What are the guidelines for post-exposure rabies (Rabies) vaccination?

Rabies Post-Exposure Prophylaxis Guidelines

Immediate Wound Management

All persons with potential rabies exposure should immediately wash the wound thoroughly with soap and water for approximately 15 minutes, followed by application of a virucidal agent such as povidone-iodine solution if available. 1, 2

• Thorough wound cleansing alone has been shown in animal studies to markedly reduce the likelihood of rabies transmission 1
• Tetanus prophylaxis should be administered as indicated based on immunization status 1, 3
• Avoid suturing wounds when possible to allow drainage 1

Post-Exposure Prophylaxis Regimen for Previously Unvaccinated Persons

For individuals never previously vaccinated against rabies, administer both rabies immune globulin (RIG) and a 4-dose vaccine series on days 0,3,7, and 14. 2, 4

Rabies Immune Globulin (RIG) Administration

• Administer 20 IU/kg body weight of human rabies immune globulin (HRIG) once at the beginning of prophylaxis 1, 2
• If anatomically feasible, infiltrate the full dose thoroughly in and around all wounds 1
• Inject any remaining volume intramuscularly at a site distant from vaccine administration 1
• Never administer RIG in the same syringe or at the same anatomical site as the vaccine 1, 2
• If RIG was not given on day 0, it can still be administered up to and including day 7 of the vaccine series 1
• Beyond day 7, RIG is not indicated as antibody response to vaccine is presumed to have occurred 1

Vaccine Administration

• Administer 1.0 mL doses of HDCV (human diploid cell vaccine) or PCECV (purified chick embryo cell vaccine) intramuscularly on days 0,3,7, and 14 2, 4
• For adults and older children, always inject in the deltoid muscle; for young children, the anterolateral thigh is acceptable 1, 4
• Never administer vaccine in the gluteal area as this results in lower neutralizing antibody titers 1, 4

Post-Exposure Prophylaxis for Previously Vaccinated Persons

Individuals who have previously received a complete pre-exposure or post-exposure vaccination series with a cell culture vaccine should receive only vaccine (no RIG) on days 0 and 3. 1, 4

• RIG is unnecessary and should not be given to previously vaccinated persons as it may inhibit the anamnestic immune response 1
• This applies to persons who completed recommended regimens with HDCV, PCECV, or RVA, or who have documented rabies virus neutralizing antibody titers 1

Special Populations

Immunocompromised Patients

For immunosuppressed individuals, administer a 5-dose vaccine schedule on days 0,3,7,14, and 28 (in addition to RIG if previously unvaccinated). 2, 4

• Serologic testing should be performed 7-14 days after the final dose to document adequate antibody response 1

Timing and Schedule Deviations

Post-exposure prophylaxis should be initiated as soon as possible after exposure, but is indicated regardless of the time interval between exposure and treatment initiation, provided clinical signs of rabies are not present. 1, 2, 4

• Incubation periods exceeding 1 year have been documented in humans 1
• Minor delays of a few days for individual doses are acceptable 1
• For substantial deviations, resume the schedule maintaining the same intervals between doses 1
• When major interruptions occur, assess immune status by serologic testing 7-14 days after the final dose 1

Risk Assessment for Prophylaxis Initiation

High-Risk Exposures Requiring Immediate Prophylaxis

• Any bite or scratch from bats should be considered a rabies exposure and prophylaxis initiated immediately 3
• Bites from wild carnivores (raccoons, skunks, foxes) should be regarded as rabid unless proven negative by laboratory testing 3, 5
• Any physical contact with bats when bite, scratch, or mucous membrane contact cannot be excluded 3

Domestic Animals (Dogs, Cats, Ferrets)

• If the animal is healthy and available for 10-day observation, do not begin prophylaxis unless the animal develops clinical signs of rabies 3, 5
• If the animal is rabid or suspected rabid, begin prophylaxis immediately 3, 5
• If the animal escapes or is unavailable, consult public health officials 3, 5

Low-Risk Exposures

• Bites from small rodents (squirrels, hamsters, guinea pigs, gerbils, chipmunks, rats, mice), rabbits, and hares almost never require prophylaxis 3, 5
• Indirect contact (petting, handling, contact with blood/urine/feces, or saliva on intact skin) does not constitute exposure 3

Critical Pitfalls to Avoid

The most common failures of post-exposure prophylaxis result from insufficient infiltration of RIG around all wound sites. 1, 2

• Do not exceed the recommended 20 IU/kg dose of RIG, as higher doses can suppress active antibody production 1
• Never use the gluteal area for vaccine administration 1, 4
• Do not delay prophylaxis to observe animals other than healthy domestic dogs, cats, or ferrets 3, 5
• Ensure complete wound cleansing is performed before biologics administration 1, 2

Historical Context and Evidence Quality

The current 4-dose regimen (days 0,3,7,14) represents an evolution from the WHO's original 6-dose schedule over 90 days (1977), later reduced to 5 doses over 28 days, and finally to the current 4-dose schedule for immunocompetent individuals 2, 4. This reduction maintains efficacy while providing significant cost savings to the healthcare system 2, 4. The 5-dose regimen remains standard for immunocompromised patients 2, 4.