Since the recently reported case of rabies in a man from BC, Canada, I’ve done a lot of interviews. One thing that has struck me is the continued misconception about what rabies post-exposure prophylaxis (PEP) is, and the perception that it’s a long, painful ordeal.

It isn’t (at least not anymore)… and I know that from personal experience.

Rabies PEP is a set of injections given to someone who’s been exposed to rabies virus to prevent (prophylactically) the onset of disease. A long time ago, PEP involved enduring a large set of ~21 injections into the abdomen, which was quite unpleasant. Even though this is no longer the case, there’s an ongoing perception that rabies PEP is bad, painful or difficult (however it is still very expensive).

So, what does current-day rabies PEP involve?

There are two approaches to PEP, depending on whether the person has been previously vaccinated (and has an adequate antibody titre) or not.

PEP for an unvaccinated individual

  • The first day (day 0), the person gets a dose of anti-rabies antibodies (also known as rabies immunoglobulin or RIG), and a rabies vaccine (so the body will make more of its own anti-rabies antibodies).
  • The RIG is dosed based on the person’s weight.  If there is a wound (e.g. bite) where the virus likely entered the body, as much of the RIG as possible is injected around the wound (this can be tricky when the wound is on a small part of the body like a finger).  The rest is given in a large muscle.
  • Then the person get a rabies vaccine booster on days 3, 7 and 14.

PEP for a vaccinated individual 

  • We have it easier. We just get two doses of vaccine on days 0 and 3 (in a large muscle, e.g. upper arm).
  • No RIG is given, as it’s assumed a previously vaccinated person already has some anti-rabies antibodies and will respond to the first dose of vaccine very quickly because the immune system has already been primed.
  • This is the same reason an exposed domestic animal should be vaccinated again as soon as possible, even if it’s vaccines are up-to-date.  The goal is to activate the immune system again to help “intercept” any rabies virus in the body before it can cause infection of the central nervous system.  The response is typically much better in a previously vaccinated animal, and there is no RIG that can be given to animals.

Does it hurt?

  • A bit. It’s no different than any vaccine. I’d say my annual flu shot hurts at least as much as my rabies shots did.

Regardless, a rabies vaccine is a lot better to get than rabies. Anything we can do to encourage self-reporting of potential exposure, including making people aware that PEP isn’t a horrible ordeal, is important.  That message hasn’t apparently gotten out well enough.  However, avoiding exposure to the virus in the first place, by not handling wildlife and avoiding bites from domestic and wild animals alike, should always be the first line of defense.  While PEP may not be as painful as it once was, it is still very expensive and there is a limited supply, so it should be saved for those who truly need it.