AAP endorses reduced-dose schedule for rabies prevention

April 1, 2011

The American Academy of Pediatrics (AAP) is endorsing the recommendation of the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention that reduces the number of human diploid cell vaccine or purified chick embryo cell vaccine doses from 5 to 4 for postexposure prophylaxis (PEP) for the prevention of rabies.

The American Academy of Pediatrics (AAP) is endorsing the recommendation of the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention that reduces the number of human diploid cell vaccine or purified chick embryo cell vaccine doses from 5 to 4 for postexposure prophylaxis (PEP) for the prevention of rabies.

The AAP rabies-prevention policy update appeared in Pediatrics.

According to ACIP recommendations, PEP doses should be administered on day 0 (considered the first day of prophylaxis) and then on days 3, 7, and 14 after the initial dose. Persons with suppressed immune systems still should receive the original 5-dose schedule.

ACIP began to review rabies vaccination options in 2007 when the supply of human rabies vaccine was limited. The committee decided to adopt the 4-dose vaccination regimen and announced its recommendation in March 2010.

A review of the evidence supporting the 4-dose schedule for PEP shows that adequate immune response to vaccination in approximately 1,000 persons was achieved by day 14, when the fourth dosage of cell-derived vaccine was administered. Furthermore, observational studies show that no cases of human rabies occurred in persons who received only 3 or 4 doses instead of 5 after being exposed to confirmed rabid animals.

In addition, animal models indicate that timely PEP is critical but that the absolute number of doses does not make a significant difference in the rate of survival. The occurrence of adverse effects in children from cell-derived rabies vaccines is rare and is expected to be the same or less with 4 doses as compared with 5. Finally, research indicates that a reduced-dose schedule could result in a $16 million savings for the US health care system.

Approximately 55,000 persons globally-nearly half of these are children-die each year from rabies. Some 20,000 to 30,000 persons in the United States receive PEP annually, with 1 to 3 cases of human rabies occurring each year.

Committee on Infectious Diseases. Policy statement-rabies prevention policy update: new reduced dose schedule. Pediatrics. 2011;127(4):785-787.