What is the recommended vaccination schedule for the Rabipur (inactivated rabies virus) vaccine in adults and children?

Rabipur Vaccination Schedule

Post-Exposure Prophylaxis (PEP) for Previously Unvaccinated Individuals

For previously unvaccinated persons, administer 4 doses of Rabipur (1.0 mL intramuscularly) on days 0,3,7, and 14, combined with human rabies immune globulin (HRIG) at 20 IU/kg on day 0. 1

Standard 4-Dose Regimen

• Day 0: First dose of 1.0 mL Rabipur intramuscularly + HRIG 20 IU/kg (day 0 is defined as the day the first dose is given, not necessarily the day of exposure) 1, 2
• Day 3: Second dose of 1.0 mL intramuscularly 1, 2
• Day 7: Third dose of 1.0 mL intramuscularly 1, 2
• Day 14: Fourth dose of 1.0 mL intramuscularly 1, 2

Administration Sites

• Adults and older children: Inject in the deltoid muscle 1, 2
• Young children: Inject in the anterolateral thigh 1, 2
• Never use the gluteal area as this produces inadequate antibody response and is associated with vaccine failure 1, 2

HRIG Administration Details

• Administer HRIG at 20 IU/kg body weight on day 0, ideally at the same time as the first vaccine dose 1, 2
• Infiltrate the full dose around and into the wound(s) if anatomically feasible, with any remaining volume given intramuscularly at a site distant from vaccine administration 1, 2
• Do not administer HRIG in the same syringe or anatomical site as the vaccine 1, 2
• If HRIG was not given initially, it can be administered up to and including day 7 after the first vaccine dose 1, 3
• Beyond day 7, HRIG is not indicated as antibody response to the vaccine is presumed to have occurred 3

Post-Exposure Prophylaxis for Previously Vaccinated Individuals

Previously vaccinated persons require only 2 doses of Rabipur (1.0 mL each) on days 0 and 3, and do NOT need HRIG. 1, 2

• This simplified regimen applies to persons who have completed a recommended preexposure or postexposure vaccination regimen with a cell culture vaccine 2
• HRIG should not be given to previously vaccinated persons as it will inhibit the anamnestic response 1

Special Populations: Immunocompromised Patients

Immunocompromised patients require a 5-dose regimen on days 0,3,7,14, and 28, plus HRIG at 20 IU/kg on day 0, even if previously vaccinated. 1, 2

Critical Modifications for Immunosuppressed Individuals

• Administer 5 intramuscular doses of 1.0 mL each on days 0,3,7,14, and 28 (not the standard 4-dose schedule) 1
• This applies to patients on corticosteroids, other immunosuppressive agents, antimalarials, or those with immunosuppressive illnesses including HIV and chronic lymphoproliferative leukemia 1
• Mandatory serologic testing: One or more serum samples must be tested for rabies virus-neutralizing antibody 1-2 weeks after the final vaccine dose (day 42) using the rapid fluorescent focus inhibition test (RFFIT) 1
• An acceptable antibody response is defined as complete neutralization of challenge virus at a 1:5 serum dilution 1
• If no acceptable antibody response is detected, manage in consultation with the patient's physician and public health officials 1

Pre-Exposure Prophylaxis

For pre-exposure prophylaxis, administer 3 doses of Rabipur (1.0 mL intramuscularly) on days 0,7, and 28. 4

• All subjects develop rabies virus-neutralizing antibody titers ≥0.5 IU/mL after this 3-dose schedule 4
• In immunocompromised persons at risk for rabies, virus-neutralizing antibody responses must be checked after completing the pre-exposure series 1
• If possible, postpone pre-exposure prophylaxis until the immunocompromising condition is resolved 1

Pediatric Considerations

• Children receive the same vaccine dose volume (1.0 mL) as adults 1, 2
• Use the anterolateral thigh for vaccine administration in young children 1, 2
• For category 2 exposures (nibbling of uncovered skin or minor scratches without bleeding), a 4-year-old child receives 4 doses on days 0,3,7, and 14 without RIG 1
• If the child is immunocompromised, upgrade to the 5-dose regimen (days 0,3,7,14, and 28) with RIG 1

Managing Schedule Deviations

• Delays of a few days for individual doses are unimportant 1, 3
• For missed doses, administer the missed dose immediately when the patient presents and resume the schedule maintaining the same intervals between remaining doses 3
• Most interruptions do not require restarting the entire series 1, 3
• For substantial deviations, assess immune status by serologic testing 7-14 days after the final dose 1, 3

Essential Wound Care

Immediately wash all wounds with soap and water for 15 minutes before any other intervention—this is perhaps the most effective single measure for preventing rabies. 1, 2

• Follow with irrigation using a virucidal agent such as povidone-iodine solution if available 1, 2

Critical Timing Principles

• Initiate PEP as soon as possible after exposure, ideally within 24 hours 1, 2
• There is no absolute cutoff beyond which PEP should be withheld—once exposure is recognized, begin prophylaxis immediately regardless of time elapsed 1, 2
• Delays of even a few hours matter because rabies is nearly 100% fatal once clinical symptoms develop 1
• When administered promptly and appropriately, PEP is nearly 100% effective in preventing human rabies 1, 2

Common Pitfalls to Avoid

• Never administer vaccine in the gluteal area (associated with vaccine failure) 1, 2
• Never give HRIG in the same syringe or anatomical site as vaccine 1, 2
• Never exceed the recommended HRIG dose of 20 IU/kg (may suppress active antibody production) 1
• Never give HRIG to previously vaccinated persons unless they are immunocompromised 1, 2
• Never use the standard 4-dose schedule for immunocompromised patients—they require the 5-dose regimen 1, 2