Rabies vaccination schedule in india
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Here is a complete overview of the rabies vaccination schedule in India, based on the MoHFW National Guidelines on Rabies Prophylaxis and WHO/Park's Textbook recommendations:
Rabies Vaccination Schedule in India
Step 1: Wound Category Classification (WHO/NCDC)
| Category | Type of Contact | Action |
|---|---|---|
| I | Touching/feeding animal, licks on intact skin | No PEP needed |
| II | Nibbling uncovered skin, minor scratches/abrasions without bleeding | Wound care + vaccine only |
| III | Transdermal bites/scratches, licks on broken skin, mucous membrane contact, bat contact | Wound care + vaccine + RIG |
Step 2: First Aid (All Bite Cases)
Wash the wound immediately with soap and water for at least 15 minutes, then apply a virucidal agent (povidone-iodine/70% alcohol). This alone significantly reduces viral load. Do NOT apply chillies, lime, salt, or mustard oil - these confer no benefit.
A. Post-Exposure Prophylaxis (PEP) - Unvaccinated Individuals
Intramuscular (IM) Route - Essen Regimen
India officially uses the 4-dose updated Essen regimen (reduced from 5):
| Dose | Day | Site |
|---|---|---|
| 1st | Day 0 (date of first dose) | Deltoid (adults); anterolateral thigh (infants/children) |
| 2nd | Day 3 | Deltoid |
| 3rd | Day 7 | Deltoid |
| 4th | Day 28 | Deltoid |
Note: The older 5-dose schedule (Days 0, 3, 7, 14, 28) was the original Essen regimen and is still referenced in some guidelines. The 4-dose schedule (0, 3, 7, 28) is now standard in India per NCDC/NRCP. Never inject in the gluteal region - fat tissue impairs antigen absorption and immune response.
Intradermal (ID) Route - 2-Site Regimen
This is the regimen approved in India (endorsed by DCGI) and is cost-saving since one vial serves multiple patients:
| Dose | Day | Sites | Volume per site |
|---|---|---|---|
| 1st | Day 0 | 2 sites (both deltoids) | 0.1 ml each |
| 2nd | Day 3 | 2 sites | 0.1 ml each |
| 3rd | Day 7 | 2 sites | 0.1 ml each |
| 4th | Day 28 | 2 sites | 0.1 ml each |
Total vaccine used = 1/5th of IM course per visit, making this far more affordable.
B. Rabies Immunoglobulin (RIG) - Category III Only
Given once only, ideally on Day 0, never after Day 7 post-first-dose:
| Type | Dose | Notes |
|---|---|---|
| HRIG (Human) | 20 IU/kg body weight | Preferred; lower anaphylaxis risk |
| ERIG (Equine) | 40 IU/kg body weight | Cheaper, widely available; 1/45,000 anaphylaxis risk |
- Infiltrate as much as possible directly into/around the wound
- Remaining volume injected IM at a site away from vaccine injection site
- Do NOT perform skin test for ERIG - it does not predict reactions
C. Pre-Exposure Prophylaxis (PrEP)
For high-risk groups: lab workers, veterinarians, animal handlers, wildlife wardens, quarantine officers, travellers to endemic areas. IAP recommends considering PrEP for children.
| Dose | Day | IM Route | ID Route |
|---|---|---|---|
| 1st | Day 0 | 1 ml or 0.5 ml (vaccine-dependent) | 0.1 ml (1 site) |
| 2nd | Day 7 | Same | 0.1 ml |
| 3rd | Day 21 or 28 | Same | 0.1 ml |
Boosters: Routine boosters are not needed for travellers after a complete primary series. For those at continual occupational risk, antibody monitoring (RVNA titre) is preferred over routine boosters - a booster is given only if titres fall below 0.5 IU/ml.
- Lab workers handling live virus: test every 6 months
- Veterinarians/animal health officers: test every 2 years
D. PEP for Previously Vaccinated Individuals (Re-exposure)
No RIG required. Simplified 2-dose schedule:
| Dose | Day |
|---|---|
| 1st | Day 0 |
| 2nd | Day 3 |
Alternatively, a single-visit 4-site ID regimen (4 × 0.1 ml at both deltoids/thighs) may be used.
E. Special Situations
| Situation | Schedule |
|---|---|
| Immunocompromised/HIV | 5-dose IM (Days 0, 3, 7, 14, 28) + RIG; check RVNA titre 2-4 weeks after |
| Dog/cat under 10-day observation stays healthy | Convert PEP to PrEP - skip Day 14 dose (Essen); give Day 28 dose normally. ID: complete full course regardless |
| Pregnancy | PEP is NOT contraindicated; vaccinate normally |
Vaccines Available in India (Cell Culture - DCGI Approved)
- PVRV (Purified Vero Cell Rabies Vaccine) - e.g., Rabipur, Vaxirab
- PCEC (Purified Chick Embryo Cell vaccine)
- PDEV (Purified Duck Embryo Vaccine)
- HDCV (Human Diploid Cell Vaccine)
All must have potency ≥ 2.5 IU/IM dose. Store at +2°C to +8°C, protect from sunlight. Use immediately after reconstitution (within 6-8 hours).
Free PEP is available at government hospitals, PHCs, CHCs, and district hospitals under the National Rabies Control Programme (NRCP). Private clinics charge approximately Rs. 250-600 per dose.
Key References:
- National Guidelines on Rabies Prophylaxis, MoHFW/NCDC India
- Park's Textbook of Preventive and Social Medicine, 26th Ed., pp. 324-325
State the regimens
Here are all the rabies vaccination regimens used in India:
Rabies Vaccination Regimens in India
1. Essen Regimen (Standard IM - PEP)
5-dose original: Days 0, 3, 7, 14, 28
4-dose updated (current NCDC standard): Days 0, 3, 7, 28
- Route: Intramuscular (deltoid)
- Dose: 1 full vial per injection
- Notation: 1-1-1-1 (4-dose) or 1-1-1-1-1 (5-dose)
2. Zagreb Regimen (2-1-1 Regimen - IM PEP)
- Days: 0 (×2), 7, 21
- Route: IM, but 2 doses on Day 0 (one in each deltoid), then 1 dose each on Day 7 and Day 21
- Notation: 2-1-1
- Advantage: Faster completion (3 visits vs 4-5), fewer total doses
- Less commonly used in India but WHO-approved
3. Updated Thai Red Cross Regimen (2-Site ID - PEP)
Also called the UTRCS regimen or 2-2-2-0-2:
| Day | Sites | Volume/site |
|---|---|---|
| 0 | 2 (both deltoids) | 0.1 ml |
| 3 | 2 | 0.1 ml |
| 7 | 2 | 0.1 ml |
| 28 | 2 | 0.1 ml |
- Notation: 2-2-2-0-2 (original 5-visit) or 2-2-2-2 (4-visit, India-approved)
- DCGI-approved for India
- 1 vial shared among multiple patients - highly cost-effective
4. Oxford/Modified ID Regimen (8-0-4-0-1-1)
- Older regimen, largely obsolete
- Not recommended in current Indian guidelines
5. Pre-Exposure Prophylaxis (PrEP) Regimen
IM: 1 full dose on Days 0, 7, and 21 or 28
ID: 0.1 ml (1 site) on Days 0, 7, and 21 or 28
- 3 doses total
- Used for high-risk individuals (vets, lab workers, travellers)
6. PEP in Previously Vaccinated Individuals
2-dose booster:
- Days 0 and 3 only (IM or ID)
- No RIG required
OR single-visit 4-site ID regimen on Day 0
7. Immunocompromised / HIV - PEP
- 5-dose IM Essen: Days 0, 3, 7, 14, 28
- Plus RIG on Day 0
- Check RVNA titre 2-4 weeks after completion
Quick Comparison Table
| Regimen | Route | Doses | Days | Visits |
|---|---|---|---|---|
| Essen (4-dose) | IM | 4 | 0, 3, 7, 28 | 4 |
| Essen (5-dose) | IM | 5 | 0, 3, 7, 14, 28 | 5 |
| Zagreb (2-1-1) | IM | 4 | 0×2, 7, 21 | 3 |
| ID 2-site (UTRCS) | ID | 8 sites total | 0, 3, 7, 28 | 4 |
| PrEP | IM or ID | 3 | 0, 7, 21/28 | 3 |
| Re-exposure booster | IM or ID | 2 | 0, 3 | 2 |
| Immunocompromised | IM | 5 | 0, 3, 7, 14, 28 | 5 |
The 4-dose Essen (IM) and 2-site ID regimen are the two most widely used in India under the NRCP. The Zagreb regimen is WHO-approved but less commonly adopted in Indian public health settings.
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