ARV schedule
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Here is a comprehensive summary of the Anti-Rabies Vaccine (ARV) schedule from authoritative sources:
Anti-Rabies Vaccine (ARV) Schedule
Step 1 - Wound Management (All Categories)
- Thorough wound washing with soap and water, then irrigation with 1:9 diluted povidone-iodine
- Tetanus prophylaxis and antibiotics if indicated
- Suturing should be delayed or loosely done after RIG infiltration
Step 2 - WHO Exposure Categories and PEP Decision
| Category | Type of Contact | PEP Required |
|---|---|---|
| I | Touching/feeding animal; licks on intact skin | None |
| II | Nibbling of uncovered skin; minor scratches/abrasions without bleeding | Vaccination + wound care |
| III | Transdermal bites/scratches; licks on broken skin; mucous membrane contact with saliva; bat contact | Vaccination + RIG + wound care |
Post-Exposure Prophylaxis (PEP) Schedules
A. Intramuscular (IM) Regimens
1. Essen Regimen (5-dose) - for Category II & III
- Days 0, 3, 7, 14, 28 - 1 IM dose each day
- 1.0 mL or 0.5 mL into deltoid (anterolateral thigh in children <2 yr)
- Used in immunocompromised patients
2. Abbreviated Multisite IM Regimen (Zagreb / 2-1-1) - 4 doses
- Day 0: 2 doses (one in each deltoid/thigh)
- Day 7: 1 dose
- Day 21: 1 dose
3. US 4-Dose Regimen (current CDC/ACIP standard since 2010)
- Days 0, 3, 7, 14 - 1 IM dose each day (deltoid only)
- Day 28 dose removed from standard schedule in 2010
- Day 28 still given for immunocompromised patients (5-dose series)
B. Intradermal (ID) Regimen (WHO-endorsed for endemic countries)
2-site ID Regimen (2+2+2+0+2)
- 0.1 mL at 2 sites on days 0, 3, 7, and 28 (day 14 is skipped)
- One ID dose = one-fifth of the IM dose
Rabies Immunoglobulin (RIG) - Category III / Unvaccinated
| Type | Dose | Notes |
|---|---|---|
| Human RIG (HRIG) | 20 IU/kg body weight | Preferred; infiltrate around wound |
| Equine RIG | 40 IU/kg body weight | Used when HRIG unavailable; skin test not predictive |
Key RIG rules:
- Administer once only, at or as soon as possible after first vaccine dose
- Not indicated after day 7 (endogenous antibody production assumed by then)
- Never inject RIG in the same syringe or site as vaccine
- Infiltrate as much as possible into/around wound; remainder IM at distant site
Pre-Exposure Prophylaxis (PrEP)
For high-risk individuals (veterinarians, lab workers, travelers to endemic areas, spelunkers):
| Route | Schedule |
|---|---|
| IM | 1 mL or 0.5 mL on days 0, 7, and 21 or 28 |
| ID | 0.1 mL per site on days 0, 7, and 21 or 28 |
- Antibody titer check every 2 years for at-risk individuals; booster if <0.5 IU/mL
Previously Vaccinated Individuals (PEP after prior complete vaccination)
- 2 doses only - days 0 and 3 (IM or ID)
- No RIG needed
- Alternative: single-visit 4-site ID regimen (0.1 mL × 4 sites on day 0)
Special Populations
| Population | Modification |
|---|---|
| Immunocompromised | Full 5-dose IM series; check antibody titer 2-4 weeks post-vaccination |
| Pregnant | Not a contraindication; vaccinate normally |
| Children <2 yr | Use anterolateral thigh instead of deltoid |
| Gluteal route | Contraindicated - associated with rare vaccine failures |
Available Vaccines (Cell-Culture & Embryonated Egg-Based)
- Human Diploid Cell Vaccine (HDCV) - e.g., Imovax
- Purified Chick Embryo Cell Culture Vaccine (PCECV) - e.g., RabAvert
- Vero cell-derived vaccines
- Potency: ≥2.5 IU per single IM dose
Note: Neural tissue vaccines (older type) are still used in some developing countries but carry risk of neuroparalytic complications (post-infectious encephalomyelitis, Guillain-Barré) and should be phased out.
Sources: Park's Textbook of Preventive & Social Medicine; Harrison's Principles of Internal Medicine 22E (2025); Tintinalli's Emergency Medicine; WHO Expert Consultation on Rabies (3rd Report)
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