What is the recommended rabies vaccination schedule?

Rabies Vaccination Schedule

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

Post-Exposure Prophylaxis (PEP) for Previously Unvaccinated Persons

Immediate Wound Care

• Thoroughly wash all wounds with soap and water for 15 minutes immediately after exposure 2, 3
• Irrigate wounds with a virucidal agent such as povidone-iodine solution if available 2, 4
• This local wound treatment is perhaps the most effective single measure for preventing rabies 2

Vaccine Administration

• Administer 4 doses of HDCV (human diploid cell vaccine) or PCECV (purified chick embryo cell vaccine), 1.0 mL per dose, intramuscularly on days 0,3,7, and 14 1, 2, 5
• Day 0 is defined as the day the first dose is given, not necessarily the day of exposure 2
• Inject in the deltoid muscle for adults and older children 2, 3
• Use the anterolateral thigh for young children 2, 3
• Never use the gluteal area—this produces inadequate antibody response and is associated with vaccine failure 2, 3

Rabies Immune Globulin (RIG) Administration

• Administer RIG at 20 IU/kg body weight on day 0, ideally at the same time as the first vaccine dose 2, 5, 4
• Infiltrate the full dose around and into the wound(s) if anatomically feasible 2, 6, 4
• Any remaining volume should be administered intramuscularly at a site distant from vaccine administration 2, 6, 4
• RIG should not be administered in the same syringe or at the same anatomical site as the vaccine 2, 6, 4
• If RIG was not given on day 0, it can still be administered up to and including day 7 after the first vaccine dose 2, 6
• Beyond day 7, RIG is not indicated because antibody response to the vaccine is presumed to have occurred 6
• Do not exceed the recommended 20 IU/kg dose, as higher doses can suppress active antibody production 6, 5, 4

Post-Exposure Prophylaxis for Previously Vaccinated Persons

• Previously vaccinated individuals require only 2 doses of vaccine on days 0 and 3 1, 2, 5
• RIG should NOT be administered to previously vaccinated persons—this is a critical error that will inhibit the anamnestic antibody response 1, 2, 6
• This applies to persons who have received one of the recommended pre-exposure or postexposure regimens of HDCV, PCECV, or RVA, or those who received another vaccine and had a documented rabies virus neutralizing antibody titer 1

Pre-Exposure Prophylaxis

Primary Vaccination Schedule

• Administer 3 doses of HDCV or PCECV, 1.0 mL intramuscularly, on days 0,7, and 21 or 28 1, 3
• Use the deltoid area for adults and older children 1, 3
• Use the anterolateral aspect of the thigh for infants and small children 3

Indications for Pre-Exposure Prophylaxis

• Rabies researchers and laboratory workers handling rabies virus 1, 3
• Veterinarians and their staff 1, 3
• Animal handlers and wildlife officers in areas where rabies is enzootic 1, 3
• Persons who frequently handle bats, regardless of location 1
• International travelers likely to come in contact with animals in areas where dog or other animal rabies is enzootic and immediate access to appropriate medical care might be limited 1, 3
• Children living in or visiting countries where exposure to rabid animals is a constant threat 3

Pre-Exposure Booster Doses

• Continuous risk category (rabies research laboratory workers, biologics production workers): Check serum antibody titer every 6 months; administer booster if titer falls below complete neutralization at 1:5 serum dilution 1, 3
• Frequent risk category (diagnostic laboratory workers, cavers, veterinarians, animal-control officers, persons who frequently handle bats): Check serum antibody titer every 2 years; administer single booster dose if titer is below 1:5 1, 3
• Infrequent exposure group (veterinarians in areas where rabies is uncommon, international travelers who completed pre-exposure series): No routine serologic testing or booster doses required 1, 3

Special Populations

Immunocompromised Patients

• Immunocompromised individuals must receive the full 5-dose vaccine regimen on days 0,3,7,14, and 28, plus RIG at 20 IU/kg 2, 5
• This applies even if previously vaccinated 2
• The standard 4-dose schedule is inadequate for this population 2
• For pre-exposure prophylaxis, immunosuppressed persons should have their viral neutralizing antibody titers checked after completing the series 3

Pediatric Patients

• Children receive the same vaccine dose volume (1.0 mL) as adults 2, 5
• Children receive the same RIG dose (20 IU/kg) as adults 6
• Use the anterolateral thigh for vaccine administration in young children 2, 3

Timing Considerations

• Initiate PEP as soon as possible after exposure, ideally within 24 hours 2
• There is no absolute cutoff beyond which PEP should be withheld—treatment should begin immediately upon recognition of exposure, even if weeks or months have elapsed 2
• Delays of even a few hours matter significantly because rabies is nearly 100% fatal once clinical symptoms develop 2
• Delays of a few days for individual vaccine doses are unimportant, though the effect of longer lapses is unknown 2
• Most interruptions do not require restarting the entire series 2

Critical Pitfalls to Avoid

• Never administer vaccine in the gluteal area 2, 3
• Never give RIG to previously vaccinated persons 2, 6
• Never administer RIG and vaccine in the same syringe or anatomical location 2, 6, 4
• Never exceed the recommended 20 IU/kg dose of RIG 6, 5, 4
• Do not forget to upgrade immunocompromised patients to the 5-dose regimen 2, 5

Efficacy

• When administered promptly and appropriately, rabies PEP combining wound care, RIG infiltration, and the vaccine series is nearly 100% effective in preventing human rabies 2, 5
• The reduction from the historical 5-dose to the current 4-dose schedule was estimated to save approximately $16.6 million annually in the U.S. healthcare system without compromising efficacy 5
• Post-vaccination serologic testing is not necessary in immunocompetent individuals, as all healthy persons demonstrate adequate antibody response when prophylaxis is administered according to guidelines 1