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Annually, 59,000 people die of rabies, the world’s oldest known infectious disease, globally. In the United States, canine rabies has been virtually eliminated but the risk of rabies due to wildlife, especially raccoons, skunks, and bats, has required post exposure prophylaxis (PEP) be administered to more than 60,000 patients annually¹. In 2021, 5 people in the United States² died of rabies mostly due to misinformation or improper treatment. Rabies post exposure prophylaxis consists of three steps, wound washing, administration of human rabies immune globulin (HRIG) and a full course of vaccine³. In 2022, Whitehouse⁴ published that there were 122 breakthrough rabies infections when PEP was given due to four factors: 1) deviations from core practice 2) delays in seeking health care 3) errors in administration of HRIG 4) comorbidities or immunosuppression.  It is estimated that over 40% of PEP administration is given inappropriately.

The publication,” Safety, and efficacy of rabies immunoglobulin in pediatric patients with suspected exposure”, Human Vaccines & Immunotherapeutics, 17:7, 2090–2096⁵, was the first study that prospectively reviewed the use of human rabies immune globulin 150 IU/ml in 30 pediatric patients ages 0.5–14.9 years old.

Globally, 40% of people bitten by animals suspected of being infected with the rabies virus are children under the age of 15.⁶

This paper will look at risk reduction strategies that will include:

1. Proper Identification of major rabies vectors
2. Special risks associated with bat exposures in children 
3. Administration of human rabies immune globulin with volume considerations in children
4. Special administration consideration for rabies vaccines
5. “Just -in- time “Education for health care providers

Illustrative cases will be used to demonstrate each of these strategies of risk as well as the strategies for risk reduction.