Rabies Vaccine Administration in Adults and Pediatrics

Post-Exposure Prophylaxis (PEP) for Previously Unvaccinated Persons

For previously unvaccinated individuals exposed to rabies, administer 4 doses of rabies vaccine (1.0 mL intramuscularly) on days 0,3,7, and 14, combined with human rabies immune globulin (HRIG) at 20 IU/kg on day 0. 1, 2

Immediate Wound Management

Thoroughly wash all wounds with soap and water for 15 minutes immediately—this is the single most effective measure for preventing rabies infection. 1, 2
Follow with irrigation using a virucidal agent such as povidone-iodine solution if available. 2, 3

Vaccine Administration Details

Dose and Schedule:

Administer 1.0 mL of HDCV (human diploid cell vaccine), RVA (rabies vaccine adsorbed), or PCECV (purified chick embryo cell vaccine) intramuscularly on days 0,3,7, and 14. 1, 2, 4
Day 0 is defined as the day the first dose is given, not necessarily the day of exposure. 2

Injection Sites:

Adults and older children: Inject into the deltoid muscle. 1, 2, 4
Infants and young children: Use the anterolateral aspect of the thigh. 1, 2, 4
CRITICAL: Never use the gluteal area—this produces inadequate antibody response and is associated with vaccine failures. 1, 2, 5

HRIG Administration

Dosing:

Administer exactly 20 IU/kg body weight on day 0, ideally simultaneously with the first vaccine dose. 1, 2
This dose applies to all ages, including infants and children—the formula is universal. 1, 2

Administration Technique:

Infiltrate the full calculated dose around and into the wound(s) if anatomically feasible. 1, 2
Inject any remaining volume intramuscularly at a site distant from vaccine administration. 1, 2
Never administer HRIG in the same syringe or at the same anatomical site as the vaccine. 1, 2, 5
Do not exceed 20 IU/kg—higher doses suppress active antibody production. 1, 2

Timing Flexibility:

If HRIG was not given on day 0, it can still be administered up to and including day 7 after the first vaccine dose. 1, 2
Beyond day 7, do not give HRIG, as vaccine-induced antibodies are presumed to have developed. 1, 2

Post-Exposure Prophylaxis for Previously Vaccinated Persons

Previously vaccinated individuals require only 2 doses of vaccine (on days 0 and 3) and do NOT need HRIG. 1, 2, 5

This applies to anyone who has completed a recommended pre-exposure or post-exposure vaccination series with a cell culture vaccine. 2, 5
Giving HRIG to previously vaccinated persons is a critical error that suppresses the memory immune response. 2, 5

Special Considerations for Immunocompromised Patients

Immunocompromised patients require a 5-dose vaccine regimen (days 0,3,7,14, and 28) plus HRIG at 20 IU/kg on day 0, even if previously vaccinated. 1, 2, 5

Who Qualifies as Immunocompromised:

Patients on corticosteroids or other immunosuppressive agents 2
HIV infection 2
Chronic lymphoproliferative leukemia 2
Other immunosuppressive illnesses 2

Mandatory Serologic Testing:

Test rabies virus-neutralizing antibody by RFFIT 1-2 weeks after the final vaccine dose (day 42). 2, 5
An acceptable response is complete neutralization at a 1:5 serum dilution. 2
If no adequate response is detected, consult with public health officials. 2

Medication Management:

Immunosuppressive agents should not be administered during PEP unless essential for other conditions. 2

Pre-Exposure Prophylaxis

For persons at high risk (veterinarians, animal handlers, laboratory workers, international travelers to rabies-endemic areas), administer 3 doses of 1.0 mL intramuscularly on days 0,7, and 21 or 28. 1, 2, 4

Injection Sites:

Use the deltoid area for adults and older children. 1
Use the anterolateral thigh for young children. 1

Booster Recommendations:

Continuous risk category (laboratory workers with live virus): Check titers every 6 months, boost as needed. 4
Frequent risk category (diagnostic lab workers, veterinarians, animal control officers): Check titers every 2 years. 4
Infrequent risk category (veterinarians in low-endemicity areas): No routine boosters needed after completing primary series. 4

Critical Timing Principles

Initiate PEP as soon as possible after exposure, ideally within 24 hours, though treatment remains indicated even if weeks or months have elapsed. 2

Rabies is nearly 100% fatal once clinical symptoms develop. 2
There is no absolute cutoff beyond which PEP should be withheld. 2
The incubation period typically ranges from 1-3 months but can extend from days to over a year. 1, 2

Schedule Flexibility:

Delays of a few days for individual doses are unimportant and do not compromise protection. 2, 5
For substantial deviations (weeks), assess immune status by serologic testing 7-14 days after the final dose. 2

Common Pitfalls to Avoid

Never use the gluteal area for vaccine administration—this results in inadequate immune response and vaccine failure. 1, 2, 5
Never exceed 20 IU/kg of HRIG—higher doses suppress active antibody production. 1, 2
Never give HRIG to previously vaccinated persons (unless immunocompromised)—this critically impairs the memory immune response. 2, 5
Never administer HRIG and vaccine in the same syringe or anatomical site. 1, 2, 5
Do not delay wound washing—this is the most crucial first step and should not be postponed for any reason. 2, 3
Do not withhold treatment while waiting for animal observation results in rabies-endemic areas—treatment can be discontinued if the animal remains healthy after 10 days. 2
Do not downgrade immunocompromised patients to the 4-dose schedule—they require the full 5-dose regimen regardless of previous vaccination status. 2, 5

Pediatric-Specific Considerations

Children receive the same vaccine dose volume (1.0 mL) and HRIG dose (20 IU/kg) as adults. 2, 3

Administration Sites for Children:

Young children and infants: Use the anterolateral thigh for vaccine administration. 1, 2, 3
Older children: May use the deltoid muscle. 1, 2

Safety Profile:

Studies demonstrate that HRIG and rabies vaccine are safe and effective in pediatric patients, with the majority of side effects being mild. 3
No serious events, rabies infections, or deaths have been reported in properly treated children. 3

Immunocompromised Children:

Follow the same 5-dose regimen (days 0,3,7,14,28) with HRIG as for adults. 3
Consider serologic testing 7-14 days after the last dose to ensure seroconversion. 3

Efficacy of the 4-Dose Regimen

When administered promptly and appropriately, rabies PEP is nearly 100% effective in preventing human rabies. 1, 2

All healthy persons completing the 4-dose regimen demonstrate adequate antibody response (≥0.5 IU/mL) by day 14, with 100% seroprotection maintained through day 180. 2
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. 2
No case of human rabies in the United States has ever been attributed to receiving fewer than the complete vaccine course since cell culture vaccines have been routinely used. 2

Why 4 Doses Are Sufficient:

Virus-neutralizing antibodies peak by approximately day 14-28 after starting vaccination. 2
HRIG provides immediate passive immunity during the first 7-10 days before vaccine-induced antibodies develop. 2
By day 14, vaccine-induced antibodies have already established protective immunity. 2

No Routine Serologic Testing Needed

Routine post-vaccination antibody testing is unnecessary in immunocompetent individuals completing the 4-dose PEP regimen. 2, 5, 4

Testing Is Only Indicated For:

Immunocompromised patients 2, 4
Unusual circumstances when the patient is known to be immunosuppressed 4
Substantial schedule deviations (weeks or more) 2

What is the recommended rabies vaccine dose, schedule, injection site, and rabies immune globulin administration for post‑exposure prophylaxis in adults and children, including special considerations for infants, immunocompromised patients, and pre‑exposure prophylaxis?

Help us tailor your experience