What is the protocol for administering the anti-rabies (rabies) vaccine, including post-exposure prophylaxis and pre-exposure prophylaxis?

Anti-Rabies Vaccine Protocol

The current CDC-recommended protocol for rabies post-exposure prophylaxis (PEP) consists of thorough wound cleansing, administration of rabies immune globulin (20 IU/kg) infiltrated around the wound, and a 4-dose vaccine regimen administered intramuscularly on days 0,3,7, and 14. 1

Post-Exposure Prophylaxis (PEP)

Immediate Wound Care

• Thoroughly wash all wounds with soap and water for at least 15 minutes 2
• Apply a virucidal agent such as povidone-iodine solution if available 1, 3
• Evaluate need for tetanus prophylaxis and antibiotics for bacterial infection 3

Risk Assessment

Evaluate the following factors:

1. Animal species involved: Dogs, cats, bats, skunks, foxes, raccoons, and other carnivores are high-risk species 3
2. Circumstances of bite: Unprovoked attacks are more likely to indicate rabid animals 4
3. Type of exposure:
   • Bite: Any penetration of skin by teeth
   • Nonbite: Scratches, abrasions, or mucous membranes contaminated with saliva 3
4. Vaccination status of animal: Properly vaccinated animals have minimal chance of transmitting rabies 3

PEP Administration for Previously Unvaccinated Persons

1. Human Rabies Immune Globulin (HRIG):

   • Administer 20 IU/kg body weight at first vaccine dose or within 7 days of first dose 1, 3
   • Infiltrate full dose thoroughly around and into all wounds
   • Inject any remaining volume IM at a site distant from vaccine administration 1
   • Never administer HRIG in same syringe or anatomical site as vaccine 3

2. Vaccine Administration:

   • Administer 1.0 mL IM in deltoid muscle (never in gluteal area) 1
   • 4-dose regimen: Days 0,3,7, and 14 1
   • For immunocompromised patients: 5-dose regimen on days 0,3,7,14, and 28 1

PEP for Previously Vaccinated Persons

• Only 2 doses of vaccine (1.0 mL each) administered IM on days 0 and 3 1, 3
• No HRIG administration necessary 1, 3

Pre-Exposure Prophylaxis (PrEP)

Indications

• Laboratory workers handling rabies virus
• Veterinarians and staff
• Animal control officers
• Wildlife officers in endemic areas
• Spelunkers
• Travelers to rabies-endemic areas staying longer than 1 month 1, 5

Administration

• 3-dose regimen: 1.0 mL IM on days 0,7, and 21 or 28 1
• For those on antimalarial medications, IM administration is preferred over intradermal 4

Booster Doses

• High-risk individuals (lab workers): Check antibody titers every 6 months 4
• Frequent-risk individuals (veterinarians, animal control): Check titers every 2 years 4
• Booster dose if titer falls below complete neutralization at 1:5 serum dilution 4

Important Considerations

Timing

• Begin PEP as soon as possible after exposure (ideally within 24 hours)
• PEP should be administered regardless of time elapsed since exposure, even months later, as long as clinical signs of rabies are not present 1

Special Populations

• Pregnancy is not a contraindication to PEP 1
• Corticosteroids and immunosuppressive agents may interfere with vaccine response 1
• Immunocompromised patients should receive the 5-dose regimen and have antibody titers checked 1

Common Pitfalls to Avoid

1. Administering vaccine in gluteal area (leads to lower antibody titers)
2. Failing to thoroughly infiltrate HRIG around all wounds
3. Administering HRIG and vaccine at same anatomical site
4. Delaying PEP while waiting for animal testing results
5. Neglecting proper wound cleansing, which alone can significantly reduce rabies risk 4, 1, 3

When in doubt about the need for PEP, consult with local or state public health officials for guidance on specific cases 1, 3.