Rabies Post-Exposure Prophylaxis

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Rabies post-exposure prophylaxis (PEP) - Schedule¹

Adapted from: Centers for Disease Control and Prevention. Use of a Reduced (4-Dose) Vaccine Schedule for Post-exposure Prophylaxis to Prevent Human Rabies: Recommendations of the Advisory Committee on Immunization Practices (ACIP) MMWR 2010;59(No. RR-2)

I. For People not Previously Vaccinated:

Wound cleansing
All PEP should begin with immediate thorough cleansing of all wounds with soap and water. If available, a virucidal agent (e.g., povidone-iodine solution) should be used to irrigate the wounds. 

Human rabies immune globulin (HRIG)
Administer 20 IU/kg body weight. If anatomically feasible, the full dose should be infiltrated around and into the wound(s), and any remaining volume should be administered at an anatomical site (intramuscular) distant from vaccine administration. Also, HRIG should not be administered in the same syringe as vaccine. Because HRIG might partially suppress active production of rabies virus antibody, no more than the recommended dose should be administered.

Vaccine
Human diploid cell vaccine (HDCV) or purified chick embryo cell vaccine (PCECV) 1.0 mL, intramuscular (deltoid area²), 1 each on days 0³, 3, 7, and 14.⁴

Both HRIG and vaccine should be used, regardless of how long ago the exposure occurred. There is no approved regimen in the USA that omits the use of HRIG for persons who were not previously vaccinated.⁵ Note also that the number of vaccine doses recommended for the PEP of immune competent persons has decreased from 5 to 4 doses.

II. For People who were Previously Vaccinated:⁵

Wound cleansing
All PEP should begin with immediate thorough cleansing of all wounds with soap and water. If available, a virucidal agent such as povidone-iodine solution should be used to irrigate the wounds.

Vaccine
HDCV or PCECV 1.0 mL, intramuscular (deltoid area ²), 1 each on days 0 ³, and 3.

HRIG should NOT be administered.

Footnotes

¹These regimens are applicable for all age groups, including children.

²The deltoid area is the only acceptable site of vaccination for adults and older children. For younger children, the outer aspect of the thigh may be used. Never administer the vaccine in the gluteal area.

³Day 0 is the day dose 1 of vaccine is administered

⁴For persons with immunosuppression, rabies PEP should be administered using 5 doses of vaccine on days 0, 3, 7, 14, and 28.

⁵"Previously vaccinated" is defined as any person with a history of pre-exposure vaccination with HDCV, PCECV, or rabies vaccine adsorbed (RVA); prior PEP with HDCV, PCECV, or RVA; or previous vaccination with any other type of rabies vaccine and a documented history of antibody response to the prior vaccination.