What is the protocol for a rabies (Rabies virus) vaccination?

From the Guidelines

If you've been bitten by an animal that might have rabies, you should immediately seek medical attention for post-exposure prophylaxis (PEP), which includes wound cleaning, rabies immune globulin (RIG) administered at the wound site, and a series of four rabies vaccine doses given on days 0,3,7, and 14, as recommended by the Advisory Committee on Immunization Practices 1.

Key Considerations

• The reduced 4-dose vaccine schedule is recommended for persons previously unvaccinated with rabies vaccine, with the first dose administered as soon as possible after exposure (day 0), and additional doses on days 3,7, and 14 after the first vaccination 1.
• For persons who previously received a complete vaccination series with a cell-culture vaccine, a 2-dose PEP vaccination series is recommended, with doses administered on days 0 and 3, and no RIG is needed 1.
• Prompt rabies PEP, including wound care, infiltration of RIG into and around the wound, and multiple doses of rabies cell-culture vaccine, continues to be highly effective in preventing human rabies 1.

Important Details

• The vaccine works by stimulating the immune system to produce antibodies against the rabies virus before it reaches the brain.
• Rabies is nearly always fatal once symptoms appear, making prompt treatment crucial.
• Common side effects of the vaccine include soreness at the injection site, headache, and mild fever, but these are temporary and far outweigh the risk of untreated rabies.
• Even if you're unsure about the animal's rabies status, it's safer to get vaccinated, especially for bites from wild animals like bats, raccoons, skunks, and foxes.

From the FDA Drug Label

When this course is not possible, immunosuppressed persons who are at risk for rabies should have their viral neutralizing antibody titers checked after completing the pre-exposure series. If no acceptable antibody response is detected, the patient should be managed in consultation with their physician and appropriate public health officials The essential components of rabies post-exposure prophylaxis are wound treatment and, for previously unvaccinated persons, the administration of both human rabies immune globulin (RIG) and vaccine. Post-exposure antirabies vaccination should always include administration of both passive antibody and vaccine, with the exception of persons who have ever previously received complete vaccination regimens (pre-exposure or post-exposure) with a cell culture vaccine or persons who have been vaccinated with other types of vaccines and have previously had a documented rabies virus neutralizing antibody titer. The recommended dose of Imogam Rabies – HT is 20 IU/kg (0.133 mL/kg) or 9 IU/lb (0. 06 mL/lb) of body weight administered at the time of the first vaccine dose.

The protocol for a rabies vaccination includes:

• Pre-exposure prophylaxis:
  • Primary course of vaccination for individuals at risk
  • Serologic testing every 6 months for individuals with continuous exposure, every 2 years for those with frequent exposure, and no testing for those with infrequent exposure
  • Booster vaccination if antibody titer is below acceptable level
• Post-exposure prophylaxis:
  • Local treatment of wounds with thorough washing and flushing, and application of a viricidal topical preparation
  • Administration of both human rabies immune globulin (RIG) and vaccine for previously unvaccinated persons
  • Post-exposure antirabies vaccination should include administration of both passive antibody and vaccine, unless the person has previously received complete vaccination regimens
  • The recommended dose of RIG is 20 IU/kg of body weight administered at the time of the first vaccine dose 2, 3, 3

From the Research

Rabies Vaccination Protocol

The protocol for a rabies vaccination involves several steps, including:

• Thorough local wound cleansing
• Active immunization with a series of rabies vaccine doses
• Passive immunization with human rabies immune globulin (HRIG) for individuals who have not previously received preexposure prophylaxis 4, 5, 6

Postexposure Prophylaxis (PEP)

For individuals previously unimmunized against rabies virus, the recommended PEP regimen includes:

• Five doses of rabies vaccine administered intramuscularly in the deltoid muscle on days 0,3,7,14, and 28 4
• HRIG (20 IU/kg) given on day 0, with administration into and around the wounds, and the remaining volume given intramuscularly at a site distant from the vaccine site 4

Preexposure Prophylaxis

Certain individuals at high risk for rabies exposure are candidates for preexposure prophylaxis, which consists of:

• Three doses of rabies vaccine administered 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 4, 6

Administration Routes and Regimens

Different administration routes and regimens have been studied, including:

• Intramuscular (IM) and intradermal (ID) routes of vaccine delivery 7
• A new, one-week ID regimen using less vaccine, injected at multiple sites, and involving two clinic visits, which could increase the accessibility of highly immunogenic prophylaxis and reduce the prohibitive cost 7
• Intravenous (IV) administration of HRIG, which has been shown to produce higher serum neutralizing antibody concentrations and may be a viable alternative to IM administration 8