Rabies Vaccination for Children: Recommendations and Considerations

In 2022, the Indian Academy of Paediatrics (IAP) recommended PrEP for all children, acknowledging the country's significant burden of animal bites, which, according to the Indian Council of Medical Research-National Institute of Epidemiology (ICMR-NIE), amounts to approximately 9.1 million annually, with dogs causing over three-quarters of these incidents. An estimated 5,726 people die from rabies in India each year.

Experts have varying opinions about which children should receive PrEP. Many argue that children in households with pets or those at higher risk of dog encounters should be considered for vaccination. India's national rabies guidelines suggest offering PrEP to high-risk groups, but the IAP's recommendation can be viewed on a voluntary basis.

Dr. Khan Amir Maroof, a rabies researcher, noted that PrEP may not be necessary for all children, despite the IAP's position. He highlighted the existing vaccination demands on children due to the Universal Immunisation Programme and stressed that any addition of vaccines must be supported by strong scientific evidence. The National Centre for Disease Control (NCDC) has discussed PrEP's potential but is not actively pursuing it at this time.

According to Dr. Maroof, the decision to vaccinate should be based on the likelihood of exposure, with the World Health Organisation (WHO) recommending PrEP in areas where the risk is particularly high—5% or more. Most regions in India report dog bite rates around 2-2.5%. WHO suggests PrEP for individuals with consistent or heightened exposure risks or those traveling to high-risk areas.

India's guidelines recommend three doses for PrEP, with typical schedules on days 0, 7, and 21 or 28. A recent study in India is exploring simplified intradermal PrEP schedules to improve vaccine accessibility in these settings.

Children are especially vulnerable to rabies due to their higher likelihood of close contact with dogs and less awareness of animal behavior. As noted by Dr. Sanjay Wazir from Motherland Hospital, children's stature increases the risk of severe bites. The WHO has documented that children constitute a significant proportion of dog-bite victims and often face severe injuries, particularly to the head and neck.

Dogs are central to rabies control, as they are responsible for 99% of human rabies cases globally. Vaccinating dog populations is essential for effective public health intervention, reinforcing a study published in The Lancet Regional Health.

It is crucial for parents to understand that PrEP does not replace post-exposure prophylaxis (PEP). Dr. Ashu Khajuria emphasized that even if a child has received PrEP, medical evaluation is still necessary after a potential rabies exposure. PrEP serves to prime the immune system, simplifying future management if a rabies exposure occurs, as vaccinated individuals typically require fewer doses of the rabies vaccine.

Regardless of PrEP status, immediate action following a dog bite is critical. The wound should be washed with soap and water for at least 15 minutes, followed by medical assessment. WHO guidelines recommend immediate vaccination for moderate exposures and rabies immunoglobulin for severe cases.

Correctly administered PEP is highly effective in preventing rabies deaths, with studies showing that timely treatments can reduce mortality rates significantly. A recent study by NIMHANS indicated that many rabies fatalities were due to missed or improperly administered care, reinforcing the importance of timely medical intervention.