Exposure category, vaccine regimen and immunoglobulin, following the WHO position paper of April 2018.
Before anything else — wash the wound. Immediate, thorough wound washing and flushing with soap and water, with copious amounts of water, is required. Where available, an iodine-containing, or similarly viricidal, topical preparation should be applied to the wound.
Decision-support only — not a prescription. This reproduces WHO 2018 guidance. Vaccine and immunoglobulin availability, and product choice, vary locally — check what your centre stocks and follow national policy where it differs. The treating clinician remains responsible.
✓ Clinically reviewed by Dr Syed Usama Hussain, MBBS, BSc · 05 Aug 2026.
Step 1 · What was the exposure?
WHO 2018 · exposure categories
Category I — No exposure
Touching or feeding animals, animal licks on intact skin.
Category II — Exposure
Nibbling of uncovered skin, minor scratches or abrasions without bleeding.
Category III — Severe exposure
Single or multiple transdermal bites or scratches, contamination of mucous membrane or broken skin with saliva from animal licks, exposures due to direct contact with bats.
Step 2 · Has the patient had rabies vaccine before?
WHO 2018 · previously immunised
No previous rabies vaccination
Immunologically naive — full course required.
Previously immunised
Has completed a rabies vaccine course at some point in the past.
Completed a full PEP course within the last 3 months
A recent, documented complete course.
Step 3 · Vaccine regimen
WHO 2018 · PEP schedules
Choose an exposure category and vaccination history first.
Step 4 · Rabies immunoglobulin
WHO 2018 · RIG
Infiltrate into the wound — do not give the remainder IM. Infiltrate as much as possible into the wound. The remainder of the calculated dose does NOT need to be injected intramuscularly at a distance from the wound — it can be fractionated into smaller individual syringes for other patients, aseptic retention given.
No skin test. As eRIG products are now highly purified, skin testing before administration is unnecessary and should be abandoned.
If RIG is unavailable. If RIG is not available, thorough prompt wound washing together with immediate administration of the first vaccine dose, followed by a complete course of rabies vaccine, is highly effective in preventing rabies. Vaccines should never be withheld, regardless of the availability of RIG.
If supply is limited, prioritise RIG for
If only a limited amount of RIG is available, WHO prioritises it for exposed patients meeting any of the following:
Multiple bites
Deep wounds
Bites to highly innervated parts of the body (head, neck, hands)
Severe immunodeficiency
The biting animal is a confirmed or probable rabies case
Bites, scratches or mucous-membrane exposures caused by a bat
Step 5 · Wound care and follow-up
WHO 2018 · wound management
Immediate, thorough wound washing and flushing with soap and water, with copious amounts of water, is required. Where available, an iodine-containing, or similarly viricidal, topical preparation should be applied to the wound.
Suturing. Wounds that require suturing should be sutured loosely, and only after RIG infiltration into the wound.
Practice points
Changes in rabies vaccine product and/or route of administration during the same PEP course are acceptable, if unavoidable, to ensure the course is completed.
Should a vaccine dose be delayed for any reason, the PEP schedule should be RESUMED, not restarted.
Individuals with documented immunodeficiency should be evaluated case by case and receive a complete course of ID or IM PEP, including RIG.
Category III includes any direct contact with bats — bat exposures are severe even without an obvious wound.
Frequently asked questions
What are the WHO rabies exposure categories?
Category I is touching or feeding animals, or licks on intact skin — no exposure, no PEP. Category II is nibbling of uncovered skin, or minor scratches or abrasions without bleeding — vaccine, no immunoglobulin. Category III is single or multiple transdermal bites or scratches, contamination of mucous membrane or broken skin with saliva, or any direct contact with bats — vaccine plus rabies immunoglobulin.
What is the shortest rabies vaccine schedule?
The one-week two-site intradermal regimen (the IPC regimen, 2-2-2-0-0): two sites on days 0, 3 and 7, completing the whole course in 7 days. It is dose- and cost-sparing, and WHO notes cost-effectiveness rises with the number of patients a clinic sees — which suits a busy OPD.
Should the leftover rabies immunoglobulin be given intramuscularly?
No — and this changed in 2018. WHO now advises infiltrating as much as possible into the wound, and states the remainder of the calculated dose does not need to be injected intramuscularly at a distance from the wound. It can instead be fractionated into smaller syringes for other patients. The older teaching of giving the rest IM is obsolete.
Do I need to skin test before giving equine immunoglobulin?
No. WHO states that as eRIG products are now highly purified, skin testing before administration is unnecessary and should be abandoned.
What if immunoglobulin is not available?
Give the vaccine anyway. WHO is explicit: thorough prompt wound washing with immediate administration of the first vaccine dose, followed by a complete course, is highly effective — and vaccines should never be withheld regardless of immunoglobulin availability. If supply is limited, WHO prioritises RIG for multiple bites, deep wounds, bites to highly innervated areas such as head, neck and hands, severe immunodeficiency, a confirmed or probable rabid biting animal, and bat exposures.
What is the maximum immunoglobulin dose?
20 IU/kg for human RIG and 40 IU/kg for equine RIG. WHO states these are maximums and that there is no minimum dose — the volume actually given is limited by how much can be infiltrated into the wound.
What if the patient has had rabies vaccine before?
A previously immunised patient needs only one site intradermally on days 0 and 3, or four sites intradermally on day 0, or one site intramuscularly on days 0 and 3. Immunoglobulin is never indicated for them. And if they completed a full PEP course within the last 3 months, only wound treatment is required — no vaccine and no immunoglobulin.
What if a vaccine dose is missed or delayed?
Resume the schedule — do not restart it. WHO also accepts changing vaccine product or route mid-course if that is unavoidable to get the course finished.
Can wounds be sutured?
Wounds that require suturing should be sutured loosely, and only after immunoglobulin has been infiltrated into the wound.
Clinically reviewed by Dr Syed Usama Hussain, MBBS, BSc
MBBS, BSc — active medical practitioner in Pakistan. Graduated from Federal Medical & Dental College, Islamabad (2021) and completed a one-year clinical internship at the Pakistan Institute of Medical Sciences (PIMS), Islamabad (2022).
Sources
WHO — Rabies vaccines: WHO position paper, April 2018 (Weekly Epidemiological Record 93/16)
WHO Expert Consultation on Rabies, third report — WHO Technical Report Series, Geneva 2018
Background reading — the wound-washing step, the bleeding line between Category II and III, and why the immunoglobulin remainder should never go into a buttock: dog bite in Pakistan.