Rabies pre-exposure vaccination and titers for the veterinary team

PrEP doesn’t eliminate the need for additional treatment after rabies exposure. What it does eliminate is the need for post-exposure rabies immunoglobulin administration. It also decreases the number of post-exposure doses of vaccine needed. Rabies PrEP also may provide some protection if post-exposure rabies treatment is delayed or if rabies exposure goes unrecognized.

Vaccination recommendations

The U.S. Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) develops recommendations on vaccine use for the prevention of disease—including rabies—in U.S. human populations.

In May 2022, the ACIP redefined its categories for people at risk of rabies, and revised its recommendations concerning rabies PrEP. Veterinarians, credentialed veterinary technicians, and veterinary assistants (including non-credentialed staff working as technicians) are now considered to be in risk category 3 of 5, and are recommended to get a primary PrEP series with two doses of rabies vaccine, seven days apart, to provide protection for up to three years. In addition, either of the following also is recommended:

• A one-time rabies antibody titer check between one and three years after the primary two-dose series, then a booster if the titer is less than 0.5 IU/mL
• A single booster between three weeks and three years after the first dose in the primary series was given

Although not specifically mentioned by ACIP, the same recommendations could be presumed to apply to other members of the veterinary team who have contact with animals, as well as veterinary students.

That’s it. No additional boosters or titer checks are recommended, although the recommendations are more stringent for people at elevated risk for unrecognized rabies exposures (i.e., those in risk categories 1 or 2).

Vaccination may be performed with either the human diploid cell vaccine or the purified chick embryo cell vaccine, by intramuscular administration in the deltoid area of the arm. Failure to complete the primary two-dose PrEP series puts you at risk of incomplete protection if exposed to rabies.

Rabies vaccines can be ordered by a physician, or you can arrange vaccination through your local or state health department. Insurance coverage varies, so ask your provider whether your policy includes coverage, either full or partial. (AVMA LIFE’s basic protection packages do include rabies vaccination benefits.)

The ACIP recommends that a value of 0.5 IU/mL be used as the minimum acceptable rabies antibody titer for determining whether a booster dose of rabies vaccine is needed. This value aligns with guidance from the World Health Organization.

Serial testing of rabies antibody titers every two years is no longer recommended for veterinary personnel/students and other people in risk category 3. The rationale is that such people are likely to recognize when they’ve been exposed to rabies, and this knowledge would automatically prompt evaluation for post-exposure treatment anyway. Plus, data indicate that an antibody titer of at least 0.5 IU/mL one year after the primary two-dose PrEP series confers long-term immunoprotection.

Two commercial laboratories in the United States perform the ACIP-recommended rapid fluorescent focus inhibition test (RFFIT), which measures the ability of rabies virus-neutralizing antibodies in serum samples to prevent the rabies virus from invading cells:

• Kansas State University—Titer testing at KSU may also be requested through Quest Labs under the name Rabies Vaccine Response End Point Titer (order # 5789)
• University of Missouri Veterinary Medical Diagnostic Laboratory
• Atlanta Health Associates

Veterinarians and veterinary team members aren't legally required to be vaccinated against rabies or have titers determined. As for veterinary students, most veterinary schools require pre-exposure vaccinations prior to admission or during pre-clinical coursework, and they may offer subsequent titer measurement prior to graduation.

AVMA LIFE includes rabies vaccination coverage with its Member Basic Protection Package for veterinarians and with its Student Basic Protection Package for veterinary students. The coverage includes up to $600 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 titer testing is covered under both the member and student plans. AVMA Life also sponsors the Wellness Booth at the AVMA Convention annually, offering $50 rabies titers for veterinarians, dependents, team members, and veterinary students.

In general, veterinary practices are not required to pay for rabies vaccination for veterinary staff. However, practice owners are encouraged to consult state regulations to determine their obligations and should weigh the benefits of providing the vaccination to their employees against the potential costs. 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 protect your 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 is a covered benefit.