Rabies post exposure prophylaxis (RPEP) of previously unimmunized individuals must consist of both rabies immune globulin (RIG) and rabies vaccine. Please read the entirety of this document.

DOCUMENTATION: Keep accurate records of RIG and vaccine administration by recording product name, date and time of administration, dose, site(s) of administration, route(s), lot number(s), and expiry date(s).

Important

Rabies Immune Globulin (RIG)

• DO NOT administer the rabies vaccine in the same anatomical site as the RIG.
• NEVER use the same syringe for both RIG and rabies vaccine.

Rabies Vaccine

• NEVER give rabies vaccine in the gluteal region.
• DO NOT administer rabies vaccine in the same anatomical site as the RIG.
• NEVER use the same syringe for both rabies vaccine and RIG.

Dosage

Rabies Immune Globulin (RIG)
The recommended dose of RIG is 20 IU/kg body weight for all age groups, including children. HyperRAB® S/D human RIG is supplied in 1 mL vials (300 IU/mL). Imogam and KamRAB are supplied in 2 mL vials (150 IU/mL).  
Please confirm patient weight (wt.). Calculate the dose of RIG in mL:  

For 1 mL vials containing 300 IU/mL RIG:
20 IU/kg x (client wt in kg) ÷ 300 IU/mL = dose in mL (dose in mL ÷ 1 mL/vial = # of vials to order) Example: A 70 kg adult would require 4.67 mL of RIG
For 2 mL vials containing 150 IU/mL RIG:
20 IU/kg x (client wt in kg) ÷ 150 IU/mL= dose in mL (dose in mL ÷ 2 mL/vial = # of vials to order) Example: A 70 kg adult would require 9.33 mL of RIG

Ensure the total calculated dosage is administered but do not exceed. There may be some RIG remaining in one of the vials after administration with the remainder of the RIG being discarded.

REMINDER: Unless not possible, reserve a limb free of RIG, in which to give the rabies vaccine.

Rabies Vaccine

Doses of rabies vaccine are provided according to Table 1 below. Each vial contains 1 mL of vaccine to be administered in its entirety each scheduled day. The full vial should be administered – there should NOT be any leftover vaccine after each dose.

Administration

Rabies Immune Globulin (RIG)

RIG is administered into the wound(s) ideally the same day (day 0) of the exposure, thereby providing immediate protective antibodies to where they are most effective. Wash, flush, and disinfect all wounds first.

• Administer RIG into the wound(s) (or site of exposure if a wound is not evident) and surrounding edges. This applies whether the wound is fresh or old.
• For multiple wound sites, divide the RIG into separate syringes and needles for each site.
• If possible, the FULL dose of RIG should be infiltrated into the wound(s) and surrounding area (as per above dosage).
• If the calculated dose of RIG is insufficient to infiltrate all wounds, the RIG (HyperRAB and Imogam) can be diluted in a diluent permitted by the specific product labelling in order to provide the full amount of RIG required for thorough infiltration of all wounds. KamRAB (RIG) can be diluted two-fold to three-fold with sterile saline (0.9% sodium chloride).
• Certain anatomical sites must be infiltrated carefully (such as fingers) to avoid increased pressures in the tissue compartment.
• If the entire calculated dose of RIG cannot be anatomically infiltrated around the wound or site of exposure, give the remainder of the dose IM (you can use the wounded limb), but reserve a limb free of RIG, in which to give rabies vaccine.
• If the site of the wound is unknown (e.g., some bat exposures or healed wounds), the entire dose should be administered intramuscularly. Reserve a limb free of RIG, in which to give rabies vaccine.

Rabies Vaccine

• DO NOT administer the rabies vaccine in the same anatomical site as the RIG.
• Administer vaccine intramuscularly in the deltoid or anterolateral thigh, distant to the site of RIG administration, preferably in a different limb.
• NEVER give the vaccine in the gluteal region.
• For infants and small children, the anterolateral thigh is preferred.

Schedule

Rabies Immune Globulin (RIG)

• RIG is ideally given on day zero (0) when rabies vaccine is given.
• RIG is not recommended if more than 7 days have elapsed after the first dose of rabies vaccine as it may interfere with antibody production.
• Exceeding the calculated recommended dose of RIG may interfere with antibody production.
• RIG is supplied in 1 mL or 2 mL vials. RCDHU will provide the appropriate number of vials according to the dosage calculation on page 1 based on a subjectively reported weight. Please confirm the patient’s weight.

Rabies Vaccine

Start RPEP as soon as possible after the exposure has been assessed. Administer the recommended doses as per the table below. Adhere to the schedule to achieve the most rapid protection possible. Advise all patients of the importance of follow-up for additional vaccine doses at the correct time intervals. A dose given before the minimum interval has elapsed will not count and will have to be repeated. Late doses mean delayed protection and the timing of subsequent doses must be adjusted to respect the minimum intervals.

Table 1. RPEP rabies vaccine schedule