Updated recommendations for rabies pre-exposure prophylaxis (PrEP) approved Wednesday by the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) will not include children younger than 18 years due to concerns raised by David W. Kimberlin, M.D., FAAP.
ACIP recommended reducing the number of intramuscular vaccine doses in the rabies PrEP series from three to two in immunocompetent people over 18 for whom it is indicated. That group includes travelers who are at increased risk for exposure to rabid dogs and may have difficulty getting access to safe post-exposure prophylaxis.
“The reason we are recommending a two-dose PrEP series is not just for cost savings. It’s because the data indicates … the efficacy is no different from that for a three-dose series,” said Capt. Agam Rao, M.D., co-lead of the ACIP rabies workgroup.
Dr. Kimberlin, however, was concerned about the paucity of long-term efficacy data of a two-dose regimen in children. He noted that children traveling to another country may be at higher risk of contracting rabies than adults due to their inability to protect themselves from a rabid dog.
“We don’t have real-world experience with this (two-dose) approach, and it concerns me when the disease is 100% lethal,” said Dr. Kimberlin, who pointed out that he was speaking for himself and not as a member of the Academy.
The committee agreed to remove children under 18 from the recommendation until the AAP Committee on Infectious Diseases has a chance to review the data and make a recommendation.
ACIP also voted to recommend an intramuscular booster dose of rabies vaccine, as an alternative to a titer check, for immunocompetent persons ages 18 and older who have sustained and elevated risk for recognized rabies exposures. This would not include short-term travelers. The booster dose should be administered between days 21 days and three years after the two-dose PrEP series.
The recommendations still must be approved by the CDC director.
