What is the recommended dose and administration schedule for intradermal (ID) rabies vaccination?

Intradermal Rabies Vaccination: Dose and Schedule

For intradermal (ID) rabies preexposure prophylaxis, administer three 0.1-mL doses of HDCV (Imovax Rabies I.D.) over the deltoid area on days 0,7, and 21 or 28. 1

Approved Vaccine and Administration

• Only HDCV (Imovax Rabies I.D.) is FDA-approved for intradermal administration in the United States, specifically in a pre-packaged syringe designed to reliably deliver 0.1 mL 1
• The vaccine must be reconstituted in the syringe just before administration 1, 2
• RVA and PCEC are NOT approved for intradermal use and should never be administered by this route 1
• The 1.0-mL vial of HDCV is not approved for multidose ID use 1

Injection Site

• Administer in the area over the deltoid (lateral aspect of the upper arm), not the gluteal area 1
• Each 0.1-mL dose is given at a single site per visit 1

Critical Contraindications for ID Route

Do not use the intradermal route if the patient is taking antimalarial medications (chloroquine, mefloquine, or structurally related drugs), as these interfere with antibody response to ID vaccination 1

Management with antimalarials:

• If ID vaccination can be completed at least 1 month before starting antimalarial prophylaxis, proceed with ID route 1
• If this timeline is not possible, switch to the intramuscular route (three 1.0-mL doses on days 0,7, and 21 or 28) 1
• The IM route provides sufficient safety margin when antimalarials are being used 1

Booster Dosing

• For routine preexposure booster vaccination, administer a single 0.1-mL ID dose 1
• Booster frequency depends on risk category:
  • Continuous risk (laboratory workers with rabies virus): test antibody every 6 months, boost if titer falls below 1:5 neutralization 1
  • Frequent risk (veterinarians, animal control officers): test antibody every 2 years, boost if inadequate 1

Postexposure Management

Previously vaccinated persons exposed to rabies should receive two 1.0-mL IM doses (not ID) on days 0 and 3, without rabies immune globulin 1, 3

Important Caveats

• While research shows ID regimens can be effective for postexposure prophylaxis in resource-limited settings 4, 5, this is not FDA-approved in the United States 1
• Some evidence suggests ID preexposure vaccination may produce lower anamnestic responses compared to IM vaccination, though all subjects ultimately achieve protective titers by day 14 6
• The ID route is cost-effective but requires strict adherence to approved products and administration technique 1