All cases of suspected exposure to rabies should be treated immediately in order to prevent the onset of symptoms and death. Post-exposure prophylaxis (PEP) consists of local treatment of the wound, a course of potent, effective rabies vaccine that meets WHO recommendations and administration of rabies immunoglobulin (if indicated).

Prompt local treatment of all potentially contaminated bite wounds and scratches with immediate, thorough flushing and washing of the wound for a minumum of 15 minutes with soap and water, detergent, povidone iodine or other substances with virucidal activity is an effective means of protection.

The recommended post-exposure prophylaxis depends on the category of exposure to suspected or confirmed rabid animals (see table).

Recommended post-exposure prophylaxis for rabies infection

Category of exposure to suspect rabid animal Post-exposure measures
Category I – touching or feeding animals, licks on intact skin (i.e. no exposure) None
Category II – nibbling of uncovered skin, minor scratches or abrasions without bleeding Immediate vaccination and local treatment of the wound
Category III – single or multiple transdermal bites or scratches, licks on broken skin; contamination of mucous membrane with saliva from licks, exposures to bats. Immediate vaccination and administration of rabies immunoglobulin; local treatment of the wound

WHO recommends replacement of the nerve tissue vaccine with modern concentrated and purified cell culture derived and embryonated egg-based rabies vaccines. Intradermal vaccination has been shown to be as safe and immunogenic as intramuscular vaccination and requires a lower volume for both pre- and post-exposure prophylaxis, leading to lower direct costs. This alternative should thus be considered in settings constrained by cost and/or supply issues.

Other factors that should be taken into consideration when deciding whether to initiate post-exposure prevention include:

  • The likelihood of the implicated animal being rabid
  • The clinical features of the animal and its availability for observation and laboratory testing

In developing countries, the vaccination status of the suspected animal alone should not be considered when deciding whether to initiate prophylaxis or not.