Anti-Rabies Vaccine Administration
For post-exposure prophylaxis in unvaccinated individuals, administer cell-culture rabies vaccine (HDCV or PCECV) as 4 doses of 1.0 mL intramuscularly on days 0,3,7, and 14, combined with rabies immune globulin (RIG) 20 IU/kg on day 0. 111
Post-Exposure Prophylaxis (PEP) for Unvaccinated Persons
The ACIP guidelines establish a clear 4-dose regimen that replaced the older 5-dose schedule, saving approximately $16.6 million annually to the U.S. healthcare system while maintaining equivalent efficacy 1. This recommendation is supported by overwhelming evidence demonstrating safety and effectiveness 2.
Complete PEP Protocol:
Immediate wound care:
- Thoroughly wash and flush all wounds for approximately 15 minutes with soap and copious water
- Apply povidone-iodine solution or similar virucidal agent if available 13
Rabies Immune Globulin (RIG):
- Administer 20 IU/kg body weight on day 0
- Infiltrate the full dose around and into the wound(s) if anatomically feasible
- Inject any remaining volume intramuscularly at a site distant from vaccine administration
- Never administer RIG in the same syringe or same anatomic site as the vaccine 11
- If RIG was not given on day 0, it can still be administered up to and including day 7 1
Vaccine schedule:
- 1.0 mL intramuscularly on days 0,3,7, and 14
- Use HDCV (human diploid cell vaccine) or PCECV (purified chick embryo cell vaccine) 13
Critical administration details:
- Adults and older children: Inject into the deltoid muscle only
- Infants and small children: Anterolateral aspect of the thigh is acceptable
- Never use the gluteal area - this results in diminished immunologic response 13
- Children receive the same 1.0 mL dose as adults 1
Important Exception - Immunosuppressed Patients:
Use a 5-dose schedule on days 0,3,7,14, and 28 for immunocompromised individuals 11
Post-Exposure Prophylaxis for Previously Vaccinated Persons
Previously vaccinated individuals require only 2 vaccine doses (1.0 mL each) on days 0 and 3, with NO rabies immune globulin. 11
"Previously vaccinated" means any person with:
- History of pre-exposure vaccination with HDCV, PCECV, or RVA
- Prior PEP with cell-culture vaccines
- Previous vaccination with documented rabies virus-neutralizing antibody response 1
Do not administer HRIG to previously vaccinated persons - it may inhibit the anamnestic response 1
Pre-Exposure Prophylaxis
For pre-exposure prophylaxis, administer 3 doses of 1.0 mL intramuscularly on days 0,7, and either day 21 or 28. 33
Risk-Based Booster Strategy:
Continuous risk category (rabies research/production workers):
- Check antibody titers every 6 months
- Administer booster if titer falls below 1:5 dilution by RFFIT 3
Frequent risk category (diagnostic lab workers, cavers, veterinarians, wildlife officers in endemic areas, bat handlers):
- Check serum every 2 years
- Single booster dose if titer inadequate 3
Infrequent risk category (veterinarians/wildlife officers in low-endemic areas, at-risk international travelers):
Common Pitfalls to Avoid
- Never delay PEP initiation - begin immediately after exposure regardless of time interval since exposure 1
- Never exceed the recommended RIG dose - excess RIG may partially suppress active antibody production 1
- Never administer vaccine in gluteal area - associated with lower neutralizing antibody titers 3
- Never give RIG to previously vaccinated persons - unnecessary and potentially harmful 1
- Do not routinely test serology after PEP in healthy patients - only indicated for immunosuppressed individuals 1
When to Discontinue PEP
If laboratory testing (direct fluorescent antibody test) confirms the exposing animal was not rabid, discontinue PEP 33. Consult local or state health departments for guidance in uncertain cases.