What should be done if a dose of anti-rabies vaccine (ARV) is missed?

Management of Missed Anti-Rabies Vaccine Doses

If a dose of anti-rabies vaccine (ARV) is missed, the vaccination should be resumed as though the patient were on schedule without restarting the entire series, maintaining the same interval between remaining doses. 1

General Principles for Managing Missed Doses

• For minor deviations from the schedule (delays of a few days), the missed dose should be administered as soon as possible and the schedule resumed from that point 1
• Most interruptions in the vaccine schedule do not require reinitiating the entire series 1
• Once vaccination is initiated, short delays for individual doses are not considered clinically significant for effectiveness 1

Specific Approach to Missed Doses

For Minor Delays (Few Days):

• Administer the missed dose immediately when the patient presents 1
• Continue with the remaining doses, maintaining the same intervals between subsequent doses 1
• Example: If a patient misses the day 7 dose and presents on day 10, administer the day 7 dose on day 10 and adjust subsequent doses accordingly 1

For Substantial Delays (Weeks or More):

• Still administer the missed dose when the patient presents 1
• Complete the remaining doses of the series 1
• Consider immune status assessment by performing serologic testing 7-14 days after administration of the final dose in the series 1

Important Considerations

• The standard post-exposure prophylaxis (PEP) regimen for unvaccinated persons now consists of 4 doses (days 0,3,7, and 14) rather than the previous 5-dose schedule 1, 2
• The effectiveness of PEP depends primarily on the first 4 doses, with evidence showing that all healthy persons develop rabies virus-neutralizing antibodies by day 14 1
• Rabies is nearly always fatal once symptoms appear, making timely completion of the vaccination series critical 3
• Wound cleansing and proper administration of rabies immune globulin (RIG) at the wound site remain essential components of PEP 1

Common Pitfalls to Avoid

• Never restart the entire vaccination series due to minor delays 1
• Never administer rabies vaccine in the gluteal area as this results in lower neutralizing antibody titers; use the deltoid for adults or anterolateral thigh for children 1
• Never administer human rabies immune globulin (HRIG) in the same syringe or anatomical site as the first vaccine dose 1
• Do not assume that a missed dose negates the effectiveness of previously administered doses 1

Special Situations

• For patients who received partial PEP outside the United States with regimens or biologics not used in the US, consult state or local health departments for specific advice 1
• For immunocompromised patients, the standard 5-dose regimen may still be recommended, and serologic testing should be considered to confirm adequate response 2