Rabies PEP Administration: Part 2 - Special Considerations

Hello, I'm Dr. Fasselman Hodge, an emergency medicine pharmacist and rabies subject matter expert at CDC. We are going to discuss some special considerations for rabies post-exposure prophylaxis, or rabies PEP. Who should get rabies PEP? Following a potential rabies exposure, public health professionals should perform a risk assessment to determine if rabies PEP is needed. Once recommended, rabies PEP is appropriate for all ages and can be administered to people who are pregnant or breastfeeding. There are no known absolute contraindications for rabies PEP. For children 2 years of age and younger, vaccines should be given in the anterolateral thigh rather than the deltoid. Diluting H-Rig for Multiple or Large Wounds. If the patient has multiple or large wounds, it is important to fully infiltrate H-Rig. H-Rig products can be diluted for infiltration. Follow manufacturer instructions on the appropriate diluent for the product you are using. PEP for Previously Vaccinated People. If the patient has completed a rabies vaccine series with modern cell culture vaccines such as Rabavirt, Imivax, or ViroRab at any point in their life, they do not need H-Rig. Instead, administer a dose of vaccine on day 0 and a dose on day 3. Remember, day 0 is the day you give the first dose of vaccine. Vaccines should be administered in the deltoid for adults and children older than 2 years of age. For children 2 years of age and younger, the anterolateral thigh is the preferred site of vaccine administration. No Visible Wound from a Bat Exposure. Remember, PEP may be recommended even without a visible wound. H-Rig should be infiltrated in and around the potential exposure site after contact with a bat where a bite or scratch cannot be ruled out. If there is not a known exposure site, H-Rig should be injected intramuscularly in the deltoid or quadriceps muscle, anatomically distant from where vaccine is administered. People with Immunocompromising Conditions. Patients on immunosuppressive medications should speak with their provider about whether those treatments can be temporarily paused during PEP to allow for the best immune response to vaccine. For immunocompromised patients without prior vaccination, rabies PEP should include wound washing and H-Rig infiltration around the wound on day 0 and a 5-dose vaccine regimen, 1 dose on days 0, 3, 7, 14, and 28. All patients with immunocompromising conditions or on immunosuppressive medications should have a rabies titer drawn no later than 4 weeks after completing the series. However, earlier titer draws may be recommended in certain situations. Consult public health officials to guide further management and timing of the titer.