Tetanus & Rabies Post-Exposure Prophylaxis

Tetanus & Rabies Opener.jpeg

This module describes how to give post-exposure prophylaxis for tetanus and rabies. Both tetanus and rabies are notifiable diseases. Contact the Department of Environmental Health of your local municipality to report suspected cases.

Tetanus prophylaxis is given as primary immunisation for children, booster vaccines every 10 years, and post-exposure as a vaccine (passive) and an immunoglobulin (active). Rabies vaccines are only given to people at high risk of exposure such as veterinarians and animal handlers, or post-exposure with or without immunoglobulin.


Tetanus

Tetanus exposure

Tetanus-prone wounds tend to be:

  1. Older than 6 hours

  2. More than 1 cm deep

  3. Star-shaped or avulsed (torn skin) wounds

  4. Containing dead tissue

  5. Contaminated with dirt, manure or rust

  6. Gunshot wounds

  7. Puncture or crush wounds

  8. Wounds from burns or frostbite

All other wounds are considered non-tetanus-prone.

Tetanus prophylaxis schedule

Patient who was fully vaccinated as a child:

Tetanus-prone wound: administer an intramuscular tetanus vaccine in the deltoid if their last tetanus vaccine or booster was given more than

. If giving the vaccine, also administer tetanus immunoglobulin into the opposite deltoid, only if immunodeficient/IV drug user. Other wound: give a tetanus vaccine if their last tetanus vaccine or booster was given more than 10 years ago.

Patient who was not fully vaccinated as a child:

Tetanus-prone wound: give a tetanus vaccine, and a dose of tetanus immunoglobulin. Other wound: give a tetanus vaccine, but no tetanus immunoglobulin. Refer these patients to their local clinic to complete their immunisation.

Rabies

Rabies exposure

Rabies is spread by

, and is rare in South Africa, but 100% fatal.

  • Risk category I: Touching or feeding an animal suspected of rabies
  • Risk category II: Animal nibbling skin or causing minor scratches without bleeding
  • Risk category III: Animal bites, scratches drawing blood, contamination of mucus membranes, or licking broken skin

Rabies prophylaxis

  • Risk category I: None required.
  • Risk category II: Give one dose of the rabies vaccine into the deltoid on days 0, 3, 7, 14, and 28.
  • Risk category III: Give one dose of the rabies vaccine into the deltoid on days 0, 3, 7, 14, and 28.

Give 20 IU/kg rabies immunoglobulin into and around the wound, with first dose as soon as possible. Inject the rest intramuscularly into the deltoid,

, unless the wound is in the buttock.


Refer to Intramuscular Injection for technique, troubleshooting, and risks.

Additionally, in suspected rabies cases:

  1. Wash the wound thoroughly with soap under running water for 5-10 minutes.

  2. Apply disinfectant if available.

  3. Do not suture bite wounds unless on the head/face.

  4. Clean thoroughly, dress (avoid compressive dressings) and review after 48 hours for secondary closure at that time.

  5. If possible, the suspect animal should be observed, and if still well after 10 days, rabies prophylaxis may be stopped.

  6. Antibiotics are only indicated for category III exposure for hand wounds.


  1. Newell KA. Wound Closure.In: Essential Clinical Procedures, Third Edition. Philadelphia: Elsevier; 2013. p. 250-272.

  2. Centers for Disease Control and Prevention. Tetanus: For Clinicians. Available at: https://www.cdc.gov/tetanus/clinicians.html

  3. WHO. WHO Guide for Rabies Pre and Post Exposure Prophylaxis in Humans. 2014.