What is the recommended vaccination schedule for a patient who missed their second rabies vaccine dose and presents 14 days later?

Rabies Vaccination Schedule for Missed Second Dose at 14 Days

If a patient missed their second rabies vaccine dose and presents 14 days after the first dose, continue the original 4-dose schedule by administering the second dose immediately (on day 14), then give the third dose 3 days later (day 17), and the fourth dose 7 days after that (day 24). 1, 2

Key Principle: Do Not Restart the Series

• Delays of a few days for individual doses are unimportant and do not compromise protection—the series should be continued, not restarted. 1, 2
• The ACIP explicitly states that interruptions in the vaccine schedule do not require restarting the entire series, as long as the patient eventually completes all four doses. 3
• Day 0 is defined as the day the first dose was given (not the exposure date), so if the patient received dose 1 on what we call "day 0" and returns on day 14, they are simply receiving their doses later than ideal but should continue forward. 1, 2

Recommended Modified Schedule

When the patient presents on day 14 after missing the day 3 dose:

• Day 14 (today): Administer the second dose immediately 1, 2
• Day 17: Administer the third dose (3 days after the second dose) 1, 2
• Day 24: Administer the fourth dose (7 days after the third dose) 1, 2

Critical Considerations for HRIG Administration

• If HRIG was not given with the first dose on day 0, it can still be administered up to and including day 7 of the PEP series. 3, 2
• Beyond day 7, HRIG should NOT be administered because vaccine-induced antibodies are presumed to have already developed, and HRIG would interfere with the active immune response. 3, 1
• Since this patient is presenting on day 14, the window for HRIG administration has closed—do not give HRIG at this point. 1, 2

Immunological Rationale

• Virus-neutralizing antibodies typically peak by day 14-28 after starting vaccination, meaning protective immunity develops well before completion of the series. 2
• Over 1,000 persons annually in the United States receive only 3 or 4 doses with schedule deviations, with no documented cases of rabies developing, even when >30% had confirmed exposure to rabid animals. 2
• The most critical period is the first 14 days when antibodies are developing—by day 14, the patient has likely already begun producing protective antibodies from the first dose. 2

Special Populations Requiring Different Management

• Immunocompromised patients require a 5-dose regimen (days 0,3,7,14, and 28) plus mandatory serologic testing 1-2 weeks after the final dose. 3, 1, 2
• For immunocompromised patients with missed doses, consultation with public health officials is essential, and serologic testing should be performed to ensure adequate antibody response. 3, 1

Common Pitfall to Avoid

• Do not restart the entire series from day 0—this wastes vaccine, delays completion of prophylaxis, and is not supported by ACIP guidelines. 1, 2
• The effect of longer lapses (weeks or more) is unknown, but for substantial deviations, immune status should be assessed by serologic testing 7-14 days after the final dose. 2

When to Consider Serologic Testing

• For this patient with a significant delay (11 days between doses 1 and 2), consider serologic testing 7-14 days after completing the modified 4-dose series to confirm adequate antibody response (≥0.5 IU/mL by RFFIT). 3, 1
• Testing is particularly important if the patient is immunocompromised or if there are concerns about vaccine potency or administration technique. 3, 1