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Rabies Vaccine

Class: Vaccines
ATC Class: J07BG01
VA Class: IM100
Brands: Imovax, RabAvert

Introduction

Inactivated virus vaccine.208 234 236 Rabies vaccine contains rabies virus antigens and is used to stimulate active immunity to rabies infection.208 234 236 Commercially available in the US as human diploid-cell rabies vaccine (HDCV; Imovax) and purified chick embryo cell culture rabies vaccine (PCECV; RabAvert).208 234 Other rabies vaccines (e.g., vero cell rabies vaccine, duck embryo rabies vaccine, nerve tissue vaccine [NTV]) may be available in other countries.213 236 249

Uses for Rabies Vaccine

Prevention of Rabies

Prevention of rabies in children, adolescents, and adults exposed to or at increased risk of exposure to rabies disease or virus.208 213 234 236 250

Rabies is a viral infection transmitted by saliva of infected mammals, most commonly wild, terrestrial carnivores (e.g., skunks, raccoons, foxes, coyotes) or bats.213 236 In the US, the greatest risk for naturally acquired rabies is from contact with and bites from insectivorous bats.222 236 242 Following exposure and infection, rabies virus usually moves along a neural pathway and enters the CNS.234 236 After entrance into the CNS, the virus is unlikely to be affected by antirabies antibodies and encephalomyelitis usually develops and almost always is fatal.234 236 In the US, approximately 16,000–39,000 individuals receive rabies postexposure prophylaxis each year.234 236 250 Although there were 27 rabies cases reported in the US during 2000–2008,250 these individuals evidently did not receive rabies postexposure prophylaxis.250 Rabies prevention and control strategies and elimination of canine rabies virus variants and enzootic transmission among dogs have lowered the number of rabies cases in the US to an average of 1–2 per year.250 However, worldwide, rabies is much more common and at least 55,000 rabies-related deaths occur each year.249 250

USPHS Advisory Committee on Immunization Practices (ACIP) and AAP recommend preexposure vaccination with rabies vaccine (series of 3 doses with booster doses when indicated) in children, adolescents, and adults who are or will be at increased risk of exposure to the virus.213 236 (See Preexposure Vaccination Against Rabies in High-risk Groups under Uses.)

Postexposure prophylaxis with a regimen that includes local wound treatment, rabies vaccine (series of 4 or 5 doses), and a single dose of rabies immune globulin (RIG) is recommend for previously unvaccinated children, adolescents, and adults following potential rabies exposure.213 236 Postexposure prophylaxis with a regimen that includes local wound treatment and a series of 2 booster doses of rabies vaccine (without RIG) is recommended for previously vaccinated children, adolescents, and adults following potential rabies exposure.213 236 (See Postexposure Prophylaxis of Rabies under Uses.)

Preexposure Vaccination Against Rabies in High-risk Groups

Preexposure vaccination in children, adolescents, and adults who are or will be at risk of exposure to rabies virus.208 213 234 236

Preexposure vaccination does not eliminate the need for prompt postexposure prophylaxis if an exposure to rabies occurs.208 213 234 236 250 (See Postexposure Prophylaxis of Rabies under Uses.)

Need for rabies preexposure vaccination depends on the nature of risk and associated level of potential exposure.236 Consider preexposure vaccination for individuals whose risk of rabies exposure is greater than that of the general population (e.g., veterinarians and their staff, animal-control and wildlife workers, field biologists, spelunkers, missionaries, rabies researchers, certain laboratory workers).212 236 Also consider preexposure vaccination for individuals whose activities bring them into frequent contact with rabies virus or potentially rabid bats, raccoons, skunks, cats, dogs, or other species at risk for having rabies.236 (For ACIP definitions of risk categories and recommendations regarding preexposure vaccination for each category, see Table 1.)

Travelers to areas where rabies is endemic may be at risk, especially if they are likely to come in contact with animals in areas where dog or other animal rabies is enzootic and immediate access to appropriate medical care (including rabies vaccine and RIG) is unlikely.212 236 237 249 Canine rabies remains highly endemic in certain areas of the world (e.g., parts of Africa, Asia, Central and South America).212 237 CDC recommends preexposure vaccination based on local incidence of rabies in the country to be visited, availability of appropriate agents for rabies postexposure prophylaxis in that country, and intended activity and duration of stay.212

Minimum acceptable antibody titer is complete virus neutralization at a 1:5 serum dilution by the rapid fluorescent focus inhibition test (RFFIT). Give booster dose of rabies vaccine if titer falls below this level.

Adapted from the Recommendations of the Advisory Committee on Immunization Practices (ACIP) on Human Rabies Prevention. MMWR Recomm Rep. 2008; 57 (RR-3):1-28.

Table 1. US Rabies Risk Categories and Recommendations for Preexposure Vaccination236

Category of Rabies Risk

Nature of Risk

Typical Population

Preexposure Vaccination

Continuous

Virus present continuously (often in high concentrations); specific exposure likely to go unrecognized; bite, nonbite, or aerosol exposure

Rabies research laboratory workers, rabies biologics production workers

Yes; then perform serologic testing every 6 months and give booster dose if antibody titer decreases to less than acceptable level

Frequent

Exposure usually episodic; source recognized, but exposure may go unrecognized; bite, nonbite, or aerosol exposure

Rabies diagnostic laboratory workers, cavers, veterinarians and their staff, animal-control and wildlife workers in rabies enzootic areas, individuals who frequently handle bats

Yes; then perform serologic testing every 2 years and give booster dose if antibody titer decreases to less than acceptable level

Infrequent (but greater than in general population)

Exposure is nearly always episodic with a recognized source; bite or nonbite exposure

Veterinarians and animal-control staff working with terrestrial animals in areas where rabies is uncommon to rare, veterinary students, travelers visiting areas where rabies is enzootic and immediate access to appropriate medical care is limited

Yes; serologic testing and booster doses not necessary

Rare (population at large)

Exposure always episodic with a recognized source; bite or nonbite exposure

US population at large, including those in rabies-epizootic areas

Not necessary

Postexposure Prophylaxis of Rabies

Postexposure prophylaxis of rabies in previously vaccinated and unvaccinated children, adolescents, and adults following exposure to rabies disease or virus.208 213 234 236 250

History of previous vaccination against rabies simplifies the postexposure prophylaxis regimen, but does not eliminate the need for prompt postexposure prophylaxis if an exposure to rabies occurs.208 234 236 250

Whenever a possible human exposure to rabies occurs, the risk of infection must be accurately assessed to determine the need for postexposure prophylaxis.236 250 Base decisions regarding the need for postexposure prophylaxis on vaccination status of exposed individual (see Table 2), type of exposure (bite, nonbite), information about the animal involved (type, vaccination status, condition at time of attack) (see Table 3), and rabies epidemiology in the specific geographic region.213 236 250 Consult local or state public health officials for assistance when evaluating rabies exposures and the need for postexposure prophylaxis.213 236 250

Any person with a history of a complete preexposure or postexposure vaccination regimen with HDCV, PCECV, or rabies vaccine adsorbed (RVA; not commercially available in the US), or previous vaccination with any other type of rabies vaccine and a documented history of antibody response to the prior vaccination

Individuals with immunosuppression should receive a 5-dose regimen of rabies vaccine; give 1 mL (HDCV or PCECV) IM once on days 0, 3, 7, 14, and 28.

Deltoid area is the only acceptable site for IM administration of rabies vaccine in adults, adolescents, and older children. For younger children, deltoid or anterolateral thigh should be used. Never administer in gluteal area.

Day 0 is the day the first dose of rabies vaccine is administered.

Adapted from Use of a Reduced (4-Dose) Vaccine Schedule for Postexposure Prophylaxis to Prevent Human Rabies. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2010; 59 (RR-2):1-9.

Table 2. US Rabies Postexposure Prophylaxis Schedule for Adults, Adolescents, or Children250

Vaccination Status

Treatment

Regimen

Not previously vaccinated

Wound cleansing

Immediately cleanse all wounds thoroughly with soap and water; if available, irrigate wounds with virucidal agent (e.g., povidone-iodine solution)

RIG

Administer 20 international units/kg of RIG; if anatomically feasible, infiltrate full RIG dose around and into wound(s) and give any remaining portion of the dose IM at an anatomical site distant from site of rabies vaccine administration

Rabies vaccine

Administer 4-dose regimen of rabies vaccine; give 1 mL (human diploid-cell vaccine [HDCV; Imovax] or purified chick embryo cell culture vaccine [PCECV; RabAvert]) IM once on days 0, 3, 7, and 14

Previously vaccinated

Wound cleansing

Immediately cleanse all wounds thoroughly with soap and water; if available, irrigate wounds with virucidal agent (e.g., povidone-iodine solution)

RIG

RIG should not be administered

Rabies vaccine

Administer 2-dose regimen of rabies vaccine; give 1 mL (HDCV or PCECV) IM once on days 0 and 3

Regardless of rabies immunization status, ACIP and AAP recommend that postexposure prophylaxis of rabies begin immediately with thorough cleansing of all bite wounds and scratches using soap and water and, if available, irrigation with a virucidal agent such as povidone-iodine solution.213 236 250 Local wound treatment is an essential initial step in rabies postexposure prophylaxis in all individuals.213 236 250 (See General under Dosage and Administration.)

In previously unvaccinatedchildren, adolescents, and adults following potential rabies exposure, a postexposure prophylaxis regimen of active immunization with a 4- or 5-dose regimen of rabies vaccine and passive immunization with a single dose of RIG is recommended as soon as possible.208 213 234 236 250 The ACIP states that a 4-dose regimen of rabies vaccine in conjunction with RIG is sufficient for postexposure prophylaxis in previously unvaccinated individuals who are immunocompetent; however, a 5-dose vaccine regimen in conjunction with RIG should be used in those with altered immunocompetence.250

In previously vaccinated children, adolescents, and adults following potential rabies exposure, a 2-dose booster regimen of rabies vaccine (without RIG) is recommended as soon as possible.213 236 250

During the 10-day observation period, begin postexposure prophylaxis in the exposed individual at the first sign of rabies in a dog, cat, or ferret that has bitten them. If the animal exhibits clinical signs of rabies, euthanize it immediately and perform appropriate testing.

Initiate postexposure prophylaxis as soon as possible following exposure to such wildlife, unless animal is available for testing and public health authorities are facilitating expeditious laboratory testing or it is already known that brain material from the animal has tested negative. Other factors that might influence urgency of decision-making regarding initiation of postexposure prophylaxis before diagnostic results are known include the animal species, general appearance and behavior of the animal, whether encounter was provoked by a human, and the severity and location of bites. Discontinue postexposure prophylaxis if appropriate laboratory tests (i.e., direct fluorescent antibody test) are negative.

Euthanize the animal and test as soon as possible. Holding for observation is not recommended.

Adapted from the Recommendations of the Advisory Committee on Immunization Practices (ACIP) on Human Rabies Prevention. MMWR Recomm Rep. 2008; 57 (RR-3):1-28.

Table 3. US Rabies Postexposure Prophylaxis Guide Based on Type and Status of Animal Involved236

Animal Type

Evaluation and Disposition of Animal

Postexposure Prophylaxis Recommendations

Dogs, cats, ferrets

Healthy and available; confine for 10 days of observation

Do not begin prophylaxis unless animal develops clinical signs of rabies

Rabid or suspected rabid

Immediately begin postexposure prophylaxis

Unknown (e.g., escaped)

Consult public health officials

Skunks, raccoons, foxes, and most other carnivores; bats

Regard as rabid unless animal proven negative by laboratory tests

Consider immediate postexposure prophylaxis

Livestock, small rodents, lagomorphs (rabbits, hares), large rodents (woodchucks, beavers), other mammals

Consider individually

Consult public health officials. Bites from squirrels, hamsters, guinea pigs, gerbils, chipmunks, rats, mice, other small rodents, rabbits, and hares almost never require rabies postexposure prophylaxis

Bite exposures include any skin penetration by teeth; all bite exposures from an animal known or suspected to be rabid, regardless of bite location, pose a potential risk of rabies transmission and require postexposure prophylaxis.213 236 Risk of transmission varies in part based on species of biting animal, anatomic site of bite, and severity of wound.236 Rabies transmission can occur from bites of some animals (e.g., bats) that inflict rather minor injury and wounds that are difficult to detect.236

Any potential exposure to a bat requires thorough evaluation.236 If possible, the bat should be submitted for rabies diagnosis.236 Postexposure prophylaxis is not necessary if the individual can be reasonably certain a bite, scratch, or mucous membrane exposure did not occur or if the bat is available for testing and is negative for rabies virus.236 Situations that might qualify as exposures include finding a bat in the same room as a person who might be unaware that a bite or direct contact occurred (e.g., a deeply sleeping individual awakened to find a bat in the room or an adult observes a bat in the room with a previously unattended child, mentally disabled person, or intoxicated person).236 Other household members who did not have direct contact with the bat or were awake and aware when in the room with the bat should not be considered as having exposure to rabies.236

Nonbite exposures include contamination of preexisting open wounds, abrasions, mucous membranes, or scratches with saliva or other potentially infectious material (e.g., neural tissue) from an animal known or suspected to be rabid.213 236 Although nonbite exposures only rarely cause rabies, such exposures require assessment to determine if sufficient reasons exist to consider postexposure prophylaxis.213 236 Nonbite exposures of highest risk occur in surgical recipients of corneas, solid organs, and vascular tissue transplanted from patients who died of rabies and individuals exposed to large amounts of aerosolized rabies virus.236

Transmission of rabies to individuals performing autopsies not reported to date;251 no confirmed cases of rabies reported in individuals performing postmortem examinations of humans or animals.251 CDC recommends that personnel performing autopsies on decedents with confirmed or suspected rabies use appropriate personal protective equipment, wear heavy or chain mail gloves, minimize aerosol generation by using a handsaw rather than oscillating saw, limit the number of individuals participating in the procedure and collection of specimens, and use ample amounts of 10% sodium hypochlorite solution during and after the procedure to ensure decontamination of all exposed surfaces.251 CDC states that preexposure vaccination against rabies usually is not required for individuals performing autopsies and that rabies postexposure prophylaxis is recommended in autopsy personnel only if a wound or mucous membrane gets contaminated with the patient's saliva or other potentially infectious material (e.g., neural tissue) during the procedure.251

Other forms of contact in the absence of a bite or nonbite exposure (e.g., petting a rabid animal or contact with blood, urine, or feces of a rabid animal, contact of saliva with intact skin) are not considered exposure and postexposure prophylaxis is not necessary.236

In health-care personnel, routine delivery of health care to a patient with rabies is not an indication for postexposure rabies prophylaxis; postexposure prophylaxis in such personnel is indicated if they have been bitten by the patient or if they have mucous membranes or nonintact skin (e.g., open wounds) that were contaminated with the patient's saliva or other potentially infectious material (e.g., neural tissue).236

Because the rabies incubation period in humans can range from days to years (usually 1–3 months),212 213 234 236 250 initiate rabies postexposure prophylaxis (regardless of the length of delay) if a documented or likely exposure has occurred and clinical signs of rabies have not appeared in the exposed individual.236

Postexposure prophylaxis failures have not been reported in the US when recommended wound management and postexposure regimens were followed using commercially available rabies vaccines and RIG.236 250 ACIP states that rabies pathogenesis data, animal data, clinical studies, and epidemiologic surveillance indicate that a 4-dose vaccine series is as effective as a 5-dose vaccine series when used in conjunction with wound management and RIG.250 Rare reports of postexposure prophylaxis failures in other countries usually involved some deviation from recommended procedures (e.g., postexposure prophylaxis not given or substantially delayed, wounds not adequately cleansed, rabies vaccine given IM into the gluteal rather than deltoid region, failure to passively immunize with RIG by infiltrating the wound site, use of less than the recommended dose of RIG, use of less than the recommended number of vaccine doses).234 236 250

Travelers to rabies-endemic countries should be warned about the risk of acquiring rabies and educated in bite prevention strategies (e.g., avoiding contact with bats, avoiding stray dogs, monkeys, or cats).212 Because appropriate preparations of RIG or rabies vaccine may be not available for postexposure prophylaxis in the destination country, CDC recommends that travelers to such countries have a preplanned strategy in place that may involve identifying a different country where appropriate postexposure prophylaxis can be obtained if necessary.212 CDC states that rabies vaccines grown in animal brains (nerve tissue vaccines; NTV) may still be used in some developing countries; if offered such a vaccine (identified by a regimen that requires 5-mL injections once daily for 14–21 days), travelers should refuse the vaccine and travel to a country where an acceptable rabies vaccine and RIG are available.212 If travelers in other countries receive postexposure prophylaxis with regimens and/or preparations not recommended by ACIP (or not used in the US), additional therapy may be necessary following return to the US.212 236 In such cases, consult state and local health authorities for advice regarding the need for additional postexposure prophylaxis.236 Consider serologic testing in these travelers to verify efficacy of the regimen used and to ensure an adequate immune response.236 (See Pre- and Postvaccination Serologic Testing under Cautions.)

Rabies Vaccine Dosage and Administration

General

  • Rabies postexposure prophylaxis in previously unvaccinated individuals involves thorough cleansing of all bite and nonbite wounds followed by active immunization with rabies vaccine and passive immunization with RIG.212 213 236 250

  • Rabies postexposure prophylaxis in previously vaccinated individuals involves thorough cleansing of all bite and nonbite wounds followed by booster doses of rabies vaccine (without RIG).212 213 236 250

  • Because rabies virus may remain localized at the site of inoculation for a variable time before entering neural tissue, immediately wash all bites and scratches with soap and water; if available, irrigate with a virucidal agent (e.g., povidone-iodine solution).212 213 236 250 Institute tetanus prophylaxis and measures to control secondary infection as indicated.208 213 236 Consider cosmetic factors and the potential for bacterial infection before deciding to suture large wounds.213 236 AAP states that, if possible, the wound should not be sutured.213

Administration

IM Administration

Administer by IM injection.208 213 234 236

Do not administer sub-Q, intravascularly, or intradermally.208 234 (See Administration Precautions under Cautions.)

Depending on patient age, administer IM into the deltoid muscle or anterolateral thigh.208 211 212 213 234 236 250

For adults, adolescents, and older children, the deltoid is the only acceptable IM injection site; for younger children, the deltoid or anterolateral thigh should be used.208 211 212 213 234 236 250

Avoid use of the gluteal area as a possible IM injection site.208 209 210 211 212 213 216 221 234 (See Administration Precautions under Cautions.)

Avoid injection into or near blood vessels or nerves.208 234

To ensure delivery into muscle, IM injections should be made at a 90° angle to the skin using a needle length appropriate for the individual's age and body mass, thickness of adipose tissue and muscle at the injection site, and injection technique.211

Administer immediately after reconstitution.208 234 Use entire volume of reconstituted single-dose vaccine vial.208 236

Use separate needles for reconstitution and administration.208 234

Do not administer rabies vaccine in the same syringe or simultaneously at the same injection site as RIG.213 236 246 216 (See Specific Drugs under Interactions.)

Do not mix with any other vaccine or solution.211 213

Reconstitution (HDCV; Imovax)

To reconstitute, add entire contents of syringe containing diluent provided by the manufacturer to the single-dose vial of lyophilized vaccine.208 Use only the diluent supplied by the manufacturer.208

Attach reconstitution needle and plunger to the syringe and inject diluent into vaccine vial.208 Gently swirl until completely dissolved.208 The lyophilized vaccine is creamy white to orange; reconstituted suspension is pink to red.208

Remove reconstitution needle and discard.208 Use a suitable needle for IM administration.208 Use immediately after reconstitution.208

Reconstitution (PCECV; RabAvert)

To reconstitute, add entire contents of vial containing diluent (1 mL of sterile water for injection) provided by the manufacturer to the single-dose vial of lyophilized vaccine.234 Use only the diluent supplied by the manufacturer.234

Using the longer of the 2 needles provided by the manufacturer, withdraw entire contents of the diluent into the syringe.234 Insert the needle at a 45° angle into the vaccine vial; slowly inject entire contents of diluent vial into the vaccine vial.234 Mix gently to avoid foaming.234 Lyophilized vaccine is white; reconstituted suspension is clear or slightly opaque.234

Withdraw entire amount of dissolved vaccine into the syringe and replace the long needle with the smaller one for IM injection.234 Use immediately after reconstitution.234

The vaccine vial contains negative pressure that may impede withdrawal of the full dose of reconstituted vaccine.234 The manufacturer recommends that the syringe be disconnected from the needle after reconstitution to allow any remaining vacuum to exhaust; however, creating positive pressure (e.g., by injecting air into the vial) is not recommended since over-pressurization may interfere with withdrawal of the proper vaccine dose.234

Dosage

Whenever possible, the rabies vaccine (HDCV [Imovax], PCECV [RabAvert]) used for the initial dose should be used for subsequent doses in the vaccine series in the same individual.213 234 236 Although only limited data available to date, most experts state that rabies vaccines currently available in the US may be considered interchangeable.213 234 236 ACIP states clinical studies not available to date showing differences in efficacy or safety if the vaccine series is completed with a different preparation.236

Adhere to the recommended vaccination schedule as closely as possible.236 If a minor deviation from the schedule occurs (e.g., a dose is delayed by a few days), give the dose and resume the vaccination schedule using the same interval between doses.236 If a substantial deviation from the schedule occurs, perform serologic testing 7–14 days after the final vaccine dose to assess immune status.236 (See Pre- and Postvaccination Serologic Testing under Cautions.)

Pediatric Patients

Preexposure Vaccination Against Rabies in High-risk Groups
Primary Immunization in Children and Adolescents
IM

Primary immunization consists of a series of 3 doses.208 213 234 236 Each dose consists of the entire contents (1 mL) of a reconstituted single-dose vial.208 234 236

Give first dose on a selected date; give second and third doses 7 and 21 (or 28) days, respectively, after first dose.208 213 234 236

Completion of the recommended 3-dose primary series before an expected exposure to rabies virus ensures the highest level of protection.208 213 234 236

Serologic confirmation of rabies immunity following the 3-dose primary series is not necessary in most individuals.208 212 213 234 236 (See Pre- and Postvaccination Serologic Testing under Cautions.)

Duration of immunity following the recommended 3-dose primary series is ≥2 years.213 234 236 (See Duration of Immunity under Cautions.) Need for additional (booster) doses depends on the category of risk for rabies infection and levels of antirabies antibody.236 (See Booster Doses in Children and Adolescents under Dosage and Administration.)

Booster Doses in Children and Adolescents
IM

Each booster dose consists of the entire contents (1 mL) of a reconstituted single-dose vial.208 213 234 236

Give a booster dose if indicated to maintain adequate levels of antirabies antibody.208 213 234 236 Booster doses may be indicated in those at continuous or frequent risk of rabies, but not in those at infrequent or rare risk.208 213 234 236 (For ACIP definitions of risk categories and recommendations regarding preexposure vaccination for each category, see Table 1 under Uses.)

In those at continuous risk of rabies, perform serologic testing every 6 months and administer booster dose if necessary.208 212 213 236 (See Pre- and Postvaccination Serologic Testing under Cautions.)

In those at frequent risk, perform serologic testing every 2 years and administer booster dose if necessary.208 212 213 236 (See Pre- and Postvaccination Serologic Testing under Cautions.)

Postexposure Prophylaxis of Rabies
Previously Unvaccinated Children and Adolescents
IM

Postexposure prophylaxis in previously unvaccinated individuals consists of active immunization with a series of 4 or 5 doses of rabies vaccine in conjunction with passive immunization with a single dose of RIG.208 213 234 236 250

Although the manufacturers recommend a 5-dose regimen of rabies vaccine in conjunction with RIG for postexposure prophylaxis in all previously unvaccinated individuals,208 234 the ACIP states that a 4-dose regimen of rabies vaccine in conjunction with RIG is sufficient for previously unvaccinated individuals who are immunocompetent and that a 5-dose vaccine regimen in conjunction with RIG should be used in those with altered immunocompetence.250

Immunocompetent children and adolescents: ACIP recommends first vaccine dose as soon as possible after exposure (day 0); give 3 remaining doses on days 3, 7, and 14, respectively, after first dose.250 Each dose consists of the entire contents (1 mL) of a reconstituted single-dose vial.208 234 236 250

Immunocompromised children and adolescents: ACIP recommends first vaccine dose as soon as possible after exposure (day 0); give 4 remaining doses on days 3, 7, 14, and 28, respectively, after first dose.250 Each dose consists of the entire contents (1 mL) of a reconstituted single-dose vial.208 234 236 250

Administer RIG dose preferably at the time of the first dose of rabies vaccine.208 213 234 236 250 If rabies vaccine is not immediately available, administer RIG dose and start the vaccine series as soon as possible.213 250 If RIG is not immediately available, it may be administered at any time through day 7 following the first vaccine dose.213 236 RIG is not necessary after day 7 since sufficient vaccine-induced rabies antibody will be present in most vaccine recipients.236 (See Specific Drugs under Interactions.)

Previously Vaccinated Children and Adolescents
IM

Postexposure prophylaxis in previously vaccinated individuals consists of a series of 2 booster doses of rabies vaccine (without RIG).208 213 234 236 250

Each booster dose consists of the entire contents (1 mL) of a reconstituted single-dose vial.208 234 236 250

Give first dose as soon as possible after exposure (day 0); give second dose 3 days later.208 213 234 236 250

This 2-dose regimen can be used in those who previously received a preexposure or postexposure vaccination regimen with HDCV (Imovax), PCECV (RabAvert), Imovax Rabies I.D. (no longer commercially available in the US), or rabies vaccine adsorbed (RVA; no longer commercially available in the US) or those who previously received preexposure vaccination with some other vaccine and had documented levels of antirabies antibody considered adequate.208 213 234 236 250 (See Pre- and Postvaccination Serologic Testing under Cautions.)

Adults

Preexposure Vaccination Against Rabies in High-risk Groups
Primary Immunization in Adults
IM

Primary immunization consists of a series of 3 doses.208 213 234 236 Each dose consists of the entire contents (1 mL) of a reconstituted single-dose vial.208 234 236

Give first dose on a selected date; give second and third doses 7 and 21 (or 28) days, respectively, after first dose.208 213 234 236

Completion of the 3-dose primary series before an expected exposure to rabies virus ensures the highest level of protection.208 213 234 236

Serologic confirmation of rabies immunity following the 3-dose primary series is not necessary in most individuals.208 212 213 234 236 (See Pre- and Postvaccination Serologic Testing under Cautions.)

Duration of immunity following the recommended 3-dose primary series is ≥2 years.213 234 236 (See Duration of Immunity under Cautions.) Need for additional (booster) doses depends on the category of risk for rabies infection and levels of antirabies antibody.236 (See Booster Doses in Adults under Dosage and Administration.)

Booster Doses in Adults
IM

Each booster dose consists of the entire contents (1 mL) of a reconstituted single-dose vial.208 213 234 236

Give a booster dose if indicated to maintain adequate levels of antirabies antibody.208 213 234 236 Booster doses may be indicated in those at continuous or frequent risk of rabies, but not in those at infrequent or rare risk.208 213 234 236 (For ACIP definitions of risk categories and recommendations regarding preexposure vaccination for each category, see Table 1 under Uses.)

In those at continuous risk of rabies, perform serologic testing every 6 months and administer booster dose if necessary.208 212 213 236 (See Pre- and Postvaccination Serologic Testing under Cautions.)

In those at frequent risk, perform serologic testing every 2 years and administer booster dose if necessary.208 212 213 236 (See Pre- and Postvaccination Serologic Testing under Cautions.)

Postexposure Prophylaxis of Rabies
Previously Unvaccinated Adults
IM

Postexposure prophylaxis in previously unvaccinated individuals consists of active immunization with a series of 4 or 5 doses of rabies vaccine in conjunction with passive immunization with a single dose of RIG.208 213 234 236 250

Although the manufacturers recommend a 5-dose regimen of rabies vaccine in conjunction with RIG for postexposure prophylaxis in all previously unvaccinated individuals,208 234 the ACIP states that a 4-dose regimen of rabies vaccine in conjunction with RIG is sufficient for previously unvaccinated individuals who are immunocompetent and that a 5-dose vaccine regimen in conjunction with RIG should be used in those with altered immunocompetence.250

Immunocompetent adults: ACIP recommends first vaccine dose as soon as possible after exposure (day 0); give 3 remaining doses on days 3, 7, and 14, respectively, after first dose.250 Each dose consists of the entire contents (1 mL) of a reconstituted single-dose vial.208 234 236 250

Immunocompromised adults: ACIP recommends first vaccine dose as soon as possible after exposure (day 0); give 4 remaining doses on days 3, 7, 14, and 28, respectively, after first dose.250 Each dose consists of the entire contents (1 mL) of a reconstituted single-dose vial.208 234 236 250

Administer RIG dose preferably at the time of the first dose of rabies vaccine.208 213 234 236 250 If rabies vaccine is not immediately available, administer RIG dose and start the vaccine series as soon as possible.213 250 If RIG is not immediately available, it may be administered at any time through day 7 following the first vaccine dose.213 236 250 RIG is not necessary after day 7 since sufficient vaccine-induced rabies antibody will be present in most vaccine recipients.236 (See Specific Drugs under Interactions.)

Previously Vaccinated Adults
IM

Postexposure prophylaxis in previously vaccinated individuals consists of a series of 2 booster doses of rabies vaccine (without RIG).208 213 234 236 250

Each booster dose consists of the entire contents (1 mL) of a reconstituted single-dose vial.208 234 236 250

Give first dose as soon as possible after exposure (day 0); give second dose 3 days later.208 213 234 236 250

This 2-dose regimen can be used in those who previously received a preexposure or postexposure vaccination regimen with HDCV (Imovax), PCECV (RabAvert), Imovax Rabies I.D. (no longer commercially available in the US), or rabies vaccine adsorbed (RVA; no longer commercially available in the US) or those who previously received preexposure vaccination with some other vaccine and had documented titers of antirabies antibody considered adequate.208 213 234 236 250 (See Pre- and Postvaccination Serologic Testing under Cautions.)

Special Populations

Hepatic Impairment

No specific dosage recommendations.

Renal Impairment

No specific dosage recommendations.

Geriatric Patients

No specific dosage recommendations.

Cautions for Rabies Vaccine

Contraindications

  • HDCV (Imovax) for preexposure vaccination: Manufacturer states none known other than situations such as developing febrile illness, etc.208 (See Concomitant Illness under Cautions.)

  • PCECV (RabAvert) for preexposure vaccination: History of anaphylactic reactions to the vaccine or any component.234 (See Sensitivity Reactions under Cautions.)

  • HDCV (Imovax) and PCECV (RabAvert) for postexposure prophylaxis: No known contraindications, including pregnancy, because of the almost invariably fatal outcome of rabies infection.208 234 (See Pregnancy under Cautions.)

Warnings/Precautions

Warnings

Nervous System Effects

Neurologic effects, sometimes serious (e.g., Guillain-Barré syndrome, transient neuroparalysis, myelitis, retrobulbar neuritis, multiple sclerosis, subacute peripheral and focal CNS disorders) temporally associated with HDCV (Imovax) and PCECV (RabAvert).208 234

If neurologic effects occur, carefully consider the individual's risk of acquiring rabies when deciding whether to discontinue the vaccination series.208 234 Contact state health departments or CDC for advice and assistance regarding management of these individuals.208 236

Use of corticosteroids to treat life-threatening neuroparalytic reactions may interfere with the immune response to rabies vaccine.208 234 (See Specific Drugs under Interactions.) Perform serologic testing in individuals receiving corticosteroids to verify seroconversion following vaccination.208 (See Pre- and Postvaccination Serologic Testing under Cautions.)

Immediately report all serious vaccine-associated neuroparalytic reactions to the manufacturer and to the Vaccine Adverse Event Reporting System (VAERS) at 800-822-7967 or .208 234

Administration Precautions

Administer IM into the deltoid or anterolateral thigh in infants and young children and into the deltoid in adults, adolescents, and older children.211 213 236 250 (See Administration under Dosage and Administration.)

Do not administer into gluteal muscle; suboptimal immunologic response may occur.208 209 210 211 212 213 216 221 234 250 Reason for suboptimal response unclear; may occur because of inadvertent sub-Q injection or administration into fatty tissue instead of muscle.209 210 211 221 Fatal rabies paralysis and encephalitis reported in several individuals who received HDCV (Imovax) by IM injection into the gluteal area.210 216 221

Inadvertent intravascular injection of PCECV (RabAvert) may result in systemic reactions (e.g., shock); immediate countermeasures include use of catecholamines, volume replacement, high doses of corticosteroids, and oxygen.234

Do not administer RIG in the same syringe or simultaneously at the same injection site as rabies vaccine.213 236 246 250 (See Specific Drugs under Interactions.)

Individuals with Altered Immunocompetence

May be administered to individuals immunosuppressed as the result of disease or immunosuppressive therapy.211 233 236 250 Consider possibility that the immune response to rabies vaccine and efficacy may be reduced in these individuals.208 213 234 236 250

ACIP states that recommendations concerning use of rabies vaccine in individuals with altered immunocompetence (e.g., patients with HIV infection, congenital immunodeficiency, leukemia, lymphoma, aplastic anemia, generalized malignancy, solid organ transplant, asplenia, renal failure, diabetes, alcoholism, or alcoholic cirrhosis, or in those receiving therapy with alkylating agents, antimetabolites, radiation, corticosteroids, or other chronic immunosuppressive therapy) generally are the same as those for patients who are not immunocompromised.233 236 250 However, the ACIP states that a 5-dose vaccine series (not a 4-dose series) of HDCV (Imovax) or PCECV (RabAvert) should be used when rabies postexposure prophylaxis is indicated in previously unvaccinated individuals with altered immunocompetence.250 (See Previously Unvaccinated Children and Adolescents and also see Previously Unvaccinated Adults under Dosage and Administration.)

Postpone preexposure vaccination (3-dose primary series) in immunocompromised individuals and advise them to avoid activities for which rabies preexposure vaccination is indicated.212 236 If this is not possible, administer preexposure vaccination and perform serologic testing to document seroconversion.212 236 (See Pre- and Postvaccination Serologic Testing under Cautions.) Individuals who fail to seroconvert after the third vaccine dose should be managed in consultation with their clinician and appropriate public health officials.236

Avoid use of immunosuppressive agents during rabies postexposure prophylaxis, unless considered essential for the treatment of other conditions.233 234 236 250 (See Specific Drugs under Interactions.)

If rabies postexposure prophylaxis is indicated in an immunocompromised individual, serologic testing is considered essential after completion of the postexposure prophylaxis regimen to confirm than an adequate antibody response is obtained.234 236 250 If an acceptable antibody response is not detected after the final vaccine dose of the postexposure prophylaxis series, the patient should be managed in consultation with their clinician and appropriate public health officials.216 250 (See Pre- and Postvaccination Serologic Testing under Cautions.)

Risk of Transmissible Agents in Preparations Containing Albumin

HDCV (Imovax) and PCECV (RabAvert) contain albumin human.208 234

Since albumin is prepared from pooled human plasma, it is a potential vehicle for transmission of human viruses, including the causative agents of viral hepatitis and HIV infection, and theoretically may carry a risk of transmitting the causative agent of Creutzfeldt-Jakob disease (CJD) or variant CJD (vCJD).234 245

Improved donor screening, viral-inactivation procedures (e.g., solvent/detergent treatment), and/or filtration procedures have reduced, but not completely eliminated, risk of pathogen transmission with plasma-derived preparations.234

Sensitivity Reactions

Hypersensitivity Reactions

Allergic reactions, including anaphylaxis and immune complex-like reactions, reported in association with HDCV (Imovax) or PCECV (RabAvert).208 219 234 236 Bronchospasm, edema, pruritus, and urticaria also reported during postmarketing surveillance.234

Serious anaphylactic reactions during rabies vaccination pose a serious therapeutic dilemma.208 234 236 Carefully consider the individual's risk of acquiring rabies when deciding whether to discontinue the vaccination series.208 236 Contact state health departments or CDC for advice and assistance regarding management of these individuals.208 236

When rabies vaccine is indicated in an individual with a history of hypersensitivity to the vaccine or any ingredient, observe patient closely following each dose and ensure that appropriate therapy (e.g., epinephrine, corticosteroids, oxygen) is readily available to treat a reaction if it occurs.208 234 236 Use of prophylactic antihistamines is acceptable.234 236

Immediately report all serious anaphylactic reactions associated with rabies vaccine to the manufacturer and the Vaccine Adverse Event Reporting System (VAERS) at 800-822-7967 or .213 234 236

Immune Complex-like Reactions

Immune complex (serum sickness)-like (type III hypersensitivity) reactions reported in up to 6% of individuals 2–21 days following booster doses of HDCV (Imovax).208 219 236 Similar reactions also reported following primary immunization with HDCV (Imovax), but much less frequently.208 219 236

These reactions involved generalized urticaria with or without arthralgia, arthritis, angioedema, nausea, vomiting, fever, and malaise and were not life-threatening.208 219 236

May be caused by β-propiolactone-altered albumin human formed as a result of the manufacturing process for HDCV (Imovax); β-propiolactone is thought to render the albumin allergenic resulting in development of IgE antibodies to the allergen.236

Do not administer additional doses of HDCV (Imovax) in individuals who experienced immune complex-like reactions to a previous dose, unless postexposure prophylaxis with the vaccine is considered necessary.208

Allergy to Neomycin or Other Anti-infectives

Each dose of HDCV (Imovax) contains <150 mcg of neomycin sulfate.208 Each dose of PCECV (RabAvert) contains <1 mcg of neomycin and trace amounts of chlortetracycline (<20 ng) and amphotericin B (<2 ng).234

Use caution in individuals sensitive to these antibiotics.234 Weigh possibility of an allergic reaction against the potential risk of contracting rabies if the vaccine is not given.208 234

Neomycin allergy usually results in delayed-type (cell-mediated) hypersensitivity reactions manifested as contact dermatitis.211 ACIP and AAP state that vaccines containing trace amounts of neomycin should not be used in individuals with a history of anaphylactic reaction to neomycin, but use of such vaccines may be considered in those with a history of delayed-type neomycin hypersensitivity if benefits of vaccination outweigh the risks.211 213

Gelatin Allergy

PCECV (RabAvert) contains <12 mg of polygeline (bovine gelatin).234 Consider possibility of allergic reactions in individuals sensitive to bovine gelatin.211 234 Bovine components of the vaccine originate only in the US, Australia, and New Zealand.234

Allergy to Egg-related Antigens

PCECV (RabAvert) is produced in chick embryo cell culture and may contain minimal amounts of chicken protein.234 HDCV (Imovax) is produced in human diploid cells and does not contain chicken protein.208

Consider possibility that an allergic reaction may occur if PCECV (RabAvert) is used in individuals allergic to chicken protein.234

Safety data regarding use of PCECV (RabAvert) in individuals with egg allergy not available.234 Experience with other vaccines produced using primary cultures of chick embryo fibroblasts indicate that documented egg hypersensitivity does not necessarily predict an increased likelihood of adverse reactions.234

No evidence to date that individuals with allergies to chickens or feathers are at increased risk of reaction to vaccines produced in chick embryo fibroblasts.234

General Precautions

Local or Systemic Adverse Effects

Once initiated, postexposure prophylaxis for rabies should not be interrupted or discontinued because of local or mild systemic adverse reactions to rabies vaccine.208 234 236 These reactions generally can be managed with NSAIAs or antipyretic agents (e.g., ibuprofen, acetaminophen).208 234 236

Serious systemic, anaphylactic, or neuroparalytic reactions pose a therapeutic dilemma.208 236 Contact state health departments or CDC for advice and assistance regarding management of these individuals.208 236

Limitations of Vaccine Effectiveness

May not protect all vaccine recipients against rabies.234

May not prevent rabies in individuals who do not achieve adequate antibody titers.234 236 (For information on adequate antibody titers, see Pre- and Postvaccination Serologic Testing under Cautions.)

Duration of Immunity

Duration of immunity following the recommended 3-dose preexposure vaccine series (primary immunization) of HDCV (Imovax) or PCECV (RabAvert) is ≥2 years.213 234 236

Need for additional (booster) doses after primary immunization depends on the nature and category of risk associated with the potential exposure.236 (See Booster Doses in Children and Adolescents and also see Booster Doses in Adults under Dosage and Administration)

Concomitant Illness

A decision to administer or delay vaccination in an individual with current or recent febrile illness depends on the severity of symptoms and etiology of the illness.211

ACIP states that minor acute illness, such as mild diarrhea or mild upper respiratory tract infection (with or without fever) generally does not preclude vaccination.211 212 213

The manufacturers and ACIP state that preexposure rabies vaccination (but not postexposure prophylaxis) with HDCV (Imovax) or PCECV (RabAvert) generally should be deferred in individuals with moderate or severe acute illness until improvement of the condition is noted.208 211 234

Individuals with Bleeding Disorders

Because bleeding may occur following IM administration in individuals with thrombocytopenia or a bleeding disorder (e.g., hemophilia) or in those receiving anticoagulant therapy, use caution in such individuals.211

ACIP states that vaccines may be given IM to individuals who have bleeding disorders or are receiving anticoagulant therapy if a clinician familiar with the patient's bleeding risk determines that the vaccine can be administered with reasonable safety.211 In these cases, use a fine needle (23 gauge) to administer the vaccine and apply firm pressure to the injection site (without rubbing) for ≥2 minutes.211 If patient is receiving antihemophilia therapy, administer the IM vaccine shortly after a scheduled dose of such therapy.211

Advise the individual and/or their family about the risk of hematoma from IM injections.211

Pre- and Postvaccination Serologic Testing

If serologic testing for serum antirabies antibody is performed 1–2 weeks after preexposure vaccination or postexposure prophylaxis, ACIP defines an adequate antibody response as complete virus neutralization at a 1:5 serum dilution when determined by rapid fluorescent-focus inhibition test (RFFIT).236 250 WHO states that an antirabies antibody titer of ≥0.5 international units/mL can be considered protective.249

Serologic confirmation of rabies immunity following preexposure vaccination (3-dose primary series) is not necessary in most individuals because of the high rate of response in immunocompetent adults, adolescents, and children when the recommended vaccine regimen is used.208 212 213 234 236

Postvaccination serologic testing may be particularly important in immunocompromised individuals who receive preexposure vaccination since these individuals may have impaired immune response to vaccination.208 213 234 236 Manage individuals who fail to seroconvert after the third vaccine dose in the primary series in consultation with appropriate public health officials.236 (See Individuals with Altered Immunocompetence under Cautions.)

To determine the need for preexposure booster doses of rabies vaccine in individuals who received preexposure vaccination with a primary vaccine series, serum antirabies antibody titers should be measured every 6 months in those at continuous risk of rabies exposure and every 2 years for those at frequent risk of rabies exposure.208 212 213 236 (For ACIP definitions of risk categories and recommendations regarding preexposure vaccination for each category, see Table 1 under Uses.)

Serologic testing is not indicated prior to postexposure prophylaxis in previously vaccinated individuals who are exposed to rabies.236 Such testing is inappropriate because it would delay postexposure prophylaxis and, although antirabies neutralizing antibodies are an important component of immunity, other immune effectors also play a role in disease prevention.236

Serologic confirmation of rabies immunity following postexposure prophylaxis is not necessary in most individuals because of the high rate of vaccine response among immunocompetent adults, adolescents, and children when the recommended rabies postexposure prophylaxis regimen is used (i.e., proper wound care followed by a single dose of RIG and a 4- or 5-dose regimen of a cell culture-derived rabies vaccine).208 212 213 236

When postexposure prophylaxis against rabies is indicated in an immunocompromised individual, serologic testing is considered essential after completion of the postexposure prophylaxis regimen to confirm that an adequate antibody response was obtained.208 213 234 236 This includes individuals receiving immunosuppressive agents (e.g., those receiving corticosteroids for the treatment of life-threatening neuroparalytic reactions to rabies vaccine).236 (See Individuals with Altered Immunocompetence under Cautions.)

Consider serologic testing to confirm that an adequate antibody response was obtained in travelers who received rabies postexposure prophylaxis with regimens and/or preparations not currently recommended by ACIP.236 (See Postexposure Prophylaxis of Rabies under Uses.)

Improper Storage and Handling

Improper storage or handling of vaccines may result in loss of vaccine potency and reduced immune response in vaccinees.211

Do not administer HDCV (Imovax) or PCECV (RabAvert) that has been mishandled or has not been stored at the recommended temperature.211 (See Storage under Stability.)

Inspect all vaccines upon delivery and monitor during storage to ensure that the appropriate temperature is maintained.211 If there are concerns about mishandling, contact the manufacturer or state or local health departments for guidance on whether the vaccine is usable.211

Specific Populations

Pregnancy

Category C.208 234

Manufacturers state that HDCV (Imovax) and PCECV (RabAvert) should be given to pregnant women only if clearly needed.208 234

However, ACIP, CDC, AAP, American College of Obstetricians and Gynecologists (ACOG), and the manufacturers state that pregnancy is not considered a contraindication for postexposure prophylaxis with rabies vaccine because of the potential risks of inadequately treated rabies exposure and because there is no evidence of an association between fetal abnormalities and rabies vaccine.204 208 212 213 234 236 ACOG recommends that each pregnant woman be considered individually and that public health authorities be consulted.204

Preexposure vaccination may also be indicated during pregnancy when a substantial risk of rabies exposure is present.208 236

Lactation

Not known whether antigens contained in rabies vaccine are distributed into milk.234 CDC states that use of rabies vaccine in nursing women should follow the same guidelines as other adults.212

Because inactivated vaccines do not multiply within the body, the ACIP states that they should not pose any unusual problems for nursing women or their infants.211

PCECV (RabAvert): Manufacturer states nursing is not considered a contraindication when the vaccine is indicated for postexposure prophylaxis because of the possible risks of inadequately treated rabies exposure.234 In addition, use of the vaccine for preexposure vaccination may be indicated in nursing women when a substantial risk of rabies exposure is present.234

Pediatric Use

HDCV (Imovax): Safety and efficacy in children established.208

PCECV (RabAvert): Limited data available regarding safety and efficacy in children.234 Used effectively for preexposure vaccination in children ≥2 years of age and for postexposure prophylaxis in children ≥1 year of age.234

Children are at higher risk of rabies exposure compared with adults because of increased potential for animal contact and because they are more likely to be bitten on the head, face, and neck leading to more severe injuries.212 213 237 249

ACIP, CDC, AAP, and the manufacturers recommend that postexposure prophylaxis in children follow the same guidelines as in adults.208 212 213 234 236

Geriatric Use

PCECV (RabAvert): Insufficient experience in patients ≥65 years of age to determine whether geriatric patients respond differently to the vaccine than younger adults.234 Clinical experience with PCECV (RabAvert) reveals that there are no overall differences in safety between geriatric and younger individuals.234

Common Adverse Effects

HDCV (Imovax): Local effects at injection site (pain, swelling, erythema, itching), mild systemic reactions (headache, nausea, abdominal pain, muscle aches, dizziness).208

PCECV (RabAvert): Local effects at injection site (pain, swelling, erythema, itching), influenza-like symptoms (mild to moderate asthenia, fatigue, fever, myalgia, malaise, headache).234

Interactions for Rabies Vaccine

Other Vaccines

HDCV (Imovax) and PCECV (RabAvert) rabies vaccines are inactivated viral vaccines; interactions with other inactivated vaccines, live virus vaccines, recombinant vaccines, or toxoids are unlikely.211 213 Inactivated vaccines can be administered either simultaneously with or at any time before or after inactivated or live vaccines.211 213 However, each vaccine should be administered using a different syringe and a different injection site.211 213

Specific Drugs

Drug

Interaction

Comments

Immunosuppressive agents (e.g., alkylating agents, antimetabolites, corticosteroids, radiation)

Potential for decreased antibody response to rabies vaccine; concomitant administration may predispose patient to rabies infection208 212 213 233 234 236

Postpone preexposure vaccination and consider avoiding activities for which vaccination is indicated;212 236 250 if not possible, serologic testing should be performed after preexposure vaccination to document seroconversion236 250 (see Pre- and Postvaccination Serologic Testing under Cautions)

Avoid immunosuppressive therapy during rabies postexposure prophylaxis unless considered essential for treatment of other serious conditions208 233 234 236 250

If rabies postexposure prophylaxis is indicated in a previously unvaccinated individual receiving immunosuppressive therapy that cannot be discontinued, ACIP states that a 5-dose series (not a 4-dose series) of HDCV (Imovax) or PCECV (RabAvert) should be used250 (see Postexposure Prophylaxis or Rabies under Uses)

If rabies postexposureprophylaxis is used in individuals receiving immunosuppressive agents or when corticosteroids are used to treat life-threatening neuroparalytic reactions to rabies vaccine, perform serologic testing for rabies antibody after completion of the regimen to ensure adequate immune response208 233 234 236 250 (see Pre- and Postvaccination Serologic Testing under Cautions)

Rabies immune globulin (RIG)

Passively acquired antibody to rabies antigen, which is present in RIG, may partially suppress the active immune response to rabies vaccine;213 234 236 250 there is evidence that a single RIG dose of 20 international units/kg given at the same time as the first dose of rabies vaccine provides maximum circulating antirabies antibody with minimal interference with the active immune response to the vaccine246

Neutralization of rabies vaccine may occur if RIG and the vaccine are mixed in the same syringe or administered into the same injection site211 213 236

If rabies postexposure prophylaxis requires active immunization with rabies vaccine and passive immunization with RIG, a single dose of RIG should be administered simultaneously with the first vaccine dose;208 213 234 236 250 infiltrate the full RIG dose around the wound(s) if anatomically feasible and administer any remaining portion of the RIG dose IM (using a different syringe and different injection site than rabies vaccine)213 234 236 250

To minimize potential suppression of the active immune response to the vaccine, do not give single doses of RIG >20 international units/kg or repeated RIG doses213 234 236 250

RIG may be administered simultaneously with or through day 7 after the first dose of rabies vaccine without impairing the active immune response to the vaccine213 234 236 250

RIG is not indicated for postexposure prophylaxis in individuals who previously received recommended preexposure or postexposure regimens of HDCV (Imovax), PCECV (RabAvert), Imovax Rabies I.D. (no longer commercially available in the US), or rabies vaccine adsorbed (RVA) (no longer commercially available in the US) or in those who previously received other rabies vaccines and have documented adequate antirabies antibody titers213 236 250

Stability

Storage

Parenteral

Suspension for IM Injection

HDCV (Imovax): Prior to reconstitution, 2–8°C; avoid freezing.208

PCECV (RabAvert): Prior to reconstitution, 2–8°C; protect from light.234

Must be used immediately after reconstitution; discard if not used immediately.208 234

HDCV (Imovax) and PCECV (RabAvert) do not contain thimerosal or any other preservatives.208 234

Actions

  • Rabies vaccine is a sterile, freeze-dried vaccine containing inactivated rabies virus antigen (≥2.5 international units/mL).208 234

  • Commercially available as human diploid-cell rabies vaccine (HDCV; Imovax) or purified chick embryo cell culture rabies vaccine (PCECV; RabAvert).208 234

  • HDCV (Imovax) contains antigen prepared from the Wistar Institute Pitman-Moore strain (PM-1503-3M) of rabies virus propagated in MRC-5 strain of human diploid-cell tissue culture.208 PCECV (RabAvert) contains antigens prepared from the fixed-virus strain Flury low egg passage (LEP) of rabies virus propagated in primary cultures of chicken fibroblasts.234

  • Stimulates active immunity to rabies by inducing production of antirabies neutralizing antibodies.208 213 234 236 Antirabies antibodies neutralize rabies virus and are believed to have a primary role in preventing rabies infection.236

  • HDCV (Imovax) and PCECV (RabAvert) are highly immunogenic in immunocompetent children, adolescents, and adults.208 234 236 When administered according to the recommended preexposure immunization schedule in clinical studies, 100% of vaccinees achieved protective levels of antirabies antibody.208 234

  • Following IM administration of rabies vaccine, antirabies antibody levels are detectable in serum within 7–10 days and persist for several years.236

  • Development of immunity and protection from rabies infection are evaluated by appearance of antirabies antibody in serum.236 Minimum titers of antirabies antibodies indicating protection against rabies have not been definitely established to date (varies among laboratories and by type of test performed).236 ACIP considers antirabies antibody titers ≥1:5 as determined by RFFIT to be indicative of an adequate response to rabies immunization.236 250 WHO states that an antirabies antibody titer of ≥0.5 international units/mL can be considered protective.249

  • Following rabies exposure and inoculation, the virus remains close to the wound for an indeterminate time and can be partially neutralized with RIG while at this site.213 In susceptible individuals, the virus is transported to the CNS via the peripheral nerves.249 Following entrance into the CNS, the virus is unlikely to be affected by antirabies antibodies and a fatal encephalomyelitis almost always develops.234 249

  • Incubation period for rabies infection in humans can range from days to years (usually 1–3 months).212 213 234 236 250 After severe bites to the face, neck, or arms, the incubation period may be as short as 10 days.246

  • Common prodromal symptoms of rabies infection include malaise, anorexia, fatigue, headache, and fever followed by pain or paresthesia at the site of exposure.234 249 Anxiety, agitation, and irritability may also occur during the prodromal stage followed by hyperactivity, disorientation, seizures, aerophobia, hydrophobia, hypersalivation, and eventually paralysis, coma, and death.212 213 234 249 Following appearance of clinical symptoms of rabies, use of rabies vaccine or RIG will not improve the prognosis and may be detrimental; there is no specific proven effective treatment for rabies once symptoms develop.212 213 236 249

  • There have been no cases of rabies in the US in previously unvaccinated individuals who received the recommended postexposure prophylaxis regimen (i.e., proper wound care followed by a single dose of RIG and a 4- or 5-dose regimen of HDCV [Imovax] or PCECV [RabAvert] rabies vaccine).236 246 250

Advice to Patients

  • Prior to administration of each vaccine dose, provide a copy of the appropriate CDC Vaccine Information Statement (VIS) to the patient or patient's legal representative as required by the National Childhood Vaccine Injury Act (VISs are available at ).244

  • Advise the patient and/or patient's parent or guardian of the risks and benefits of vaccination with rabies vaccine.208 234

  • Advise the patient and/or patient's parent or guardian that rabies vaccine is used to prevent rabies and is given to persons at high risk of exposure to rabies as a result of employment, travel, or hobbies (e.g., certain laboratory workers, veterinarians, animal control and wildlife workers, spelunkers, hunters).208 234

  • Advise the patient and/or patient's parent or guardian that rabies vaccine is also used to prevent rabies in individuals who have been bitten, scratched, or licked on an open wound by an animal known or suspected of having rabies.208 234

  • When rabies preexposure vaccination is indicated, importance of completing the 3-dose primary vaccination series.213 236

  • When rabies postexposure prophylaxis is indicated in previously unvaccinated individuals, importance of completing a 4- or 5-dose series of rabies vaccine and receiving a single dose of RIG as soon as possible following rabies exposure.208 213 234 236

  • When rabies postexposure prophylaxis is indicated in previously vaccinated individuals, importance of receiving a 2-dose regimen of rabies vaccine as soon as possible following rabies exposure.208 213 234 236

  • Importance of informing clinicians if the patient has a weakened immune system (e.g., cancer, HIV/AIDS) or receives treatment that may weaken the immune system (e.g., corticosteroids, cancer treatment).208 234

  • Importance of informing clinicians if a patient has a fever or serious illness.208 234 Advise patient that preexposure vaccination may be deferred if they are moderately or severely ill, but that rabies postexposure prophylaxis will still be administered, regardless of any other illness they may have.244

  • Importance of informing clinicians if any serious adverse reactions (e.g., hypersensitivity, neurologic reactions) occur.208 234 Clinicians or individuals can report any adverse reactions that occur following vaccination to the Vaccine Adverse Event Reporting System (VAERS) at 800-822-7967 or .208 213 234

  • Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs, and any concomitant illnesses.208 234

  • Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.208 234

  • Importance of informing patients of other important precautionary information.208 234 (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Rabies Vaccine (Human Diploid-cell)

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Parenteral

For injectable suspension, for IM use only

≥2.5 units (of rabies antigen)

ImovaxRabies

Sanofi Pasteur

Rabies Vaccine (Purified Chick Embryo Cell Culture)

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Parenteral

For injectable suspension, for IM use only

≥2.5 units (of rabies antigen)

RabAvert

Novartis

AHFS DI Essentials. © Copyright, 2004-2014, Selected Revisions September 1, 2010. American Society of Health-System Pharmacists, Inc., 7272 Wisconsin Avenue, Bethesda, Maryland 20814.

References

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