Rabies Post-Exposure Prophylaxis for Previously Vaccinated Individuals
A patient who completed an antirabies vaccination series last month only needs two doses of rabies vaccine (on days 0 and 3) without rabies immunoglobulin if bitten again, not another full course of vaccination. 1
Post-Exposure Protocol for Previously Vaccinated Individuals
- Previously vaccinated individuals are defined as those who have received one of the recommended pre-exposure or post-exposure regimens of HDCV, PCECV, or RVA, or those who have a documented rabies virus neutralizing antibody titer 2, 1
- For these individuals, post-exposure prophylaxis consists of:
- Thorough wound cleansing with soap and water, and if available, a virucidal agent such as povidone-iodine solution 3
- Two intramuscular doses (1.0 mL each) of rabies vaccine administered in the deltoid muscle 1, 4:
- First dose: immediately upon presentation (day 0)
- Second dose: 3 days after the first dose (day 3)
- Rabies immunoglobulin (RIG) should NOT be administered to previously vaccinated individuals 2, 1, 4
Rationale for Modified Protocol
- Previously vaccinated individuals develop a rapid anamnestic antibody response following booster vaccination, regardless of their pre-booster antibody titer 1, 5
- This robust immune response eliminates the need for rabies immunoglobulin and the full vaccination series 1
- Administration of RIG to previously vaccinated persons is unnecessary and should be avoided because it might inhibit the relative strength or rapidity of the expected anamnestic response 2, 1
- Determining the rabies virus neutralizing antibody titer before administering boosters to previously vaccinated persons is unnecessary and inappropriate, as it would delay treatment 2, 1
Special Considerations
- Immunosuppressed individuals may have suboptimal response to vaccination and require special consideration 1
- For immunosuppressed previously vaccinated individuals, consultation with public health officials is recommended 1
- The two-dose booster regimen is effective regardless of the time elapsed since the previous vaccination, though antibody titers may decline over time 2, 6
- Despite potential decline in antibody levels over time, the anamnestic response in previously vaccinated individuals is still robust enough to protect against rabies when the two-dose booster regimen is administered 1, 5
Common Pitfalls to Avoid
- Administering rabies immunoglobulin to previously vaccinated individuals, which can suppress the anamnestic antibody response 2, 1
- Delaying wound cleansing, which is crucial for reducing rabies virus transmission 3
- Administering vaccine in the gluteal area, which can result in diminished immune response 2
- Waiting for antibody test results before initiating post-exposure prophylaxis, which unnecessarily delays treatment 2, 1
- Restarting a complete vaccination series (5 doses) for previously vaccinated individuals, which is unnecessary and wasteful of resources 1, 4