Who do not require Rabies Immunoglobulin (RIG)?

Rabies Immunoglobulin (RIG) Administration: Who Does Not Require It

Rabies Immunoglobulin (RIG) should NOT be administered to previously vaccinated persons, as it may inhibit the strength or rapidity of the expected anamnestic response. 1

Definition of Previously Vaccinated Persons

Previously vaccinated persons are defined as those who have:

• Received one of the ACIP-recommended pre-exposure or post-exposure prophylaxis regimens with cell-culture vaccines 2
• Received another vaccine regimen (or vaccines other than cell-culture vaccine) and have documented adequate rabies virus-neutralizing antibody response 2

Post-Exposure Prophylaxis for Previously Vaccinated Persons

For individuals previously vaccinated against rabies who experience a new exposure:

• They should receive 2 vaccine doses (1.0 mL each in the deltoid area)
  • First dose: immediately upon presentation
  • Second dose: 3 days after the first dose 2, 1
• RIG should NOT be administered 2, 1
• Local wound care remains essential 2

Rationale for Withholding RIG in Previously Vaccinated Persons

The Advisory Committee on Immunization Practices (ACIP) recommends against RIG administration in previously vaccinated individuals because:

• Previously vaccinated persons are already immunologically primed against rabies 2
• Administration of passive antibody (RIG) might inhibit the relative strength or rapidity of the expected anamnestic response 2, 1
• For previously vaccinated persons exposed to rabies, determining the rabies virus neutralizing antibody titer for decision-making about prophylaxis is inappropriate for several reasons:
  • Several days will be required to collect serum and determine test results
  • No definitive "protective" titer is known
  • Other immune effectors beyond neutralizing antibodies are operative in disease prevention 2

Other Considerations for RIG Administration

RIG is indicated for:

• Previously unvaccinated persons with rabies exposures 3
• Should be administered with the first dose of vaccine (day 0) or up to 7 days after the first vaccine dose 1, 3
• Should not be administered beyond 7 days after the first vaccine dose, as excessive dosage can partially suppress active antibody production 1

Special Populations

• Immunocompromised patients require special management, including consultation with public health officials 1
• Pregnancy is not a contraindication to post-exposure prophylaxis 1
• Corticosteroids and other immunosuppressive agents can interfere with vaccine response and should not be administered during post-exposure prophylaxis unless essential 1

Wound Management

Even for previously vaccinated persons who do not require RIG, thorough wound cleansing remains crucial:

• Immediate and thorough washing with soap and water for at least 15 minutes 1, 3
• Use of virucidal agents to irrigate wounds if available 1
• Tetanus prophylaxis and measures to control bacterial infection as indicated 3

Remember that post-exposure prophylaxis for rabies is virtually 100% effective in preventing rabies when given promptly and appropriately 1. The key is to properly identify those who truly need RIG versus those who are already protected through previous vaccination.