AAP Endorses CDC's Rabies Vaccine Dose Regimen

Laurie Barclay, MD

March 28, 2011

March 28, 2011 — The American Academy of Pediatrics (AAP) endorses the recommendations of the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) for postexposure prophylaxis (PEP) to prevent human rabies. The new recommendations call for lowering the number of doses from 5 to 4 of human diploid cell vaccine or purified chick embryo cell vaccine, according to the AAP Committee on Infectious Diseases Policy Statement published online March 28 and appearing in the April issue of Pediatrics.

"The incubation period (1–3 months) is long enough to render immunization a highly effective strategy for ...PEP," write AAP Committee on Infectious Diseases 2010-2011 chairperson Michael T. Brady, MD, and colleagues. "Approximately 20 000 to 30 000 persons receive PEP in the United States each year, and 1 to 3 cases of human rabies occurs annually. ...Keys to effective PEP have included prompt washing of the wound with copious amounts of soap and water, infiltration of human rabies immunoglobulin into and around the wound, and a 5-dose schedule of intramuscular vaccine administered over 28 days."

Because human rabies vaccine was in limited supply in 2007, the ACIP convened a rabies work group to review vaccination options and underlying evidence and then accepted its recommendations to implement a 4-dose regimen.

The new, recommended dosing regimen is that vaccine should be given on day 0 (first day of prophylaxis) and on days 3, 7, and 14 after the first dose. The first dose should be given as soon as possible after exposure, but if signs and symptoms of rabies are not present, the vaccine regimen may be started weeks to months after the exposure.

Individuals with immunosuppression should continue to receive the 5-dose regimen. No changes were made to recommendations for the use of human rabies immunoglobulin.

The statement authors note that use of the reduced-dose schedule could result in a $16 million cost savings to the United States healthcare system, based on preliminary economic assessments.

"The induction of rabies-neutralizing antibody is a surrogate for an adequate immune response to vaccination and was achieved in all subjects (~1000) by day 14, when the fourth dose of cell-derived rabies vaccine was given," the statement authors write concerning the evidence supporting their recommendations. "From observational studies that included persons likely exposed to confirmed rabid animals and with imperfect adherence to the 5-dose vaccine schedule, the Rabies Working Group estimated that more than 300 persons in the United States received only 3 or 4 doses annually, and there were no resulting cases of human rabies. Although human PEP failures do occur rarely worldwide, no cases have been attributed to the lack of receipt of the fifth rabies vaccine dose on day 28."

The statement authors have disclosed no relevant financial relationships.

Pediatrics. 2011;127:785-787. Full text

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