What is the recommended dose schedule for Rabipur (Rabies vaccine) in adults and children with potential exposure to rabies, considering their medical history and previous vaccinations?

Rabipur Dose Schedule

For previously unvaccinated individuals, administer Rabipur 1.0 mL intramuscularly on days 0,3,7, and 14, combined with human rabies immune globulin (HRIG) 20 IU/kg on day 0. 1, 2

Standard Post-Exposure Prophylaxis Regimen

Previously Unvaccinated Persons

• Administer 4 doses of Rabipur (PCECV), 1.0 mL each, intramuscularly on days 0,3,7, and 14 1, 2
• Day 0 is defined as the day the first dose is administered, not necessarily the exposure date 2
• Inject in the deltoid muscle for adults and older children 1, 2
• Use the anterolateral thigh for young children 1, 2
• Never administer in the gluteal area, as this produces inadequate antibody response and is associated with vaccine failure 1, 2

Human Rabies Immune Globulin (HRIG) Administration

• Administer HRIG at exactly 20 IU/kg body weight on day 0, ideally simultaneously with the first vaccine dose 1, 2, 3
• Infiltrate the full calculated dose around and into the wound(s) if anatomically feasible 1, 2, 3
• Inject any remaining volume intramuscularly at a site distant from vaccine administration 1, 2, 3
• HRIG should never be administered in the same syringe or at the same anatomical site as the vaccine 1, 2, 3
• Do not exceed 20 IU/kg, as higher doses suppress active antibody production 1, 2
• If HRIG was not given on day 0, it can still be administered up to and including day 7 after the first vaccine dose 2, 4, 3

Previously Vaccinated Persons

• Administer only 2 doses of Rabipur (1.0 mL each) on days 0 and 3 1, 2
• Do NOT administer HRIG to previously vaccinated persons, as it will inhibit the anamnestic antibody response 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 2

Immunocompromised Patients

• Administer 5 doses of Rabipur on days 0,3,7,14, and 28, plus HRIG at 20 IU/kg on day 0 1, 2
• This extended regimen is required even if the patient was previously vaccinated 2
• Perform serologic testing 1-2 weeks after the final dose to confirm adequate antibody response 2
• An acceptable response is complete neutralization of challenge virus at a 1:5 serum dilution 2

Pediatric Dosing

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

Immediate Wound Management

• Immediately wash all wounds thoroughly with soap and water for 15 minutes before administering any biologicals 1, 2
• Follow with irrigation using a virucidal agent such as povidone-iodine solution if available 1, 2, 3
• This single intervention markedly reduces rabies risk in animal studies 2

Timing Considerations

• Initiate post-exposure prophylaxis as soon as possible after exposure, ideally within 24 hours 2
• Treatment remains indicated even if weeks or months have elapsed since exposure, as rabies incubation periods can exceed one year 2
• There is no absolute cutoff for initiating prophylaxis, as the disease is uniformly fatal once symptoms appear 2

Managing Schedule Deviations

• Delays of a few days for individual doses are unimportant 2, 5
• For missed doses, administer the missed dose immediately when the patient presents and resume the schedule from that point 5
• Most interruptions do not require restarting the entire series 2, 5
• For substantial deviations, assess immune status by serologic testing 7-14 days after the final dose 2, 5

Critical Pitfalls to Avoid

• Never use the gluteal area for vaccine administration 1, 2, 5
• Never give HRIG to previously vaccinated persons 2, 4
• Never administer HRIG and vaccine in the same syringe or anatomical location 1, 2, 4, 3
• Never exceed 20 IU/kg of HRIG 1, 2, 4
• Do not withhold treatment while waiting for animal observation results in rabies-endemic areas 2