What is the recommended post-exposure prophylaxis (PEP) schedule for a previously vaccinated person and a vaccinated dog exposed to a potentially rabid animal?

Post-Exposure Prophylaxis for Previously Vaccinated Person Bitten by Vaccinated Dog

A previously vaccinated person exposed to a dog bite should receive two doses of rabies vaccine (1.0 mL intramuscularly in the deltoid) on days 0 and 3, without rabies immunoglobulin, regardless of the dog's vaccination status. 1, 2, 3

Immediate Wound Management

• Thoroughly wash all bite wounds with soap and water for 15 minutes immediately after exposure. 4, 5
• Consider tetanus prophylaxis as clinically indicated. 4
• This local wound care is critical even for previously vaccinated persons and may be the most effective single measure for preventing rabies. 1, 4

Vaccination Schedule for Previously Vaccinated Persons

Previously vaccinated individuals are defined as those who have:

• Completed a recommended pre-exposure or post-exposure regimen of HDCV, PCECV, or RVA, OR 1, 2
• Documented rabies virus neutralizing antibody titer from previous vaccination 1, 3

The simplified two-dose regimen consists of:

• First dose: Administer 1.0 mL intramuscularly in the deltoid immediately upon presentation 1, 2, 3
• Second dose: Administer 1.0 mL intramuscularly in the deltoid exactly 3 days after the first dose 1, 2, 3

This abbreviated schedule works because previously vaccinated persons develop a rapid anamnestic (memory) antibody response following booster vaccination, regardless of their pre-booster antibody titer. 3

Critical: Do NOT Administer Rabies Immunoglobulin

Rabies immunoglobulin (RIG) is contraindicated and should NOT be given to previously vaccinated persons. 1, 2, 3

• RIG may actually inhibit the strength or rapidity of the expected anamnestic immune response in previously vaccinated individuals. 1, 2, 3
• The passive antibody from RIG can suppress the active immune response that the person's immune system is primed to mount. 1

Dog Vaccination Status: Important but Not Determinative

While the dog's vaccination status is relevant for risk assessment, it does not change the post-exposure prophylaxis recommendation for a previously vaccinated person:

• A healthy dog (even if vaccinated) should be confined and observed for 10 days. 4
• If the dog remains healthy throughout the observation period, prophylaxis can be discontinued. 4
• However, prophylaxis should be initiated immediately while awaiting the observation period outcome, particularly if the dog's behavior was abnormal or unprovoked. 4
• If the dog develops signs of rabies during observation, it should be euthanized immediately and tested. 4

Special Considerations and Pitfalls

For immunosuppressed individuals:

• The standard two-dose regimen may be insufficient. 6, 3
• These patients may require the full 5-dose series (days 0,3,7,14, and 28) even if previously vaccinated. 6
• Antibody titers should be checked 7-14 days after completing the series to confirm adequate response. 6, 3
• Consultation with public health officials is strongly recommended. 1, 3

Common pitfall to avoid:

• Do not delay treatment to obtain pre-booster antibody titers. 3
• Determining antibody levels before administering boosters is inappropriate because it delays treatment, and no specific "protective" titer threshold is definitively established for decision-making. 1, 3

Timing considerations:

• Post-exposure prophylaxis is a medical urgency, not an emergency, but should be initiated as soon as possible (ideally within 24 hours). 4
• Delays of a few days for individual doses are acceptable, though treatment should not be unnecessarily postponed. 6

No Routine Serologic Testing Required

• Healthy persons completing the two-dose regimen do not require routine antibody testing to document seroconversion. 1
• All healthy persons tested 2-4 weeks after completion of prophylaxis according to ACIP guidelines have demonstrated adequate antibody response. 1
• Testing is only indicated for immunosuppressed individuals. 1, 3