Rabies Post-Exposure Prophylaxis Pathway

Based on the Indian National Guidelines for Rabies Prophylaxis (2019) & WHO Position Paper (2018) · v1.5
How to use this tool: Enter the exposure category, the wound details and the previous immunisation status. The tool returns the vaccine schedule, and whether rabies immunoglobulin or monoclonal antibody is needed and at what dose.
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.
Bats Exposure does not currently warrant PEP in India.
Rodents/Rabbits Domestic rodents do not ordinarily require PEP. Forest rodents require PEP.
2. Contraindications & Safety
Zero Contraindications: Due to the ~100% fatality rate, there are absolutely no contraindications to PEP.
  • 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 Immunization: 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: Antibody titer estimation is recommended 14 days after completion to assess the need for additional doses.
4. Wound Management & Passive Immunization Infiltration
Washing Flush thoroughly with soap and water for 15 minutes. Apply virucidal antiseptics like 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.
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): The Paradigm Shift
WHO 2018 Position Paper: If available, the use of monoclonal antibody products instead of RIG is encouraged for passive immunization during PEP.

Two RMAb products are licensed in India and serve as alternatives to conventional RIG. Unlike polyclonal RIG (derived from human or equine plasma), monoclonal antibodies are produced in vitro, offering consistent batch-to-batch potency, no risk of blood-borne pathogens, and potentially superior supply at lower cost. The infiltration principle is identical to RIG: instill the full dose into and around 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.
Dosing Alert: Rabishield (3.33 IU/kg) and Twinrab (40 IU/kg) have vastly different dose calculations. Always verify the specific product before calculating the dose. These are NOT interchangeable on a per-IU basis.
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)
Algorithm References & Evidence Base
  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

AMA Style:
Umakanth S. Rabies Post-Exposure Prophylaxis Pathway. MEDiscuss. Published 2026. Accessed .

Vancouver Style:
Umakanth S. Rabies Post-Exposure Prophylaxis Pathway [Internet]. MEDiscuss.org; 2026 [cited ]. Available from:

Disclaimer and scope
Disclaimer: This decision-support system is intended for healthcare professionals. It does not substitute clinical judgment. These algorithms are evidence-based, but medical knowledge evolves continuously. The treating physician retains absolute responsibility for all diagnostic, dosing, and therapeutic decisions. Always verify outputs against current institutional protocols and individual patient contexts.
© 2026 MEDiscuss.org. All rights reserved. This CDSS Module was designed and developed by Dr. Shashikiran Umakanth using the available evidence base. 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: 29 July 2026
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