What are the World Health Organization (WHO) guidelines for rabies vaccination?

WHO Guidelines for Rabies Vaccination

The World Health Organization (WHO) recommends a 4-dose rabies vaccine schedule for post-exposure prophylaxis (PEP) in previously unvaccinated persons, with doses administered on days 0,3,7, and 14, along with rabies immunoglobulin (RIG) infiltrated at the wound site for optimal protection against this fatal disease. 1

Post-Exposure Prophylaxis Components

Post-exposure prophylaxis consists of three essential components:

• Immediate and thorough wound cleansing with soap and water for at least 15 minutes, followed by application of a virucidal agent such as povidone-iodine solution 1, 2
• Administration of rabies immunoglobulin (RIG) for previously unvaccinated individuals 1
• Administration of rabies vaccine according to the appropriate schedule 1

Vaccination Schedules

For Previously Unvaccinated Persons:

• Wound cleansing: Immediate thorough cleansing with soap and water, plus povidone-iodine solution if available 1
• Human Rabies Immunoglobulin (HRIG): 20 IU/kg body weight, with the full dose infiltrated around and into the wound(s) if anatomically feasible, and any remaining volume administered intramuscularly at a site distant from vaccine administration 1
• Vaccine: Human Diploid Cell Vaccine (HDCV) or Purified Chick Embryo Cell Vaccine (PCECV), 1.0 mL, intramuscular (deltoid area), one dose each on days 0,3,7, and 14 1

For Previously Vaccinated Persons:

• Wound cleansing: Same as above 1
• HRIG: Not required 1
• Vaccine: HDCV or PCECV, 1.0 mL, intramuscular (deltoid area), one dose each on days 0 and 3 only 1

Special Considerations:

• For immunosuppressed patients, a 5-dose schedule is still recommended (days 0,3,7,14, and 28) 1
• The deltoid area is the only acceptable site for vaccination in adults and older children; for younger children, the anterolateral thigh may be used 1
• Vaccine should never be administered in the gluteal area as this may result in diminished immune response 1

Rabies Immunoglobulin Administration

• HRIG is administered only once at the beginning of PEP to provide immediate antibodies until the patient develops their own response to the vaccine 1
• If not administered at the start of vaccination, HRIG can be given up to day 7 of the PEP series 1
• Beyond day 7, HRIG is not indicated as an antibody response to the vaccine is presumed to have occurred 1
• The full dose of HRIG should be infiltrated around and into all wounds; any remaining volume should be injected intramuscularly at a site distant from vaccine administration 3
• HRIG should never be administered in the same syringe or anatomical site as the vaccine 1

Important Considerations

• PEP should begin immediately after exposure, regardless of the time interval between exposure and initiation of treatment 1
• Even with delayed recognition of exposure, PEP is indicated as incubation periods of greater than 1 year have been reported 1
• The intradermal 1-week vaccination regimen recommended by WHO carries important cost-, dose-, and time-sparing benefits compared to older regimens 2
• Clear doctor-patient communication is essential throughout the PEP process to increase compliance and avoid dangerous misconceptions about animal bite treatment and rabies risk 2

Historical Context

• The WHO previously recommended a 6-dose vaccine schedule over 90 days (in 1977) 1
• This was later updated to a 5-dose schedule over 28 days 1
• In 2010, based on evidence of efficacy and safety, the schedule was reduced to 4 doses over 14 days for immunocompetent individuals 1, 4
• The reduction from 5 to 4 doses provides cost savings while maintaining efficacy 1

Remember that rabies is nearly 100% fatal once symptoms appear, making proper and timely administration of PEP critical for preventing death in exposed individuals 3.