3, 7, 14, 28). [1] [3] [5]
Is a pregnant woman who was bitten by a bat vaccinated?
Yes. Pregnancy is not a contraindication to PEP, and any contact of a bat with bare skin or hair is grounds for seeking PEP. [1]
A traveler was offered daily 5 mL injections abroad. Should they accept?
No. This describes a brain-derived (nerve tissue) vaccine; travelers should decline these vaccines and travel to a location where acceptable vaccines and RIG are available. [1]
References
- Centers for Disease Control and Prevention. Rabies. In: CDC Yellow Book: Health Information for International Travel, 2026 edition. Page dated April 23, 2025. Accessed October 12, 2026. https://www.cdc.gov/yellow-book/hcp/travel-associated-infections-diseases/rabies.html. Accessed October 12, 2026.
- U.S. Food and Drug Administration. IMOVAX Rabies product page (content current as of 07/30/2025). Accessed October 12, 2026. https://www.fda.gov/vaccines-blood-biologics/vaccines/imovax-rabies. Accessed October 12, 2026.
- IMOVAX RABIES (rabies vaccine), for intramuscular injection: prescribing information, revised 7/2025. Sanofi Pasteur SA. U.S. Food and Drug Administration. Accessed October 12, 2026. https://www.fda.gov/media/75709/download?attachment. Accessed October 12, 2026.
- U.S. Food and Drug Administration. RabAvert product page (content current as of 10/31/2024). Accessed October 12, 2026. https://www.fda.gov/vaccines-blood-biologics/vaccines/rabavert. Accessed October 12, 2026.
- RabAvert (rabies vaccine): prescribing information as posted on FDA's product page (older-format label with no revision date in the posted document). Bavarian Nordic A/S. U.S. Food and Drug Administration. Accessed October 12, 2026. https://www.fda.gov/media/83874/download?attachment. Accessed October 12, 2026.
- Centers for Disease Control and Prevention. Rabies vaccine: what you need to know. Vaccine Information Statement, June 2, 2022. Accessed October 12, 2026. https://www.cdc.gov/vaccines/hcp/current-vis/rabies.html. Accessed October 12, 2026.
For professional education. Check current labeling and guidance before acting. Not medical advice.
