Rabies Post-Exposure Prophylaxis Guidelines

Vaccination Schedule

The Centers for Disease Control and Prevention recommends continuing the vaccination schedule from where you left off without restarting the entire series if you have started but not completed your rabies post-exposure prophylaxis series, with delays of a few days being acceptable, though longer interruptions may require antibody testing after completion 1
Immunocompetent individuals should complete the full 4-dose series on days 0, 3, 7, and 14 2, 3
If a dose is missed, the series should not be restarted, but rather resumed as though on time, with the next dose given as soon as possible and the remaining doses maintaining the same intervals 1

The American Academy of Pediatrics and the Centers for Disease Control and Prevention recommend that immunosuppressed patients receive the full 5-dose series, even if previously vaccinated, and obtain antibody titers 7-14 days after completing the series to confirm adequate response 2, 3
Previously vaccinated individuals, as defined by the World Health Organization, only need 2 doses, one immediately and one 3 days later, and should not receive rabies immunoglobulin 4, 5

The World Health Organization recommends that rabies immunoglobulin can be administered up to and including day 7 of the vaccine series if it wasn't given initially, but not after day 7, as it may suppress active antibody production 1
The Centers for Disease Control and Prevention advises against administering RIG after day 7 of the vaccine series, and against giving RIG to previously vaccinated persons, as it inhibits the anamnestic response 1, 4, 5
Healthy persons completing at least 4 doses do not need routine antibody testing, but if titers are obtained, serum collected 1-2 weeks after the last dose should neutralize virus at ≥1:5 dilution by RFFIT, according to the Centers for Disease Control and Prevention 3

The Centers for Disease Control and Prevention recommends that if a patient received only 2 doses of rabies vaccine and 5 months have passed, they should resume the series from where they left off, administering the remaining doses as soon as possible 6
The Advisory Committee on Immunization Practices guidelines state that most interruptions in the vaccine schedule do not require reinitiation of the entire series, and the patient should receive their remaining doses with the same intervals as the original schedule 6
Delays of a few days for individual doses are unimportant, though the effect of longer lapses is not fully characterized 6

For a patient who received 2 doses of rabies vaccine and had a 5-month lapse, the patient should receive their third dose immediately, then receive the fourth dose 7 days later, treating this as the completion of the original series 6
The patient should receive serologic testing 7-14 days after administration of the final dose to confirm adequate antibody response, with the serum completely neutralizing challenge virus at least at a 1:5 dilution by rapid fluorescent focus inhibition test (RFFIT) 6

If the patient is immunocompromised, they should receive a complete 5-dose regimen starting over, with mandatory serologic testing afterward 7
The Centers for Disease Control and Prevention estimates that over 1,000 persons annually in the U.S. receive only 3-4 doses with no documented rabies cases, even when exposed to confirmed rabid animals, suggesting that immunologic memory persists 8
No case of human rabies in the United States has been attributed to receiving less than the 5-dose vaccine course, supporting the approach of continuing rather than restarting the vaccine series 8