What is the recommended dose of rabies (Rabies Immunoglobulin) vaccine?

From the Guidelines

The recommended dose of rabies vaccine for postexposure prophylaxis in previously unvaccinated persons is a regimen of 5 1-mL doses of HDCV or PCECV administered intramuscularly on days 0,3,7,14, and 28, while for pre-exposure prophylaxis, three 1.0-mL injections of HDCV or PCECV are administered intramuscularly on days 0,7, and 21 or 28. When considering the administration of the rabies vaccine, it is crucial to prioritize the most recent and highest quality evidence to ensure optimal outcomes in terms of morbidity, mortality, and quality of life. According to the recommendations of the Advisory Committee on Immunization Practices 1, the dose and schedule of the rabies vaccine are tailored based on the individual's vaccination history. For individuals who have never been vaccinated against rabies, the postexposure antirabies vaccination should include administration of both passive antibody (HRIG) and vaccine (HDCV or PCECV), with HRIG administered only once at the beginning of antirabies prophylaxis. Key points to consider in the administration of the rabies vaccine include:

• The first dose of the vaccine should be administered as soon as possible after exposure (day 0) for postexposure prophylaxis.
• Additional doses should then be administered on days 3,7,14, and 28 after the first vaccination for previously unvaccinated persons.
• For pre-exposure vaccination, the regimen consists of three 1.0-mL injections of HDCV or PCECV administered intramuscularly on days 0,7, and 21 or 28.
• The vaccine should be injected into the deltoid muscle in adults or the anterolateral thigh in children, as recommended by general medical practice guidelines, although specific injection site recommendations are not detailed in 1. It is essential to follow these guidelines to ensure effective prevention of rabies, considering the severity of the disease and its nearly always fatal outcome once symptoms appear, as implied by the critical need for prompt and thorough prophylaxis 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION The recommended dose for HyperRAB S/D is 20 IU/kg (0.133 mL/kg) of body weight given preferably at the time of the first vaccine dose. VaccineHDCV, RVA, or PCEC 1. 0 mL, IM (deltoid area† ), one each on days 0‡, 3,7,14, and 28. The dose of rabies vaccine is 1.0 mL administered intramuscularly, with a schedule of:

• Day 0: 1.0 mL
• Day 3: 1.0 mL
• Day 7: 1.0 mL
• Day 14: 1.0 mL
• Day 28: 1.0 mL 2

From the Research

Dose of Rabies Vaccine

• The recommended dose of rabies vaccine is 4 doses on days 0,3,7, and 14 for previously unvaccinated persons, as part of postexposure prophylaxis to prevent human rabies 3, 4.
• This 4-dose vaccine schedule is safe and effective, and is likely to induce an adequate, long-lasting antibody response that is able to neutralize rabies virus and prevent disease in exposed patients 3.
• Abridged schedules with less doses have potential to save costs, increase patient compliance, and thereby improve equitable access to life-saving postexposure prophylaxis for at-risk populations 5.
• The 1-week, 2-site intradermal postexposure prophylaxis schedule was found to be most advantageous, as it was safe, immunogenic, supported by clinical outcome data and involved the least direct costs compared to other schedules 5.
• Changes in the rabies vaccine product and/or the route of administration during postexposure prophylaxis is possible, and evidence suggests that it is safe and immunogenic 6.
• The Advisory Committee on Immunization Practices (ACIP) guidelines for the vaccination series, as well as the 20 units/kg administration of immunoglobulin (RIG), are commonly followed for postexposure prophylaxis 7.

Special Considerations

• Gaps exist in understanding the safety and immunogenicity of novel postexposure prophylaxis schedules in special populations such as infants and immunocompromised individuals 5.
• Available data indicate that administering rabies vaccines during pregnancy is safe and effective 5.
• Patient compliance for follow-up rabies vaccine series completion can be improved by scheduling the remainder of the vaccination series at an outpatient infusion center or by using a "Nurse Only" return visit to the Emergency Department 7.

Administration

• The route of administration of rabies vaccine can be either intramuscular or intradermal, and changes in the route of administration during postexposure prophylaxis is possible 6.
• The use of a dose rounding protocol for RIG can result in potential cost savings 7.