Rabies exposure is an occupational hazard for the veterinary healthcare team, and preventive measures are necessary to protect personnel. Pre-exposure rabies vaccination provides additional protection for at-risk veterinarians, vet techs and other staff, but does not replace good preventive measures such as personal protective equipment, and safe animal and specimen handling procedures.
Veterinarians and veterinary support staff are in the frequent-risk group with regard to rabies exposure and should be administered pre-exposure rabies vaccinations, according to the recommendations of the U.S. Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP). According to the National Association of State Public Health Veterinarians’ Compendium of Veterinary Standard Precautions for Zoonotic Disease Prevention in Veterinary Personnel, all staff with animal contact must be vaccinated against rabies, followed by periodic titer checks and rabies vaccine boosters, in accordance with the ACIP recommendations.
Pre-exposure rabies vaccination does not eliminate the need for additional treatment after a rabies exposure, but it eliminates the need for post-exposure rabies immunoglobulin administration and decreases the number of post-exposure doses of vaccine needed. Pre-exposure prophylaxis may also provide protection if post-exposure rabies treatment is delayed or if rabies exposure is unrecognized.
The active antibody response develops in approximately 7–10 days, and detectable rabies virus neutralizing antibodies generally persist for several years. The duration of protection varies, so regular titers are necessary to assess the need for a booster vaccination. According to the ACIP guidelines: “Although virus neutralizing antibody levels might not definitively determine a person’s susceptibility or protection from a rabies virus exposure, titers in persons at risk for exposure are used to monitor the relative rabies immune status over time. To ensure the presence of a primed immune response over time among persons at higher than normal risk for exposure, titers should be checked periodically, with booster doses administered only as needed.”
Pre-exposure rabies vaccination with either the human diploid cell vaccine (HDCV) or the purified chick embryo cell vaccine (PCEC) is administered intramuscularly in the deltoid area of the arm in a schedule of three injections, with one injection per day on days 0, 7, and 21 or 28. Failure to complete the series puts you at risk of incomplete protection if exposed to rabies.
Pre-exposure vaccination for veterinarians, veterinary technicians or others on the veterinary team can be ordered by a physician or arranged through your local or state health department. Insurance coverage varies, so ask your provider about the availability of full or partial coverage for the vaccination. (AVMA LIFE offers rabies vaccination benefits; see below.)
Veterinarians and veterinary staff are not legally required to be vaccinated against rabies or have titers determined. Most, if not all, veterinary schools require pre-exposure vaccinations prior to admission or during pre-clinical coursework, and may offer subsequent titers prior to graduation.
The ACIP recommends titers on a schedule of every two years to assess protective immunity, with a single-injection booster vaccination recommended if the titer level is below 1:5 serum dilution (0.1-0.2 IU/mL). The World Health Organization’s (WHO) rabies titer cutoff is higher; WHO recommends that a single booster rabies vaccination be given when the titer drops below 0.5 IU/mL by the RFFIT. That said, there is no established “protective titer,” and post-exposure prophylaxis is still necessary after known exposure.
According to the Kansas State Veterinary Diagnostic Laboratory, titer levels or IU/mL values equal to or above 0.5 IU/mL (~1:50), provide evidence of a robust immune response after rabies vaccination. Although the presence of antibodies after vaccination is important, a specific level above 0.5 IU/mL does not give complete assurance of protection against the disease in every individual because there are other immunological factors involved in the protection from rabies infection. However, an overview of rabies challenge studies indicates rabies virus neutralizing antibody (RVNA) levels equal to or above 0.5 IU/mL provides at least equal assurance of protection as does current vaccination status.
There are two laboratories in the U.S. that perform the ACIP-recommended Rapid Fluorescent Foci Inhibition Test (RFFIT), which measures the ability of RVNA to prevent the rabies virus from invading cells.
Although ACIP guidelines recommend that booster vaccination should be based on the results of the RFFIT, the test is not mandated, and some veterinarians may opt for the booster instead of the titer.
AVMA LIFE, the AVMA insurance trust that provides life and disability insurance plans, offers rabies vaccination coverage with its Member Basic Protection Package for veterinarians and with the Student Basic Protection Package for veterinary students. Up to $600 will be paid for a series of rabies prophylaxis given to a member veterinarian or an eligible dependent either before or after rabies exposure; the student plan provides a benefit up to $300. Rabies titers also are covered under both the member and student plans. AVMA Life also sponsors the Wellness Booth at the AVMA Convention annually, which offers rabies titers for veterinarians/dependents, staff and veterinary students at $50 per titer.
To our knowledge, the veterinary practice is not required to pay for rabies vaccination for veterinary staff; however, practice owners should consult their state regulations to determine their obligations and should weigh the benefits of providing the vaccination to their employees. Note that the cost of post-exposure rabies prophylaxis can easily reach into the thousands, and may involve workers compensation claims; providing pre-exposure rabies vaccination could not only provide protection for staff, but could reduce overall costs associated with rabies exposure. If you offer medical benefits to your staff, check with your health insurance carrier to make sure this a covered benefit.
Advisory Committee on Immunization Practices (ACIP)
Should My Staff and I Be Vaccinated? (CDC)
Preexposure Vaccinations (CDC)
Rabies Vaccination (WHO)