South African Rabies Guidelines

Human rabies is effectively always fatal once symptoms begin, yet almost always preventable when prophylaxis is given promptly and correctly. This is the operational South African framework for that prophylaxis: exposure categorisation, immediate wound care, post-exposure prophylaxis (PEP), pre-exposure prophylaxis (PrEP), rabies immunoglobulin (RIG), the special-population rules, and laboratory submission. It follows the 2021 National Department of Health guideline and the NICD specimen-collection guide.

When to think rabies

South Africa has approximately ten laboratory-confirmed human cases of rabies per year, concentrated in KwaZulu-Natal, the Eastern Cape, Mpumalanga, the Free State and Limpopo. The vast majority of human exposures come from the canid cycle (domestic dogs and black-backed jackals); a smaller proportion from the yellow mongoose cycle on the central plateau and from the bat-eared fox cycle in the western provinces. Any contact with a bat is treated as a potential exposure regardless of region. From 2024, rabies in Cape fur seals has been documented along the Western and Northern Cape coast, and PrEP is recommended for water-sports users and seal handlers in affected areas.

The NICD 24-hour clinician hotline is 0800 212 552.

Exposure categorisation (WHO Category I / II / III)

Stratify every potential exposure by skin breach. This is the single most important step in the consultation.

Category	Exposure	Management
I	Touching or feeding animals; licks on intact skin	None (no skin breach); wash exposed area only
II	Minor scratches or abrasions without bleeding; nibbling of uncovered skin	Wound care + vaccine alone (no RIG)
III	Single or multiple transdermal bites or scratches; mucosal contact with saliva (eyes, nose, mouth); licks on broken skin; any contact with a bat	Wound care + vaccine + RIG

The bat-in-room rule: bat teeth are tiny and bites may leave no visible wound, so a bat in a room with a sleeping or otherwise incapacitated person is treated as Category III even without a remembered bite.

Immediate wound care

The first step is also the most effective. Wash all wounds with soap and running water for at least five to ten minutes (fifteen minutes per the Quick Reference summary), then flush thoroughly. Disinfect with chlorhexidine 0.05% or povidone-iodine 10%.

• Avoid suturing the wound unless required for haemostasis; if suturing is unavoidable, infiltrate RIG into and around the wound first.
• Avoid infiltrating local anaesthetic at the wound, which risks forcing virus into deeper tissues.
• Update tetanus prophylaxis; consider antibiotic prophylaxis (amoxicillin-clavulanate) for a clearly contaminated bite.

Rabies vaccine

The only PEP and PrEP regimens recommended in South Africa use modern inactivated cell-culture-grown vaccines.

Post-exposure prophylaxis (PEP), 4-dose IM schedule:

• Days 0, 3, 7, and one day between 14 and 28.
• One full vial per administration; adult and paediatric doses are identical.
• Site: deltoid in adults and older children; anterolateral thigh in children under 2 years. Never gluteal (impaired immunogenicity).
• A delayed dose does not require restarting the course; resume from where the schedule was missed. Brand switching is acceptable if unavoidable.

Pre-exposure prophylaxis (PrEP), 2-dose schedule:

• Immunocompetent: 2 doses IM on days 0 and 7.
• Intradermal dose-sparing alternative: 2 sites per visit on days 0 and 7 (0.1 mL per site).
• Immunocompromised (symptomatic HIV, active cancer chemotherapy, high-dose corticosteroids ≥20 mg/day prednisone for ≥2 weeks, transplant immunosuppression): 3-visit schedule on days 0, 7 and 21–28, IM or ID.
• Indicated for veterinarians, animal welfare and laboratory workers, bat researchers and enthusiasts, spelunkers, and travellers to endemic areas where reliable PEP access is uncertain.
• Boosters guided by titres (every ~2 years for ongoing high-risk exposure such as veterinarians).
• If a potential exposure occurs more than 3 months after PrEP completion, give booster doses; standard PEP is otherwise required in event of exposure regardless of antibody titre.

Rabies immunoglobulin (RIG)

RIG provides passive antibody covering the window before vaccine- induced immunity develops. It is only effective if given within 7 days of the first vaccine dose. After that, endogenous antibody is present and adding RIG may reduce the patient’s own vaccine response.

Dosing:

• HRIG (human): Rabigam or KamRAB; both 150 IU/mL, 20 IU/kg.
• ERIG (equine): Equirab, 200 IU/mL, 40 IU/kg. Skin testing is not required.

Worked example (50 kg patient on HRIG): 20 × 50 = 1,000 IU = 6.66 mL = ~3.33 vials of Rabigam (2 mL/vial).

Administration technique, current SA practice:

• Infiltrate the entire calculated dose into and around the wound(s). Do not inject the remainder at a distant IM site (this is a change from older practice).
• Dilute with normal saline if wounds are multiple, small, or the full volume cannot be accommodated without causing compartment syndrome.
• For small wounds, infiltrate as much as is anatomically feasible.
• Never mix RIG with the vaccine in the same syringe; never inject RIG at the same anatomical site as the vaccine, because they neutralise each other.

If the patient is previously vaccinated, no RIG is given.

Special populations

HIV. A patient with HIV who is on effective ART and clinically well is not classified as immunocompromised for the purposes of rabies prophylaxis; the standard schedules apply. Symptomatic HIV or low CD4 triggers the immunocompromised algorithm: full 4-dose IM vaccine plus RIG regardless of exposure category and regardless of prior vaccination.

Pregnancy and lactation. Both vaccine and RIG are safe and effective; the same dosing as non-pregnant adults applies. There are no obstetric contraindications.

Paediatric. Same vaccine dose as adults (one full vial). Site of administration is the anterolateral thigh in children under 2 years; deltoid in older children. Never gluteal. For PEP in infants under 2, HNIG/HRIG administration around the wound is unchanged but RIG dose calculation uses paediatric weight.

Previously vaccinated patients (prior PrEP or prior PEP):

• No RIG.
• 2 vaccine doses on days 0 and 3.
• No PEP needed at all if the new exposure occurs within 3 months of completing previous PEP. After 3 months, give the 2-dose abbreviated schedule.

Delayed presentation. Start the schedule as if day 0 is the day of presentation; infiltrate RIG around the now-healed wound site as best as anatomy allows. RIG is no longer indicated more than 7 days after the first vaccine dose.

Source-animal handling

Domestic dogs, cats and ferrets that can be safely observed are managed by the 10-day observation rule: PEP is started immediately, the animal is quarantined under Veterinary Services supervision, and if the animal remains clinically healthy at day 10, PEP may be stopped. The rule applies only to these three species, which shed virus in saliva only within the 10 days preceding clinical signs.

For stray or wild animals that cannot be reliably observed, or any animal showing neurological signs, do not delay PEP while awaiting test results. Animals are typically euthanised for testing; the whole brain (or, failing that, caudal brain, spinal cord and salivary gland) is submitted in 50% glycerol-saline in a leak-proof container marked “suspected rabies” to the NICD or a state veterinary laboratory. The diagnostic test is the Fluorescent Antibody Test (FAT), over 99% reliable.

PEP for bite-contact unvaccinated dogs or cats themselves is not recommended in the South African veterinary protocol.

Laboratory specimen submission

Rabies remains an exceedingly difficult clinical diagnosis without laboratory confirmation. No single ante-mortem specimen is sensitive at all stages. Submit the full panel if rabies is in the differential.

Ante-mortem human specimens

Specimen	Volume / size	Container	Notes
Saliva	≥500 μL, 3 specimens collected on 3 consecutive days (one daily)	Universal specimen container	Use a syringe or suction device; sputum is not acceptable. Begin as soon as rabies enters the differential.
CSF	≥500 μL	Untreated sterile plastic tube
Nuchal skin biopsy	5–6 mm diameter × 5–7 mm depth; must include hair follicles and cutaneous nerves at the base of the follicles	Screw-top container	Place biopsy on sterile gauze moistened with saline or water; cover with the same gauze to prevent drying. No fixative.

Post-mortem human specimens

The preferred post-mortem specimen is brain tissue: 2 cm × 2 cm cubes from both the cerebellum and the cerebrum. Place in 50% glycerol-saline (half glycerol, half PBS) in a screw-top container, not glass. Do not fix in formalin. Collection is usually by the Forensic Pathologist. If brain tissue is not available, a post-mortem nuchal skin biopsy as above is an acceptable substitute.

Packaging and transport

• Triple-package per dangerous biological goods guidelines, with absorbent material in the secondary container.
• Keep cool on ice packs (do not freeze unless brain is being sent without glycerol-saline).
• Send directly to NICD as soon as possible.
• Notify the laboratory in advance of any submission.
• Every submission must accompany a fully completed Suspected Human Rabies Case History Form (available on the NICD website).

Submission address

National Institute for Communicable Diseases (NICD), NHLS Centre for Emerging Zoonotic and Parasitic Diseases No. 1 Modderfontein Road, Sandringham 2131, Gauteng

Direct contact: Dr Jacqueline Weyer, 082 903 9131, jacquelinew@nicd.ac.za 24-hour clinician hotline: 0800 212 552

Notification and One-Health surveillance

Rabies is a Category 1 Notifiable Medical Condition in South Africa: immediate notification is required for any suspected case (via the NICD NMC system).

On the animal side, rabies is notifiable under the Animal Diseases Act, 1984 (Act No. 35 of 1984) through state Veterinary Services (Department of Agriculture, Land Reform and Rural Development). Surveillance is coordinated under a One-Health framework between the NICD, NHLS reference laboratory, and the DALRRD veterinary network. Mass dog-vaccination programmes remain the primary public- health intervention.

Available South African products

Vaccines: modern inactivated cell-culture vaccines in 0.5 mL vials, given intramuscularly or intradermally. Both purified Vero cell and purified chick embryo cell (PCEC) products are used; Vero cell vaccines are suitable in patients with egg allergy.

Rabies immunoglobulin:

• Rabigam (HRIG; 150 IU/mL, 2 mL vials).
• KamRAB (HRIG; 150 IU/mL, available in 2 / 5 / 10 mL vials).
• Equirab (ERIG; 200 IU/mL, 5 mL vials).

Monitoring after vaccination

Anti-rabies antibody titre testing is available in South Africa. WHO recommends checking titres every 2 years for high- or continuous-risk persons (e.g., veterinarians), and boosting per serology. PEP is still required in the event of an exposure regardless of antibody titres induced by PrEP.

References

• South African National Department of Health. National Guidelines for the Prevention of Rabies in Humans, South Africa (September 2021; replaces the 2010 edition). The primary source for this article.
• National Institute for Communicable Diseases. Human Rabies: Ante-mortem & Post-mortem Specimen Collection Guide (Updated 2019, republished 2021). Centre for Emerging Zoonotic and Parasitic Diseases, NHLS. The primary source for the specimen-submission section of this article.
• National Institute for Communicable Diseases. What you need to know about rabies in seals in South Africa (August 2025). NICD Centre for Emerging Zoonotic and Parasitic Diseases. The reference for the Cape fur seal outbreak.