What is the protocol for post-exposure prophylaxis (PEP) for rabies vaccination?

From the Guidelines

Rabies vaccination is essential for preventing this fatal viral disease, and the most effective approach is to administer a 4-dose series of rabies vaccine (such as HDCV or PCECV) on days 0,3,7, and 14 for postexposure prophylaxis in unvaccinated individuals, along with rabies immune globulin (RIG) at 20 IU/kg infiltrated around the wound 1. For pre-exposure prophylaxis, healthy individuals should receive a 3-dose series of rabies vaccine on days 0,7, and 21 or 28, administered intramuscularly in the deltoid. The key points to consider for rabies vaccination are:

• For post-exposure prophylaxis, previously vaccinated individuals only need 2 doses of vaccine on days 0 and 3 1.
• Children receive the same dosage as adults.
• The vaccine works by stimulating the immune system to produce antibodies against the rabies virus before it can reach the nervous system.
• For those at high risk (veterinarians, animal handlers, laboratory workers), booster doses may be needed every 2-3 years.
• Side effects are generally mild and include pain at the injection site, headache, and low-grade fever 1. Since rabies is nearly always fatal once symptoms appear, timely vaccination is critical for prevention, and the reduced 4-dose vaccine schedule for postexposure prophylaxis has been shown to be effective in preventing human rabies 1. Some important considerations for the administration of rabies vaccine include:
• Wound cleansing with soap and water, and the use of a virucidal agent such as povidine-iodine solution if available 1.
• The deltoid area is the only acceptable site of vaccination for adults and older children, while the outer aspect of the thigh may be used for younger children 1.
• Vaccine should never be administered in the gluteal area 1.

From the FDA Drug Label

Bites to highly innervated areas such as the face and hands carry the highest risk, but the site of the bite should not influence the decision to begin treatment The essential components of rabies postexposure prophylaxis are prompt local treatment of wounds and administration of both HRIG and vaccine. A complete course of postexposure treatment for previously unvaccinated adults and children consists of a total of 5 doses of vaccine, each 1. 0 mL: one IM injection (deltoid) on each of Days 0,3,7,14, and 28.

The rabies vaccination schedule consists of 5 doses of vaccine for previously unvaccinated individuals, given on Days 0,3,7,14, and 28. Additionally, HRIG should be administered exactly 20 IU/kg body weight in total, with the full dose infiltrated in the area around and into the wounds if anatomically feasible 2. Local treatment of wounds with immediate and thorough washing with soap and water is also an important measure for preventing rabies.

• Key points:
  • Prompt local treatment of wounds
  • Administration of both HRIG and vaccine
  • 5 doses of vaccine for previously unvaccinated individuals
  • HRIG administration exactly 20 IU/kg body weight in total
• Important considerations:
  • The site of the bite should not influence the decision to begin treatment
  • Treatment should begin as soon as possible after exposure
  • HRIG is not indicated beyond the seventh day after administration of the first dose of vaccine 3

From the Research

Rabies Vaccination Overview

• Rabies is a lethal disease once symptoms appear, and its prevention is crucial, including community awareness, mass dog vaccination, and post-exposure prophylaxis (PEP) 4.
• The global rabies burden is still high, and access to adequately-delivered PEP remains challenging, despite the availability of safe and potent rabies vaccines 4.

Post-Exposure Prophylaxis (PEP)

• PEP consists of washing the wound with water and soap, assessing the need for rabies biologicals, administering rabies immunoglobulin or monoclonal antibodies, starting the WHO-recommended intradermal 1-week vaccination regimen, and informing patients adequately throughout the PEP process 4.
• The intradermal 1-week vaccination regimen recommended by WHO is as safe as other regimens but carries important cost-, dose-, and time-sparing benefits 4, 5.
• Abridged schedules with less doses have potential to save costs, increase patient compliance, and thereby improve equitable access to life-saving PEP for at-risk populations 5.

Vaccination Schedules and Administration Routes

• The 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 compared to other schedules 5.
• Evidence suggests that changes in the rabies vaccine product and/or the route of administration during PEP is possible, and administering rabies vaccines during pregnancy is safe and effective 5, 6.
• The administration of a rabies immune globulin is generally recommended in conjunction with the first dose of the rabies vaccine, and nerve tissue origin vaccines are not recommended if cell or tissue culture vaccines are available 7.

Pre-Exposure Prophylaxis

• Pre-exposure prophylaxis consists of 3 doses of an approved rabies vaccine administered either intramuscularly or intradermally on days 0,7, and 21 or 28 with periodic booster doses or titre determination depending on the level of risk of potential exposure to the virus 7.
• Rabies pre-exposure immunisation is recommended for those individuals at risk of exposure to the virus, such as primary care providers and individuals working with animals 8, 7.