Rabies Postexposure Prophylaxis

Last updated 3/18/2010

All animal bites should be reported to OC Animal Care at 714-935-6848. Please call Epidemiology and Assessment at (714) 834-8180 for assistance in assessing the risk of rabies and indications for rabies postexposure prophylaxis (PEP).

For further information on rabies, visit the CDC rabies home page at: www.cdc.gov/rabies.

Giving Rabies PEP

Because most physicians and nurses are not familiar with rabies PEP, it is crucial to review the following information prior to providing treatment. The three components that are critical to rabies PEP are as follows:

  1. Immediate and thorough washing of the wound(s) with soap and warm water. If available, a virucidal solution such as povidone-iodine solution should be used to irrigate the wound(s). Consider need for tetanus vaccine booster.
  2. Administration of Human Rabies Immune Globulin (HRIG)
    HRIG is not indicated if the patient has had pre-exposure prophylaxis or previous rabies PEP treatment with currently licensed products.

    1. Imogam® Rabies-HT, Sanofi Pasteur, (800) 822-2463 
      https://www.vaccineshoppe.com/
    2. HyperRabTM S/D, Talecris Biotherapeutics, (800) 243-4153 
      www.talecris-pi.info

HRIG is given only once at the beginning of treatment. As much of the HRIG as possible should be infiltrated into and around the site of the wound(s). Any remaining HRIG should be injected intramuscularly (IM), using a separate needle, at an anatomical site distant from vaccine administration. If there is no visible wound, and there is no history of a percutaneous exposure, HRIG should be given IM at an anatomical site distant from vaccine administration. Although it is preferable to give HRIG at the time of the first dose of vaccine, it can be given up to 7 days after starting the vaccine series:

The dose for HRIG is 20 IU/kg for adults and children. It is supplied in a concentration of 150 IU/ml. To determine the dose, complete the following calculations:

(Patient's weight in pounds) ÷ (2.2 pounds/kg) = (Patient's weight in kg)

(Patient's weight in kg) x (20 IU/kg) ÷ (150 IU/ml) = dose of HRIG in ml 

OR (multiplying all the constants in the above equations) (Patient's weight in pounds) x 0.06 = dose of HRIG in ml

Example: A 150-pound person would require a dose of 9.1 ml. Please note: As the example demonstrates, you will be giving a large number of ml's.

It is important not to exceed the recommended dose since HRIG can suppress active production of the antibody response. Also, the same syringe should NOT be used for HRIG and vaccine

There are two licensed HRIG products available.

As a reminder, immunization with measles, mumps and rubella (MMR) and varicella (VZV) vaccines should not be given until at least 3 months after receiving HRIG.

  1. Administration of Human Rabies Vaccine Series

    The CDC Advisory Committee on Immunization Practices (ACIP) recommendations for rabies PEP is a series of four 1.0-ml doses of vaccine given on days 0, 3, 7, and 14.*  NOTE: updated 2010 recommendations delete the 5th dose (on day 28) of vaccine, except for in immunocompromised persons. Give all doses of rabies vaccine IM in the deltoid in adults and older children and in the anterolateral aspect of the thigh for young children. Do NOT give rabies vaccine in the gluteus muscle.

    1. Human Diploid Cell Vaccine (HDCV), trade name Imovax® Rabies, distributed by Sanofi Pasteur, (800) 822-2463 
      www.vaccineshoppe.com/
    2. Purified Chick embryo Cell Culture (PCEC), trade name RabAvert®, distributed by Novartis Vaccines and Diagnostics, (800) 244-7668
      www.rabavert.com/

(The ACIP recommendations are available at: www.cdc.gov/mmwr/ MMWR Recommendations and Reports, volume 59, No. RR-2, 3/19/2010).

Persons who have previously completed rabies pre-exposure or postexposure prophylaxis with currently licensed products, or who have received other types of rabies vaccine and have previously had a documented rabies virus neutralizing antibody titer, should only receive two doses of vaccine for PEP on days 0 and 3.

The 2010 ACIP MMWR report also includes specific recommendations for patients with altered immunocompetence: persons with immunosuppression should receive 5 doses of vaccine (days 0, 3, 7, 14, and 28) and should be tested for rabies virus neutralizing antibody by the rapid fluorescent focus inhibition test (RFFIT) to ensure an acceptable response. Immunosuppressive agents should not be administered during rabies PEP unless essential for the treatment of other conditions.

There are two rabies vaccines licensed for use and currently available in the United States:

Please refer to the package inserts for warnings, precautions, and adverse reactions. NOTE: the ACIP recommendations provided on this webpage and in the MMWR document should be followed even though the current vaccine label instructions still list the 5-dose series.

SUMMARY OF RABIES POST-EXPOSURE PROPHYLAXIS

No history of pre- or post- exposure rabies immunization

History of previous pre- or post- exposure rabies immunization with currently licensed products

HRIG
(Imogam® Rabies-HT or HyperRabTM S/D)

  • Yes

  • Dose: 20 IU/kg

  • Dose calculation: (Patient's weight in pounds) x 0.0606 = mls of HRIG

  • Infiltrate as much as possible into the wound site(s), give the rest intramuscularly (IM) in an anatomical site distant from vaccine administration

  • Give concurrently with first dose of vaccine if possible but no later than 7 days after first dose of vaccine.

None

Vaccine
(Imovax® Rabies or RabAvertä )

  • Four 1-ml doses given IM in the deltoid (anterolateral thigh in young children).

  • Doses given on days 0, 3, 7, and 14.

  • See above text for recommendations for immunosuppressed persons.

  • Two 1-ml doses given IM in the deltoid (anterolateral thigh in young children).

  • Doses given on days 0, 3