a Includes situations where the exposure may be difficult to categorise, because a person does not know or cannot communicate if or how an exposure to a bat has occurred.
b Previously immunised — documentation of a completed recommended pre-exposure prophylaxis or PEP rabies vaccine regimen. This is regardless of the time since the last dose was given. It may be either a completed primary pre-exposure course or a post-exposure course, and includes people given subsequent boosters or whose documented rabies VNAb titres are ≥0.5 IU/mL.
c Non-immune — person who has never received pre- or post-exposure rabies vaccine, or has had an incomplete or inadequate primary vaccination course.
There are 3 categories of exposure to lyssaviruses from bats: 1) touching or feeding animals, or animal licks on intact skin. 2) Animal nibbling of uncovered skin, or minor scratches or abrasions without bleeding. 3) Single or multiple transdermal bites or scratches; or contamination of mucous membrane or broken skin with saliva from animal licks (also see note a). Category 1 does not require any prophylaxis if the contact history is reliable. Category II or III exposure in people who have been previously immunised (see note b) requires vaccination. If in doubt, treat as non-immune (see note b). Immunocompetent people and immunocompromised people receive 2 doses intramuscularly on days 0 and 3. HRIG is not indicated. Immunocompromised people should have their serology checked 2–4 weeks after dose 2; if VNAb titre is <0.5 IU/mL, seek expert advice for total number of doses. Category II or III exposure in a non-immune person (see note b) requires vaccination and HRIG. Immunocompetent people receive 4 doses intramuscularly on days 0, 3, 7 and 14. They receive 1 dose of HRIG as soon as possible after starting PEP. Do not give HRIG beyond the 7th day after the 1st vaccine dose on day 0. Immunocompromised people receive 5 doses on days 0, 3, 7, 14 and 28. They receive 1 dose of HRIG as soon as possible after starting PEP. Do not give HRIG beyond the 7th day after the 1st vaccine dose on day 0. Immunocompromised people also have their serology checked 2–4 weeks after dose 5, and receive another dose if VNAb titre is <0.5 IU/mL. If any of these groups is further exposed in the future, treat as previously immunised and follow the algorithm as above. If there is ongoing occupational exposure, see the booster algorithm.
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Figure. Post-exposure prophylaxis algorithm for potential exposure to lyssaviruses from a terrestrial animal in a rabies-enzootic area
Figure. Recommended technique for giving multiple vaccine injections into the anterolateral thigh in an infant
- human rabies immunoglobulin
- post-exposure prophylaxis
- international units