What are the recommendations for post-exposure prophylaxis (PEP) and vaccinating against rabies after a dog bite from a stray animal?

Rabies Post-Exposure Prophylaxis for Stray Dog Bites

For a stray dog bite, immediately begin rabies post-exposure prophylaxis (PEP) with both rabies immune globulin (RIG) and vaccine, unless the animal can be captured and observed for 10 days or euthanized immediately for rabies testing. 1, 2, 3

Immediate Wound Management (All Cases)

• Thoroughly wash and flush all bite wounds with soap and water for approximately 15 minutes immediately after the bite 1, 2, 3
• Apply a virucidal agent such as povidone-iodine solution to the wound 1, 2, 3
• Administer tetanus prophylaxis and antibiotics as indicated for bacterial infection control 1, 2, 3
• Wound cleansing alone can markedly reduce the likelihood of rabies transmission 1

Decision Algorithm for Stray Dog Bites

Option 1: Animal Available for Testing or Observation

• If the stray dog can be captured, either confine and observe for 10 days OR euthanize immediately and submit the head for rabies testing 1
• Do not begin PEP if the dog remains healthy throughout the 10-day observation period 1, 2, 3
• Dogs that remain alive and healthy for 10 days after biting would not have been shedding rabies virus at the time of the bite 1, 4
• Begin PEP immediately at the first sign of illness in the confined animal during observation 2, 3
• If rabies testing is negative, discontinue PEP 2, 3

Option 2: Animal Unavailable (Escaped or Cannot Be Captured)

• Immediately initiate rabies PEP without waiting 1, 2, 3
• Consult local public health officials for guidance on regional rabies epidemiology 2, 3

Rabies Post-Exposure Prophylaxis Protocol

For Previously Unvaccinated Persons:

• Administer rabies immune globulin (RIG) 20 IU/kg body weight on day 0 1, 2
• Infiltrate the full dose of RIG thoroughly into and around the wound if anatomically feasible 1
• Inject any remaining RIG volume intramuscularly at a site distant from vaccine administration 1
• Never administer RIG in the same syringe or anatomical site as the vaccine 1
• Administer rabies vaccine on days 0,3,7,14, and 28 1, 5, 2, 3
• RIG can be given up to 7 days after the first vaccine dose if not administered initially 1

For Previously Vaccinated Persons:

• Administer vaccine only (no RIG needed) if the person has completed a prior rabies vaccination series with documented antibody response 1, 2, 3

Risk Assessment Factors

High-Risk Indicators for Rabies:

• Unprovoked attacks are more likely to indicate rabies than provoked attacks 1
• Regional epidemiology matters: in the United States, rabies in dogs is most common along the US-Mexico border and in areas with enzootic wildlife rabies 1, 5
• In most of Asia, Africa, and Latin America, dogs remain the major source of human rabies exposure 5, 6
• Stray or unwanted dogs carry higher risk than owned, vaccinated dogs 1

Critical Timing Considerations

• Rabies PEP is a medical urgency, not an emergency, but should not be delayed once exposure is confirmed 4
• Begin PEP immediately for stray dog bites when the animal cannot be observed or tested 1, 2, 3
• Incubation periods exceeding 1 year have been reported, so PEP is indicated regardless of delay if clinical rabies signs are absent 1

Common Pitfalls to Avoid

• Do not delay PEP initiation while attempting to locate an escaped stray dog 1
• Do not assume a dog is not rabid based solely on appearance; healthy-appearing dogs can be in early stages of rabies 1
• Inadequate wound cleansing increases transmission risk; thorough washing is essential 1, 5
• Failing to infiltrate RIG into the wound site reduces effectiveness 1
• Do not withhold PEP based on vaccination status of the biting animal alone if the animal is unavailable for observation 1

Special Circumstances

• Dogs account for >99% of human rabies cases globally, making stray dog bites particularly high-risk 6
• Once clinical rabies develops, it is almost certainly fatal, making prevention through PEP critical 6, 7
• The 10-day observation period is reliable only for healthy domestic dogs, cats, and ferrets—not for other animals 1