Rabies Post-Exposure Prophylaxis for Previously Vaccinated Individuals
If you have received a complete rabies vaccination series in the past (either pre-exposure or post-exposure), you need only 2 doses of rabies vaccine on days 0 and 3—no rabies immunoglobulin (HRIG) is required. 1, 2
Immediate Wound Management
Thoroughly wash all wounds with soap and water for approximately 15 minutes as soon as possible after exposure, as wound cleansing alone markedly reduces rabies transmission risk. 1, 3, 2
Apply a virucidal agent such as povidone-iodine solution to the wound site if available. 3, 2
Avoid suturing wounds when possible to prevent deeper viral inoculation. 1, 3
Administer tetanus prophylaxis if indicated based on the patient's immunization history. 3, 4
Consider antibiotic prophylaxis based on wound characteristics and infection risk. 2
Simplified Vaccination Protocol for Previously Vaccinated Persons
The rationale for this simplified approach is that previously vaccinated individuals have immunological memory and mount a rapid anamnestic antibody response. 2 HRIG is actually contraindicated in this population because it can suppress the anamnestic antibody response. 1, 2, 4
Vaccine Administration
Administer 1.0 mL of rabies vaccine (HDCV or PCECV) intramuscularly on day 0 and day 3 only. 1, 2
Inject in the deltoid area for adults and older children (never use the gluteal area, which reduces immunogenicity). 1, 2
For younger children, use the anterolateral aspect of the thigh. 1
What NOT to Do
Do NOT administer HRIG to previously vaccinated persons—this is explicitly contraindicated and may suppress the immune response. 1, 2, 4
Do NOT use the 5-dose schedule intended for unvaccinated persons. 2
Do NOT delay treatment based on time since last vaccination—immunological memory persists even decades after initial vaccination. 2, 5
Definition of "Previously Vaccinated"
You are considered previously vaccinated if you have completed any of the following: 1, 6
- A complete pre-exposure prophylaxis series (3 doses on days 0,7, and 21 or 28)
- A complete post-exposure prophylaxis series with a cell culture vaccine
- Any documented rabies virus neutralizing antibody titer from prior vaccination
Critical Exception: Immunocompromised Patients
If the patient is immunocompromised, they require the full 5-dose vaccine schedule (days 0,3,7,14, and 28) even with prior vaccination history. 3, 2, 6 This includes patients on immunosuppressive therapy, those with HIV/AIDS, or other conditions affecting immune function. 3
Serologic testing should be performed to confirm adequate antibody response in immunocompromised individuals. 2
Timing Considerations
Begin treatment immediately—this is a medical urgency, though not an emergency. 2
Treatment should be initiated regardless of the time interval since exposure, as rabies incubation periods exceeding 1 year have been documented. 2, 4
Even delayed treatment is indicated if clinical signs of rabies are not present. 3, 7
Animal Observation Option
If the biting animal is a healthy domestic dog, cat, or ferret that can be confined and observed for 10 days, you may delay initiating PEP unless the animal develops signs of rabies during observation. 3, 4, 6
If the animal remains healthy for 10 days or tests negative for rabies, prophylaxis can be discontinued. 2, 4
For wild animals (bats, raccoons, skunks, foxes) or stray/unavailable domestic animals, immediate PEP initiation is recommended without waiting for observation. 3, 4
Evidence Supporting This Approach
The 2010 ACIP guidelines explicitly state that persons who have ever previously received complete vaccination regimens should receive only vaccine without HRIG. 1 Research demonstrates that previously vaccinated individuals maintain immunological memory and show adequate booster responses even after long time intervals, with the majority demonstrating anamnestic responses by day 7. 2, 5 This simplified 2-dose regimen is both safe and effective while reducing costs and healthcare visits. 1
Common Pitfalls to Avoid
Failing to thoroughly cleanse wounds, which is the critical first step in rabies prevention. 3, 7
Administering HRIG to previously vaccinated persons, which is contraindicated and counterproductive. 2
Using the gluteal area for vaccine administration, which results in diminished immune response. 3, 7
Delaying treatment due to uncertainty about prior vaccination status—when in doubt, treat as previously unvaccinated with the full regimen. 4, 6