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Rabies disease prevention: Preexposure and postexposure vaccination against rabies
Factors to consider include: species of biting animal, circumstances of biting incident (provoked vs unprovoked bite), type of exposure to rabies infection (bite vs nonbite), vaccination status of biting animal, and presence of rabies in the region. Refer to local/state health department and CDC for more information.
The Advisory Committee on Immunization Practices (ACIP) recommends a primary course of prophylactic immunization (preexposure vaccination) for the following (ACIP [Manning 2008]):
- Persons with continuous risk of infection, including rabies research laboratory and biologics production workers
- Persons with frequent risk of infection, including rabies diagnostic laboratory workers, cavers, veterinarians and their staff, and animal control and wildlife workers in areas where rabies is enzootic; persons who frequently handle bats
- Persons with infrequent risk of infection, including veterinarians and animal control staff working with terrestrial animals in areas where rabies infection is rare, veterinary students, and travelers visiting areas where rabies is enzootic and immediate access to medical care and biologicals is limited
The ACIP recommends the use of postexposure vaccination for a particular person be assessed by the severity and likelihood versus the actual risk of acquiring rabies. Consideration should include the type of exposure, epidemiology of rabies in the area, species of the animal, circumstances of the incident, and the availability of the exposing animal for observation or rabies testing. Postexposure vaccination is used in both previously vaccinated and previously unvaccinated individuals (ACIP [Manning 2008]; ACIP [Rupprecht 2010]).
Preexposure prophylaxis: Life-threatening hypersensitivity to rabies vaccine or any component of the formulation
Postexposure prophylaxis: There are no contraindications listed within the FDA-approved manufacturers labeling.
Preexposure vaccination: IM: A total of 3 doses, 1 mL each, on days 0, 7, and 21 or 28.
Booster vaccination (for persons with continuous or frequent risk of infection): IM: 1 mL based on antibody titers
Note: Prolonging the interval between doses does not interfere with immunity achieved after the concluding dose of the basic series.
Postexposure vaccination: All postexposure treatment should begin with immediate cleansing of the wound with soap and water
Persons not previously immunized as above: IM: 5 doses (1 mL each) on days 0, 3, 7, 14, 28. In addition, patients should receive rabies immune globulin with the first dose (day 0). Note: A regimen of 4 doses (1 mL each) on days 0, 3, 7, 14 may be used in persons who are not immunosuppressed (ACIP [Rupprecht 2010]).
Persons who have previously received postexposure prophylaxis with rabies vaccine, received a recommended IM pre-exposure series of rabies vaccine or have a previously documented rabies antibody titer considered adequate: IM: Two doses (1 mL each) on days 0 and 3; do not administer rabies immune globulin
Refer to adult dosing.
Refer to adult dosing.
There are no dosage adjustments provided in the manufacturer 's labeling.
There are no dosage adjustments provided in the manufacturer 's labeling.
Reconstitute with provided diluent; gently swirl to dissolve. Use immediately after reconstitution.
Imovax: Suspension will appear pink to red
RabAvert: Suspension will appear clear to slightly opaque
For IM administration only; do not administer intradermally or subcutaneously; in adults and children, administer IM injections in the deltoid muscle; for younger children, use the outer aspect of the thigh. Avoid administration into the gluteal area; may result in lower response. Postexposure prophylaxis should begin with immediate cleansing of wounds with soap and water; if available, a virucidal agent (eg povidone-iodine solution) should be used to irrigate the wounds. US law requires that the date of administration, the vaccine manufacturer, lot number of vaccine, and the administering persons name, title, and address be entered into the patient's permanent medical record.
For patients at risk of hemorrhage following intramuscular injection, the vaccine should be administered intramuscularly if, in the opinion of the physician familiar with the patient's bleeding risk, the vaccine can be administered by this route with reasonable safety. If the patient receives antihemophilia or other similar therapy, intramuscular vaccination can be scheduled shortly after such therapy is administered. A fine needle (23 gauge or smaller) can be used for the vaccination and firm pressure applied to the site (without rubbing) for at least 2 minutes. The patient should be instructed concerning the risk of hematoma from the injection. Patients on anticoagulant therapy should be considered to have the same bleeding risks and treated as those with clotting factor disorders (NCIRD/ACIP 2011).
Prior to reconstitution, store under refrigeration at 2 ‚ °C to 8 ‚ °C (36 ‚ °F to 46 ‚ °F); do not freeze. RabAvert should be protected from light.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Injectable, Intramuscular [preservative free]:
Imovax Rabies: 2.5 units/mL (1 ea) [contains albumin human, neomycin sulfate]
Suspension Reconstituted, Intramuscular:
RabAvert: 2.5 units (1 ea) [contains albumin human, chicken protein, edetate disodium, gelatin (bovine), neomycin]
Do not mix with other vaccines or injections. Separate needles and syringes should be used for each injection.
Belimumab: May diminish the therapeutic effect of Vaccines (Inactivated). Management: Patients should receive inactivated vaccines prior to initiation of belimumab therapy whenever possible, due to the risk for an impaired response to the vaccine during belimumab therapy. Consider therapy modification
Chloroquine: May diminish the therapeutic effect of Rabies Vaccine. Monitor therapy
Fingolimod: May diminish the therapeutic effect of Vaccines (Inactivated). Management: Vaccine efficacy may be reduced. Complete all age-appropriate vaccinations at least 2 weeks prior to starting fingolimod. If vaccinated during fingolimod therapy, revaccinate 2 to 3 months after fingolimod discontinuation. Consider therapy modification
Immunosuppressants: May diminish the therapeutic effect of Vaccines (Inactivated). Management: Vaccine efficacy may be reduced. Complete all age-appropriate vaccinations at least 2 weeks prior to starting an immunosuppressant. If vaccinated during immunosuppressant therapy, revaccinate at least 3 months after immunosuppressant discontinuation. Exceptions: Cytarabine (Liposomal). Consider therapy modification
Venetoclax: May diminish the therapeutic effect of Vaccines (Inactivated). Monitor therapy
Monitor for syncope for 15 minutes following administration (NCIRD/ACIP 2011). If seizure-like activity associated with syncope occurs, maintain patient in supine or Trendelenburg position to reestablish adequate cerebral perfusion.
Antibody response to vaccination is not recommended for otherwise healthy persons who complete the pre-exposure or postexposure regimen. Serologic testing to determine if the antibody titer is at an acceptable level is required for the following persons (booster vaccination recommended if titer is below the acceptable level) (ACIP [Manning 2008]):
Persons with continuous risk of infection: Serologic testing every 6 months
Persons with frequent risk of infection: Serologic testing every 2 years
Persons who are immunocompromised: Serologic testing after completion of preexposure or postexposure prophylaxis series
All serious adverse reactions must be reported to the U.S. Department of Health and Human Services (DHHS) Vaccine Adverse Event Reporting System (VAERS) 1-800-822-7967 or online at https://vaers.hhs.gov/esub/index. In Canada, adverse reactions may be reported to local provincial/territorial health agencies or to the Vaccine Safety Section at Public Health Agency of Canada (1-866-844-0018).
>10%:
Central nervous system: Dizziness, headache, malaise
Gastrointestinal: Abdominal pain, nausea
Local: Erythema, itching, pain, swelling
Neuromuscular & skeletal: Myalgia
Miscellaneous: Lymphadenopathy
Uncommon, frequency not defined, postmarketing, and/or case reports:
Cardiovascular: Circulatory reactions, edema, palpitation
Central nervous system: Chills, fatigue, fever >38 ‚ °C (100 ‚ °F), Guillain-Barre syndrome, encephalitis, meningitis, multiple sclerosis, myelitis, neuroparalysis, seizures, vertigo
Dermatologic: Pruritus, urticaria, urticaria pigmentosa
Endocrine & metabolic: Hot flashes
Gastrointestinal: Diarrhea, vomiting
Local: Hematoma, limb swelling (extensive)
Neuromuscular & skeletal: Arthralgia, limb pain, monoarthritis, neuropathy, paralysis (transient), paresthesias (transient), weakness
Ocular: Retrobulbar neuritis, visual disturbances
Respiratory: Bronchospasm, dyspnea, wheezing
Miscellaneous: Allergic reactions, anaphylaxis, hypersensitivity reactions, serum sickness, swollen lymph nodes
Concerns related to adverse effects:
- Anaphylactoid/hypersensitivity reactions: Immediate treatment (including epinephrine 1 mg/mL) for anaphylactoid and/or hypersensitivity reactions should be available during vaccine use (NCIRD/ACIP 2011). Once postexposure prophylaxis has begun, administration should generally not be interrupted or discontinued due to local or mild adverse events. Continuation of vaccination following severe systemic reactions should consider the persons risk of developing rabies. Report serious reactions to the State Health Department or the manufacturer/distributor.
- Immune complex-like reactions (serum sickness): An immune complex reaction is possible to 2 to 21 days following booster doses of HDCV. Symptoms may include arthralgia, arthritis, angioedema, fever, generalized urticaria, malaise, nausea, and vomiting.
- Neurologic reactions: Rare cases of Guillian-Barre syndrome (, transient neuroparalytic illnesses that resolves without sequelae in 12 weeks, and ,focal subacute central nervous system disorders, potentially fatal encephalitis, meningitis, transient paralysis, myelitis, retrobulbar neuritis, and multiple sclerosis have been reported .
- Syncope: Syncope has been reported with use of injectable vaccines and may result in serious secondary injury (eg, skull fracture, cerebral hemorrhage); typically reported in adolescents and young adults and within 15 minutes after vaccination. Procedures should be in place to avoid injuries from falling and to restore cerebral perfusion if syncope occurs (NCIRD/ACIP 2011).
Disease-related concerns:
- Bleeding disorders: Use with caution in patients with a history of bleeding disorders (including thrombocytopenia) and/or patients on anticoagulant therapy; bleeding/hematoma may occur from IM administration; if the patient receives antihemophilia or other similar therapy, IM injection can be scheduled shortly after such therapy is administered (NCIRD/ACIP 2011).
Special populations:
- Altered immunocompetence: Use with caution in severely immunocompromised patients (eg, patients receiving chemo/radiation therapy [including high-dose corticosteroids]); may have a reduced response to vaccination. Withhold nonessential immunosuppressive agents during postexposure prophylaxis; if possible postpone pre-exposure prophylaxis until the immunocompromising condition is resolved. Persons with altered immunocompetence should receive the five-dose postexposure vaccine regimen. In general, household and close contacts of persons with altered immunocompetence may receive all age appropriate vaccines (IDSA [Rubin 2014]; NCIRD/ACIP 2011).
Concurrent drug therapy issues:
- Vaccines: In order to maximize vaccination rates, the ACIP recommends simultaneous administration (ie, >1 vaccine on the same day at different anatomic sites) of all age-appropriate vaccines (live or inactivated) for which a person is eligible at a single clinic visit, unless contraindications exist. The ACIP prefers each dose of a specific vaccine in a series come from the same manufacturer when possible (NCIRD/ACIP 2011).
Dosage form specific issues:
- Albumin: Products may contain albumin and therefore carry a remote risk of transmitting Creutzfeldt-Jakob or other viral diseases.
- Imovax Rabies: Contains neomycin.
- RabAvert: Contains amphotericin B, bovine gelatin, chicken protein, chlortetracycline, and neomycin.
Other warnings/precautions:
- Antipyretics: Antipyretics have not been shown to prevent febrile seizures; antipyretics may be used to treat fever or discomfort following vaccination (NCIRD/ACIP 2011). One study reported that routine prophylactic administration of acetaminophen to prevent fever prior to vaccination decreased the immune response of some vaccines; the clinical significance of this reduction in immune response has not been established (Prymula 2009).
- Appropriate use: Rabies vaccine should not be used in persons with a confirmed diagnosis of rabies; use after the onset of symptoms may be detrimental (ACIP [Manning 2008]). Postexposure vaccination may begin regardless of the length of time from documented or likely exposure, as long as clinical signs of rabies are not present.
- Effective immunity: Vaccination may not result in effective immunity in all patients. Response depends upon multiple factors (eg, type of vaccine, age of patient) and may be improved by administering the vaccine at the recommended dose, route, and interval. Vaccines may not be effective if administered during periods of altered immune competence (NCIRD/ACIP 2011).
C
Animal reproduction studies have not been conducted. Pregnancy is not a contraindication to postexposure prophylaxis. Pre-exposure prophylaxis during pregnancy may also be considered if risk of rabies is great. Inactivated vaccines have not been shown to cause increased risks to the fetus (NCIRD/ACIP 2011).
Rabies vaccine is an inactivated virus vaccine which promotes immunity by inducing an active immune response. The production of specific antibodies requires about 7-10 days to develop. Rabies immune globulin or antirabies serum, equine (ARS) is given in conjunction with rabies vaccine to provide immune protection until an antibody response can occur.
IM: Rabies antibody: ~7 to 10 days; Peak effect: ~30 to 60 days
≥1 year
- Discuss specific use of vaccine and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)
- Patient may experience injection site pain, edema, or irritation, headache, abdominal pain, muscle pain, or dizziness. Have patient report immediately to prescriber joint pain, joint edema, joint rigidity, severe nausea, severe vomiting, severe loss of strength and energy, facial paralysis, muscle weakness, or difficulty moving (HCAHPS).
- Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.
Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for health care professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience, and judgment in diagnosing, treating, and advising patients.