What are the IAP (Indian Academy of Pediatrics) guidelines for rabies vaccine administration?

IAP Guidelines for Rabies Vaccine Administration

The Indian Academy of Pediatrics (IAP) follows the World Health Organization's recommendation of 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

Components of Rabies Post-Exposure Prophylaxis

Wound Management

• Immediate and thorough washing of all bite wounds and scratches with soap and water for 15 minutes, followed by irrigation with a virucidal agent such as povidone-iodine solution 2, 3
• Thorough wound cleansing alone has been shown to markedly reduce the likelihood of rabies 2
• Tetanus prophylaxis and measures to control bacterial infection should also be administered as indicated 2

Rabies Immunoglobulin (RIG) Administration

• For previously unvaccinated individuals, administer 20 IU/kg body weight of Human Rabies Immunoglobulin (HRIG) 1, 4
• The full dose of RIG should be thoroughly infiltrated in and around all wounds if anatomically feasible 2
• Any remaining volume should be injected intramuscularly at a site distant from vaccine administration 2, 4
• RIG is administered only once at the beginning of PEP to provide immediate antibodies 2
• If RIG was not administered when vaccination began, it can be administered through the seventh day after the first dose of vaccine 2, 4
• RIG should never be administered in the same syringe or at the same anatomical site as the vaccine 2, 4

Vaccination Schedule

• For previously unvaccinated persons: 4 doses of 1 mL of Human Diploid Cell Vaccine (HDCV) or Purified Chick Embryo Cell Vaccine (PCECV) administered intramuscularly on days 0,3,7, and 14 2, 1
• For immunocompromised patients: 5 doses on days 0,3,7,14, and 28 2, 5
• For previously vaccinated persons: 2 doses on days 0 and 3 only, with no RIG required 2, 5

Administration Technique

• For adults and older children, vaccines should always be administered intramuscularly in the deltoid area 2
• For younger children, the anterolateral aspect of the thigh is also acceptable 2
• The gluteal area should never be used for vaccine injections as this may result in lower neutralizing antibody titers 2, 5
• Children should receive the same vaccine dose (i.e., vaccine volume) as recommended for adults 2

Special 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 5
• Failure to thoroughly infiltrate RIG around all wounds has been associated with rare PEP failures 4
• Using more than the recommended dose of RIG may suppress active antibody production 4

Historical Context

• The WHO previously recommended a 6-dose vaccine schedule over 90 days (in 1977), which was later updated to a 5-dose schedule over 28 days, and finally to the current 4-dose schedule over 14 days for immunocompetent individuals 1
• The reduction from 5 to 4 doses provides cost savings while maintaining efficacy 1, 6
• The 1-week, 2-site intradermal PEP schedule has been found to be advantageous in some settings, as it is safe, immunogenic, and involves the least direct costs compared to other schedules 7

The 4-dose vaccine regimen, when administered correctly along with proper wound care and RIG, has been shown to be safe and effective in preventing human rabies in exposed patients 6.