What is the recommended rabies (Rabies virus) shot series for post-exposure prophylaxis?

Recommended Rabies Post-Exposure Prophylaxis Shot Series

For post-exposure prophylaxis against rabies, a 4-dose vaccine regimen should be administered on days 0,3,7, and 14, along with human rabies immune globulin (HRIG) at the initial visit for previously unvaccinated individuals. 1

Components of Post-Exposure Prophylaxis

1. Wound Cleansing

• Immediate and thorough washing of all wounds with soap and water for 15 minutes
• Application of a virucidal agent such as povidone-iodine solution if available 2
• Local wound cleansing alone can significantly reduce the likelihood of rabies infection 2

2. Human Rabies Immune Globulin (HRIG)

• For previously unvaccinated individuals only
• Dose: 20 IU/kg body weight 1, 3
• Administration:
  • If anatomically feasible, infiltrate the full dose around and into the wound(s)
  • Inject any remaining volume intramuscularly at a site distant from vaccine administration
  • Can be administered up to and including day 7 after the first vaccine dose 1
  • Never administer in the same syringe or at the same anatomical site as the first vaccine dose 3

3. Rabies Vaccine

• For previously unvaccinated individuals:

  • 4 doses of 1.0 mL human diploid cell vaccine (HDCV) or purified chick embryo cell vaccine (PCECV)
  • Administration schedule: days 0,3,7, and 14 1
  • Administer intramuscularly in the deltoid area for adults or anterolateral thigh for children
  • Never administer in the gluteal area (results in lower antibody titers) 1, 2

• For immunosuppressed individuals:

  • 5 doses of vaccine on days 0,3,7,14, and 28 1

• For previously vaccinated individuals:

  • 2 doses of vaccine on days 0 and 3
  • No HRIG is needed 1, 3

Special Considerations

Timing of Prophylaxis

• Begin as soon as possible after exposure, ideally within 24 hours
• No absolute time limit for starting treatment (rabies incubation periods can exceed one year) 2
• Even delayed administration of prophylaxis can be effective 3

Schedule Deviations

• Minor delays of a few days for individual doses are not critical
• For major deviations, immune status should be assessed by serologic testing 7-14 days after the final dose 1, 2

Common Pitfalls to Avoid

1. Incorrect HRIG administration:

   • Failure to infiltrate wounds completely with HRIG (associated with rare treatment failures) 2
   • Administering HRIG in the same syringe or anatomical site as the vaccine 1, 3

2. Improper vaccine administration:

   • Using the gluteal area for injection (results in lower antibody titers) 1, 2
   • Omitting doses or significantly altering the schedule 1

3. Withholding treatment due to time elapsed after exposure:

   • Post-exposure prophylaxis should still be administered even with significant delays 2, 3

4. For previously vaccinated individuals:

   • Erroneously administering HRIG (may blunt the rapid memory response) 1, 3

Definition of Previously Vaccinated

A previously vaccinated person is defined as someone who has:

• Received a complete pre-exposure or post-exposure prophylaxis regimen with a cell culture vaccine, OR
• Been vaccinated with other types of vaccines AND has documented rabies antibody titers 1, 3

Post-exposure prophylaxis is nearly 100% effective when administered promptly and correctly, making it essential to follow these guidelines precisely to prevent this almost invariably fatal disease 2, 4.