What is the recommended rabies vaccination (Rabies Immunization) schedule for post-exposure and pre-exposure prophylaxis?

Rabies Vaccination Schedule

For post-exposure prophylaxis in previously unvaccinated individuals, a 4-dose regimen of rabies vaccine should be administered intramuscularly on days 0,3,7, and 14, along with rabies immune globulin (RIG) on day 0. 1, 2

Post-Exposure Prophylaxis (PEP)

Previously Unvaccinated Individuals

1. Wound Management:

   • Immediate thorough cleansing with soap and water for at least 15 minutes
   • Consider povidone-iodine solution if available 2
   • Avoid suturing when possible 2

2. Vaccination Schedule:

   • 4-dose regimen: 1.0 mL IM injections on days 0,3,7, and 14 1, 2
   • Preferred injection site: deltoid muscle (gluteal area should NOT be used) 1
   • Children receive same vaccine volume as adults 1

3. Rabies Immune Globulin (RIG):

   • Administer once on day 0: 20 IU/kg body weight 2, 3
   • Infiltrate full dose around and into wounds if anatomically feasible 2, 3
   • Any remaining volume injected IM at site distant from vaccine administration 1
   • If not administered on day 0, can be given up to day 7 of PEP series 1

Previously Vaccinated Individuals

1. Vaccination Schedule:

   • 2-dose regimen: 1.0 mL IM injections on days 0 and 3 only 1, 2
   • Preferred injection site: deltoid muscle 2

2. Rabies Immune Globulin:

   • NOT recommended for previously vaccinated individuals 1, 2

Special Populations

1. Immunocompromised Patients:
   • 5-dose regimen: 1.0 mL IM injections on days 0,3,7,14, and 28 1, 2
   • Serum antibody testing recommended after vaccination 1, 2
   • Avoid immunosuppressive agents during PEP unless essential 1, 2

Pre-Exposure Prophylaxis

1. Standard Schedule:

   • 3-dose regimen: IM injections on days 0,7, and 21 or 28 1, 2

2. Target Population:

   • Individuals at high risk of exposure: laboratory workers, veterinarians, animal control workers, and travelers to endemic areas 2, 4

Important Clinical Considerations

1. Timing of PEP:

   • Begin as soon as possible after exposure, ideally within 24 hours 2
   • Can still be beneficial even months after exposure if administered before symptom onset 2

2. Serologic Testing:

   • Not routinely necessary for healthy individuals completing PEP 1, 2
   • Recommended for immunocompromised patients to confirm adequate antibody response 2

3. Common Pitfalls to Avoid:

   • Delayed initiation of PEP
   • Improper wound cleansing
   • Failure to infiltrate wounds properly with RIG
   • Administering vaccine in gluteal area (reduces effectiveness)
   • Administering RIG to previously vaccinated individuals
   • Using incorrect dosing schedule for patient's immunization status

4. Consultation:

   • Consult public health officials for exposures to uncommon species, when the animal has escaped, or for any questions about the need for rabies prophylaxis 2

The 4-dose PEP regimen replaced the previous 5-dose regimen based on evidence that 4 vaccine doses in combination with RIG elicit adequate immune responses and that a fifth dose does not contribute to more favorable outcomes 1, 5, 6. This reduced schedule decreases healthcare burden while maintaining nearly 100% effectiveness in preventing this otherwise fatal disease 2, 4.