Updated Canadian guidelines for use of rabies vaccine for pre-exposure prophylaxis

Rabies is a rare but almost universally fatal infection that most commonly results from the bite of an infected animal. Treatment of rabies is almost always ineffective once symptoms develop; however, rabies can be prevented through the use of rabies post-exposure prophylaxis (PEP) after an exposure to a potentially rabid animal or the rabies virus in a laboratory setting.1Rabies vaccination before an exposure (rabies pre-exposure prophylaxis, PrEP) is recommended for certain groups who are at increased risk of exposure to potentially rabid animals or to the rabies virus in a laboratory.1 The National Advisory Committee on Immunization (NACI) recently released updated guidance for use of rabies vaccine for PrEP. The guidance is based on current evidence and NACI expert opinion.1The following highlights the NACI’s updated recommendations on rabies PrEP:1. Risk groups for PrEP NACI now categorizes people recommended to receive PrEP into three groups: very high risk, high risk and moderate risk. For each group, NACI provides recommendations regarding vaccination schedules and the need for and frequency of serology testing to monitor the response to the vaccine (see Table 1 in the guidelines).12. Immunization schedules for rabies PrEP by risk groupMost groups are recommended to receive an initial series of three doses of rabies vaccine for PrEP or two doses plus a booster, with schedules varying by risk group. People in the moderate risk group (e.g., travellers who are not immunocompromised) and whose risk is only expected to be short-term (i.e., < 3 years) are now recommended to receive a two-dose series.1 Note that PrEP schedules that deviate from days 0, 7 and 21–28 are off-label and this should be discussed with the person receiving the vaccine.23. Route of administration for rabies PrEPRabies PrEP may be administered either intramuscularly (at one injection site for each dose) or intradermally (at two injection sites for each dose). Both routes are acceptable and interchangeable if needed.1 Note that intradermal administration is off-label and this should be discussed with the person receiving the vaccine. The body sites for ID injections are the deltoid region, or the anterolateral thigh or suprascapular regions.2 Vaccination strategies that use fewer numbers of doses or two-site intradermal administration (which requires lower vaccine doses than intramuscular administration) produce a similar immune response and are expected to provide similar benefits compared to current PrEP strategies. Using fewer doses or lower volumes of vaccine are potentially cost saving, require fewer patient visits, potentially increasing acceptability of PrEP for those for whom it is recommended, and helps prevent and/or mitigate shortages of rabies vaccine products.24. Serology testing after rabies PrEPRoutine serology is no longer recommended after intradermal administration if given at two sites per dose. Serology is recommended after vaccination for people who are immunocompromised and for those taking chloroquine/hydroxychloroquine, and on a regular basis for those whose occupational risk means they may not recognize an exposure and therefore might not seek post-exposure prophylaxis (PEP).15. Post-exposure prophylaxis for those who previously received rabies PrEPNACI continues to recommend that anyone who receives PrEP should still seek post-exposure prophylaxis (PEP) after a potential exposure to rabies. NACI provides guidance regarding PEP schedules for those who have previously received rabies vaccination, noting that the PEP schedule is generally simpler for those who have previously received PrEP.16. Vaccine interchangeabilityWhen possible, the same vaccine product should be used for all doses. However, purified chick embryo cell vaccines (PCECV), human diploid cell vaccines (HDCV) and purified Vero cell rabies vaccines (PVRV) are considered interchangeable if required.1 Two rabies vaccines are authorized for use in Canada: Rabavert (inactivated, purified chick embryo cell rabies vaccine), Bavarian Nordic A/S (PCECV) and Imovax Rabies (inactivated, human diploid cell rabies vaccine), Sanofi Pasteur Ltd (HDCV). Key characteristics of these vaccines are summarized in a table in the full guidelines (see Table A.2.). Both can be used for PrEP and PEP.2 The same route of administration should be used for all doses in the rabies vaccine primary series whenever possible. However, if this is not feasible, a change in theroute of administration (1-site intramuscular to 2-site intradermal or vice versa) during a rabies vaccine primary series is acceptable.2Full guidelinesHealthcare providers should consult the full updated guidelines for more detailed information on rabies epidemiology, risk factors, clinical presentation, disease distribution, rabies vaccine safety, immunization during pregnancy/breastfeeding, and immunization while taking chloroquine or hydroxychloroquine.2 Future rabies PEP updateIn addition to this update on rabies PrEP, NACI is working on more detailed guidance about when and how to provide post-exposure prophylaxis (PEP) after a potential rabies exposure.1References:National Advisory Committee on Immunization (NACI). Summary of NACI statement of January 30, 2026: updated guidance for use of rabies vaccine for pre-exposure prophylaxis (PrEP). January 30, 2026. (accessed February 10, 2026).National Advisory Committee on Immunization (NACI). Updated guidance for use of rabies vaccine for pre-exposure prophylaxis (PrEP). January 30, 2026. (accessed February 10, 2026).

Updated Canadian guidelines for use of rabies vaccine for pre-exposure prophylaxis

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