Rabies vaccination and immune globulin are medically necessary for treatment of rabies exposure where the animal has escaped or is known to be rabid at the time of direct exposure or attack.
Treatment for all other indications is considered experimental and investigational.
Continuation of Therapy
Continuation of rabies vaccination and immune globulin therapy is medically necessary for all members (including new members) who meet all initial medical necessity criteria.
Rabies vaccine and immune globulin therapy given to people at high risk of rabies to protect them if they are exposed due to their employment, volunteer, or student status.
- Veterinarians, animal handlers, and veterinary students
- Rabies laboratory workers
- Volunteers with animal rescue
- Persons who work with live vaccine to produce rabies vaccine and rabies immune globulin.
Summary of evidence
Gautret and colleagues (2018) stated that recent studies demonstrated that rabies post-exposure prophylaxis (RPEP) in international travelers is suboptimal, with only five (5) to 20 % of travelers receiving rabies Ig (RIG) in the country of exposure when indicated. These investigators hypothesized that travelers may not be receiving RIG appropriately, and practices may vary between countries; they described the characteristics of travelers who received RIG and/or RPEP during travel. These researchers conducted a multi-center review of international travelers exposed to potentially rabid animals, collecting information on RPEP administration. Travelers who started RPEP before (Group A) and at (Group B) presentation to a GeoSentinel clinic during September 2014 to July 2017 were included. These investigators included 920 travelers who started RPEP. Approximately 2/3 of Group A travelers with an indication for RIG did not receive it. Travelers exposed in Indonesia were less likely to receive RIG in the country of exposure (RR: 0.30; 95 % CI: 0.12 to 0.73; p = 0.01). Travelers exposed in Thailand (RR 1.38, 95% CI: 1.0 to 1.8; p = 0.02], Sri Lanka (RR 3.99, 95 % CI: 3.99 to 11.9; p = 0.013), and the Philippines (RR 19.95, 95 % CI: 2.5 to 157.2; p = 0.01), were more likely to receive RIG in the country of exposure. The authors concluded that the findings of this analysis highlighted gaps in early delivery of RIG to travelers and identified specific countries where travelers may be more or less likely to receive RIG. More detailed country-level information would help inform risk education of international travelers regarding appropriate rabies prevention.
Soentjens and associates (2021) noted that data on RPEP and the use of human rabies immunoglobulins (HRIG) in Belgium are scarce. These researchers examined the timely administration of HRIG after rabies exposure. The secondary objective was to evaluate the adequate antibody response following PEP. They reviewed all medical records from July 2017 to June 2018 of individuals seeking care at, or referred to, the Institute of Tropical Medicine and the University Hospital, Antwerp for the administration of HRIG following potential rabies exposure abroad or in Belgium. A timely response was defined as starting HRIG with a delay of less than or equal to 48 hours and rabies vaccination in the first seven (7) days after exposure. Adequate antibody response was defined as a titer of greater than 5.0 IU/ml in case of bat-related exposure and greater than 3.0 IU/ml in case of exposure to other animals. Titers were measured 10 days after the last PEP vaccine dose, using the rapid fluorescent focus inhibition test (RFFIT). Of the 92 cases treated with HRIG, 75 were evaluated. The majority of injuries were acquired in Asia (n = 26, 34 %) and in Western Europe (n = 18, 24 %), of which 17 in Belgium. The five (5) most frequently recorded countries overseas were Indonesia (n = 13), Thailand (n = 7), Morocco (n = 4), Peru (n = 3) and Costa Rica (n = 3). Administration of immunoglobulins was related to injuries by dogs (36 %), monkeys (25 %) or bats (22 %). A timely response was observed in 16 (21, 33 %) and in 55 (73, 33 %) of subjects receiving HRIG (less than or equal to 48 hours) or rabies vaccine (less than 7days), respectively. The mean time between exposure and the first (1st) administered dose of rabies vaccine and HRIG was 7.7 and 8.7 days, respectively. The mean delay for HRIG administration was 9.6 days and six (6) days for abroad and inland risks, respectively. In 15 of 16 (94 %) bat-related cases the antibody titer after full PEP was greater than 5.0 IU/ml. In 38 of 47 (81 %) cases related to other animals the RFFIT titer was greater than 3.0 IU/ml. All low-responders received additional rabies injections. The authors concluded that the findings of this study showed a substantial time delay between the animal-related risk and the administration of HRIG, in particular when the injury occurred abroad. More targeted communication regarding the risks of rabies and preventable measures may reduce this delay. Furthermore, the antibody response was inadequate in some cases following full PEP administration according to the Belgian recommendation.
Kessels and colleagues (2019) stated that rabies is a fatal zoonotic disease preventable through timely and adequate PEP to potentially exposed persons, i.e., wound washing and antisepsis, a series of intra-dermal (ID) or IM rabies vaccinations, and rabies immunoglobulin in WHO category III exposures. The 2010 WHO position on rabies vaccines recommended PEP schedules requiring up to five (5) clinic visits over the course of approximately one (1) month. Abridged schedules with less doses have potential to save costs, increase individual compliance, and thereby improve equitable access to life-saving PEP for at-risk populations. These investigators systematically reviewed new evidence since that considered for the 2010 position paper to examine the following: immunogenicity and effectiveness of PEP schedules of reduced dose and duration; new evidence on effective PEP protocols for special populations; and the effect of changing routes of administration (ID or IM) during a single course of PEP. The search identified a total of 14 relevant studies. The identified studies supported a reduction in dose or duration of rabies PEP schedules. The one (1)-week, 2-site ID PEP schedule was found to be most advantageous, as it was safe, immunogenic, supported by clinical outcome data and involved the least direct costs (i.e., cost of vaccine) compared to other schedules. To supplement this evidence, as yet unpublished additional data were reviewed to support the strength of the recommendations. The authors concluded that available evidence suggested that changes in the rabies vaccine product and/or the route of administration during PEP is possible. Moreover, these researchers noted that few studies have examined PEP schedules in persons with suspect or confirmed rabies exposures; gaps exist in understanding the safety and immunogenicity of novel PEP schedules in special populations such as infants and immunocompromised individuals. They also noted that available data indicated that administering rabies vaccines during pregnancy is safe and effective.