/Protocol for Rabies Post-exposure Prophylaxis (RPEP) After Exposure to a Rabies Susceptible Animal

Protocol for Rabies Post-exposure Prophylaxis (RPEP) After Exposure to a Rabies Susceptible Animal

Updated 08/21/2015

Post-exposure Rabies Vaccine Schedule Update

The March 19, 2010 issue of the Centers for Disease Control and Prevention (CDC), Morbidty and Mortality Weekly Report (MMWR) (http://www.cdc.gov/mmwr/pdf/rr/rr5902.pdf) summarizes new recommendations and updates previous recommendations of the Advisory Committee on Immunization Practices (ACIP) for postexposure prophylaxis (PEP) to prevent human rabies. (CDC. Human rabies prevention—United States, 2008: recommendations of the Advisory Committee on Immunization Practices. MMWR 2008;57[No. RR-3]). Previously, ACIP recommended a 5-dose rabies vaccination regimen with human diploid cell vaccine (HDCV) or purified chick embryo cell vaccine (PCECV). The new recommendations for PEP reduce the number of human rabies vaccine doses to 4 given on days 0, 3, 7, and 14 by eliminating the previously recommended 5th dose on day 28. Human rabies immune globulin (HRIG) continues to be recommended (20 IU/Kg) on day 0 for persons not considered previously immunized for rabies as defined in the 2008 ACIP recommendations. The Southern Nevada Health District protocol RPEP has been updated to follow these recommendations.

For information on obtaining rabies vaccine for uninsured and underinsured patients see page 4 of this document or visit http://www.cdc.gov/rabies/medical_care/programs.html.

Protocol

Exposure Defined:

The rabies virus is present in the saliva, brain and spinal cord tissue of an infected animal.

“When an exposure has occurred, the likelihood of rabies infection varies with the nature and extent of that exposure. Under most circumstances, two categories of exposure (bite and nonbite) should be considered. The most dangerous and common route of rabies exposure is from the bite of a rabid mammal. An exposure to rabies also might occur when the virus, from saliva or other potentially infectious material (e.g., neural tissue), is introduced into fresh, open cuts in skin or onto mucous membranes (nonbite exposure). Indirect contact and activities (e.g., petting or handling an animal, contact with blood, urine, or feces, and contact of saliva with intact skin) do not constitute exposures; therefore, postexposure prophylaxis should not be administered in these situations.” (Human Rabies Prevention – US 2008, MMWR 2008; 57(RR03):1-28.)

When assessing patients with bite wounds from rabies susceptible animals:

  1. Contact Animal Control in the jurisdiction where the bite occurred to report rabies susceptible animal bites (NAC 441A.415) and request guidance regarding the need for rabies post-exposure prophylaxis.
    • Clark County Animal Control: (702) 455-7710 then press “1”
    • City of Las Vegas Animal Control: (702) 229-6444 then press “2”
    • City of North Las Vegas Animal Control: (702) 633-1750
    • City of Henderson Animal Control: (702) 267-4970 then press “‘4”
    • Boulder City Animal Control: (702) 293-9283
    • City of Mesquite Animal Control: 1-(702) 346-5268
  2. Immediate and thorough washing of all bite wounds and scratches with soap and water or a virucidal agent are important measures for preventing rabies.
  3. Contact SNHD at (702)759-1389 if Rabies Post-Exposure Prophylaxis (RPEP) is warranted, to report circumstances surrounding the bite incident.
  4. Follow guidelines in Table 1 if RPEP is warranted:

Guidelines for administration of RPEP

  • If exposed to a dog, cat, ferret or other domestic animal that is not exhibiting signs of rabies, is normal and healthy and available for observation:
    • Do not initiate Rabies Post-Exposure Prophylaxis (RPEP) until the animal has been observed for 10 days
    • Recommend initiating RPEP if the animal becomes ill or dies with a rabies like illness during quarantine and the results of a brain specimen sent to the Nevada State Department of Agriculture for rabies testing are positive for rabies.
  • If exposed to a dog, cat, ferret that has not been apprehended, and therefore unavailable for observation:
    • Recommend RPEP if animal control authority has determined that the bite was not provoked and the animal was exhibiting abnormal behavior;
    • Consult as needed with the SNHD regarding the epizoology of rabies and the circumstances of the exposure.
  • If exposed to a wild animal such as a raccoon, fox, skunk, or coyote:
    • Recommend RPEP if:
      • Recommend RPEP if animal control authority has determined that the bite was not provoked and the animal was exhibiting abnormal behavior;
      • Consult as needed with the SNHD regarding the epizoology of rabies and the circumstances of the exposure.
    • Discontinue RPEP if the animal’s brain specimen is negative for rabies.
  • If exposed to a bat:
    • Recommend RPEP when direct contact between a human and a bat has occurred (unless the exposed person can be certain an exposure did not occur) and:
      • the animal has not been apprehended
      • the specimen is untestable
      • brain specimen testing by the Nevada State Department of Agriculture cannot be completed within 24 hours
      • the specimen is positive for rabies
    • Discontinue RPEP if the animal’s brain specimen is negative for rabies
    • Consider RPEP when
      • Persons were in the same room as the bat and may be unaware that a bite or direct contact occurred (e.g., a sleeping person awakens to find a bat in their room or an adult witnesses a bat in the room with a previously unattended child, mentally disabled person, or intoxicated person). RPEP would not be warranted for household members who were not present in the same room as the bat.
  • If exposed to a small animal or rodent (rat, mouse, squirrel, rabbit) RPEP is not recommended unless there are unusual circumstances. “Rodents are not reservoirs of rabies virus. Small rodents (e.g., squirrels, chipmunks, rats, mice, hamsters, guinea pigs, and gerbils) and lagomorphs (including rabbits and hares) are rarely infected with rabies and have not been known to transmit rabies to humans.” (Human Rabies Prevention—US 2008. MMWR. 2008: 57(RR03);1-28.)
Table 1. Rabies postexposure prophylaxis schedule – United States, 2010 5
Vaccination StatusTreatmentRegimen*
Not previously vaccinatedWound cleansingAll postexposure prophylaxis should begin with immediate thorough cleansing of all wounds with soap and water. If available, a virucidal agent such as povidine-iodine solution should be used to irrigate the wounds.
Human Rabies immune globulin (HRIG)Administer 20 IU/Kg body weight. If anatomically feasible, the full dose should be infiltrated around the wound(s) and any remaining volume should be administered intramuscularly (IM) at an anatomical site distant from vaccine administration. Also, HRIG should not be administered in the same syringe as vaccine. Because HRIG might partially suppress active production of antibiody, no more than the recommended dose should be given.
VaccineHuman diploid cell vaccine (HDCV) or purified chick embryo cell vaciine (PCECV) 1.0 mL, IM (deltoid area§), one each on days 0¶, 3, 7, and 14**.
Previously vaccinatedWound cleansingAll postexposure prophylaxis should begin with immediate thorough cleansing of all wounds with soap and water, if available, a virucidal agent such as povidine-iodine solution should be used to irrigate the wounds.
HRIGHRIG should not be administered
VaccineHDCV or PCECV 1.0 mL, IM (deltoid area§), one each on days 0¶, and 3.
* These regimens are applicable for all age groups, including children.
Any person with a history of a complete pre-exposure or postexposure vaccination regimen with HDCV, PCECV, or rabies vaccine adsorbed (RVA), or previous vaccination with any other type of rabies vacine and a documented history of antibody response to the prior vaccianation.
§ The deltoid area is the only accceptable site of vaccination for adults and older children. For younger children, the outer aspect of the thigh can be used. Vaccine should never be administered in the gluteal area.
Day 0 is the day the first dose of vaccine is administered.
** For persons with immunosuppression, rabies PEP should be administered using all 5 doses of vaccine on days 0, 3, 7, 14, and 28.

Uninsured and Underinsured Patient Assistant Programs

Both rabies vaccine manufacturers have patient assistant programs that provide medications to uninsured or underinsured patients. Sanofi Pasteur’s Indigent Patient Program (providing Imogam ® Rabies-HT and Imovax ® Rabies) is now administered through the Franklin Group. A healthcare professional or patient can either contact the Franklin Group directly, or call the customer service team (1-800-VACCINE) who will transfer them to the Franklin Group. The RabAvert ® Patient Assistance Program is managed through Rx for Hope and can be accessed at 1-800-589-0837 or at www.rxhope.com/novartis*.

Table 2. Resources for Rabies Vaccine and Human Rabies Immune Globulin (HRIG) for Southern Nevada (updated 6/13/17)
HospitalMain #HRIG/Vaccine
Boulder City(702) 293-4111Neither
Centennial Hospital(702) 835-9700Both
Desert Springs(702) 733-8800Both
Dixie Regional Medical Center(435) 251-1000Both
Henderson Hospital(702) 963-7000Both
Mesa View(702) 346-8040Vaccine
Mountain View(702) 255-5000Both
North Vista(702) 649-7711Vaccine
Southern Hills(702) 880-2100Both
Spring Valley(702) 853-3000Both
St. Rose Delima(702) 564-2622Both
St. Rose San Martin(702) 492-8000Both
St. Rose Sienna(702) 616-5000Both
Summerlin(702) 233-7700Both
Sunrise(702) 731-8000Both
e7 Health(702) 800-2723Vaccine
UMC(702) 383-2000Both
Valley(702) 388-4000Both

The patient/physician can contact the appropriate hospital to make arrangements for RPEP.

For additional animal bite exposure risk assessment contact Keith Forbes, DVM at (775) 353-3707 (office) (775)741-2050 (cell) the State of Nevada Department of Agriculture, Division of Animal Disease & Food Safety Laboratory.

*Exposure = The most dangerous and common route of rabies exposure is from the bite of a rabid mammal. An exposure to rabies also might occur when the virus, from saliva or other potentially infectious material (e.g., neural tissue), is introduced into fresh, open cuts in skin or onto mucous membranes (notbite exposure). Indirect contact and activities (e.g., petting or handling an animal, contact with blood, urine, or feces, and contact of saliva with intact skin) do not constitute exposures. RPEP = Rabies Post-exposure Prophylaxis **As assessed by the Rabies Control Authority §Unusual circumstances may occur in rabbits and small rodents that are kept in cages outside and may have been bitten by a rabid animal. In instances the cage protected them from more serious wounds that may have caused death. This situation is very rare.

1 Moran, GJ, Talan, DA, Mower, W et.al. Appropriateness of Rabies Postexposure Prophylaxis Treatment for Animal Exposures. JAMA, August 22/30, 2000, 284;8:1001-1007.

2 Adapted from: New York State Department of Health “Rabies Treatment Algorithm” http://www.health.ny.gov/publications/3028.pdf PDF and

3 Adapted from: North Carolina Department of Health and Human Services “Evaluation of Animal Bites for Rabies Risk” http://epi.publichealth.nc.gov/cd/rabies/docs/exp_eval_2010.pdf PDF

4 Human Rabies Prevention – US 2008, MMWR 2008; 57(RR03):1-28

5 Rupprecht, Charles E. et. al. “Use of a Reduced (4-Dose) Vaccine Schedule for Postexposure Prophylaxis to Prevent Human Rabies” MMWR 2010; 59(02);1-9 www.cdc.gov/mmwr/preview/mmwrhtml/rr5902a1.htm?s_cid=rr5902a1_x PDF

Contact Information

Phone: (702) 759-1389

 

Updated on:  February 5, 2019

2019-02-05T13:18:53+00:00