What should be done for a patient who received the first dose of rabies vaccine on day 0, the third dose on day 3, but missed the second dose, and now presents 30 days later for completion of the rabies PEP series?

Management of Interrupted Rabies PEP Series at 30 Days

Complete the remaining doses immediately without restarting the series—administer the missed day 7 and day 14 doses now, maintaining the standard intervals between doses. 1, 2

Core Management Principle

• Interruptions in the rabies vaccine schedule do not require restarting the entire series—the patient should simply resume and complete all four doses regardless of delays. 1

• The patient has received doses on days 0 and 3, so they still need the day 7 and day 14 doses to complete the standard 4-dose regimen. 1, 2

Immediate Action Steps

• Administer the third dose (originally scheduled for day 7) immediately upon presentation at day 30. 1, 2

• Schedule and administer the fourth dose approximately 7 days after the third dose to maintain appropriate spacing between doses. 1, 2

• The exact timing is flexible—delays of a few days for individual doses do not compromise protection, but the patient must eventually complete all four doses. 1, 2

Critical HRIG Considerations

• Do NOT administer HRIG at this 30-day visit, even if it was missed initially. 1, 3

• HRIG can only be given up to and including day 7 of the PEP series because vaccine-induced antibodies are presumed to have developed by that time. 1, 3

• Beyond day 7, HRIG administration would interfere with the active antibody response already underway from the vaccine doses. 3

• If HRIG was not given on day 0, this represents a significant protocol deviation—however, at day 30, it is too late to administer it. 1, 3

Serologic Testing Recommendation

• Consider serologic testing 7-14 days after completing the modified series to confirm adequate antibody response (≥0.5 IU/mL by RFFIT), particularly given the interrupted schedule. 1

• This is especially important if the patient is immunocompromised or if there are concerns about vaccine potency or administration technique. 1

• Routine testing is not mandatory in immunocompetent individuals, but the significant delay and missed doses warrant verification of seroconversion. 1

Special Population Considerations

• If the patient is immunocompromised, they require a 5-dose regimen (days 0,3,7,14, and 28) plus mandatory serologic testing 1-2 weeks after the final dose. 1, 2

• For immunocompromised patients presenting at day 30 with only 2 doses completed, administer the remaining 3 doses and ensure serologic confirmation. 1, 2

Evidence Supporting This Approach

• Over 1,000 persons annually in the United States receive only 3 or 4 doses instead of the older 5-dose regimen, with no documented cases of rabies developing, even when >30% had confirmed exposure to rabid animals. 4, 1

• Virus-neutralizing antibodies peak by approximately day 14-28 after starting vaccination, meaning protective immunity is established well before completion of the series. 4, 1

• In the United States, of 27 human rabies cases reported during 2000-2008, none had received any PEP before illness—failures are due to not receiving PEP at all, not to incomplete series. 4

Common Pitfalls to Avoid

• Do not restart the entire series from day 0—this wastes vaccine, delays completion, and provides no additional benefit. 1, 2

• Do not administer HRIG at day 30—it is contraindicated beyond day 7 and will suppress the active immune response. 1, 3

• Do not assume the patient is adequately protected with only 2 doses—they must complete all 4 doses for full protection. 1, 2, 5

• Ensure vaccine is administered in the deltoid muscle (adults) or anterolateral thigh (young children), never in the gluteal area, as gluteal administration results in inadequate immune response. 1, 2, 3