What is the recommended rabies vaccination schedule for an individual exposed to rabies, with or without prior rabies vaccination?

Rabies Vaccination Schedule

Post-Exposure Prophylaxis for Previously Unvaccinated Persons

For individuals never vaccinated against rabies who are exposed, administer a 4-dose vaccine series on days 0,3,7, and 14, combined with human rabies immune globulin (HRIG) at 20 IU/kg on day 0. 1

Immediate Wound Management

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

Vaccine Administration Details

• Administer 1.0 mL of HDCV (human diploid cell vaccine) or PCECV (purified chick embryo cell vaccine) 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 in the deltoid muscle for adults and older children 1, 2
• Use the anterolateral thigh for young children 1, 2
• Never use the gluteal area—this produces inadequate antibody response and has been associated with vaccine failures 2, 4

HRIG Administration

• Administer HRIG at exactly 20 IU/kg body weight on day 0, ideally simultaneously with the first vaccine dose 1, 2
• Infiltrate the full calculated dose around and into the wound(s) if anatomically feasible 1, 2
• Inject any remaining volume intramuscularly at a site distant from vaccine administration 1
• Do not administer HRIG in the same syringe or at the same anatomical site as the vaccine 2, 4
• Do not exceed 20 IU/kg—higher doses suppress active antibody production 2
• If HRIG was not given initially, it can be administered up to and including day 7 after the first vaccine dose 2, 5

Post-Exposure Prophylaxis for Previously Vaccinated Persons

Previously vaccinated individuals require only 2 doses of vaccine on days 0 and 3, and do NOT need HRIG. 1, 2, 4

• This simplified regimen applies to anyone who has completed a recommended pre-exposure or post-exposure vaccination series with a cell culture vaccine 1
• Critical pitfall: Giving HRIG to previously vaccinated persons is a major error that suppresses the memory immune response 2

Special Population: Immunocompromised Patients

Immunocompromised patients require a modified 5-dose vaccine regimen on days 0,3,7,14, and 28, plus HRIG at 20 IU/kg on day 0, even if previously vaccinated. 2, 4

• This applies to patients on corticosteroids, other immunosuppressive agents, antimalarials, or those with immunosuppressive illnesses including HIV 2
• Serologic testing must be performed 1-2 weeks after the final vaccine dose to confirm adequate antibody response 2
• An acceptable response is complete neutralization of challenge virus at a 1:5 serum dilution 2

Pre-Exposure Prophylaxis

For pre-exposure vaccination, administer three 1.0 mL injections intramuscularly on days 0,7, and 21 or 28. 1, 6

• This schedule is recommended for persons at continuous or frequent risk of rabies exposure (laboratory workers, veterinarians, animal control officers, cavers, bat handlers) 1, 6
• Routine serologic testing and booster doses are only needed for those at continuous risk (every 6 months) or frequent risk (every 2 years) 6

Timing Considerations

• Initiate PEP as soon as possible after exposure, ideally within 24 hours 2
• There is no absolute cutoff for initiating PEP—treatment can be started immediately upon recognition of exposure even if weeks or months have elapsed, as rabies incubation periods can exceed one year and the disease is uniformly fatal once symptoms appear 2
• Delays of a few days for individual doses are unimportant 2, 5
• For missed doses, administer immediately when the patient presents and resume the schedule maintaining the same intervals between remaining doses 5

Critical Pitfalls to Avoid

• Never administer vaccine in the gluteal area 2, 4
• Never give HRIG to previously vaccinated persons (unless immunocompromised) 2, 4
• Never administer HRIG in the same syringe or anatomical site as vaccine 2, 4
• Never exceed 20 IU/kg of HRIG 2, 4
• Never use the standard 4-dose schedule for immunocompromised patients—they require 5 doses 2, 4

Pediatric Considerations

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

Efficacy

When administered promptly and appropriately, this PEP regimen combining wound care, HRIG infiltration, and the vaccine series is nearly 100% effective in preventing human rabies. 2, 4