What is the recommended protocol for rabies (Rabies virus) vaccination and post-exposure prophylaxis?

Rabies Vaccination and Post-Exposure Prophylaxis Protocol

For previously unvaccinated individuals exposed to rabies, immediately administer a 4-dose vaccine series (days 0,3,7, and 14) plus human rabies immune globulin (HRIG) at 20 IU/kg body weight, with the full HRIG dose infiltrated into and around the wound site if anatomically feasible. 1, 2

Immediate Wound Management

• Wash all bite wounds and scratches thoroughly with soap and water for 15 minutes immediately after exposure—this is perhaps the most effective single measure for preventing rabies. 3, 2, 4
• Apply a virucidal agent (such as povidone-iodine solution) to the wound after washing if available. 2, 5
• Avoid suturing wounds when possible to allow drainage. 3
• Administer tetanus prophylaxis and antibiotics as clinically indicated. 6, 5

Post-Exposure Prophylaxis for Previously Unvaccinated Persons

Vaccine Administration

• Administer 4 doses of human diploid cell vaccine (HDCV) or purified chick embryo cell vaccine (PCECV) at 1.0 mL per dose intramuscularly on days 0,3,7, and 14. 1, 2
• Day 0 is defined as the day the first dose is given, not necessarily the day of exposure. 2
• Inject vaccine in the deltoid muscle for adults and older children; use the anterolateral thigh for young children. 1, 2
• Never administer vaccine in the gluteal area—this produces inadequate antibody response. 1, 2

HRIG Administration

• Administer HRIG at 20 IU/kg body weight on day 0, infiltrating the full dose around and into all wounds if anatomically feasible. 3, 2, 6
• Any remaining HRIG volume after wound infiltration should be injected intramuscularly at a site distant from vaccine administration. 2, 6
• HRIG can be administered up to and including day 7 of the vaccine series if not given initially, but is not indicated beyond day 7. 3, 1, 2
• Never administer HRIG in the same syringe or anatomical site as the vaccine. 1, 2
• Do not exceed the recommended 20 IU/kg dose, as excess HRIG can suppress active antibody production. 3

Post-Exposure Prophylaxis for Previously Vaccinated Persons

• Previously vaccinated individuals require only 2 doses of vaccine (days 0 and 3) and do NOT need HRIG. 3, 1, 2
• This simplified regimen applies to anyone who has completed a full pre-exposure or post-exposure vaccination series with cell culture vaccine, or who has documented rabies virus neutralizing antibody titer. 3
• HRIG should not be given to previously vaccinated persons as it may inhibit the anamnestic immune response. 3

Special Populations

Immunocompromised Patients

• Immunocompromised individuals require the full 5-dose vaccine regimen (days 0,3,7,14, and 28) plus HRIG. 1, 2
• Serologic testing 2-4 weeks after completion is recommended to confirm adequate antibody response in immunosuppressed patients. 3

Pediatric Patients

• The same 4-dose schedule applies to children of all ages. 2
• Use the anterolateral thigh for vaccine injection in young children. 1, 2

Timing Considerations

• Begin PEP immediately after exposure recognition, regardless of time elapsed since exposure—there is no absolute cutoff beyond which prophylaxis should be withheld. 2, 7
• Even delays of hours matter significantly given rabies is nearly 100% fatal once clinical symptoms develop. 2, 7
• PEP has been successfully initiated many months after exposure when recognition was delayed. 2
• Delays of a few days for individual vaccine doses are unimportant, though longer lapses require serologic testing 7-14 days after the final dose. 2

Discontinuation Criteria

• Discontinue PEP if laboratory testing (direct fluorescent antibody test) confirms the exposing animal was not rabid. 3, 6, 5

Pre-Exposure Prophylaxis

• Pre-exposure vaccination consists of 3 doses of rabies vaccine on days 0,7, and 21 or 28. 8, 9
• Recommended for high-risk individuals including laboratory workers handling rabies virus, veterinarians, animal control workers, cavers, and travelers to rabies-endemic areas with limited access to medical care. 3, 5, 9
• Continuous-risk workers (rabies researchers, biologics production workers) require serologic testing every 6 months with booster doses if titers fall below protective levels. 3, 5
• Frequent-risk workers (diagnostic lab workers, veterinarians, wildlife officers) require serologic testing every 2 years. 3, 5

Critical Pitfalls to Avoid

• Never delay PEP initiation while awaiting animal testing results—begin immediately and discontinue only if testing proves negative. 6, 5
• Do not withhold PEP based on time elapsed since exposure, as incubation periods exceeding 1 year have been documented. 1, 2
• Never use the gluteal area for vaccine administration. 1, 2
• Do not exceed the recommended HRIG dose of 20 IU/kg. 3, 2
• Do not administer HRIG after day 7 of the vaccine series. 3, 1, 2

Exposure Risk Assessment

• Bites from dogs, cats, skunks, raccoons, foxes, coyotes, bats, and other carnivores warrant immediate PEP unless the animal can be observed or tested. 6, 5
• For healthy dogs and cats available for 10-day observation, withhold PEP unless the animal develops rabies signs during observation. 6, 5
• Any physical contact with bats warrants PEP when bite or mucous membrane contact cannot be excluded, as bat bites may be undetectable. 6
• Bites from squirrels, hamsters, guinea pigs, gerbils, chipmunks, rats, mice, rabbits, and hares almost never require PEP. 6, 5