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Anti rabies vaccine dosage

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anti rabies vaccine dosage schedule post-exposure prophylaxis 2024 WHO

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Anti-Rabies Vaccine Dosage

Wound Exposure Categories (WHO Classification)

Before deciding on treatment, classify the exposure:
CategoryType of ExposureAction
ITouching/feeding animals, licks on intact skinNo treatment needed
IINibbling of uncovered skin, minor scratches without bleedingWound care + vaccine
IIISingle/multiple transdermal bites, contamination of mucous membrane or broken skin with saliva, direct contact of broken skin with bat secretionsWound care + vaccine + RIG

Step 1: Immediate Wound Care

  1. Flush and wash wound with soap and water for at least 15 minutes under running water
  2. Apply virucidal agent - povidone-iodine (0.01% aqueous) or 40-70% alcohol
  3. Do NOT suture immediately; if necessary, suture after 24-48 hrs with minimum stitches under local RIG cover
  4. Give antibiotics and anti-tetanus as indicated
  • Park's Textbook of Preventive and Social Medicine

Step 2: Rabies Immunoglobulin (RIG) - For Category III (and previously unvaccinated)

  • Human Rabies Immunoglobulin (HRIG): 20 IU/kg body weight
    • Infiltrate as much as possible around the wound(s); remaining volume given IM at a site distant from the vaccine
    • Give on Day 0 only (one-time dose)
    • Can be given up to Day 7 after first vaccine dose if initially unavailable
    • Do NOT administer in the same syringe as the vaccine
    • Do NOT exceed recommended dose (may suppress active antibody production)
  • Tintinalli's Emergency Medicine; CDC PEP guidelines

Step 3: Post-Exposure Prophylaxis (PEP) Vaccine Schedules

Available Vaccines

  • HDCV - Human Diploid Cell Vaccine (Imovax, Sanofi Pasteur)
  • PCECV - Purified Chick Embryo Cell Vaccine (RabAvert)

A. Intramuscular (IM) Regimens

1. Essen Regimen (5-dose): Days 0, 3, 7, 14, 28
  • 1 dose of 1.0 mL (or 0.5 mL depending on vaccine brand) IM in deltoid (adults and children ≥2 yrs) or anterolateral thigh (children <2 yrs)
  • Never inject in the gluteal region (impairs immune response)
2. Zagreb Regimen / Abbreviated Multisite (2-1-1): Days 0, 7, 21
  • Day 0: 2 doses (1 in each deltoid)
  • Day 7: 1 dose
  • Day 21: 1 dose
  • For healthy, immunocompetent persons only
3. Reduced 4-dose Schedule (USA ACIP, 2010): Days 0, 3, 7, 14
  • 1.0 mL IM per dose
  • Standard for healthy immunocompetent adults in the US
  • Tintinalli's Emergency Medicine
4. Immunocompromised Persons (5-dose): Days 0, 3, 7, 14, 28
  • An extra 5th dose on Day 28 is added
  • Check antibody titre (seroconversion) 7-14 days after completing the series
  • Avoid immunosuppressive agents during PEP if possible

B. Intradermal (ID) Regimen (WHO - resource-limited settings)

2-site ID regimen: Days 0, 3, 7, 28
  • 0.1 mL per site, 2 sites per visit (deltoid/thigh)
  • Day 14 dose is omitted
  • 60-80% vaccine saving compared to IM
  • Must be endorsed by national health authority
  • Suitable for Category II and III exposures
  • Park's Textbook of Preventive and Social Medicine; WHO PEP guide
Newest WHO recommendation (1-week schedule):
  • Days 0, 3, and 7 with 2-site ID injection each day
  • Particularly useful for compliance and dose savings

Step 4: Pre-Exposure Prophylaxis (PrEP)

For high-risk individuals (veterinarians, animal handlers, lab workers, travelers to endemic areas):
DoseDayRoute
Dose 1Day 01.0 mL IM or 0.1 mL ID
Dose 2Day 71.0 mL IM or 0.1 mL ID
Dose 3Day 21 or 281.0 mL IM or 0.1 mL ID
  • Booster: For those at permanent risk (lab workers) - check titre every 6 months; give booster if titre falls below 0.5 IU/mL
  • For veterinarians and wildlife handlers at frequent risk - check titre every 2 years

Previously Vaccinated Persons (PEP after prior immunization)

If previously fully vaccinated (complete PrEP or PEP):
  • No RIG needed
  • Vaccine only: 1.0 mL IM on Day 0 and Day 3 (2-dose regimen)
  • Tintinalli's Emergency Medicine

Key Points to Remember

  • Antibody response takes 7-10 days to develop; RIG provides immediate passive protection during this window
  • Rabies neutralizing antibodies persist for several years after vaccination
  • Never inject in the gluteal muscle (impaired immune response)
  • Do not restart the series if a dose is missed; continue from where left off
  • PEP efficacy is nearly 100% when properly administered
  • Old nerve tissue vaccines (Semple, suckling mouse brain) are obsolete - use cell culture vaccines only
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