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Wilderness Medical Society - snowmass 2005 (Page 140)

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Wilderness Medical Society - snowmass 2005
11
the need for additional therapy after rabies exposure, but simplifies post-exposure therapy
by eliminating the requirement for rabies immune globulin (RIG) and by decreasing the
number of doses of vaccine required. Prevention with human diploid cell vaccine
(HDCV) is 3 doses given 1.0 ml IM in the deltoid muscle on days 0, 7, and 21 or 28. A
new dosage of 0.1 ml intradermally given on the same dosage schedule also seems
effective for prophylaxis. Caution should be taken to avoid taking chloroquine for
malaria prophylaxis while receiving rabies immunization as it has been shown to reduce
the antibody response.

Post-exposure immunization for those previously immunized is 2 doses (1 ml each) on
days 0 and 3, with no RIG. If no prior immunization, give RIG 20 IU/kg (injecting as
much as possible into and around the bite site and and any additional IM at a site distant
from the HDCV injection site) and 5 doses (1 ml each) of HDCV on days 0, 3, 7, 14, and
28. These injections must be given in the deltoid muscle as 2 incidents of failure of post-
exposure immunization with RIG and HDCV have occurred when these injections were
given in the gluteal muscle.

To determine if a booster is needed, obtain antibody testing every two years. There is a
very low incidence of side effect with the new diploid cell vaccine; some local irritation
possible and occasional muscle ache and headache. In persons receiving a booster shot
up to 6% may have hives, lymph node enlargement, and fever.

Tetanus - Diphtheria

Recommended as part of a standard immunization program regardless of travel.


All persons should have a tetanus booster every 10 years; 5 years for puncture wounds,
bites, and other contaminated wounds. This vaccine is so effective, that a booster sooner
than every 10 years is probably not required. Dosage is 0.5 ml of dT vaccine given IM.
A different vaccine is prepared for use in children. Infants receive a special diphtheria-
tetanus-pertussis vaccine that is also a different formulation than that used in children.
Family physicians, pediatricians, and travel medicine clinics generally have all three
vaccines in stock at all times. Both adult and children's vaccine should be given with
diphtheria toxoid in combination. Infants should follow the routine pediatric
immunization schedule with tetanus-diphtheria-pertussis-Hib combination vaccine. A
local reaction at injection site is possible; fever may occur; severe allergic reactions are
rare.

Typhoid

Recommended for travelers outside of the United States, northern Europe, Australia and
New Zealand.


A new high potency oral vaccine became available in 1990 which provides at least 80%
effective protection and which has considerably less side effects than the USP vaccine.
Immunization is with one capsule of the live attenuated Ty21a vaccine (Vivotif Berna

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