Protocol for Administering Catch-Up Doses of Human Rabies Vaccine
For most minor deviations from the rabies vaccination schedule, simply administer the missed dose when the patient presents and resume the schedule from that point, maintaining the same intervals between remaining doses. 1
General Principles for Missed Rabies Vaccine Doses
- Once rabies vaccination is initiated, delays of a few days for individual doses are considered unimportant, though the effect of longer lapses of weeks or more is unknown 1
- Most interruptions in the vaccine schedule do not require restarting the entire series 1
- The current recommended schedule for previously unvaccinated persons is 4 doses administered on days 0,3,7, and 14 1, 2
Specific Approach to Catch-Up Dosing
- When a patient misses a scheduled dose, administer the missed dose immediately when they present for care 1
- Resume the vaccination schedule from that point, maintaining the same interval between subsequent doses 1
- For example, if a patient misses the dose scheduled for day 7 and presents on day 10:
- Administer the day 7 dose immediately on day 10
- Schedule the remaining doses at the same intervals (i.e., 7 days later on day 17, and 14 days after that on day 31) 1
Special Considerations
- All rabies vaccine doses should be administered intramuscularly in the deltoid area for adults and older children, or in the anterolateral thigh for younger children 1, 3
- Never administer rabies vaccine in the gluteal area as this may result in lower neutralizing antibody titers 1, 3
- For substantial deviations from the schedule, immune status should be assessed by performing serologic testing 7-14 days after administration of the final dose in the series 1
Importance of Completing the Series
- Every attempt should be made to adhere to the recommended vaccination schedule as rabies is nearly 100% fatal once clinical symptoms develop 2, 4
- Even with delayed recognition of exposure or interruptions in the vaccine schedule, post-exposure prophylaxis should still be completed 3, 4
- The full series must be completed to ensure adequate protection against rabies 4, 5
Different Scenarios Based on Vaccination Status
- For previously unvaccinated persons: Complete the 4-dose series (days 0,3,7,14) with catch-up as needed 1, 2
- For immunocompromised patients: The 5-dose schedule (days 0,3,7,14,28) is still recommended 1, 3
- For previously vaccinated persons: Only 2 doses are required (days 0 and 3), so if one is missed, simply administer it as soon as possible 1, 3
Human Rabies Immune Globulin (HRIG) Considerations
- HRIG is administered only once at the beginning of post-exposure prophylaxis for previously unvaccinated persons 1, 2
- If HRIG was not administered when vaccination began (day 0), it can be given up to and including day 7 of the post-exposure prophylaxis series 1, 3
- Beyond day 7, HRIG is not indicated as antibody response to the vaccine is presumed to have occurred 1