Summary of the National Advisory Committee on Immunization (NACI) Statement: Updated guidance for use of rabies vaccine for pre-exposure prophylaxis (PrEP)

Background: Rabies is a rare but almost universally fatal disease.While treatment is ineffective once symptoms develop, infection can be prevented through timely post-exposure prophylaxis (PEP).Pre-exposure prophylaxis (PrEP) is recommended for people at risk of rabies exposure.While PrEP generally simplifies PEP, it does not replace the need for PEP.The National Advisory Committee on Immunization (NACI) updated its PrEP guidance following a review of recent evidence.Objective: To summarize NACI's updated recommendations on rabies PrEP, including risk groups, vaccination schedules, routes of administration, serologic testing, product interchangeability and PEP guidance for previously vaccinated individuals.Methods: NACI used an evidence-to-recommendation framework, including a systematic review of immunogenicity by number of doses (one, two or three) and route of administration (one-site intramuscular [IM] vs two-site intradermal [ID]).These recommendations were reviewed and approved by NACI based on the available evidence.Results: NACI re-defined PrEP risk categories into very high, high and moderate risk.For most groups, a three-dose schedule (which includes two doses plus a booster/third dose) is recommended.For non-immunocompromised individuals in the moderate risk group with risk lasting less than three years, a two-dose schedule is recommended.Both one-site IM and twosite ID routes are acceptable.Serologic testing recommendations are provided by risk group, and routine serology solely because PrEP was administered by the two-site ID route is not recommended.Vaccine products and routes of administration are considered interchangeable when necessary.The importance of PEP, including for those who have previously received PrEP, is emphasized, and guidance provided for those who have received one or more prior rabies vaccine doses.Conclusion: Updated NACI guidance reduces doses for some groups and increases flexibility in administration while maintaining protection.NACI will continue to monitor evidence and update recommendations as needed.The full NACI guidance is available in the NACI statement entitled Updated Guidance for Use of Rabies Pre-Exposure Prophylaxis (PrEP) and is also summarized in the Rabies vaccines chapter of the Canadian Immunization Guide.