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

Rabies Post-Exposure Prophylaxis (PEP) Schedule

The standard rabies post-exposure prophylaxis schedule for previously unvaccinated persons consists of wound cleansing, human rabies immune globulin (HRIG) administration, and a 4-dose vaccine regimen given on days 0,3,7, and 14. 1

Components of Rabies PEP

1. Immediate Wound Management

• Thorough cleansing of all wounds with soap and water
• If available, irrigate with virucidal agent (e.g., povidone-iodine solution)
• Avoid suturing wounds when possible to prevent deeper contamination 2
• Address tetanus prophylaxis and bacterial infection control as needed

2. Human Rabies Immune Globulin (HRIG)

• Administer 20 IU/kg body weight as soon as possible after exposure
• 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
• HRIG can be given up to day 7 after the first vaccine dose if not available initially
• Never administer HRIG in the same syringe or at the same anatomic site as the first vaccine dose 1, 2

3. Rabies Vaccine Administration

For previously unvaccinated individuals:

• 4 doses of 1.0 mL human diploid cell vaccine (HDCV) or purified chick embryo cell vaccine (PCECV)
• Administered intramuscularly in the deltoid area (or anterolateral thigh in young children)
• Schedule: days 0,3,7, and 14 (day 0 is the day of first dose) 1
• Note: Immunocompromised patients should receive 5 doses on days 0,3,7,14, and 28 1

For previously vaccinated individuals:

• 2 doses of 1.0 mL HDCV or PCECV
• Administered intramuscularly in the deltoid area
• Schedule: days 0 and 3
• HRIG is not administered to previously vaccinated persons 1

Critical Considerations

Timing of PEP

• Begin PEP as soon as possible after exposure
• Do not delay initiation of treatment while awaiting test results from the animal
• PEP can still be effective when started late (even months after exposure), but the sooner treatment begins, the better 2

Anatomical Site for Vaccination

• Always use the deltoid area in adults and older children
• The anterolateral thigh is acceptable for younger children
• Never administer vaccine in the gluteal area, as this can result in diminished immune response 1

Common Pitfalls to Avoid

1. Delaying PEP while waiting for animal testing results
2. Administering vaccine in the gluteal area
3. Using less than the full dose of HRIG
4. Failing to infiltrate wounds with HRIG
5. Administering HRIG and first vaccine dose at the same anatomic site
6. Missing scheduled vaccine doses
7. Not providing the 5-dose schedule for immunocompromised patients

The 4-dose vaccine regimen (replacing the previous 5-dose recommendation) has been shown to be highly effective in preventing human rabies following exposure. Clinical trials and observational studies demonstrate that all healthy persons develop detectable rabies virus-neutralizing antibodies by day 14 of the regimen 1. This schedule is supported by the Advisory Committee on Immunization Practices (ACIP) based on extensive evidence review 1.

Remember that rabies is almost always fatal once clinical symptoms develop, making proper and timely PEP administration critical for preventing mortality 3, 4.