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Rabies

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Rabies
How common is rabies in the United States?
In 2018, 54 reporting jurisdictions (U.S. states and territories) reported 4,951 cases of rabies in animals and 3 human rabies deaths to CDC (Hawaii is the only state that is rabies free). The total number of reported cases increased approximately 11% from those reported in 2017 (4,454 rabid animals and 2 human cases). Ninety-three percent of rabid animals were wildlife, with bats the most frequently reported animal in the United States at 33% of all reported rabid animals. In the last 100 years, the number of human deaths from rabies in the United States has fallen from 100 or more per year to an average of 2 or 3 per year. This decline is due to both the improved control and vaccination of domestic animals and to the development of effective postexposure treatment and vaccines. Although human deaths from rabies are now rare in the United States, each year interactions with suspect animals result in the need to observe or test hundreds of thousands of animals and to administer rabies postexposure prophylaxis to 30,000 to 60,000 persons.
What kind of vaccine is the rabies vaccine?
Two rabies vaccines are available in the United States. Both vaccines contain inactivated rabies virus. HDCV vaccine (Imovax, Sanofi Pasteur) is produced in human diploid cell culture. PCECV vaccine (RabAvert, Novartis) is produced in chick embryo cell culture. Both types are considered equally safe and effective.
Can you switch brands of rabies vaccine to complete the 4-dose series?
Yes. The two rabies vaccines licensed for use in the United States are interchangeable.
What is the schedule for rabies vaccine?
Primary vaccination with either type of rabies vaccine consists of 3 intramuscular doses (deltoid injection only), one injection per day on days 0, 7, and 21 or 28. A booster dose as often as every 6 months to 2 years may be required for person at highest risk for exposure to rabies virus, such as persons who work with rabies virus in research laboratories or vaccine production facilities, veterinarians and staff, and animal control and wildlife officers. Persons with infrequent exposure and persons vaccinated prior to international travel do not require routine booster doses but may require postexposure prophylaxis if exposed. More information on this topic is available in the rabies ACIP statement at www.cdc.gov/mmwr/PDF/rr/rr5703.pdf.
A patient recently exposed to a bat received the rabies vaccine series. One of the doses was given in the gluteus. Does this dose count?
No. Doses of rabies vaccine given in the gluteus should not be counted as valid and should be repeated. If repeating the invalid dose results in an interval between doses more than 3 days longer than the recommended interval, then you should perform a rabies serology 7–14 days after administration of the final dose in the series to ensure an adequate immune response to the series. For more information about rabies serology, see www.cdc.gov/rabies/specific_groups/doctors/serology.html.
Who should be offered pre-exposure rabies vaccination?
Pre-exposure vaccination should be offered to persons in high-risk groups, such as veterinarians and their staff, animal handlers, rabies researchers, and certain laboratory workers. Pre-exposure vaccination also should be considered for other persons 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. In addition, some international travelers might be candidates for pre-exposure vaccination 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 immune globulin, might be limited.
Where can I find the current recommendations for prevention of rabies?
The ACIP statement ("Human Rabies Prevention-United States, 2008, Recommendations of the Advisory Committee on Immunization Practices") was published in MMWR on May 23, 2008. This document updates the status of rabies and antirabies biologics in the United States. To view this document, go to www.cdc.gov/mmwr/PDF/rr/rr5703.pdf.
In March 2010, ACIP eliminated the fifth dose of vaccine given post-exposure to previously unvaccinated persons with no immunosuppression. This decision was based upon evidence that immunity would not be compromised, a need to conserve vaccine supplies, and the benefit to the patient's health as well as economics by minimizing the number of visits and vaccine doses required. To view the recommendations, go to www.cdc.gov/mmwr/pdf/rr/rr5902.pdf.
How does postexposure prophylaxis differ from getting vaccinated before an exposure?
Treatment after an exposure in a previously unvaccinated person requires receiving a dose of rabies immune globulin and four (or five if the person's immune system is suppressed) doses of vaccine. Vaccination before exposure requires only three doses of vaccine and no immune globulin.
What is rabies immune globulin?
Human rabies immune globulin (HRIG) is the IgG fraction of plasma from human donors who have received multiple doses of rabies vaccine and have high levels of anti-rabies antibody. HRIG is administered once to previously unvaccinated persons exposed to a rabid animal to provide rabies virus neutralizing antibody coverage until the patient responds to vaccination by actively producing virus-neutralizing antibodies. HRIG is administered once on day 0 at the time postexposure prophylaxis (PEP) is initiated, in conjunction with human rabies vaccine. If HRIG was not administered when vaccination was begun on day 0, it can be administered up to and including day 7 of the PEP series. If anatomically feasible, the full dose of HRIG is infiltrated around and into any wounds. Any remaining volume is injected intramuscularly at a site distant from vaccine administration. HRIG should not be administered in the same syringe or at the same anatomic site as the first vaccine dose. However, subsequent doses (i.e., on days 3, 7, and 14) of vaccine in the 4-dose vaccine series can be administered in the same anatomic location in which HRIG was administered.
My patient did not return for his postexposure rabies vaccine dose on day 7. How should I manage his series now?
Every attempt should be made to adhere to the recommended vaccination schedules. Once vaccination is initiated, delays of a few days for individual doses are unimportant, but the effect of longer lapses of weeks or more is unknown. Most interruptions in the vaccine schedule do not require reinitiation of the entire series. For most minor deviations from the schedule, vaccination can be resumed as though the patient were on schedule. For example, if a patient misses the dose scheduled for day 7 and presents for vaccination on day 10, the day 7 dose should be administered that day and the schedule resumed, maintaining the same interval between doses. In this scenario, the remaining doses would be administered on days 17 and 31. When substantial deviations from the schedule occur, immune status should be assessed by performing serologic testing 7–14 days after administration of the final dose in the series. Postexposure prophylaxis with rabies vaccine is described in detail at www.cdc.gov/mmwr/pdf/rr/rr5902.pdf.
Can a pregnant woman receive rabies vaccine if exposed to rabies?
Yes. A pregnant woman should receive rabies vaccine if indicated. No fetal abnormalities have been reported with the rabies vaccine. A pregnant woman can receive routine pre-exposure vaccination against rabies if her risk of exposure is high.
What side effects have been reported with this vaccine?
Most reactions to this vaccine are mild, such as soreness and redness at the injection site. Moderate problems, including hives, pain in the joints, and fever, are possible in a small percentage of patients (6%) given booster doses. Once initiated, rabies prophylaxis should not be interrupted or discontinued because of local or mild systemic adverse reactions to rabies vaccine. Usually, such reactions can be successfully managed with anti-inflammatory and antipyretic agents, such as ibuprofen or acetaminophen.
Who should not receive the rabies vaccine?
The rabies vaccine is not recommended for routine use in the general population. Anyone for whom the pre-exposure vaccine is recommended should not receive a dose when they are moderately or severely ill.
If a bat is found in a room and the occupants are uncertain if direct contact has occurred (for example, a baby is sleeping, a mentally disabled person is present), do you need to give postexposure prophylaxis?
Unless rabies can be ruled out by diagnostic testing of the bat, rabies postexposure prophylaxis (PEP) is recommended. Because the details of these recommendations are fairly complex and depend on various factors, consultation with state and local health departments should be sought.
Who should I contact if I have a patient who may have been exposed to a rabid animal?
Your best source is to contact your local or state public health agency. You can find contact information by going to www.cdc.gov/rabies/resources/contacts.html.
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This page was updated on October 22, 2020.
This page was reviewed on August 30, 2020.
 
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