What is the recommended vaccination schedule for post-exposure and pre-exposure prophylaxis against rabies infection?

Rabies Vaccination Schedule

Post-Exposure Prophylaxis (PEP) for Previously Unvaccinated Persons

For previously unvaccinated individuals exposed to rabies, administer a 4-dose vaccine regimen on days 0,3,7, and 14, combined with human rabies immune globulin (HRIG) at 20 IU/kg on day 0. 1, 2

Immediate Wound Management

• Thoroughly wash all wounds with soap and water for 15 minutes immediately upon presentation - this is the single most effective measure for preventing rabies infection 2, 3
• Follow with irrigation using a virucidal agent such as povidone-iodine solution if available 1, 4
• Administer tetanus prophylaxis and antibiotics as indicated 4

Vaccine Administration

• Use human diploid cell vaccine (HDCV) or purified chick embryo cell vaccine (PCECV), 1.0 mL per dose, administered intramuscularly 1, 2
• Inject in the deltoid muscle for adults and older children; use the anterolateral thigh for young children 1, 2, 4
• Never administer vaccine in the gluteal area - this produces inadequate antibody response and has been associated with vaccine failure 1, 2, 4
• Day 0 is defined as the day the first dose is administered, not necessarily the day of exposure 1, 2

HRIG Administration

• Administer HRIG at 20 IU/kg body weight on day 0, ideally at the same time as the first vaccine dose 2, 5, 3
• Infiltrate as much of the calculated dose as anatomically possible directly into and around the wound site 2, 5, 3
• Any remaining volume should be administered intramuscularly at a site distant from the vaccine injection 2, 5, 3
• HRIG should never be administered in the same syringe or at the same anatomical site as the vaccine 1, 2, 5
• If HRIG was not given on day 0, it can still be administered up to and including day 7 after the first vaccine dose 1, 2, 5
• Do not exceed the recommended 20 IU/kg dose - higher doses can suppress active antibody production 5, 3

Post-Exposure Prophylaxis for Previously Vaccinated Persons

Previously vaccinated individuals require only 2 doses of vaccine (on days 0 and 3) and should NOT receive HRIG. 1, 2

• Previously vaccinated persons are defined as those who have received ACIP-recommended pre- or post-exposure prophylaxis with cell-culture vaccines, or who have documented adequate rabies virus-neutralizing antibody response 1
• HRIG should not be administered to previously vaccinated persons - it will inhibit the anamnestic antibody response 1, 5

Special Populations

Immunocompromised Patients

• Administer a 5-dose vaccine regimen on days 0,3,7,14, and 28, plus HRIG at 20 IU/kg 1, 2
• This applies even to previously vaccinated immunocompromised individuals 5
• Serologic testing 7-14 days after the final dose should be performed to ensure adequate antibody response 1, 2

Pediatric Patients

• Children receive the same vaccine dose volume (1.0 mL) and HRIG dose (20 IU/kg) as adults 2, 5, 4
• Use the anterolateral thigh for vaccine administration in young children 1, 2, 4

Pre-Exposure Prophylaxis

For individuals at high risk of rabies exposure (laboratory workers, veterinarians, animal control workers, travelers to endemic areas), administer a 3-dose pre-exposure series on days 0,7, and 21 or 28. 6, 7, 8

Critical Timing Considerations

• Initiate PEP as soon as possible after exposure, ideally within 24 hours 2, 3, 6
• However, PEP should be administered regardless of time elapsed since exposure - treatment has been successfully implemented even months after exposure when recognition was delayed 2
• Delays of even a few hours matter significantly because rabies is nearly 100% fatal once clinical symptoms develop 2, 6

Common Pitfalls to Avoid

• Never use the gluteal area for vaccine administration - this is associated with inadequate immune response and vaccine failure 1, 2, 4
• Never administer HRIG to previously vaccinated persons - this is a common error that inhibits the immune response 1, 5
• Never give HRIG and vaccine in the same syringe or anatomical location 1, 2, 5
• Never exceed the recommended HRIG dose of 20 IU/kg - higher doses suppress active antibody production 5, 3
• Do not delay wound cleansing - it should be performed immediately before any other intervention 2, 4