What is the recommended anti-rabies (Rabies) vaccine schedule?

Anti-Rabies Vaccine Schedule

For previously unvaccinated individuals, administer 4 doses of rabies vaccine intramuscularly on days 0,3,7, and 14, combined with human rabies immune globulin (HRIG) at 20 IU/kg on day 0. 1, 2, 3

Standard Post-Exposure Prophylaxis Regimen

For Previously Unvaccinated Persons

Vaccine Schedule:

• Administer 1.0 mL of HDCV (human diploid cell vaccine) or PCECV (purified chick embryo cell vaccine) intramuscularly on days 0,3,7, and 14 1, 2, 3
• Day 0 is defined as the day the first dose is administered, not necessarily the day of exposure 2
• This 4-dose regimen replaced the older 5-dose schedule and is equally effective when combined with HRIG 1, 4, 5

HRIG Administration:

• Give 20 IU/kg body weight on day 0, ideally at the same time as the first vaccine dose 1, 2, 3, 6
• Infiltrate the full dose around and into the wound(s) if anatomically feasible 1, 6
• Any remaining volume should be administered intramuscularly at a site distant from vaccine administration 1, 6
• HRIG can be given up to and including day 7 if not administered initially, but is not indicated beyond day 7 1, 2, 7

Injection Sites:

• Adults and older children: Deltoid muscle only 1, 2, 6
• Young children: Anterolateral thigh is acceptable 1, 2, 6
• Never use the gluteal area as this produces inadequate antibody response and risks sciatic nerve injury 1, 2, 6

For Previously Vaccinated Persons

Simplified 2-Dose Regimen:

• Administer only 2 doses of vaccine (1.0 mL each) on days 0 and 3 1, 3
• Do NOT administer HRIG as it will inhibit the anamnestic response 1, 2, 3
• This applies to persons who received prior ACIP-recommended pre- or post-exposure prophylaxis with cell-culture vaccines 1

Special Populations

Immunocompromised Patients

Critical modification required:

• Administer the full 5-dose regimen on days 0,3,7,14, and 28 1, 2, 3
• HRIG at 20 IU/kg is still required on day 0 3
• This applies even if the patient was previously vaccinated 2
• Serologic testing should be performed to confirm adequate antibody response 1
• Corticosteroids and other immunosuppressive agents should be avoided during PEP if possible 1

Pediatric Patients

• Children receive the same vaccine dose volume (1.0 mL) as adults 1, 2
• Use the anterolateral thigh for vaccine administration in young children 1, 2, 6
• The 4-dose schedule applies to all age groups 1, 2

Essential Wound Care

Immediate local treatment:

• Thoroughly wash all wounds with soap and water for 15 minutes before any other intervention 2, 3, 6
• Irrigate with a virucidal agent such as povidone-iodine solution if available 3, 6
• This is perhaps the most effective single measure for preventing rabies 2, 3

Timing and Adherence

Initiation:

• Begin PEP as soon as possible after exposure, ideally within 24 hours 2
• There is no absolute cutoff beyond which PEP should be withheld—treatment remains indicated even if weeks or months have elapsed 2

Schedule Deviations:

• Delays of a few days for individual doses are unimportant 2, 7
• For missed doses, administer immediately when the patient presents and resume the schedule maintaining the same intervals 7
• Most interruptions do not require restarting the entire series 2, 7
• For substantial deviations, assess immune status by serologic testing 7-14 days after the final dose 2, 7

Critical Pitfalls to Avoid

• Never administer vaccine in the gluteal area—this is associated with vaccine failure 1, 2, 6
• Never give HRIG in the same syringe or anatomical site as vaccine 1, 6
• Never exceed the recommended HRIG dose of 20 IU/kg as it may suppress active antibody production 3, 6
• Never give HRIG to previously vaccinated persons unless they are immunocompromised 1, 2, 3
• Never use the 4-dose regimen for immunocompromised patients—they require 5 doses 1, 2, 3

Efficacy

When administered promptly and appropriately, this PEP regimen combining wound care, HRIG infiltration, and the vaccine series is nearly 100% effective in preventing human rabies 2, 3