What is the recommended protocol for rabies vaccination (Human Diploid Cell Vaccine (HDCV) or Purified Duck Embryo Vaccine (PDEV))?

Rabies Vaccination Protocol

For previously unvaccinated persons exposed to rabies, administer both rabies immune globulin (RIG) at 20 IU/kg body weight and a 5-dose intramuscular vaccine series (HDCV or PCECV) on days 0,3,7,14, and 28, with the vaccine administered in the deltoid area for adults. 1, 2

Post-Exposure Prophylaxis for Previously Unvaccinated Persons

Immediate Wound Management

• Thoroughly wash and flush all bite wounds and scratches with soap and copious amounts of water for approximately 15 minutes immediately after exposure 3, 2, 4
• Apply a virucidal agent such as povidone-iodine solution to irrigate the wound if available 1, 5
• Debride devitalized tissue and remove foreign bodies as needed 3

Rabies Immune Globulin Administration

• Administer RIG at 20 IU/kg body weight on day 0 in conjunction with the first vaccine dose 1, 2, 5
• Infiltrate the full calculated dose of RIG into and around all wounds if anatomically feasible; inject any remaining volume intramuscularly at a site distant from vaccine administration 1, 2, 5
• RIG can be administered through day 7 after the first vaccine dose if not given initially, but beyond day 7 it is not indicated as antibody response to vaccine is presumed to have occurred 1, 5
• Never administer RIG in the same syringe or anatomical site as the vaccine 1, 6, 5
• Do not exceed the recommended dose, as RIG can partially suppress active antibody production 1, 5

Vaccine Administration Schedule

• Administer five 1.0-mL doses of HDCV or PCECV intramuscularly on days 0,3,7,14, and 28 1, 2
• For adults and older children, inject vaccine in the deltoid area only; for younger children, the anterolateral thigh is acceptable 1, 6, 2
• Never administer vaccine in the gluteal area, as this results in lower neutralizing antibody titers 1, 6, 2
• Begin the first dose as soon as possible after exposure (day 0) 1, 2

Post-Exposure Prophylaxis for Previously Vaccinated Persons

Previously vaccinated persons require only 2 doses of vaccine (1.0 mL each) administered intramuscularly on days 0 and 3, with no RIG administration. 1, 2

• This simplified regimen applies to persons who have received complete pre-exposure or post-exposure vaccination with a cell culture vaccine, or who have documented rabies virus neutralizing antibody titers 1
• RIG should not be administered to previously vaccinated persons, as passive antibody might inhibit the anamnestic response 1
• Local wound care remains essential even for previously vaccinated persons 1

Pre-Exposure Prophylaxis

Primary Vaccination Schedule

• Administer three 1.0-mL injections of HDCV or PCECV intramuscularly in the deltoid area on days 0,7, and 21 or 28 1, 2
• Pre-exposure prophylaxis is recommended for high-risk groups including veterinarians and staff, animal handlers, rabies researchers, laboratory workers, cavers, and international travelers to rabies-endemic areas with limited access to medical care 1, 2

Booster Dose Recommendations by Risk Category

• Continuous risk category (rabies research laboratory workers, vaccine production workers): Check antibody titers every 6 months and administer booster if titer falls below complete neutralization at 1:5 serum dilution 1, 2
• Frequent risk category (diagnostic laboratory workers, cavers, veterinarians, animal control officers in enzootic areas, bat handlers): Check titers every 2 years and administer booster if inadequate 1, 2
• Infrequent risk category (veterinarians in low-enzootic areas, travelers): No routine serologic testing or booster vaccination required 1, 2

Available Vaccines in the United States

Human Diploid Cell Vaccine (HDCV)

• Prepared from Pitman-Moore strain of rabies virus grown in MRC-5 human diploid cell culture 1
• Inactivated with betapropiolactone and supplied as lyophilized vaccine reconstituted to 1.0 mL for intramuscular administration 1, 2
• Equally efficacious and safe as other licensed vaccines 1

Purified Chick Embryo Cell Vaccine (PCECV)

• Licensed cell culture vaccine available for both pre-exposure and post-exposure prophylaxis 1
• Administered in same dosing schedule as HDCV 1

Note: Rabies Vaccine Adsorbed (RVA) is no longer available in the United States 1

Special Considerations

Immunosuppressed Patients

• Immunosuppressed persons should postpone pre-exposure vaccination when possible and avoid high-risk activities 1, 2
• When vaccination is necessary, check rabies virus neutralizing antibody titers after completion of the series 1, 2
• For post-exposure prophylaxis in immunosuppressed patients, the standard 5-dose schedule should be used 6
• Routine post-vaccination serologic testing is not recommended for healthy persons but is indicated for immunosuppressed individuals 1

Timing and Efficacy

• Begin post-exposure prophylaxis immediately after exposure, regardless of time interval between exposure and treatment initiation 1, 6, 7
• The combination of local wound treatment, passive immunization with RIG, and active vaccination is uniformly effective when appropriately applied 1, 8
• All healthy persons tested 2-4 weeks after completing prophylaxis per ACIP guidelines demonstrated adequate antibody response 1
• Antibody response requires approximately 7-10 days to develop and usually persists for ≥2 years 1

Common Pitfalls to Avoid

• Failing to infiltrate RIG into and around wounds: The full dose should be infiltrated at wound sites when anatomically feasible, as smaller amounts infiltrated at exposure sites have been associated with rare prophylaxis failures 1
• Administering vaccine in the gluteal area: This results in lower neutralizing antibody titers and should never be done 1, 6, 2
• Giving RIG to previously vaccinated persons: This is unnecessary and may inhibit the anamnestic immune response 1
• Administering RIG and vaccine in the same syringe or anatomical site: These must always be given at separate sites 1, 6, 5
• Exceeding the recommended RIG dose: More than 20 IU/kg can partially suppress active antibody production 1, 5
• Inadequate wound cleaning: Thorough washing with soap and water for 15 minutes is the most important initial step 3, 4
• Discontinuing prophylaxis prematurely: If prophylaxis is initiated and the animal is later proven non-rabid by laboratory testing, treatment can be discontinued; otherwise, complete the full series 2