Adult dose and durationOne intradermal dose is 0.1 mL; one intramuscular dose is the whole vial (0.5 mL or 1.0 mL depending on the product). Never previously vaccinated, category II or III exposure - any ONE of the three WHO regimens: 2-site intradermal on days 0, 3 and 7 (one-week course); OR 1-site IM on days 0, 3, 7 and one dose between day 14 and 28 (4-dose Essen); OR 2-site IM on day 0 then 1-site IM on days 7 and 21 (Zagreb). Previously vaccinated: 1-site intradermal on days 0 and 3, OR 4-site intradermal on day 0, OR 1-site IM on days 0 and 3 - and no immunoglobulin. x 7 days for the intradermal one-week course; 21 to 28 days for the intramuscular regimens. The schedule IS the dose - finish it.
Paediatric doseChildren get the SAME schedule and the SAME volumes as adults - there is no weight-based rabies dose, and WHO writes its regimens for individuals of all age groups. Only the site differs: an intramuscular rabies vaccine goes into the deltoid in an adult, and into either the deltoid or the anterolateral thigh in a child - for the youngest, under 2 years, WHO specifies the anterolateral area of the thigh.
Dose sourceWHO. Rabies vaccines: WHO position paper - April 2018. Wkly Epidemiol Rec. 2018;93(16):201-220 (who-rabies-position-paper-2018.txt), Administration of rabies vaccines and Table 1 Post-exposure prophylaxis (PEP) by category of exposure
WhyStray-dog bites are an everyday Cairo presentation. WHO states the indication and the schedule in one document: post-exposure prophylaxis is the wound washed and flushed thoroughly; then a course of rabies vaccine begun promptly after the exposure; and, where indicated, rabies immunoglobulin infiltrated into and around the wound, again promptly. The volumes and all three regimens are printed. This is still an emergency card: the patient goes to an anti-rabies centre today. The schedule is here so the referring doctor knows what is being started, can tell the patient how many visits it means, and can recognise an interrupted course. Four Egyptian products are registered, from 67.50 EGP. Note that the register files VERORAB under VACCINE RABIES rather than RABIES VACCINE.
Cautions- THIS IS AN EMERGENCY - the patient goes to an anti-rabies centre today, not at the next appointment. WHO's figure for post-exposure prophylaxis given promptly after a severe exposure is 100% prevention.
- Wash the wound first and for long enough. On animal work, washing under soap and water for 15 minutes or more cuts the risk of rabies by 30%. Follow it, where you have one, with a virucidal irrigation such as povidone-iodine.
- NEVER into the buttock. The article bars the gluteal site for the vaccine, and WHO says the same - no intramuscular rabies vaccine into the gluteal region. Nor do the vaccine and the human rabies immunoglobulin share a syringe or a site.
- There is no reason to withhold it. Rabies kills so reliably that no contraindication to the vaccine exists when it is given as post-exposure prophylaxis. Pregnancy and breastfeeding are not reasons to withhold it either: expert opinion worldwide holds the vaccine safe in pregnancy and while breastfeeding, and what data there are show no rise in fetal anomaly, in premature birth, or in miscarriage.
- Late is not too late. WHO's position is that a recognised category III exposure is always vaccinated, whether the contact was recent or months or years ago.
- Already vaccinated? Then vaccine only, no immunoglobulin - someone who has had the vaccine before needs the vaccine alone after an exposure judged to carry a rabies risk. Immunoglobulin must NOT be given to them: it gets in the way of the antibody response they would otherwise mount.
- A repeat exposure inside 3 months of a completed course needs neither. WHO: where the new exposure follows the last one by under 3 months and a full course of post-exposure prophylaxis was completed, treat the wound and stop there - no vaccine, no immunoglobulin.
- Vaccine quality matters: WHO backs only the vaccines grown in cell culture or in embryonated eggs (CCEEVs), each vial of a potency no lower than 2.5 IU, and advises against the nerve-tissue vaccines altogether.
- This is prophylaxis, not treatment. Neither the immunoglobulin nor the vaccine has any part in managing rabies once it is established - the clinical studies show that neither changes the course of the illness. Once hydrophobia and encephalitis have started, care is palliative.