E&A: Rabies Postexposure Prophylaxis

For further information, visit the CDC rabies home page at: www.cdc.gov/ncidod/dvrd/rabies

Giving Rabies PEP

Because most physicians and nurses are not familiar with rabies PEP, it is crucial to review the following information prior to providing treatment. The three components that are critical to rabies PEP are as follows:

Immediate and thorough washing of the wound with soap and warm water and irrigation with a virucidal solution such as povidone-iodine solution.
Administration of Human Rabies Immune Globulin (HRIG)
HRIG is not indicated if the patient has had pre-exposure prophylaxis or previous rabies PEP treatment with currently licensed products. HRIG is given only once at the beginning of treatment. As much of the HRIG as possible should be infiltrated into and around the site of the wound(s). Any remaining HRIG should be injected IM into the gluteus muscle. If there is not a visible wound present, and there is no history of a percutaneous exposure, give the HRIG as IM injection(s) into the gluteus muscle. Although it is preferable to give HRIG at the time of the first dose of vaccine, it can be given up to 7 days after starting the vaccine series. The dose is 20 IU/kg. It is supplied in a concentration of 150 IU/ml. To determine the dose, complete the following calculations:

(Patient’s weight in pounds) ¸ (2.2 pounds/kg) = (Patient’s weight in kg)
(Patient’s weight in kg) x (20 IU/kg) ¸ (150 IU/ml) = dose of HRIG in ml
OR (multiplying all the constants in the above equations)

(Patient’s weight in pounds) x 0.06 = dose of HRIG in ml
Example: A 150-pound person would require a dose of 9.1 ml.
Please note: As the example demonstrates, you will be giving a large number of ml’s.

There are two licensed products available:

BayRabä, Bayer Corporation, (800) 288-8370

Imogam^â Rabies-HT, Aventis Pasteur, (800) 822-2463

As a reminder, immunization with measles and rubella vaccines should not be given until at least 3 months after receiving HRIG. Varicella vaccine should not be administered until at least 4 months after receiving HRIG.

Administration of Human Rabies Vaccine Series
The PEP vaccine series consists of five 1.0-ml doses of vaccine given on days 0, 3, 7, 14, and 28. Give all doses of rabies vaccine IM in the lateral deltoid in adults and in the anterolateral aspect of the thigh for young children. Do not give vaccine in the gluteus muscle.

If the patient had pre-exposure prophylaxis or previous rabies PEP treatment with currently licensed products, then only two doses of vaccine are given for PEP on days 0 and 3.

There are two rabies vaccines licensed for use and currently available in the United States:

Human Diploid Cell Vaccine (HDCV), trade name Imovax^â, distributed by Aventis Pasteur Inc. (800) 822-2463

Purified Chick embryo Cell Culture (PCEC), trade name RabAvertä, distributed by Chiron Vaccines, (800) 244-7668 x 5812.

Please refer to the package inserts for warnings, precautions, and adverse reactions. Please call Epidemiology and Assessment at (714) 834-8180 for assistance in assessing the risk of rabies and indications for rabies PEP. All animal bites should be reported to Animal Care Services at (714) 935-7419.

SUMMARY OF RABIES POST-EXPOSURE PROPHYLAXIS

	No history of pre- or post- exposure rabies immunization	History of previous pre- or post- exposure rabies immunization with currently licensed products
HRIG (BayRabä or Imogam^â Rabies-HT)	Yes Dose: 20 IU/kg Dose calculation: (Patient’s weight in pounds) x 0.0606 = mls of HRIG Infiltrate as much as possible into the wound site(s), give the rest into the gluteal area Give concurrently with first dose of vaccine if possible but no later than 7 days after first dose of vaccine.	None
Vaccine (Imovax^® Rabies^*,or RabAvertä )	Five 1-ml doses given IM in the deltoid (anterolateral thigh in young children). Doses given on days 0, 3, 7, 14, and 28	Two 1-ml doses given IM in the deltoid (anterolateral thigh in young children). Doses given on days 0, 3