The World Health Organization has issued new rabies vaccination and post-exposure prophylaxis recommendations. Here are some of the highlights:
People who have not been previously vaccinated against rabies should receive immunoglobulin (antibody) promptly, followed by a series of rabies vaccines.
Immunoglobulin can be given after vaccination has started, if logistics require that; however, it should not be given more than 7 days after the first vaccination (it won’t do much after that).
Vaccination should not be delayed while sourcing immunoglobulin if it is not immediately accessible.
If immunoglobulin is of limited availability, the following priority list should be considered (in descending order of priority):
- Patients with multiple bite wounds
- Patients with deep wounds
- Patinets with bites to highly innervated parts of the body (e.g. head, neck, hands, genitals)
- Patients with severe immunodeficiencies (who are less likely to response well to vaccination)
Rabies vaccine can be given intramuscularly or intradermally. The benefit of intradermal vaccination is that a small volume (0.1 mL in 2 sites) is used, which can be an advantage when the supply of rabies vaccine is limited.
Post-exposure vaccination options are:
- Intradermal vaccination (two sites) on days 0, 3 and 7.
- Single dose of intramuscular vaccination on each of days 0, 3, 7 and sometime between days 14-28.
- Two site intramuscular vaccination on day 0, with single site vaccination on just days 7 and 21.
People who have been previously vaccinated (including those that previously received post-exposure prophylaxis) do not receive immunoglobulin. They get one of the following:
- 1 site intradermal vaccination on days 0 and 3.
- 4 site intradermal vaccination on day 0 only.
- 1 site intramuscular vaccination on days 0 and 3.
For any approach, if there’s a delay in the post-exposure prophylaxis schedule, you just continue as soon as possible rather than starting over (i.e. resume vs restart).
Pre-exposure vaccination can be given intramuscularly or intradermally.