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Rabies post-exposure prophylaxis (United States guidelines)*[1,2]

Rabies post-exposure prophylaxis (United States guidelines)*[1,2]
Vaccination category Biologic Schedule
Not previously vaccinated RIG Total dose of HRIGΔ is 20 international units/kg body weight, administered on day 0. As much of the full dose as feasible should be infiltrated around the wound(s) and any remaining should be given IM at a different location than the vaccine§.
Vaccine HDCV or PCECV: one dose (1 mL) IM¥ on days 0, 3, 7, and 14.
Previously vaccinated RIG Not indicated
Vaccine HDCV or PCECV: one dose (1 mL) IM¥ on days 0 and 3

RIG: rabies immune globulin; IM: intramuscularly; HDCV: human diploid cell vaccine; PCECV: purified chick embryo cell vaccine; PVRV: purified Vero cell rabies vaccine.

* Post-exposure prophylaxis should be administered as soon after exposure as possible.

¶ RIG should always be given in a different syringe from the vaccine.

Δ RIG is derived from pooled plasma samples of hyperimmunized human donors (human RIG, or HRIG) or from horses (equine RIG, or ERIG). Both preparations are considered equally potent and effective, but only HRIG is recommended for use in the United States. Outside the United States, if ERIG is used, the dose is 40 international units/kg body weight.

◊ Day 0 is the day the first dose of vaccine (and RIG, if indicated) is administered.

§ The preferred location for IM administration of remaining RIG is the deltoid muscle contralateral to the vaccine dose. If there is no obvious wound (eg, suspected bat exposure), the entire volume of RIG should be administered IM, preferably into the anterolateral thigh or the deltoid muscle contralateral to the vaccine dose. Injection into the gluteus muscle should be avoided as it carries the risk for sciatic nerve damage.

¥ In adults (ie, age ≥19 years), the deltoid muscle of the arm is the only acceptable IM site of vaccine administration. In children 3 to 18 years old, the deltoid muscle of the arm is preferred, although the anterolateral aspect of the thigh is an acceptable alternative. In children ≤2 years old, the anterolateral aspect of the thigh is preferred; however, in children aged 12 months to 2 years, the deltoid muscle of the arm is an acceptable alternative if the deltoid muscle mass is adequate. Vaccine should never be administered in the gluteal area because this may result in lower antibody titers.

‡ For persons with immunosuppression, rabies post-exposure prophylaxis should be administered using five doses of vaccine on days 0, 3, 7, 14, and 28. Such patients should have antibody titers checked 7 to 14 days after the final dose to assess their response.

† To qualify as "previously vaccinated," an individual must meet one of the following criteria: prior completion of a 3-dose pre-exposure series or a post-exposure series of ≥4 doses, completion of at least two doses of a pre-exposure prophylaxis series within the 3 years prior to exposure, or prior partial completion of a pre- or post-exposure series with a subsequent titer that showed ≥0.5 international units/mL. All prior vaccine doses must have been given after the advent of modern vaccines (PCECV, HDCV, or PVRV), which became available in the United States in the early 1980s. All patients who were immunosuppressed at the time of their prior vaccinations must have had a titer check that showed ≥0.5 international units/mL. All individuals who do not meet these criteria should be treated as if they have never been vaccinated.
References:
  1. Rupprecht CE, Briggs D, Brown CM, et al. Use of a reduced (4-dose) vaccine schedule for postexposure prophylaxis to prevent human rabies: recommendations of the advisory committee on immunization practices. MMWR Recomm Rep 2010; 59:1.
  2. Rao AK, Briggs D, Moore S, et al. Use of a modified preexposure prophylaxis vaccination schedule to prevent human rabies: Recommendations of the Advisory Committee on Immunization Practices – United States, 2022. MMWR Morb Mortal Wkly Rep 2022; 71:619.
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