Rabies Update

August 22, 2013

Health Advisory: Rabies Vaccine and Human Rabies Immune Globulin Available Action Steps for Healthcare:

Action Steps for Healthcare:

   ·    Use the guidance below to obtain rabies vaccine or HRIG.

   ·    See clarifications for appropriate rabies post-exposure prophylaxis administration and appropriate evaluation of bat exposures.

August is a very active time for human/bat encounters. The Minnesota Department of Health has been receiving phone calls with concerns that HRIG is not available for rabies post-exposure prophylaxis. This information will help you obtain the needed biologics and appropriately evaluate and treat rabies exposures.

Rabies Vaccine Availability: There are two brands of rabies vaccine available in the US: RabAvert by Novartis and IMOVAX by Sanofi Pasteur. Both are available without restriction.

HRIG Availability: There are two brands of HRIG available in the US: HyperRAB by Grifols Therapeutics and Imogam Rabies HT by Sanofi Pasteur.

   ·    HyperRab (Grifols Therapeutics) HRIG is available without restriction.

   ·    HRIG produced by Sanofi Pasteur (Imogam) can only be ordered as needed for an individual patient with a documented rabies exposure. Request

      forms and instructions can be found at: www.vaccineshoppe.com/assets/pdf/MKT26616_Imogam_Post_Exposure_Form.pdf

Rabies post-exposure prophylaxis (PEP) Regimen: The PEP regimen consists of one dose of HRIG (20 IU/kg) and a series of four rabies vaccinations. HRIG and the first vaccination are given on the first day of treatment, designated as day 0. Day 0 IS NOT the day of exposure.

HRIG Administration: HRIG dosage is based on actual body weight, not ideal body weight. No maximum dose of HRIG has been identified. HRIG is always first infiltrated, as much as anatomically feasible, into and around the bite wound. The remaining HRIG is administered intramuscularly at a site distant from the vaccination site. If no bite/wound is visible, then HRIG is administered intramuscularly at a site distant from the vaccination site.

If HRIG is not immediately available, it can be given up to and including 7 days after administration of the first rabies vaccine on Day 0. HRIG is contraindicated for patients who have previously received pre-exposure or post-exposure rabies prophylaxis any time after 1985. These patients are given two rabies vaccine boosters on days 0 and 3, and are not given HRIG.

Rabies Vaccine Administration: Rabies vaccine is given on Day 0, 3, 7, and 14 in immunocompentent patients.

www.health.state.mn.us/divs/idepc/diseases/rabies/risk/table3.pdf Immunocompromised persons receive a fifth vaccination on day 28 and should be tested for seroconversion. www.health.state.mn.us/divs/idepc/diseases/rabies/risk/table4.pdf ; Rabies vaccine should be given in the deltoid in adults/older children and in the anterolateral thigh in young children. Rabies vaccines should never be given in the gluteals.

Rabies PEP does not have to be given within 72 hours or 7 days of exposure. Most often a dog or cat is confined and observed for 10 days following a bite, regardless of vaccination status. When there is no animal available to observe or test, then PEP should be given as soon as possible. However, even if a significant amount of time has passed between the patient’s exposure and seeking medical care, rabies PEP may still be warranted, and the entire regimen (HRIG plus 4 rabies vaccinations) is given. The Minnesota Department of Health is available for 24-hour rabies consultation at 651-201-5414.

Bat Exposures: Bat bites may leave little or no evidence of a wound or puncture, and evidence exists suggesting that some bat-related rabies viruses may lead to infection with inoculation into superficial epidermal layers. Therefore, the following bat exposures are considered a potential risk for rabies and warrant testing the bat or rabies PEP: 1) A person has been bitten or has had any physical contact with a bat; 2) A person wakes up to find a bat in the bedroom; 3) A bat is found in a room with an unattended child or person who cannot reliably communicate any potential exposures.

Administration of PEP following bat exposures should be deferred until after the results of rabies testing of the bat are known.  Again, the Minnesota Department of Health is available for 24-hour rabies consultation at 651-201-5414. Instructions on how to submit a bat for rabies testing to the University of Minnesota Veterinary Diagnostic Laboratory can be found here. www.health.state.mn.us/divs/idepc/diseases/rabies/risk/specimens.html