What is the recommended rabies vaccination schedule for post-exposure prophylaxis?

Rabies Post-Exposure Prophylaxis Vaccination Schedule

The recommended rabies post-exposure prophylaxis (PEP) for previously unvaccinated individuals consists of 4 doses of rabies vaccine administered intramuscularly on days 0,3,7, and 14, along with human rabies immune globulin (HRIG) at the initial visit. 1

Components of Rabies PEP

Wound Care

• All PEP should begin with immediate thorough cleansing of all wounds with soap and water for 15 minutes 1, 2
• If available, a virucidal agent (e.g., povidone-iodine solution) should be used to irrigate the wounds 1, 3

Human Rabies Immune Globulin (HRIG)

• Administer 20 IU/kg body weight at the beginning of PEP for previously unvaccinated individuals 1, 3
• If anatomically feasible, infiltrate the full dose around and into the wound(s) 1, 3
• Any remaining volume should be administered intramuscularly at a site distant from vaccine administration 1, 3
• HRIG should not be administered in the same syringe as vaccine 1, 3
• If not administered on day 0, HRIG can be given up to and including day 7 of the PEP series 1, 4
• Beyond day 7, HRIG is not indicated as antibody response to the vaccine is presumed to have occurred 4, 5

Vaccination Schedule for Previously Unvaccinated Persons

• Human Diploid Cell Vaccine (HDCV) or Purified Chick Embryo Cell Vaccine (PCECV), 1.0 mL per dose 1
• Administer intramuscularly in the deltoid area for adults and older children (anterolateral thigh for younger children) 1, 2
• Schedule: one dose each on days 0,3,7, and 14 1
• Day 0 is the day the first dose of vaccine is administered 1
• The gluteal area should never be used for vaccine administration as it may result in diminished immune response 1, 2

Special Considerations

For Immunocompromised Patients

• A 5-dose schedule is recommended (days 0,3,7,14, and 28) 1, 2
• HRIG administration remains the same as for immunocompetent individuals 1

For Previously Vaccinated Persons

• Only 2 doses of vaccine are required (days 0 and 3) 1
• HRIG should not be administered 1
• Previously vaccinated persons are those who have received a complete pre-exposure or post-exposure prophylaxis regimen with cell-culture vaccine, or have a documented adequate rabies virus-neutralizing antibody titer 1, 6

Handling Missed Doses

• If a patient misses a scheduled dose, administer the missed dose immediately when they present for care 4
• Resume the vaccination schedule from that point, maintaining the same interval between subsequent doses 4
• For substantial deviations from the schedule, immune status should be assessed by performing serologic testing 7-14 days after administration of the final dose 4

Important Clinical Considerations

• PEP should be initiated as soon as possible after exposure, regardless of the time interval between exposure and initiation of treatment 2, 6
• When administered promptly and appropriately, PEP is nearly 100% effective in preventing human rabies 2, 7
• The current 4-dose schedule replaced the previous 5-dose schedule based on evidence that 4 vaccine doses in combination with HRIG elicited adequate immune responses 1, 7
• This reduction from 5 to 4 doses provides cost savings while maintaining efficacy 1, 8

Common Pitfalls to Avoid

• Never administer rabies vaccine in the gluteal area as this may result in lower neutralizing antibody titers 1, 2
• Do not administer HRIG and vaccine in the same syringe or at the same anatomical site 1, 3
• Do not exceed the recommended HRIG dose as it might partially suppress active production of rabies virus antibody 1
• Never delay initiation of PEP while waiting for laboratory results if rabies exposure is suspected 3, 5