Rabies Post-Exposure Prophylaxis Pathway

The exposure category, the vaccine schedule, and whether immunoglobulin is needed · v1.5

  • Wash the wound first, with soap and running water for 15 minutes, before any of this.
  • Enter the exposure category, the wound details and any previous immunisation.
  • You get the vaccine schedule, and whether rabies immunoglobulin or a monoclonal antibody is due, at what dose and where it is infiltrated.
  • The basis: the National Guidelines for Rabies Prophylaxis of the National Rabies Control Programme, 2019.

  • Pre-exposure prophylaxis, and the schedules for veterinarians, laboratory staff and other occupational groups.
  • Rabies once the illness has declared itself. Prophylaxis has nothing to offer at that point.
  • Tetanus prophylaxis and antibiotic cover for the bite wound, which the tetanus and wound prophylaxis tool in this catalogue carries.
  • The veterinary and public health side: animal quarantine, the 10-day observation itself, and notification.
  • The antibody titre that decides whether an immunocompromised patient needs further doses. The tool says to estimate it 14 days after the course and leaves the value to the laboratory and the treating team.
Exposure Category
Evidence-Based Pearls

1. Exposure Definition Cautions

Rule: The standard 10-day observation period applies strictly to domestic dogs and cats.
Animal Type Clinical Action
Wild Animals Universally treated as a Category III exposure.
Monkeys Treated as a Category III exposure. Monkey bites and scratches are among the commonest exposures presenting in Indian cities and temple towns, and the 10-day observation period does not apply to them.
Bats Bat rabies has not been conclusively demonstrated in India, and on that ground the National Guidelines for Rabies Prophylaxis, 2019 hold that exposure to a bat does not warrant PEP. WHO's position is the opposite, and treats bat exposure as Category III. Where the bite was abroad, or the species is uncertain, treat it as Category III.
Rodents/Rabbits Domestic rodents do not ordinarily require PEP. Forest rodents require PEP.

2. Contraindications and Safety

There are no contraindications: rabies, once it declares itself, is close to 100% fatal.
  • Safe in: Pregnancy, lactation, infancy, old age, and concurrent illnesses.
  • Delayed Presentation: Patients presenting months or years later must be evaluated and treated as if the exposure occurred recently.

3. Immunocompromised Protocol

In individuals with documented immunodeficiency (e.g., HIV/AIDS, patients on steroids or chemotherapy), immunological memory cannot be assured.
  • Passive Immunisation: RIG or RMAb must be administered for both Category II and Category III exposures.
  • Vaccine Route: Must be administered strictly via the Intramuscular (IM) route.
  • Follow-up: Estimate the antibody titre 14 days after the course is completed, and use it to decide whether further doses are needed.

4. Wound Management and Infiltration

Washing Flush thoroughly with soap and running water for 15 minutes, before any decision about vaccine or immunoglobulin, and never skipped for want of stock. Follow it with a virucidal antiseptic such as povidone iodine or alcohol.
Dosing ERIG: 40 IU/kg. HRIG: 20 IU/kg. Rabishield: 3.33 IU/kg. Twinrab: 40 IU/kg.
Infiltration Infiltrate the entire calculated dose directly into and around all wound margins. Administer any remaining volume IM at a site distant from the vaccine injection. WHO's 2018 position is that immunoglobulin beyond the wound margins adds nothing. NCDC 2019, which this tool follows, still advises giving the remainder intramuscularly.
Suturing Avoid suturing wherever it can be avoided. Where it is surgically unavoidable, clean the wound, infiltrate the immunoglobulin first, and delay the sutures by a few hours (NCDC 2019). Place as few loose sutures as the wound allows.
When the volume will not fit Where the wounds are too small to take the calculated volume, dilute the dose two to three fold with sterile normal saline so that every wound is covered. Do not exceed the calculated dose, and do not share a syringe or a site with the vaccine.
Tetanus and infection A bite is a tetanus-prone wound as well as a contaminated one. Decide the tetanus toxoid and immunoglobulin in the Tetanus Wound Prophylaxis pathway, and consider co-amoxiclav for a bite that is deep, on the hand or the face, or already inflamed.
Timing RIG/RMAb must not be administered beyond Day 7 after the first vaccine dose, as it may blunt the developing active immune response.

5. Rabies Monoclonal Antibodies (RMAb)

WHO 2018 Position Paper: If available, the use of monoclonal antibody products instead of RIG is encouraged for passive immunization during PEP.

Monoclonals are made in vitro, so potency holds from batch to batch, there is no blood-borne infection risk, and supply is easier to hold at a lower price. Infiltration follows the same principle as RIG: the full dose into and around the wound margins on Day 0.

Product Type Dose Key Evidence
Rabishield (SII, India) Single human IgG1 MAb (17C7) 3.33 IU/kg Phase 2/3 non-inferiority to HRIG; Day 14 GMC ratio 4.23 (Gogtay et al. 2018). Licensed India 2016.
Twinrab (Zydus, India) Cocktail of 2 murine MAbs (Docaravimab + Miromavimab) 40 IU/kg Phase 3 non-inferiority to HRIG (Kansagra et al. 2021). WHO EML inclusion 2021. Licensed India 2019.
Caution: Rabishield is dosed at 3.33 IU/kg and Twinrab at 40 IU/kg. Read the label on the vial in your hand before you calculate. They are not interchangeable on a per-IU basis.

6. What This Tool Does Not Print

  • A skin test protocol before ERIG. NCDC 2019 and the product inserts differ, and the Agent tooltip carries both.
  • A value for the antibody titre. Estimated at 14 days and left to the laboratory.
  • An antibiotic regimen beyond the co-amoxiclav indication in section 4.
Abbreviations AIDS (Acquired Immunodeficiency Syndrome) · ARV (Anti-Rabies Vaccine) · EML (Essential Medicines List) · ERIG (Equine RIG) · GMC (Geometric Mean Concentration) · HIV (Human Immunodeficiency Virus) · HRIG (Human RIG) · ID (Intradermal) · IgG1 (Immunoglobulin G1) · IM (Intramuscular) · IU (International Units) · MAb (Monoclonal Antibody) · NCDC (National Centre for Disease Control) · PEP (Post-Exposure Prophylaxis) · PrEP (Pre-Exposure Prophylaxis) · RIG (Rabies Immunoglobulin) · RMAb (Rabies Monoclonal Antibody) · RVNA (Rabies Virus Neutralising Antibody) · SII (Serum Institute of India) · WHO (World Health Organization)
References
  1. Ministry of Health and Family Welfare, Government of India. National Guidelines for Rabies Prophylaxis, 2019. National Rabies Control Programme, NCDC; 2020.
  2. World Health Organization. Rabies vaccines: WHO position paper, April 2018. Vaccine. 2018;36(37):5500-3.
  3. World Health Organization. Expert Consultation on Rabies, Third report. WHO Technical Report Series, No. 1012; 2018.
  4. Gogtay NJ, Munshi R, Ashwath Narayana DH, et al. Comparison of a Novel Human Rabies Monoclonal Antibody to Human Rabies Immunoglobulin for Postexposure Prophylaxis: A Phase 2/3, Randomized, Single-Blind, Noninferiority, Controlled Study. Clin Infect Dis. 2018;66(3):387-395.
  5. Kansagra K, Parmar D, Mendiratta SK, et al. A Phase 3, Randomised, Open-Label, Non-inferiority Trial Evaluating Anti-Rabies Monoclonal Antibody Cocktail (TwinRab) Against Human Rabies Immunoglobulin. Clin Infect Dis. 2021;72(12):e667-e675.
  6. Gongal G, Sampath G. Monoclonal antibodies for rabies post-exposure prophylaxis: A paradigm shift in passive immunization. Arch Prev Med. 2020;5(1):035-038.
How to Cite This Tool

DOIhttps://doi.org/10.5281/zenodo.22401634

AMA Style:Umakanth S. Rabies Post-Exposure Prophylaxis Pathway. Version 1.5. MEDiscuss Clinical Decision Support System. Published 2026. Accessed . https://mediscuss.org/cdss/rabies-pep. doi:10.5281/zenodo.22401634

Vancouver Style:Umakanth S. Rabies Post-Exposure Prophylaxis Pathway [Internet]. Version 1.5. MEDiscuss.org; 2026 [cited ]. Available from: https://mediscuss.org/cdss/rabies-pep. doi:10.5281/zenodo.22401634

Disclaimer and scope
Disclaimer: This decision-support system is written for healthcare professionals. It does not substitute clinical judgment, and the treating physician retains absolute responsibility for every diagnostic, dosing and therapeutic decision. The algorithms are built on the evidence as it stands, and the evidence moves. Verify the output against your current institutional protocol, and against the patient in front of you.
© 2026 MEDiscuss.org. All rights reserved. Provided free of charge for clinical use. Unauthorised reproduction or redistribution is strictly prohibited.
Category Immunisation & ProphylaxisPathway
Specialties Internal Medicine, Infectious Diseases

Written and maintained by

Dr Shashikiran Umakanth

Last revised 24 August 2026

How these tools are written and reviewed

Related Clinical Tools
Tetanus Prophylaxis PathwayNeedlestick & PEP PathwayAdult Immunisation Guide