Protocol for Administering Catch-Up Doses of Human Rabies Vaccine

General Principles for Missed Rabies Vaccine Doses

The Centers for Disease Control and Prevention recommends that for most minor deviations from the rabies vaccination schedule, simply administer the missed dose when the patient presents and resume the schedule from that point, maintaining the same intervals between remaining doses 1, 2
Delays of a few days for individual doses are considered unimportant, though the effect of longer lapses of weeks or more is unknown 1, 2
Most interruptions in the vaccine schedule do not require restarting the entire series 1, 2
The current recommended schedule for previously unvaccinated persons is 4 doses administered on days 0, 3, 7, and 14 3

When a patient misses a scheduled dose, administer the missed dose immediately when they present for care 1, 2
Resume the vaccination schedule from that point, maintaining the same interval between subsequent doses 1, 2

All rabies vaccine doses should be administered intramuscularly in the deltoid area for adults and older children, or in the anterolateral thigh for younger children 3
Never administer rabies vaccine in the gluteal area as this may result in lower neutralizing antibody titers 1, 5
For substantial deviations from the schedule, immune status should be assessed by performing serologic testing 7-14 days after administration of the final dose in the series 1, 2

Every attempt should be made to adhere to the recommended vaccination schedule as rabies is nearly 100% fatal once clinical symptoms develop 4

For previously unvaccinated persons: Complete the 4-dose series (days 0, 3, 7, 14) with catch-up as needed 3
For immunocompromised patients: The 5-dose schedule (days 0, 3, 7, 14, 28) is still recommended 3
For previously vaccinated persons: Only 2 doses are required (days 0 and 3), so if one is missed, simply administer it as soon as possible 3

HRIG is administered only once at the beginning of post-exposure prophylaxis for previously unvaccinated persons 1
If HRIG was not administered when vaccination began (day 0), it can be given up to and including day 7 of the post-exposure prophylaxis series 1
Beyond day 7, HRIG is not indicated as antibody response to the vaccine is presumed to have occurred 1, 2