What is the protocol for anti-rabies (Rabies) vaccination?

Anti-Rabies Vaccination Protocol

For previously unvaccinated individuals exposed to rabies, administer a 4-dose vaccine regimen on days 0,3,7, and 14, combined with rabies immune globulin (RIG) at 20 IU/kg body weight on day 0, along with immediate thorough wound cleansing. 1, 2

Immediate Wound Management

• Wash all wounds thoroughly with soap and water for 15 minutes immediately after exposure 2, 3, 4
• Apply a virucidal agent such as povidone-iodine solution to irrigate wounds if available 3, 5
• This local wound treatment is perhaps the most effective single measure for preventing rabies and should be performed before any other intervention 2, 5

Post-Exposure Prophylaxis for Previously Unvaccinated Persons

Rabies Immune Globulin (RIG) Administration

• Administer 20 IU/kg body weight on day 0 (the day the first vaccine dose is given) 1, 2, 3
• If anatomically feasible, infiltrate the full dose around and into all wounds 1, 3
• Any remaining volume should be administered intramuscularly at a site distant from vaccine administration 1, 3
• RIG can be given up to and including day 7 of the vaccine series if not administered initially 1, 2, 3
• Never administer RIG in the same syringe or anatomical site as the vaccine 1, 3
• Do not exceed the recommended dose as this may suppress active antibody production 2, 3

Vaccine Schedule

• Administer 4 doses of 1.0 mL each on days 0,3,7, and 14 1, 2
• Use human diploid cell vaccine (HDCV) or purified chick embryo cell vaccine (PCECV) 1, 2
• Day 0 is defined as the day the first dose is administered, not necessarily the day of exposure 2

Injection Sites

• Adults and older children: deltoid muscle only 2, 3, 5
• Young children: anterolateral thigh 2, 3, 5
• Never use the gluteal area as this produces inadequate antibody response 2, 3, 5

Post-Exposure Prophylaxis for Previously Vaccinated Persons

Previously vaccinated individuals require only 2 vaccine doses (days 0 and 3) and do NOT need RIG. 1

• This applies to persons who previously received complete pre- or post-exposure prophylaxis with cell-culture vaccines 1
• RIG should not be administered to previously vaccinated persons as it may inhibit the anamnestic response 1
• Wound cleansing remains essential 1

Special Population: Immunocompromised Patients

Immunosuppressed individuals require a 5-dose vaccine regimen (days 0,3,7,14, and 28) plus RIG. 1

• This includes patients on corticosteroids, other immunosuppressive agents, or those with immunosuppressive illnesses 1
• Immunosuppressive agents should not be administered during PEP unless essential for other conditions 1
• Serologic testing should be performed 1-2 weeks after the final dose to confirm adequate antibody response 1, 2
• Adequate response is defined as complete virus neutralization at a 1:5 serum dilution by RFFIT 1

Pre-Exposure Prophylaxis

For individuals at risk before exposure, administer 3 doses of vaccine on days 0,7, and 21 or 28. 1, 5

• Recommended for rabies researchers, laboratory workers, veterinarians, animal handlers, cavers, and travelers to rabies-endemic areas 5
• Same injection sites as post-exposure: deltoid for adults/older children, anterolateral thigh for young children 5
• No RIG is administered for pre-exposure prophylaxis 5

Timing and Compliance Considerations

• Initiate PEP as soon as possible after exposure, ideally within 24 hours 2
• However, there is no absolute cutoff beyond which PEP should be withheld—treatment should begin immediately upon recognition of exposure, even if weeks or months have elapsed 2
• Delays of a few days for individual vaccine doses are unimportant 2, 6
• For substantial schedule deviations, assess immune status by serologic testing 7-14 days after the final dose 2, 6
• Most interruptions do not require restarting the entire series—simply administer the missed dose and resume the schedule 6

Critical Pitfalls to Avoid

• Never administer vaccine in the gluteal area (inadequate immune response) 2, 3, 5
• Never give RIG and vaccine in the same syringe or anatomical site 1, 3
• Never exceed the recommended RIG dose (may suppress antibody production) 2, 3
• Never administer RIG to previously vaccinated persons (inhibits anamnestic response) 1
• Never delay treatment waiting for animal testing results—begin immediately and discontinue only if testing proves the animal was not rabid 3, 5

Serologic Testing

• Routine testing after PEP is not necessary for healthy immunocompetent individuals 1
• Testing is indicated for immunosuppressed patients to confirm adequate response 1, 2
• When performed, testing should occur 1-2 weeks after the final vaccine dose 1
• Adequate titer is ≥0.5 IU/mL or complete neutralization at 1:5 dilution by RFFIT 1, 5

Human rabies is nearly 100% fatal once clinical symptoms develop, making proper PEP administration critical. 2, 7 When administered promptly and correctly, this protocol is highly effective in preventing rabies. 1, 2