What is the recommended protocol for rabies vaccination and post-exposure prophylaxis?

Rabies Vaccination and Post-Exposure Prophylaxis Protocol

The recommended protocol for rabies post-exposure prophylaxis includes immediate thorough wound cleansing, administration of rabies immunoglobulin (20 IU/kg) at the wound site, and a 4-dose vaccination schedule on days 0,3,7, and 14 for previously unvaccinated individuals. 1, 2

Post-Exposure Prophylaxis for Unvaccinated Individuals

Step 1: Wound Management

• Immediately clean all wounds thoroughly with soap and water for at least 15 minutes 2, 3
• Apply a virucidal agent (e.g., povidone-iodine solution) if available 1
• Avoid suturing wounds when possible to prevent deeper contamination 4
• Address tetanus prophylaxis and bacterial infection control as needed 4

Step 2: Rabies Immune Globulin (HRIG)

• Administer 20 IU/kg body weight of HRIG on day 0 1, 2
• Infiltrate the full dose around and into all wounds if anatomically feasible 1, 4
• Administer any remaining volume intramuscularly at a site distant from vaccine administration 1, 4
• HRIG can be given up to 7 days after the first vaccine dose if not available initially 4
• Never administer HRIG in the same syringe or at the same site as the vaccine 4

Step 3: Vaccination Schedule

• Administer 1.0 mL of human diploid cell vaccine (HDCV) or purified chick embryo cell vaccine (PCECV) intramuscularly in the deltoid area on days 0,3,7, and 14 1, 2
• For immunocompromised patients, use a 5-dose regimen with an additional dose on day 28 1, 2
• Never administer vaccine in the gluteal area as this may result in diminished immune response 1

Post-Exposure Prophylaxis for Previously Vaccinated Individuals

• Administer 1.0 mL of HDCV or PCECV intramuscularly in the deltoid area on days 0 and 3 only 1
• HRIG should NOT be administered to previously vaccinated individuals 1, 4
• Previously vaccinated individuals include those who have received complete pre-exposure or post-exposure prophylaxis with cell culture vaccines or have documented protective antibody titers 4

Pre-Exposure Vaccination

• Recommended for high-risk individuals (laboratory workers, veterinarians, travelers to endemic areas) 2
• Administer 1.0 mL of HDCV or PCECV intramuscularly on days 0,7, and 21 or 28 2, 4
• Booster doses depend on risk category and antibody titers 4
  • Continuous risk: Check antibody levels every 6 months
  • Frequent risk: Check antibody levels every 2 years
  • Infrequent risk: No routine boosters needed after primary series

Important Considerations

• PEP should begin as soon as possible after exposure, ideally within 24 hours 2
• However, PEP can still be beneficial when administered at any time before symptom onset, even months after exposure 2, 4
• The deltoid area is the only acceptable vaccination site for adults and older children; the anterolateral thigh may be used for younger children 1, 2
• Correctly administered PEP is nearly 100% effective in preventing rabies 2

Common Pitfalls to Avoid

1. Delayed initiation of PEP: Begin treatment immediately; don't wait for animal testing results in high-risk exposures 2, 4
2. Improper HRIG administration: Ensure thorough infiltration around all wounds 2
3. Incorrect injection site: Never use the gluteal area for vaccine administration 1, 4
4. Inadequate wound cleansing: Thorough cleaning is critical for prevention 2, 3
5. Withholding PEP due to time since exposure: There is no maximum time limit for starting PEP as long as the person remains asymptomatic 2
6. Administering HRIG to previously vaccinated individuals: This may suppress the rapid memory response 4

The 4-dose vaccine regimen (days 0,3,7, and 14) replaced the previous 5-dose regimen in 2010 based on evidence that it provides adequate protection while reducing costs and the burden of additional medical visits 1. This protocol is highly effective when administered properly and should be initiated without delay following a potential rabies exposure.