WHO Rabies PEP: Category II Exposure - Unattended Cat

Step 1 - Confirm the Exposure Category

Step 2 - Immediate Wound Management (Do First, Regardless of Delay)

• Wash thoroughly with soap and water for at least 15 minutes
• Apply a virucidal agent: povidone-iodine solution or 70% alcohol
• Do not suture the wound primarily if possible
• Consider tetanus prophylaxis and antibiotics as clinically indicated

Step 3 - Vaccine Schedule (WHO-Recommended IM Regimens)

Option A: Essen Regimen (5-dose, 1-1-1-1-1)

Option B: Zagreb Regimen (4-dose, 2-1-1) - Abbreviated Multisite

Option C: 4-Dose Regimen (Days 0, 3, 7, 14) - For Immunocompetent Patients

Option D: Intradermal (ID) 2-Site Regimen - where nationally endorsed

• 0.1 ml at 2 sites on Days 0, 3, 7, and 28 (day 14 is omitted)
• Requires use of WHO-prequalified cell-culture vaccine
• Latest WHO recommendation (2018 update, confirmed 2024): preferred simplified schedule is 0.1 ml x 2 sites on Days 0, 3, and 7 only (3 visits, 6 injections total - one week regimen)

Step 4 - Is RIG (Rabies Immunoglobulin) Needed?

Step 5 - Key Decision: Should PEP Be Continued or Can It Stop?

• The cat is captured and remains healthy throughout a 10-day observation period from the date of the bite
• The animal is confirmed rabies-free by laboratory examination

In developing/enzootic countries, vaccination status of the animal alone is not sufficient reason to withhold PEP.

Step 6 - Special Populations

Summary for This Case

• Cat not attended for 4 days + Category II wound = Start PEP immediately (do not wait)
• Wound wash right now with soap/water + povidone-iodine
• Vaccine: choose Essen (Days 0, 3, 7, 14, 28), Zagreb (Days 0, 0, 7, 21), or 4-dose (Days 0, 3, 7, 14) depending on local protocol
• No RIG required for Category II
• Monitor cat for 10 days if possible; PEP may be stopped if cat stays healthy

WHO Guidance: Patient Presenting 4 Days Late - Category II Cat Wound

The Core Rule: Delay Does NOT Disqualify PEP

"Patients presenting for rabies PEP even months after having been bitten should be treated as if the contact had recently occurred."

• WHO Guide for Rabies Pre and Post Exposure Prophylaxis

"PEP is recommended regardless of the interval between exposure and initiation of treatment, so long as the patient is not showing signs consistent with rabies."

• CDC (aligned with WHO)

Practical Management at Day 4 Presentation

1. Wound Care (Still Mandatory - Do It Now)

• Wash thoroughly with soap and water for 15 minutes - even though 4 days have passed, this removes any residual viral material
• Apply povidone-iodine or 70% alcohol
• Assess wound healing - if infected, treat with antibiotics
• Check tetanus status

2. Category Confirmation

Note on RIG timing: if upgrading to Cat III, RIG can be given up to Day 7 from first vaccine dose. Since patient is at Day 4 naturally, RIG can still be administered alongside the first vaccine dose today.

3. Vaccine Schedule - Start Day 0 Today

4. Animal Observation Rule

• PEP cannot be discontinued based on animal observation
• Complete the full vaccine course
• If the cat is found alive and healthy 10 days after the original bite date, PEP may be discontinued at that point

What NOT To Do

• Do not restart from Day -4 or try to "compensate" for the delay with extra doses
• Do not withhold PEP citing the delay
• Do not give RIG unless wound is re-classified as Category III
• Do not inject into the gluteal muscle (poor immunogenicity)

Summary