What is the recommended rabies (Rabies virus) prophylaxis regimen for occupational exposure?

Rabies Prophylaxis for Occupational Exposure

For occupational rabies exposure, immediate post-exposure prophylaxis should include wound cleansing, rabies immune globulin infiltration at the wound site, and a 5-dose vaccination regimen for previously unvaccinated individuals, or a 2-dose regimen for previously vaccinated individuals. 1

Assessment of Exposure

Types of Exposure

• Bite exposure: Any penetration of skin by teeth of a potentially rabid animal
• Non-bite exposure: Scratches, abrasions, open wounds, or mucous membranes contaminated with saliva or neural tissue 2
• Not considered exposures: Indirect contact, petting an animal, contact with blood/urine/feces, or contact of saliva with intact skin 2

Risk Assessment Factors

• Animal species involved (bats, raccoons, skunks, foxes carry highest risk)
• Circumstances of exposure (unprovoked attacks suggest higher risk)
• Vaccination status of animal (fully vaccinated animals have minimal risk)
• Geographic location (consider endemic areas) 1, 2

Post-Exposure Prophylaxis Protocol

For Previously Unvaccinated Individuals

1. Immediate wound cleansing:

   • Thoroughly wash and flush all wounds for 15 minutes with soap and water
   • Apply iodine-containing or virucidal topical preparation 2

2. Human Rabies Immune Globulin (HRIG):

   • Administer 20 IU/kg body weight
   • Infiltrate full dose around and into wounds if anatomically feasible
   • Inject remaining volume IM at site distant from vaccine administration
   • Must be given with first vaccine dose or up to day 7 of vaccination series 1, 2

3. Rabies Vaccine:

   • 5 doses of 1 mL IM in deltoid area (anterolateral thigh for children)
   • Administered on days 0,3,7,14, and 28
   • Never administer in gluteal area (results in lower antibody titers) 1

For Previously Vaccinated Individuals

1. Immediate wound cleansing (as above)
2. Rabies Vaccine:
   • 2 doses of 1 mL IM in deltoid area
   • Administered on days 0 and 3
   • No HRIG required 1, 3

Pre-Exposure Prophylaxis for High-Risk Occupations

Pre-exposure vaccination is recommended for:

• Laboratory workers handling rabies virus
• Veterinarians and staff
• Animal control officers
• Wildlife officers in enzootic areas
• Field personnel with potential contact with rabid animals
• Cave explorers 1

Pre-Exposure Vaccination Protocol

• Primary series: 3 doses of rabies vaccine
• Monitoring strategy:
  • High-risk individuals (lab workers directly handling rabies virus): Serum antibody testing every 6 months
  • Frequent-risk individuals (veterinarians, animal control officers): Serum antibody testing every 2 years
  • If titer falls below complete neutralization at 1:5 serum dilution, administer booster dose 1

Important Considerations

Effectiveness and Timing

• Post-exposure prophylaxis is nearly 100% effective when administered promptly and correctly
• No absolute time limit for starting prophylaxis, but earlier administration provides better outcomes 3
• Even delayed administration is indicated as incubation periods of >1 year have been reported 3

Vaccine Adverse Effects

• Common: Local pain, erythema, headache (11.4% incidence) 4
• Most adverse events are mild and resolve without complications 4

Special Situations

• If animal testing confirms the animal is not rabid, prophylaxis can be discontinued 1
• For exposures outside the United States, additional therapy may be needed upon return 1
• A systematic booster after primary pre-exposure vaccination provides long-term immunity in nearly all individuals, potentially reducing the need for frequent antibody monitoring 5

Common Pitfalls to Avoid

1. Administering HRIG in same syringe or anatomical site as vaccine - this can reduce vaccine effectiveness 1
2. Injecting vaccine in gluteal area - results in lower antibody titers 1
3. Delaying treatment while waiting for animal testing - always start prophylaxis immediately for high-risk exposures 2
4. Inadequate wound infiltration with HRIG - failures have been reported when less than the full amount was infiltrated at exposure sites 1
5. Unnecessary prophylaxis for healthcare workers - maintain strict isolation precautions and educate staff about true exposure risks 6