MINNESO
MINNESOTTA
DEP
AR
TMENT
DEPAR
ARTMENT
OF HEAL
TH
HEALTH
DISEASE CONTROL NEWSLETTER
May/June 1998
Volume 26, Number 4 (pages 29-36)
Recommended Childhood Immunization Schedule,
Minnesota, 1998
The 1998 Recommended Childhood
Immunization Schedule is included
in this issue of the Disease Control
Newsletter. The schedule is based
on recommendations jointly issued
by the Advisory Committee on
Immunization Practices (ACIP), the
American Academy of Pediatrics
(AAP) and the American Academy
of Family Physicians (AAFP), and
endorsed by the Immunization
Practices Task Force of the Minnesota Department of Health (MDH),
as chaired by G. Scott Giebink, M.D.
Please note the following changes
from the 1997 MDH schedule and,
in some cases, from the ACIP/AAP/
AAFP 1998 schedule:
Polio: The age range at which the
third dose of polio vaccine may
be given, with either the all-OPV,
all-IPV, or sequential IPV/OPV
schedules, is consistently stated
as 6 - 18 months of age. The 1997
schedule displayed it as 12-18
months of age and stated that the
third dose could be given as early
as 6 months with an all-OPV
schedule. For the 1998 schedule,
the ACIP and AAP agree on this
broader timing for both the all-OPV
and the all-IPV schedules. However, they differ on the timing of the
third dose in the sequential IPV/
OPV schedule, with the ACIP
endorsing 12-18 months and the
AAP 6-18 months. At its January
20, 1998 meeting, the MDH
Immunization Practices Task Force
voted to support the position of the
AAP and recommended that the
third dose in all three polio vaccine
options be given any time between
6 and 18 months.
every 10 years. Reminder: By state
law, all students in grades 7 through
12 are required to have evidence of
a Td booster at 11 years of age or
older as well as two doses of MMR.
MMR: The recommended age
range for routine administration
of the second dose of MMR is
now 4-6 years of age rather than
extending to 11-12 years. This is
the current joint recommendation of
the ACIP, AAP, and AAFP and is part
of a national strategy to reach the
goal of achieving and maintaining
measles elimination in the United
States. All children who receive
their second dose of MMR at entry
to kindergarten will be in compliance
with the Minnesota School Immunization Law which requires proof of
two doses in order to enroll in 7th
grade. The first dose must be given
on or after the child’s first birthday to
be in compliance with the law.
Influenza: For the first time, the
schedule includes a recommendation that all children 6 months
of age and older wishing to
obtain immunity from influenza
may be considered for vaccination. In addition to protecting the
health of children at high risk for
complications from influenza, both
the AAP and the ACIP now encourage vaccination of all children,
especially those who gather in
schools and residential institutions,
to minimize disruption of routine
activities during the influenza
season.
Adolescent visit: The health visit
at age 11-12 years is once again
highlighted to prompt an immunization assessment of all adolescents
to verify that they have received two
doses of MMR and the three-dose
hepatitis B series, and either have a
history of varicella disease or have
received vaccine. Adolescents
lacking any of these vaccines
should be given the remaining
doses and also a booster for tetanus
and diphtheria (Td). Subsequent Td
boosters are then recommended
continued...
INSIDE:
Hepatitis B Vaccination: New
School Requirements . . . . . . . . . . 32
Rabies: Current Epidemiology
and Post-Exposure Prophylaxis
Recommendations . . . . . . . . . . . . 32
Lyme Disease Vaccine . . . . . . . . . 35
Recommended Childhood Immunization Schedule
Minnesota, 1998
Bars indicate range of acceptable ages; green bars indicate catch-up vaccination. Vaccines below dotted line are for selected populations.
Note: routine early adolescent immunization visit (purple column) includes a Td booster and assessment of need for HBV, MMR, and varicella vaccines.
▲
Age
z▲
Vaccine
Hepatitis B1
Birth
1
mo
2
mos
4
mos
6
mos
12
mos
15
mos
18
mos
2
yrs
Hepatitis B - 1
Diphtheria, Tetanus,
Pertussis2
DTaP
DTaP
DTaP
Haemophilus influenzae
type b3
Hib
Hib
Hib3
Polio4
Polio
Polio
11-12
yrs
14-18
yrs
Hepatitis B1
(1-3)
Hepatitis B - 3
Hepatitis B - 2
4-6
yrs
DTaP2
DTaP
Td
Hib3
Polio4
Measles, Mumps,
Rubella5
Polio
MMR-25 MMR-25
MMR - 1
Varicella
Varicella
Varicella6
Hepatitis A7
Hepatitis A
Influenza8
Influenza (yearly)
Pneumococcal
Pneumococcal9
1. Hepatitis B (HBV): Infants born to HBsAg-negative mothers should receive
2.5 µg of Merck vaccine (Recombivax HB) or 10 µg of SmithKline Beecham
(SB) vaccine (Engerix-B). Give 2nd dose >4 weeks after the 1st dose and 3rd
dose at 6-18 months of age. Infants born to HBsAg-positive mothers should
receive 0.5 mL hepatitis B immune globulin (HBIG) within 12 hours of birth,
and either 5 µg of Recombivax HB or 10 µg of Engerix-B at a separate site.
The 2nd dose is recommended at 1-2 months of age and the 3rd dose at 6
months of age. Infants born to mothers whose HBsAg status is unknown should
receive either 5 µg of Recombivax HB or 10 µg of Engerix-B within 12 hours
of birth. The 2nd dose of vaccine is recommended at 1 month of age and the
3rd dose at 6 months of age. Children and adolescents who have not
previously received 3 doses of hepatitis B vaccine should be given HBV-2 >4
weeks after HBV-1, and HBV-3 >4 months after HBV-1 and >8 weeks after
HBV-2.
2. Diphtheria, Tetanus, Pertussis (DTP): Children should receive DTaP
(diphtheria and tetanus toxoids and acellular pertussis vaccine) instead of
whole-cell DTP because of its fewer adverse reactions and equal or greater
efficacy. Whole-cell DTP may be given in certain situations (e.g., where
inadequate DTaP supplies exist or combinations with other vaccines are
desired). Children who have a true contraindication to whole-cell pertussis
vaccine should receive DT (which is for pediatric use) and not DTP or DTaP.
Td (tetanus and diphtheria toxoids, adsorbed, for adult use) is recommended
at 11-12 years of age if at least 5 years have passed since the last dose of
DTP, DTaP, or DT. Subsequent routine Td boosters are recommended every
10 years. DTaP-4 may be given as early as 12 months of age if at least 6
months have passed since DTaP-3, and if the child is considered unlikely to
return at 15-18 months of age.
3. Haemophilus influenzae type b (Hib): Three Hib conjugate vaccines are
licensed for infant use. If PRP-OMP (PedvaxHIB from Merck) is given at 2
and 4 months of age, a dose at 6 months is not required. After completing the
primary series, any Hib conjugate vaccine may be used as a booster.
4. Polio: A schedule of 2 doses of inactivated polio vaccine (IPV) followed by 2
doses of oral poliovirus vaccine (OPV) is recommended. All-OPV or all-IPV
schedules are also acceptable, and are preferred in some situations. E.g.,
OPV alone may be useful for children on catch-up schedules, whenever parents
or providers decline extra injections, and in children likely to travel to polioendemic countries. IPV alone is recommended for immunocompromised
persons and their family contacts or to minimize the risk of vaccine-associated
paralytic polio.
5. Measles, Mumps, Rubella (MMR): MMR-2 is recommended at 4-6 yrs, but
may be given during any visit, provided >4 weeks has elapsed since the 1st
dose and both doses are given >12 months of age.
6. Varicella: Give varicella vaccine to all susceptible children at 12-18 months
of age. Unvaccinated children >18 months who lack a reliable history of
chickenpox should also be vaccinated. Children <12 years should receive 1
dose; those >13 years should receive 2 doses 4-8 weeks apart.
7. Hepatitis A: Give hepatitis A vaccine to children and adolescents who are at
increased risk of infection, as defined by ACIP*, and consider for all other
persons >2 years of age wishing to obtain immunity. A booster should be
given >6 months after the initial dose.
8. Influenza: Give influenza vaccine annually to children >6 months of age who
have specific risk factors, as defined by ACIP*, and consider for all others
wishing to obtain immunity. Children <12 years should receive split virus
vaccine in a dosage appropriate for their age (0.25 mL if 6-35 months of age
or 0.5 mL if >3 years). Children <9 years of age who are receiving influenza
vaccine for the first time should receive 2 doses separated by at least 4 weeks.
9. Pneumococcal: Give pneumococcal vaccine to children >2 years of age at
increased risk of acquiring systemic pneumococcal infections or increased
risk of serious disease if they become infected. Give a 2nd dose to children
at highest risk of serious pneumococcal infection, as defined by ACIP*. This
includes those <10 years of age if >3 years from 1st dose and those >10
years of age if >5years from 1st dose.
Based on recommendations of the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and
the American Academy of Family Physicians (AAFP), and endorsed by the Immunization Practices Task Force of the Minnesota Department of Health (MDH).
* For current ACIP recommendations or other questions, call the
Minnesota Immunization Hotline at (612) 623-5100 or toll-free (800) 657-3970.
30
Minnesota Department of Health, April 1998 IC# 141-0188
For Children Who Start Late or Have Fallen Behind
Provide MMR and varicella at >12 months. Administer a 2nd dose of MMR at 4-6 years, but may be given during any visit provided at least 4 weeks have
passed since the first dose. For vaccines given in a series, it is not necessary to start over. Refer to the tables below for recommended schedule and
minimum intervals between doses. Determine the number of previous doses of each vaccine received, find that number in the first column, and read
across to the appropriate column for the next dose and minimum interval.
Table 1. Catch-up schedule for children 4 months through 6 years (DTaP, Polio, HBV, and Hib)
Doses to be given and minimum intervals
Number of
previous doses
of each vaccine
First dose
None
DTaP
DTaP: 4 weeks after 1st dose
DTaP: 4 weeks after 2nd dose
DTaP: 6 months after 3rd dose
Polio10
Polio: 4 weeks after 1st dose
Polio: 4 weeks after 2nd dose12
Polio: 4 weeks after 3rd dose15
HBV
HBV: 4 weeks after 1st dose
HBV: 8 weeks after 2nd dose13
Hib (exception,
see 11 below)
Hib: If current age < 12 months,
4 weeks after 1st dose. If current
age 12 months to <5 years, give
final dose 8 weeks after 1st dose
(exception, see 11 below).
Hib: If current age < 12 months,
4 weeks after 2nd dose (exception:
see 14 below). If current age 12
months to <5 years, give final dose
8 weeks after 2nd dose (exception,
see 11 below).
One
Two
Three
Four
Second dose
Third dose
Fourth dose
Fifth dose
DTaP15: 6 months
after 4th dose
Hib14: Only necessary for children
age 12 months to <5 years who
received 3 doses <12 months of
age.
Table 2. Catch-up schedule for children age 7 and older (Td, Polio, and HBV)
Number of
previous doses
of each vaccine
None
Doses to be given and minimum intervals
First dose
Second dose
Booster dose
Third dose
Td
Td: 4 weeks after 1st dose
Td: 6 months after 2nd dose
Polio10
Polio: 4 weeks after 1st dose
Polio: 4 weeks after 2nd dose
Td: every 10 years (exception, see 2 on
reverse side)
Polio: see 15 below
HBV
HBV: 4 weeks after 1st dose
HBV: 8 weeks after 2nd dose13
HBV: none
One
Two
Three
10.
11.
12.
13.
14.
Polio: Children who begin the series >6 months of age may receive an all-OPV schedule to reduce the number of injections.
Hib: Any child who receives >1 dose at >15 months of age needs no further doses. Vaccine is not generally recommended for children >5 years.
Polio: For those receiving IPV alone, an interval of 6 months between IPV-2 and IPV-3 will provide optimal response and is preferred.
HBV: The minimum interval between HBV-2 and HBV-3 is 8 weeks; however, an interval of 4-12 months will result in higher final titers of anti-HBs.
Hib: If PRP-OMP was given for the first 2 doses, no more than 3 doses are needed, with the final dose given at 12-15 months and at least 8 weeks from the
previous dose. If a 3rd dose of HbOC or PRP-T is given >12 months of age, a 4th dose is not needed.
15. Polio, DTaP: Children on an IPV/OPV sequential schedule should receive all 4 doses, regardless of the age when first initiated. In such cases, the minimum
interval between the last 2 doses is 4 weeks. Neither the 4th polio in an all-IPV or all-OPV schedule nor the 5th DTaP is necessary if the previous dose was
administered after the 4th birthday.
Special Notes on Immunization
Use all clinical encounters to screen for and provide needed vaccines.
Providers should take measures to avoid missing opportunities to vaccinate.
Reporting adverse reactions: Report adverse reactions to vaccines through
the federal Vaccine Adverse Event Reporting System (VAERS). For information
on reporting reactions following vaccines administered by private physicians,
call the 24-hour national toll-free information line (800) 822-7967. Report
reactions to vaccine administered in public clinics to the Minnesota Department
of Health, (612) 623-5414 or toll-free (800) 657-3723.
There are no contraindications to simultaneous administration of vaccines
recommended for routine use in children. For children 12-18 months of age,
multiple vaccines may be administered over 1 or 2 visits, but are strongly encouraged
in 1 visit for children who have fallen behind.
Disease reporting: Report suspect cases of vaccine-preventable diseases
to the local health department or to the Minnesota Department of Health, 717
Delaware Street S.E., Minneapolis, Minnesota 55440, (612) 623-5414 or tollfree (800) 657-3723.
Children who present with a mild acute illness, with or without fever, should
not be deferred for vaccination. Only true contraindications to vaccination should
be followed. (See MDH Guide to Contraindications.)
31
Hepatitis B: While the schedule
indicates in the footnote that the
second dose may be given at 1-2
months of age, we encourage
giving the second dose at 1
month of age. The footnote states
that infants born to HBsAg-positive
mothers should receive their 2nd
dose at “1-2 months of age.” While
this is the current recommendation
within the combined ACIP, AAP, and
AAFP schedule, the 1997 schedule
published by the MDH recommended that the 2nd dose be given
at 1 month of age and we continue
to urge this more timely vaccination.
The 1998 schedule provides
optimum ages for vaccination.
Tables 1 and 2 on page 31 provide
vaccination schedules for children
who have fallen behind. These two
tables include minimum intervals
needed for catch-up. We encourage providers to follow optimal
schedules whenever possible, and
use minimum ages and intervals by
exception only.
For questions about the schedule,
call the Minnesota Immunization
Hotline at 612/623-5100 or 1-800/
657-3970.
Hepatitis B Vaccination - New School Requirements
The 1998 Legislature has amended
the School Immunization Law (MN
Statutes Section 123.70) to include
a hepatitis B vaccination requirement. The revised law requires
hepatitis B immunization for
kindergartners beginning in the
2000-01 school year and for 7th
graders beginning in the 2001-02
school year. In the interim, we
continue to recommend and
encourage that all children and
adolescents receive hepatitis B
vaccine.
B immunization has been recommended for all infants and adolescents since late 1993 in Minnesota,
and in the past several years
immunization rates of 2-3 year olds
have increased from an estimated
26 percent to 78 percent. While it is
encouraging to note the growing
acceptance of universal infant
hepatitis B vaccination, catch-up
efforts will be needed to reach
unvaccinated children who will be
enrolling in 7th grade in the fall of
2001.
Hepatitis B immunization consists of
a three-dose series. As is true for
other immunizations that require a
series of doses, a provision in the
law allows students who have
started a vaccination series to
remain in school with a designated
time frame to complete the series.
The options for medical exemption
or conscientious exemption also
apply to hepatitis B immunization.
With this new revision to the School
Immunization Law, Minnesota joins
29 other states in making hepatitis B
immunization a requirement for
school enrollment. The hepatitis B
vaccine available through the
Minnesota Vaccines for Children
(MnVFC) Program may be administered to any child from birth through
18 years who meets MnVFC
eligibility criteria.
While this amendment to the law
was not initiated by MDH, it is
consistent with MDH policy and
recommendations. Routine hepatitis
The most common risk factors for
hepatitis B virus infection both
nationally and in Minnesota are
sexual contact, use of contaminated
needles (e.g., drug use, tattooing,
body piercing), being a household
contact of a chronic carrier, and
being a health-care worker. Previous programs that have targeted
these high-risk populations have not
been successful in lowering the rate
of reported disease, except for
those directed to health-care
workers. For this reason, a comprehensive strategy has been recommended by CDC which includes 1)
prenatal testing of pregnant women
and appropriate follow-up of their
infants; 2) routine vaccination of
infants, children, and adolescents;
and 3) targeted vaccination of highrisk adults.
We encourage providers to
begin NOW to assess hepatitis B
vaccine status of all pediatric
patients and to vaccinate those
that are not yet vaccinated. A
concerted effort NOW will ease
the "bolus effect" that will
otherwise occur as the time for
the school law implementation
draws closer.
Rabies: Current Epidemiology and Post-Exposure
Prophylaxis Recommendations
INTRODUCTION
It is estimated that 36,000 human cases
of rabies occur each year worldwide.
As expected, the highest rates are from
countries in Asia (3 per 100,000
persons per year), where dog bites are
common (1). Human cases occur
infrequently in the United States, with
generally fewer than five cases reported
each year. The last human rabies case
in Minnesota occurred in 1975 and was
related to a cat bite. This is predominantly related to the decline in the
number of domestic animal cases since
32
the 1950’s due to aggressive canine
vaccination programs. However, the
recent epizootic of raccoon rabies along
the East coast and the rising number of
human cases attributed to bats in the
U.S. have changed the current epidemiology of rabies. The raccoon rabies
continued...
the state.
Figure 1. Cases of Animal Rabies Identified,
Minnesota, 1960-1997
The number of cases of rabies in
animals has varied widely by year in
Minnesota (Figure 1). For example in
1981, nearly 500 cases were observed
versus only 23 cases in 1994. Every 6
to 10 years the number of animal cases
peaks and is primarily dependent on the
number of rabid skunks in the population. In 1994, the number of rabid
animals reported was at an all time low.
It is speculated that flooding or disease
in the skunk population accounted for
this temporary decline.
Identified, Minnesota, 1960-1997
500
450
400
350
300
250
200
150
100
50
0
1960
1965
1970
1975
epizootic was first documented in
Virginia in 1977 and now has spread
throughout most of the northeastern
states and westward into eastern Ohio.
Furthermore, 21 (58%) of the 36 human
cases identified in the U.S. since 1980
have been associated with bat variants
of the rabies virus; only one of these
cases had a documented history of a
bat bite (2). Because of recent concerns about appropriate post-exposure
prophylaxis (PEP) of individuals who
are exposed to bats and recent
changes in the recommendations for
PEP, we summarize here the current
epidemiology of animal rabies in
Minnesota, and review new PEP
recommendations from the Centers for
Disease Control and Prevention (CDC)
(2).
1980
Year
1985
1990
1995
(MDH). Animals are submitted for
testing if there has been concern of
suspected rabies transmission to
humans or other animals. For animals
diagnosed with rabies, the Minnesota
Board of Animal Health conducts an onsite visit to evaluate possible human
and animal contacts. Staff in the Acute
Disease Epidemiology Section maintain
data on animals submitted to the
laboratory for rabies virus testing.
Thus, data on animal rabies in the state
are based on a laboratory system and
may not accurately reflect the occurrence of disease in animals throughout
The diagnosis of rabies in animals is
made by direct immunofluorescent
antibody staining of rabies viral antigen
in brain material submitted to the
Minnesota Department of Health
POST-EXPOSURE PROPHYLAXIS
In assessing the need for PEP, providers should consider the animal species
involved, the type of exposure and
disposition of the animal. Rabies is
usually transmitted when infectious
saliva penetrates the skin from a bite or
when saliva comes in contact with a
mucous membrane or fresh open
continued...
Table 1. Animals Tested for Rabies Virus, Minnesota, 1993-1997
No. Tests
Performed
EPIDEMIOLOGY OF ANIMAL RABIES
IN MINNESOTA
In the U.S. the primary animal reservoirs for rabies include bats, foxes,
raccoons, and skunks. These wild
animal reservoirs are geographically
dispersed and have distinct antigenic
differences. Among terrestrial animals
there are five rabies virus variants,
while there are eight variants among
bats. The bat variants seldom are
found in terrestrial animals. In Minnesota the primary reservoir species is the
striped skunk (Mephitis mephitis).
Between 1993 and 1997, 8,841 animals
were tested in Minnesota for rabies
virus. Of these, 225 (2.6%) were
positive (Table 1). During that time, the
only wild animal species testing positive
were skunks, bats, and raccoons, with
skunks having the highest positivity
rate. Rabid domestic animals included
cows, dogs, cats, and horses.
No. Tests
Percent
Positive
Positive
Wild
Skunk
408
138
33.8
Bat
635
21
3.3
Raccoon
631
2
0.3
Cat
3211
14
0.4
Dog
2425
15
0.6
Cow
577
31
5.4
Horse
92
4
4.3
Others
862
0
--
TOTAL
8841
225
2.6
Domestic
33
Figure 2. Evaluation of a Dog, Cat or Ferret Exposure*
Cat, dog, ferret
exposure
Animal not available
for observation or
testing
Animal available for
observation or
testing
At time animal is caught,
it is behaving strangely
or is ill
Animal is behaving
normally
Place in quarantine
(usually 10 days)
Laboratory test
for rabies
Animal rabid
Administer complete
postexposure
prophylaxis
Animal sickens
or dies
Animal remains
healthy
Do not administer
postexposure
prophylaxis
Animal not rabid
Do not administer
postexposure
prophylaxis
* If unusual circumstances exist, contact MDH at (612) 623-5414
wound (defined as less than 24 hours
old).
Exposure to Domestic Animals
If the animal has symptoms of rabies,
the animal should be immediately
euthanized and tested, and PEP should
be considered pending test results.
Following exposure to domestic animals
unavailable for testing or observation,
PEP should be provided. Stray or
unwanted animals can be tested for
rabies immediately, and PEP can be
administered if the animal tests positive
for rabies virus. Following exposure to
healthy pet dogs, cats or ferrets, a 10day quarantine period may be indicated
(Figure 2). Bites from dogs, cats and
ferrets should be reported to local
animal control officials who can assist
with quarantine and follow-up procedures. Bites from animals such as pigs,
horses and cattle should be assessed
on a case-by-case basis.
Exposure to Wild Animals
Exposure to skunks, bats or raccoons
warrants PEP. In general, PEP is not
indicated following exposure to rabbits,
rats, mice, or small rodents such as
squirrels, gophers or hamsters. In the
case of bats, exposure can be difficult
to assess. Bats have small sharp teeth
and puncture wounds from them can be
difficult to detect so the absence of
teeth marks does not rule out a
significant exposure. In situations
where there is a reasonable possibility that contact with a bat occurred
(e.g., a sleeping person awakes to
find a bat in the room, or an adult
witnesses a bat in the room with a
previously unattended child or
mentally disabled or intoxicated
person), PEP should be given (2).
This statement represents the current
position of CDC on this issue. We at
MDH recognize that this policy will
34
result in increased use of PEP, often
unnecessarily. However, it is clear that
a number of human rabies cases
infected with a bat strain in the U.S.
have had no documented exposure and
recent epidemiologic data suggest that
transmission of rabies virus can occur
through minor bites from bats (3).
Furthermore, PEP is safe and effective
in preventing disease and rabies is
100% fatal.
Administration of PEP
Immediate and thorough washing of all
bite wounds and scratches with soap
and water is perhaps the most effective
means of preventing rabies virus
transmission. Tetanus and antibiotic
prophylaxis should be given as indicated. PEP involves the administration
of rabies vaccine and human rabies
immune globulin (HRIG) (Table 2).
There are three rabies vaccines
licensed in the United States: human
diploid cell vaccine (HDCV), rabies
vaccine adsorbed (RVA), and purified
chick embryo cell culture (PCEC).
HRIG should be given to previously
unvaccinated patients. A recent
decision by the Advisory Committee on
Immunization Practices regarding HRIG
administration states that: “If anatomically feasible, the full dose of HRIG
should be thoroughly infiltrated in
the area around and into the
wound(s) and the remainder should
be administered at an anatomical
site distant from vaccine administration (2).”
For more information on rabies diagnosis or PEP, contact the Acute Disease
Epidemiology Section, MDH, at 612/
623-5414. By mid-summer MDH
should also have a brochure available
on bat rabies; contact the Acute
Disease Epidemiology Section for
copies.
REFERENCES
1. Fishbein DB, Robinson, LE.
Rabies. New Engl J Med
1993;329:1632-38.
2.
CDC. Human rabies - Texas and
New Jersey, 1997. MMWR
1998;47:1-5.
3.
CDC. Human rabies - Montana
and Washington, 1997. MMWR
1997;46:770-4.
Table 2. Type of Treatment and Regimen for Rabies Postexposure
Prophylaxis by Vaccination Status of Patient
Vaccination Status
Not previously
vaccinated
Previously
vaccinated §
*
Treatment
Local wound
cleansing
Regimen*
All postexposure treatment should begin with
immediate thorough cleansing of all wounds with
soap and water.
Human rabies
immune globulin
(HRIG)
20 IU per kg body weight. As much as possible of
the full dose should be infiltrated into and around
the wound(s), and the remainder should be
administered intramuscularly at an anatomical site
distant from vaccine administration. HRIG should
not be administered in the same syringe as vaccine.
Because HRIG may partially suppress active
production of antibody, no more than the
recommended dose should be given.
Vaccine
1.0 mL of human diploid cell vaccine (HDCV),
rabies vaccine adsorbed (RVA), or purified chick
embryo cell culture (PCEC) vaccine administered
intramuscularly (deltoid area ), on days 0, 3, 7, 14,
and 28 (day 0 indicates the first day of treatment).
Local wound
cleansing
All postexposure treatment should begin with
immediate thorough cleansing of all wounds with
soap and water. HRIG should not be given.
Vaccine
1.0 mL of HDCV, RVA, or PCEC administered
intramuscularly (deltoid area ) on days 0 and 3.
These regimens are applicable for all age groups, including children.
The deltoid area is the only acceptable site of vaccination for adults and older children. For
younger children, the outer aspect of the thigh may be used. Vaccine should never be
administered in the gluteal area.
§
Any person with a history of pre-exposure vaccination with HDCV, RVA, or PCEC;
previous postexposure prophylaxis with HDCV, RVA, or PCEC; or previous vaccination
with any other type of rabies vaccine and a documented history of antibody response to the
previous vaccination.
Update: Lyme Disease Vaccine
On May 26, 1998, an advisory committee to the Food and Drug Administration
(FDA) cautiously recommended
approval of LYMErix™ vaccine
(produced by SmithKline Beecham).
However, the committee expressed a
number of serious concerns including:
• Lack of data on the need, frequency
and timing for booster shots
• Lack of data on safety for people with
arthritis, undiagnosed Lyme disease
and the elderly
• Unlike other vaccines, it takes a year
for LYMErix™ to build up immunity in
most people
• The vaccine was tested only in
people over age 15
• Lack of data on long-term effects
(clinical trials have lasted only 20
months).
The vaccine has NOT yet been licensed
by the FDA (as of May 29, 1998).
However, SmithKline Beecham has
initiated a national advertising cam-
paign for their LYMErix™ vaccine. This
campaign will stimulate consumer
interest but may cause confusion about
the status and intended use of the
vaccine.
In data presented to the committee, the
vaccine was reported to be 79%
effective after three doses and 50%
after two, in clinical trials involving
10,937 people in Lyme endemic areas.
After the FDA approves the license for
continued...
35
the vaccine, the Advisory Committee on
Immunization Practices (ACIP) will
develop their recommendations for
clinical practice. This ACIP statement is
not expected to be made until October
or later.
Another pharmaceutical company,
Pasteur Merieux Connaught, has also
applied to the FDA to license its Lyme
disease vaccine, ImuLyme™. It is not
known when the FDA’s advisory
committee will make recommendations
for their vaccine.
according to directions, and watching
for early signs and symptoms of Lyme
disease.
This is a good opportunity to remind
people they need to continue taking
preventive actions when in wooded,
brushy areas within endemic counties.
Those actions include wearing light
colored clothes, regularly checking for
deer ticks, using insect repellents
For more information about Lyme
disease, contact the Acute Disease
Epidemiology Section at 612/623-5414.
For questions about the Lyme vaccine,
contact the Acute Disease Prevention
Services Section at 612/623-5237 or
the Immunization Hotline at 1-800/6573970.
Anne M. Barry, J.D., M.P.H.
Commissioner of Health
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