Table 1.

World Health Organization (WHO) recommendations for human rabies management.

Categories of Exposure to Suspected or Confirmed Rabid Animal and Actions Required
Category I	Touching or feeding animals
	Licks on intact skin
	Contact of intact skin with secretions or excretions of a rabid animal or human case
	Action required: not regarded as exposures, no post-exposure prophylaxis is required
Category II	Nibbling of uncovered skin
	Minor scratches or abrasions without bleeding
	Action required: thorough local wound care and vaccine injection as soon as possible
Category III	Single or multiple transdermal bites or scratches
	Contamination of mucous membrane with saliva from licks
	Licks on broken skin
	Exposures to bat bites or scratches
	Action required: thorough local wound care and administration of vaccine and RIG as soon as possible
Passive Immunization: Rabies Immunoglobulin (RIG)
Target population	All people with category III exposure, bites to the head, neck, face, and genitals
	Immunodeficient people with category II exposure
	Not for previously vaccinated individuals
Type, dose	Human rabies immunoglobulin: 20 IU/kg body weight
	Equine immunoglobulin: 40 IU/kg body weight
	F(ab’)2 products of equine immunoglobulin: 40 IU/kg body weight
Time and site	One administration as soon as possible, and within seven days from vaccination
	Into or around the wound site or sites. The remaining RIG (if any) should be administered IM at a site distant from the vaccination site
Active Immunization: Vaccines
Types	Cell culture vaccine (CCV) and embryonated egg-based vaccines (CCEEVs):
	-Purified Vero cell rabies vaccine (PVRV)
	-Purified chick embryo cell vaccine (PCECV)
	-Human diploid cells vaccine (HDCV)
	and
	-Purified duck embryo vaccine (PDEV)
Potency	≥2.5 IU per single IM
Route of administration, dose, vaccine type, and injection sites	Intramuscular (IM), 1.0 mL or 0.5 mL (volume depending on the type of vaccine).
	-Vaccine type: any CCEEVs
	Sites:
	-Adults and children ≥2 years: in the deltoid area of the arm
	-Children <2 years: in the anterolateral area of thigh
	-Never in the gluteal area
	Intradermal (ID), 0.1 mL per ID site
	-Vaccine type: only PVRV or PCECV
	Sites:
	-The deltoids
	-Lateral thighs
	-Suprascapular areas
Pre-Exposure Prophylaxis
Indication	Anyone at continual, frequent, or increased risk of exposure to the rabies virus, either as a result of their residence or occupation (laboratory staff, veterinarians, animal handlers and wildlife officers, etc.)
	Travelers with extensive outdoor exposure in rural high-risk areas
	Children living or visiting rabies-affected areas
IM vaccination regimen	3 doses, one IM dose on each of days 0, 7, and 21 or 28
ID vaccination regimen	3 doses, one ID injection of 0.1 mL on each of days 0, 7, and 21 or 28 *
Booster injections	Only for those working under continuous or frequent risk of exposure †, if rabies-virus neutralizing antibody titers is <0.5 IU/mL
Post-Exposure Prophylaxis
Indication	No vaccination is required for category I
	Immediate vaccination is required for category II
	Immediate vaccination is required for category III, (and administration of RIG)
Wound care	Immediate thorough washing and flushing, for 15 min, with soap or detergent
	Topical application of povidone iodine or other substances with virucidal activity
	A bleeding wound must be infiltrated with RIG
	Postpone suturing if possible; if suturing is necessary ensure that RIG has been applied locally
	Antibiotics and tetanus prophylaxis should be applied as appropriate for potentially contaminated wounds
IM vaccination regimen §	5-dose, Essen regimen (1-1-1-1-1):
	one dose on each of days 0, 3, 7, 14, and 28
	4-dose, Zagreb regimen (2-0-1-0-1 or 2-1-1):
	2 doses on day 0 (one in each of the two deltoid or thigh sites) followed by one dose on each of days 7 and 21
	4-dose shortened Essen regimen (1-1-1-1-0) for fully immunocompetent, exposed people who received wound care + high quality RIG + WHO prequalified rabies vaccine:
	One dose on each of days 0, 3, 7, and 14
	For immunocompromised individuals including patients with HIV/AIDS:
	5-dose CCEEV regimen + wound care + local infiltration with human RIG. Evaluation of the rabies-virus neutralizing antibody 2–4 weeks after vaccination and administration of an additional vaccine dose if needed.
ID vaccination regimen §	The updated Thai Red Cross regimen (2-2-2-0-2):
	Injections of 0.1 mL at two sites (deltoid and thigh) on each of days 0, 3, 7, and 28
Short Post-Exposure Prophylaxis for Previously Vaccinated Individuals
Exposed or re-exposed individuals, or individuals with rabies-virus neutralizing antibody titers of ≥0.5 IU/mL:
-One CCEEV IM dose OR one CCV ID dose on each of days 0 and 3, OR
-One visit four site: four ID injections at a single visit
-No RIG should be applied
Individuals exposed or re-exposed three months after complete vaccination:
-Wound care and booster vaccination if the dog or cat is healthy, vaccinated and available for an observation period of 10 days
Individuals with category III re- exposure who were vaccinated with a vaccine of unproven potency, or have received an incomplete course of vaccination:
-Full post-exposure vaccination course + RIG

Sources: Rabies vaccines: WHO position paper (2010) [13] and WHO Expert Consultation on Rabies (2013) [1]; Abbreviations: CCEEV, cell culture vaccine and embryonated egg-based vaccines; CCV, cell culture vaccine; HDCV, human diploid cells vaccine; ID, intradermal; IM, intramuscular; PCECV, purified chick embryo cell vaccine; PDEV, purified duck embryo vaccine; PVRV, purified Vero rabies vaccine; RIG, rabies immunoglobulin; WHO, World Health Organization; * within 6–8 h, several individuals should be vaccinated in order to utilize all the volume of the opened vials, reducing thus the overall cost; ^† antibody monitoring, is preferred to booster injections. Every six months for those at risk of exposure to high concentrations of live rabies virus (e.g., laboratory workers dealing with rabies virus and other lyssaviruses), and every two years for those not at continuous risk of exposure (e.g., veterinarians and animal health officers); ^§ at exceptional circumstances and when it is not possible to complete post-exposure prophylaxis with the same CCEEV, a rabies CCV fulfilling the WHO requirements should be used.