What is the recommended follow-up schedule after post-exposure rabies prophylaxis (PERP)?

Recommended Follow-up Schedule After Post-Exposure Rabies Prophylaxis (PERP)

For previously unvaccinated individuals who receive post-exposure rabies prophylaxis, the recommended follow-up schedule includes vaccine doses on days 0,3,7, and 14, with no routine serologic testing required after completion of the regimen. 1, 2

Standard Follow-up Schedule

Previously Unvaccinated Individuals

• The 4-dose vaccination regimen should be administered intramuscularly on days 0,3,7, and 14, with day 0 being the day the first dose is administered 1, 2
• Human rabies immune globulin (HRIG) is administered only once on day 0 at the time PEP is initiated 1
• If HRIG was not administered when vaccination began on day 0, it can be administered up to and including day 7 of the PEP series 1, 2
• No routine serologic testing is necessary for healthy individuals after completion of PEP 1

Previously Vaccinated Individuals

• Only 2 vaccine doses are required, administered on days 0 and 3 1, 2
• HRIG should not be administered to previously vaccinated persons 1
• No serologic testing is required after completion of the 2-dose regimen 1

Special Populations

Immunocompromised Individuals

• Require a 5-dose vaccination regimen on days 0,3,7,14, and 28 1, 2
• HRIG is administered once on day 0 1
• Serologic testing is recommended 1-2 weeks after completion of the vaccination series to confirm adequate antibody response 1, 2

Managing Deviations from the Schedule

• Minor delays of a few days for individual doses are generally not significant 1
• For minor deviations, vaccination can be resumed as though the patient were on schedule 1
• Example: If a patient misses the day 7 dose and presents on day 10, the day 7 dose should be administered that day and the schedule resumed, with the remaining dose given on day 17 1
• For substantial deviations from the schedule, immune status should be assessed by performing serologic testing 7-14 days after administration of the final dose 1

Post-Completion Monitoring

• No routine post-vaccination serologic testing is necessary for healthy individuals completing the recommended PEP regimen 1, 2
• When titers are obtained (such as in immunocompromised patients), serum specimens collected 1-2 weeks after prophylaxis should completely neutralize challenge virus at least at a 1:5 serum dilution by the rapid fluorescent focus inhibition test (RFFIT) 1
• No additional follow-up visits are required after completion of the vaccine series unless the patient develops concerning symptoms 2

Common Pitfalls and Caveats

• The gluteal area should never be used for vaccine administration as it may result in diminished immune response 1, 2
• Administering more than the recommended dose of HRIG might partially suppress active production of rabies virus antibody 1
• Deviations from the recommended vaccination schedule have been associated with vaccination failure and human mortality 3
• The 4-dose schedule is only for immunocompetent individuals; immunocompromised patients still require the full 5-dose regimen 2, 4

When administered properly and according to schedule, rabies PEP is nearly 100% effective in preventing human rabies 2, 4. The follow-up schedule is designed to ensure adequate antibody response while minimizing unnecessary doses and clinic visits.