What is the alternative if a rabies vaccine dose is skipped?

Management of Skipped Rabies Vaccine Doses

If a rabies vaccine dose is skipped, simply resume the vaccination schedule as though the patient were on schedule, maintaining the same intervals between doses—do not restart the entire series. 1

Core Principle for Schedule Deviations

• Delays of a few days for individual doses are unimportant, and most interruptions in the vaccine schedule do not require reinitiation of the entire series. 1
• For minor deviations, vaccination can be resumed by administering the missed dose immediately and then continuing with the remaining doses while maintaining the same intervals between them. 1

Practical Example of Schedule Adjustment

• If a patient misses the dose scheduled for day 7 and presents on day 10, administer the day 7 dose immediately on day 10, then resume the schedule with the remaining doses on days 17 and 31 (maintaining the 7-day and 14-day intervals). 1
• This approach applies to the current 4-dose regimen (days 0,3,7,14) for previously unvaccinated persons. 1

When to Assess Immune Status

• When substantial deviations from the schedule occur (lapses of weeks or more), immune status should be assessed by performing serologic testing 7-14 days after administration of the final dose in the series. 1
• The effect of longer lapses of weeks or more is unknown, making serologic confirmation prudent in these cases. 1
• Serum specimens should completely neutralize challenge virus at least at a 1:5 serum dilution by the rapid fluorescent focus inhibition test (RFFIT). 1

Critical Caveats

• Every attempt should be made to adhere to the recommended vaccination schedules, as rabies is nearly 100% fatal once clinical symptoms develop. 1, 2
• The standard 4-dose schedule (days 0,3,7,14) applies to previously unvaccinated, immunocompetent persons receiving rabies immune globulin (HRIG). 1
• Immunocompromised patients require the full 5-dose regimen (days 0,3,7,14,28) and should not have doses skipped, as their immune response may be inadequate even with the complete series. 1

Special Populations

• Previously vaccinated persons require only 2 doses (days 0 and 3) and do not need HRIG, so schedule deviations are less critical in this population. 1, 3
• For immunocompromised individuals who miss doses, consultation with public health officials is recommended, and serologic testing should be performed to ensure adequate antibody response. 1

Key Pitfall to Avoid

• Do not restart the entire vaccination series for minor schedule deviations—this wastes resources, delays completion of prophylaxis, and is unnecessary based on current evidence. 1
• The only exception would be if there is uncertainty about which doses were actually administered or if the deviation is so substantial that immune status cannot be reasonably predicted. 1