5.5.5. What do we need to know about regimens, doses and schedules?

What is the difference between intradermal and intramuscular vaccination?
- Intramuscular administration is given as a 0.5 - 1 mL volume (depending on the vaccine used) deep into the deltoid muscle in adults and into the lateral area of the thigh in infants.
- Intradermal is given as a 0.1 mL volume into the upper skin area over the deltoid muscle in adults or lateral thigh area of infants. A small bleb with an ‘orange peel’ appearance is confirmation that the vaccine was administered correctly.
- Persons of any age group can be vaccinated with WHO pre-qualified CCV vaccines (click here for the WHO list, or see the information in section 5.2.3) either intramuscularly or most of them also intradermally at the doses recommended above.
- The intradermal regimen requires considerably less vaccine than the intramuscular regimen, therefore intradermal vaccination should be used when resources are limited and the number of patients requiring PEP every day is at least two or more. However, intradermal vaccination is not licensed in every country.

What are the potential cost savings of intradermal compared to intramuscular vaccination?
- For cost-benefit comparisons of different PEP regimens under different clinic conditions, see these papers.
- A simple online tool to calculate the dose usage of different PEP regimens for clinics with different numbers of suspected rabies cases is available here.

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Photo courtesy of Saneekan Rosamontri

Is there a single dose of rabies vaccine that is available?
No.

How many doses of vaccine will I need to get for PrEP?
Three doses of vaccine given intramuscularly or intradermally on days 0, 7 and either day 21 or 28.

How many doses of vaccine will I need to get for PEP?
- PEP can be administered in one of two ways, either intramuscularly or intradermally.
- If you receive PEP intramuscularly, then you will receive either 4 or 5 doses of vaccine depending on which vaccination regimen your physician will use.
- If you receive intradermal vaccination, you will receive multiple doses of rabies vaccine given in smaller amounts generally given on four different days over a period of 28 to 90 days.

Is it okay to switch between intramuscular and intradermal administration of CCV for PEP?
This is not recommended by the WHO.

I have had a delay in my PrEP/PEP schedule, what is the flexibility of the schedules?
The regimen should be followed as closely as possible. However, a one or two day deviation from the PEP/PrEP regimen is acceptable. In case of longer delays, you should contact a physician so that he/she can evaluate the situation.

How often do I need to get a booster after I have had my PrEP?
Persons at continuous or frequent risk of exposure (workers in rabies vaccine production facilities, veterinarians living in highly endemic areas etc.) should have their titer (i.e. the quantity of antibody present in their blood) checked periodically: every 6 months for persons working with live rabies virus and every year for other professions at permanent risk of exposure to rabies. If their level falls below 0,5 IU /mL, they should receive one routine booster. Specific laboratory analyses are required to measure the level of antibody in serum samples of vaccinated individuals. These tests are costly and are currently only performed in international reference laboratories. According to WHO, other persons do not need a routine booster. However, the labels of licensed rabies vaccines do recommend periodic booster shots.

Do I need to have a blood test to check my antibody level before I receive my booster vaccination after exposure? No.

I have received three doses of vaccine in the PEP regimen and the dog that bit me is still healthy, should I continue with the vaccination regimen and complete the entire PEP course?
There is no need to continue if the dog is still healthy ten days after the exposure occurred.

The doctor administered the vaccine into my buttocks, what do I do now?
The vaccine should be re-administered correctly, in the deltoid area.

What do I do if I have missed a dose of vaccine on the prescribed date?
The regimen should be followed as closely as possible. However, a one or two day deviation from the PEP/PrEP regimen is acceptable. In case of longer delays, you should contact a physician so that he/she can evaluate the situation.

CCV - Cell-culture vaccine
IU - International Unit
PEP - Post-exposure prophylaxis
PrEP - Pre-exposure prophylaxis
WHO - World Health Organization




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next page: 5.5.6. Are there any conditions that might affect post-exposure prophylaxis?






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Version 4 - last updated May 2017