The WHO position on rabies immunization – 2018 updates

The revised WHO position complements other, parallel efforts to provide clear and practical guidance for rabies prevention, such as the 3rd WHO Expert Consultation on Rabies [2], the ongoing updates to the WHO diagnostic manual on Laboratory Techniques in Rabies, and the Global Strategic Plan to End... Full description

The revised WHO position complements other, parallel efforts to provide clear and practical guidance for rabies prevention, such as the 3rd WHO Expert Consultation on Rabies [2], the ongoing updates to the WHO diagnostic manual on Laboratory Techniques in Rabies, and the Global Strategic Plan to End Human Deaths from Dog-Mediated Rabies by 2030 [7].3 Key changes to the WHO rabies immunization position Key changes to the WHO rabies position are summarized below; the 2018 rabies position paper provides detailed descriptions of the literature and the recommendations [3].3.1 Summary of updated recommendations for PEP and PrEP [3] Evidence shows that modern rabies vaccines (>2.5 IU/IM dose), when administered ID for either PEP or PrEP, have immunogenicity and effectiveness equivalent to or higher than IM administration [8]. By contrast, if the calculated RIG dose is more than can be fully injected in and around the wound itself, WHO no longer recommends injecting the remainder of the calculated RIG dose IM at a site distant from the wound. [...]if the calculated RIG dose1The maximum dose for RIG is 40 IU/kg bodyweight for equine RIG and F(ab)’2 products, and 20 IU/kg bodyweight for human RIG.1 is likely too great for local wound infiltration, it can be fractionated into smaller, individual syringes and the residual unused RIG can be used that same day for other patients, if stored and handled aseptically. The PrEP schedules that are now recommended for people in all age groups are (a) 2-site ID on days 0 and 7, or (b) 1-site IM on days 0 and 7.3.2 Future rabies vaccine research needs The rabies working group review process identified gaps in methodological guidelines to assess non-inferiority of new rabies PEP and PrEP regimens, factors determining clinical outcomes in immunocompromised individuals, and evidence-based best practice for repeat exposures. [...]evidence is needed on the potential for even shorter PEP and PrEP regimens, such as one-visit PrEP in rabies endemic settings (including special populations).4 Public health impact of updated rabies immunization recommendations Overall, the revised recommendations will make rabies vaccine schedules more efficient by allowing for the use of shorter, cost and dose saving ID regimens, and reducing the need for RIG (Table 2) [9].