Diltiazemhydrochloride may be available in the countries listed below.
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In the US, Nitric Oxide (nitric oxide systemic) is a member of the drug class miscellaneous respiratory agents and is used to treat Respiratory Failure.
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Zosec Pro may be available in the countries listed below.
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Class: Vaccines
ATC Class: J07BG01
VA Class: IM100
Brands: Imovax, RabAvert
Inactivated virus vaccine.208 234 236 Rabies vaccine contains rabies virus antigens and is used to stimulate active immunity to rabies infection.208 234 236 Commercially available in the US as human diploid-cell rabies vaccine (HDCV; Imovax) and purified chick embryo cell culture rabies vaccine (PCECV; RabAvert).208 234 Other rabies vaccines (e.g., vero cell rabies vaccine, duck embryo rabies vaccine, nerve tissue vaccine [NTV]) may be available in other countries.213 236 249
Prevention of rabies in children, adolescents, and adults exposed to or at increased risk of exposure to rabies disease or virus.208 213 234 236 250
Rabies is a viral infection transmitted by saliva of infected mammals, most commonly wild, terrestrial carnivores (e.g., skunks, raccoons, foxes, coyotes) or bats.213 236 In the US, the greatest risk for naturally acquired rabies is from contact with and bites from insectivorous bats.222 236 242 Following exposure and infection, rabies virus usually moves along a neural pathway and enters the CNS.234 236 After entrance into the CNS, the virus is unlikely to be affected by antirabies antibodies and encephalomyelitis usually develops and almost always is fatal.234 236 In the US, approximately 16,000–39,000 individuals receive rabies postexposure prophylaxis each year.234 236 250 Although there were 27 rabies cases reported in the US during 2000–2008,250 these individuals evidently did not receive rabies postexposure prophylaxis.250 Rabies prevention and control strategies and elimination of canine rabies virus variants and enzootic transmission among dogs have lowered the number of rabies cases in the US to an average of 1–2 per year.250 However, worldwide, rabies is much more common and at least 55,000 rabies-related deaths occur each year.249 250
USPHS Advisory Committee on Immunization Practices (ACIP) and AAP recommend preexposure vaccination with rabies vaccine (series of 3 doses with booster doses when indicated) in children, adolescents, and adults who are or will be at increased risk of exposure to the virus.213 236 (See Preexposure Vaccination Against Rabies in High-risk Groups under Uses.)
Postexposure prophylaxis with a regimen that includes local wound treatment, rabies vaccine (series of 4 or 5 doses), and a single dose of rabies immune globulin (RIG) is recommend for previously unvaccinated children, adolescents, and adults following potential rabies exposure.213 236 Postexposure prophylaxis with a regimen that includes local wound treatment and a series of 2 booster doses of rabies vaccine (without RIG) is recommended for previously vaccinated children, adolescents, and adults following potential rabies exposure.213 236 (See Postexposure Prophylaxis of Rabies under Uses.)
Preexposure vaccination in children, adolescents, and adults who are or will be at risk of exposure to rabies virus.208 213 234 236
Preexposure vaccination does not eliminate the need for prompt postexposure prophylaxis if an exposure to rabies occurs.208 213 234 236 250 (See Postexposure Prophylaxis of Rabies under Uses.)
Need for rabies preexposure vaccination depends on the nature of risk and associated level of potential exposure.236 Consider preexposure vaccination for individuals whose risk of rabies exposure is greater than that of the general population (e.g., veterinarians and their staff, animal-control and wildlife workers, field biologists, spelunkers, missionaries, rabies researchers, certain laboratory workers).212 236 Also consider preexposure vaccination for individuals 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.236 (For ACIP definitions of risk categories and recommendations regarding preexposure vaccination for each category, see Table 1.)
Travelers to areas where rabies is endemic may be at risk, especially 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 RIG) is unlikely.212 236 237 249 Canine rabies remains highly endemic in certain areas of the world (e.g., parts of Africa, Asia, Central and South America).212 237 CDC recommends preexposure vaccination based on local incidence of rabies in the country to be visited, availability of appropriate agents for rabies postexposure prophylaxis in that country, and intended activity and duration of stay.212
Minimum acceptable antibody titer is complete virus neutralization at a 1:5 serum dilution by the rapid fluorescent focus inhibition test (RFFIT). Give booster dose of rabies vaccine if titer falls below this level.
Adapted from the Recommendations of the Advisory Committee on Immunization Practices (ACIP) on Human Rabies Prevention. MMWR Recomm Rep. 2008; 57 (RR-3):1-28.
Category of Rabies Risk | Nature of Risk | Typical Population | Preexposure Vaccination |
|---|---|---|---|
Continuous | Virus present continuously (often in high concentrations); specific exposure likely to go unrecognized; bite, nonbite, or aerosol exposure | Rabies research laboratory workers, rabies biologics production workers | Yes; then perform serologic testing every 6 months and give booster dose if antibody titer decreases to less than acceptable level |
Frequent | Exposure usually episodic; source recognized, but exposure may go unrecognized; bite, nonbite, or aerosol exposure | Rabies diagnostic laboratory workers, cavers, veterinarians and their staff, animal-control and wildlife workers in rabies enzootic areas, individuals who frequently handle bats | Yes; then perform serologic testing every 2 years and give booster dose if antibody titer decreases to less than acceptable level |
Infrequent (but greater than in general population) | Exposure is nearly always episodic with a recognized source; bite or nonbite exposure | Veterinarians and animal-control staff working with terrestrial animals in areas where rabies is uncommon to rare, veterinary students, travelers visiting areas where rabies is enzootic and immediate access to appropriate medical care is limited | Yes; serologic testing and booster doses not necessary |
Rare (population at large) | Exposure always episodic with a recognized source; bite or nonbite exposure | US population at large, including those in rabies-epizootic areas | Not necessary |
Postexposure prophylaxis of rabies in previously vaccinated and unvaccinated children, adolescents, and adults following exposure to rabies disease or virus.208 213 234 236 250
History of previous vaccination against rabies simplifies the postexposure prophylaxis regimen, but does not eliminate the need for prompt postexposure prophylaxis if an exposure to rabies occurs.208 234 236 250
Whenever a possible human exposure to rabies occurs, the risk of infection must be accurately assessed to determine the need for postexposure prophylaxis.236 250 Base decisions regarding the need for postexposure prophylaxis on vaccination status of exposed individual (see Table 2), type of exposure (bite, nonbite), information about the animal involved (type, vaccination status, condition at time of attack) (see Table 3), and rabies epidemiology in the specific geographic region.213 236 250 Consult local or state public health officials for assistance when evaluating rabies exposures and the need for postexposure prophylaxis.213 236 250
Any person with a history of a complete preexposure or postexposure vaccination regimen with HDCV, PCECV, or rabies vaccine adsorbed (RVA; not commercially available in the US), or previous vaccination with any other type of rabies vaccine and a documented history of antibody response to the prior vaccination
Individuals with immunosuppression should receive a 5-dose regimen of rabies vaccine; give 1 mL (HDCV or PCECV) IM once on days 0, 3, 7, 14, and 28.
Deltoid area is the only acceptable site for IM administration of rabies vaccine in adults, adolescents, and older children. For younger children, deltoid or anterolateral thigh should be used. Never administer in gluteal area.
Day 0 is the day the first dose of rabies vaccine is administered.
Adapted from Use of a Reduced (4-Dose) Vaccine Schedule for Postexposure Prophylaxis to Prevent Human Rabies. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2010; 59 (RR-2):1-9.
Vaccination Status | Treatment | Regimen |
|---|---|---|
Not previously vaccinated | Wound cleansing | Immediately cleanse all wounds thoroughly with soap and water; if available, irrigate wounds with virucidal agent (e.g., povidone-iodine solution) |
RIG | Administer 20 international units/kg of RIG; if anatomically feasible, infiltrate full RIG dose around and into wound(s) and give any remaining portion of the dose IM at an anatomical site distant from site of rabies vaccine administration | |
Rabies vaccine | Administer 4-dose regimen of rabies vaccine; give 1 mL (human diploid-cell vaccine [HDCV; Imovax] or purified chick embryo cell culture vaccine [PCECV; RabAvert]) IM once on days 0, 3, 7, and 14 | |
Previously vaccinated | Wound cleansing | Immediately cleanse all wounds thoroughly with soap and water; if available, irrigate wounds with virucidal agent (e.g., povidone-iodine solution) |
RIG | RIG should not be administered | |
Rabies vaccine | Administer 2-dose regimen of rabies vaccine; give 1 mL (HDCV or PCECV) IM once on days 0 and 3 |
Regardless of rabies immunization status, ACIP and AAP recommend that postexposure prophylaxis of rabies begin immediately with thorough cleansing of all bite wounds and scratches using soap and water and, if available, irrigation with a virucidal agent such as povidone-iodine solution.213 236 250 Local wound treatment is an essential initial step in rabies postexposure prophylaxis in all individuals.213 236 250 (See General under Dosage and Administration.)
In previously unvaccinatedchildren, adolescents, and adults following potential rabies exposure, a postexposure prophylaxis regimen of active immunization with a 4- or 5-dose regimen of rabies vaccine and passive immunization with a single dose of RIG is recommended as soon as possible.208 213 234 236 250 The ACIP states that a 4-dose regimen of rabies vaccine in conjunction with RIG is sufficient for postexposure prophylaxis in previously unvaccinated individuals who are immunocompetent; however, a 5-dose vaccine regimen in conjunction with RIG should be used in those with altered immunocompetence.250
In previously vaccinated children, adolescents, and adults following potential rabies exposure, a 2-dose booster regimen of rabies vaccine (without RIG) is recommended as soon as possible.213 236 250
During the 10-day observation period, begin postexposure prophylaxis in the exposed individual at the first sign of rabies in a dog, cat, or ferret that has bitten them. If the animal exhibits clinical signs of rabies, euthanize it immediately and perform appropriate testing.
Initiate postexposure prophylaxis as soon as possible following exposure to such wildlife, unless animal is available for testing and public health authorities are facilitating expeditious laboratory testing or it is already known that brain material from the animal has tested negative. Other factors that might influence urgency of decision-making regarding initiation of postexposure prophylaxis before diagnostic results are known include the animal species, general appearance and behavior of the animal, whether encounter was provoked by a human, and the severity and location of bites. Discontinue postexposure prophylaxis if appropriate laboratory tests (i.e., direct fluorescent antibody test) are negative.
Euthanize the animal and test as soon as possible. Holding for observation is not recommended.
Adapted from the Recommendations of the Advisory Committee on Immunization Practices (ACIP) on Human Rabies Prevention. MMWR Recomm Rep. 2008; 57 (RR-3):1-28.
Animal Type | Evaluation and Disposition of Animal | Postexposure Prophylaxis Recommendations |
|---|---|---|
Dogs, cats, ferrets | Healthy and available; confine for 10 days of observation | Do not begin prophylaxis unless animal develops clinical signs of rabies |
Rabid or suspected rabid | Immediately begin postexposure prophylaxis | |
Unknown (e.g., escaped) | Consult public health officials | |
Skunks, raccoons, foxes, and most other carnivores; bats | Regard as rabid unless animal proven negative by laboratory tests | Consider immediate postexposure prophylaxis |
Livestock, small rodents, lagomorphs (rabbits, hares), large rodents (woodchucks, beavers), other mammals | Consider individually | Consult public health officials. Bites from squirrels, hamsters, guinea pigs, gerbils, chipmunks, rats, mice, other small rodents, rabbits, and hares almost never require rabies postexposure prophylaxis |
Bite exposures include any skin penetration by teeth; all bite exposures from an animal known or suspected to be rabid, regardless of bite location, pose a potential risk of rabies transmission and require postexposure prophylaxis.213 236 Risk of transmission varies in part based on species of biting animal, anatomic site of bite, and severity of wound.236 Rabies transmission can occur from bites of some animals (e.g., bats) that inflict rather minor injury and wounds that are difficult to detect.236
Any potential exposure to a bat requires thorough evaluation.236 If possible, the bat should be submitted for rabies diagnosis.236 Postexposure prophylaxis is not necessary if the individual can be reasonably certain a bite, scratch, or mucous membrane exposure did not occur or if the bat is available for testing and is negative for rabies virus.236 Situations that might qualify as exposures include finding a bat in the same room as a person who might be unaware that a bite or direct contact occurred (e.g., a deeply sleeping individual awakened to find a bat in the room or an adult observes a bat in the room with a previously unattended child, mentally disabled person, or intoxicated person).236 Other household members who did not have direct contact with the bat or were awake and aware when in the room with the bat should not be considered as having exposure to rabies.236
Nonbite exposures include contamination of preexisting open wounds, abrasions, mucous membranes, or scratches with saliva or other potentially infectious material (e.g., neural tissue) from an animal known or suspected to be rabid.213 236 Although nonbite exposures only rarely cause rabies, such exposures require assessment to determine if sufficient reasons exist to consider postexposure prophylaxis.213 236 Nonbite exposures of highest risk occur in surgical recipients of corneas, solid organs, and vascular tissue transplanted from patients who died of rabies and individuals exposed to large amounts of aerosolized rabies virus.236
Transmission of rabies to individuals performing autopsies not reported to date;251 no confirmed cases of rabies reported in individuals performing postmortem examinations of humans or animals.251 CDC recommends that personnel performing autopsies on decedents with confirmed or suspected rabies use appropriate personal protective equipment, wear heavy or chain mail gloves, minimize aerosol generation by using a handsaw rather than oscillating saw, limit the number of individuals participating in the procedure and collection of specimens, and use ample amounts of 10% sodium hypochlorite solution during and after the procedure to ensure decontamination of all exposed surfaces.251 CDC states that preexposure vaccination against rabies usually is not required for individuals performing autopsies and that rabies postexposure prophylaxis is recommended in autopsy personnel only if a wound or mucous membrane gets contaminated with the patient's saliva or other potentially infectious material (e.g., neural tissue) during the procedure.251
Other forms of contact in the absence of a bite or nonbite exposure (e.g., petting a rabid animal or contact with blood, urine, or feces of a rabid animal, contact of saliva with intact skin) are not considered exposure and postexposure prophylaxis is not necessary.236
In health-care personnel, routine delivery of health care to a patient with rabies is not an indication for postexposure rabies prophylaxis; postexposure prophylaxis in such personnel is indicated if they have been bitten by the patient or if they have mucous membranes or nonintact skin (e.g., open wounds) that were contaminated with the patient's saliva or other potentially infectious material (e.g., neural tissue).236
Because the rabies incubation period in humans can range from days to years (usually 1–3 months),212 213 234 236 250 initiate rabies postexposure prophylaxis (regardless of the length of delay) if a documented or likely exposure has occurred and clinical signs of rabies have not appeared in the exposed individual.236
Postexposure prophylaxis failures have not been reported in the US when recommended wound management and postexposure regimens were followed using commercially available rabies vaccines and RIG.236 250 ACIP states that rabies pathogenesis data, animal data, clinical studies, and epidemiologic surveillance indicate that a 4-dose vaccine series is as effective as a 5-dose vaccine series when used in conjunction with wound management and RIG.250 Rare reports of postexposure prophylaxis failures in other countries usually involved some deviation from recommended procedures (e.g., postexposure prophylaxis not given or substantially delayed, wounds not adequately cleansed, rabies vaccine given IM into the gluteal rather than deltoid region, failure to passively immunize with RIG by infiltrating the wound site, use of less than the recommended dose of RIG, use of less than the recommended number of vaccine doses).234 236 250
Travelers to rabies-endemic countries should be warned about the risk of acquiring rabies and educated in bite prevention strategies (e.g., avoiding contact with bats, avoiding stray dogs, monkeys, or cats).212 Because appropriate preparations of RIG or rabies vaccine may be not available for postexposure prophylaxis in the destination country, CDC recommends that travelers to such countries have a preplanned strategy in place that may involve identifying a different country where appropriate postexposure prophylaxis can be obtained if necessary.212 CDC states that rabies vaccines grown in animal brains (nerve tissue vaccines; NTV) may still be used in some developing countries; if offered such a vaccine (identified by a regimen that requires 5-mL injections once daily for 14–21 days), travelers should refuse the vaccine and travel to a country where an acceptable rabies vaccine and RIG are available.212 If travelers in other countries receive postexposure prophylaxis with regimens and/or preparations not recommended by ACIP (or not used in the US), additional therapy may be necessary following return to the US.212 236 In such cases, consult state and local health authorities for advice regarding the need for additional postexposure prophylaxis.236 Consider serologic testing in these travelers to verify efficacy of the regimen used and to ensure an adequate immune response.236 (See Pre- and Postvaccination Serologic Testing under Cautions.)
Rabies postexposure prophylaxis in previously unvaccinated individuals involves thorough cleansing of all bite and nonbite wounds followed by active immunization with rabies vaccine and passive immunization with RIG.212 213 236 250
Rabies postexposure prophylaxis in previously vaccinated individuals involves thorough cleansing of all bite and nonbite wounds followed by booster doses of rabies vaccine (without RIG).212 213 236 250
Because rabies virus may remain localized at the site of inoculation for a variable time before entering neural tissue, immediately wash all bites and scratches with soap and water; if available, irrigate with a virucidal agent (e.g., povidone-iodine solution).212 213 236 250 Institute tetanus prophylaxis and measures to control secondary infection as indicated.208 213 236 Consider cosmetic factors and the potential for bacterial infection before deciding to suture large wounds.213 236 AAP states that, if possible, the wound should not be sutured.213
Administer by IM injection.208 213 234 236
Do not administer sub-Q, intravascularly, or intradermally.208 234 (See Administration Precautions under Cautions.)
Depending on patient age, administer IM into the deltoid muscle or anterolateral thigh.208 211 212 213 234 236 250
For adults, adolescents, and older children, the deltoid is the only acceptable IM injection site; for younger children, the deltoid or anterolateral thigh should be used.208 211 212 213 234 236 250
Avoid use of the gluteal area as a possible IM injection site.208 209 210 211 212 213 216 221 234 (See Administration Precautions under Cautions.)
Avoid injection into or near blood vessels or nerves.208 234
To ensure delivery into muscle, IM injections should be made at a 90° angle to the skin using a needle length appropriate for the individual's age and body mass, thickness of adipose tissue and muscle at the injection site, and injection technique.211
Administer immediately after reconstitution.208 234 Use entire volume of reconstituted single-dose vaccine vial.208 236
Use separate needles for reconstitution and administration.208 234
Do not administer rabies vaccine in the same syringe or simultaneously at the same injection site as RIG.213 236 246 216 (See Specific Drugs under Interactions.)
Do not mix with any other vaccine or solution.211 213
To reconstitute, add entire contents of syringe containing diluent provided by the manufacturer to the single-dose vial of lyophilized vaccine.208 Use only the diluent supplied by the manufacturer.208
Attach reconstitution needle and plunger to the syringe and inject diluent into vaccine vial.208 Gently swirl until completely dissolved.208 The lyophilized vaccine is creamy white to orange; reconstituted suspension is pink to red.208
Remove reconstitution needle and discard.208 Use a suitable needle for IM administration.208 Use immediately after reconstitution.208
To reconstitute, add entire contents of vial containing diluent (1 mL of sterile water for injection) provided by the manufacturer to the single-dose vial of lyophilized vaccine.234 Use only the diluent supplied by the manufacturer.234
Using the longer of the 2 needles provided by the manufacturer, withdraw entire contents of the diluent into the syringe.234 Insert the needle at a 45° angle into the vaccine vial; slowly inject entire contents of diluent vial into the vaccine vial.234 Mix gently to avoid foaming.234 Lyophilized vaccine is white; reconstituted suspension is clear or slightly opaque.234
Withdraw entire amount of dissolved vaccine into the syringe and replace the long needle with the smaller one for IM injection.234 Use immediately after reconstitution.234
The vaccine vial contains negative pressure that may impede withdrawal of the full dose of reconstituted vaccine.234 The manufacturer recommends that the syringe be disconnected from the needle after reconstitution to allow any remaining vacuum to exhaust; however, creating positive pressure (e.g., by injecting air into the vial) is not recommended since over-pressurization may interfere with withdrawal of the proper vaccine dose.234
Whenever possible, the rabies vaccine (HDCV [Imovax], PCECV [RabAvert]) used for the initial dose should be used for subsequent doses in the vaccine series in the same individual.213 234 236 Although only limited data available to date, most experts state that rabies vaccines currently available in the US may be considered interchangeable.213 234 236 ACIP states clinical studies not available to date showing differences in efficacy or safety if the vaccine series is completed with a different preparation.236
Adhere to the recommended vaccination schedule as closely as possible.236 If a minor deviation from the schedule occurs (e.g., a dose is delayed by a few days), give the dose and resume the vaccination schedule using the same interval between doses.236 If a substantial deviation from the schedule occurs, perform serologic testing 7–14 days after the final vaccine dose to assess immune status.236 (See Pre- and Postvaccination Serologic Testing under Cautions.)
Primary immunization consists of a series of 3 doses.208 213 234 236 Each dose consists of the entire contents (1 mL) of a reconstituted single-dose vial.208 234 236
Give first dose on a selected date; give second and third doses 7 and 21 (or 28) days, respectively, after first dose.208 213 234 236
Completion of the recommended 3-dose primary series before an expected exposure to rabies virus ensures the highest level of protection.208 213 234 236
Serologic confirmation of rabies immunity following the 3-dose primary series is not necessary in most individuals.208 212 213 234 236 (See Pre- and Postvaccination Serologic Testing under Cautions.)
Duration of immunity following the recommended 3-dose primary series is ≥2 years.213 234 236 (See Duration of Immunity under Cautions.) Need for additional (booster) doses depends on the category of risk for rabies infection and levels of antirabies antibody.236 (See Booster Doses in Children and Adolescents under Dosage and Administration.)
Each booster dose consists of the entire contents (1 mL) of a reconstituted single-dose vial.208 213 234 236
Give a booster dose if indicated to maintain adequate levels of antirabies antibody.208 213 234 236 Booster doses may be indicated in those at continuous or frequent risk of rabies, but not in those at infrequent or rare risk.208 213 234 236 (For ACIP definitions of risk categories and recommendations regarding preexposure vaccination for each category, see Table 1 under Uses.)
In those at continuous risk of rabies, perform serologic testing every 6 months and administer booster dose if necessary.208 212 213 236 (See Pre- and Postvaccination Serologic Testing under Cautions.)
In those at frequent risk, perform serologic testing every 2 years and administer booster dose if necessary.208 212 213 236 (See Pre- and Postvaccination Serologic Testing under Cautions.)
Postexposure prophylaxis in previously unvaccinated individuals consists of active immunization with a series of 4 or 5 doses of rabies vaccine in conjunction with passive immunization with a single dose of RIG.208 213 234 236 250
Although the manufacturers recommend a 5-dose regimen of rabies vaccine in conjunction with RIG for postexposure prophylaxis in all previously unvaccinated individuals,208 234 the ACIP states that a 4-dose regimen of rabies vaccine in conjunction with RIG is sufficient for previously unvaccinated individuals who are immunocompetent and that a 5-dose vaccine regimen in conjunction with RIG should be used in those with altered immunocompetence.250
Immunocompetent children and adolescents: ACIP recommends first vaccine dose as soon as possible after exposure (day 0); give 3 remaining doses on days 3, 7, and 14, respectively, after first dose.250 Each dose consists of the entire contents (1 mL) of a reconstituted single-dose vial.208 234 236 250
Immunocompromised children and adolescents: ACIP recommends first vaccine dose as soon as possible after exposure (day 0); give 4 remaining doses on days 3, 7, 14, and 28, respectively, after first dose.250 Each dose consists of the entire contents (1 mL) of a reconstituted single-dose vial.208 234 236 250
Administer RIG dose preferably at the time of the first dose of rabies vaccine.208 213 234 236 250 If rabies vaccine is not immediately available, administer RIG dose and start the vaccine series as soon as possible.213 250 If RIG is not immediately available, it may be administered at any time through day 7 following the first vaccine dose.213 236 RIG is not necessary after day 7 since sufficient vaccine-induced rabies antibody will be present in most vaccine recipients.236 (See Specific Drugs under Interactions.)
Postexposure prophylaxis in previously vaccinated individuals consists of a series of 2 booster doses of rabies vaccine (without RIG).208 213 234 236 250
Each booster dose consists of the entire contents (1 mL) of a reconstituted single-dose vial.208 234 236 250
Give first dose as soon as possible after exposure (day 0); give second dose 3 days later.208 213 234 236 250
This 2-dose regimen can be used in those who previously received a preexposure or postexposure vaccination regimen with HDCV (Imovax), PCECV (RabAvert), Imovax Rabies I.D. (no longer commercially available in the US), or rabies vaccine adsorbed (RVA; no longer commercially available in the US) or those who previously received preexposure vaccination with some other vaccine and had documented levels of antirabies antibody considered adequate.208 213 234 236 250 (See Pre- and Postvaccination Serologic Testing under Cautions.)
Primary immunization consists of a series of 3 doses.208 213 234 236 Each dose consists of the entire contents (1 mL) of a reconstituted single-dose vial.208 234 236
Give first dose on a selected date; give second and third doses 7 and 21 (or 28) days, respectively, after first dose.208 213 234 236
Completion of the 3-dose primary series before an expected exposure to rabies virus ensures the highest level of protection.208 213 234 236
Serologic confirmation of rabies immunity following the 3-dose primary series is not necessary in most individuals.208 212 213 234 236 (See Pre- and Postvaccination Serologic Testing under Cautions.)
Duration of immunity following the recommended 3-dose primary series is ≥2 years.213 234 236 (See Duration of Immunity under Cautions.) Need for additional (booster) doses depends on the category of risk for rabies infection and levels of antirabies antibody.236 (See Booster Doses in Adults under Dosage and Administration.)
Each booster dose consists of the entire contents (1 mL) of a reconstituted single-dose vial.208 213 234 236
Give a booster dose if indicated to maintain adequate levels of antirabies antibody.208 213 234 236 Booster doses may be indicated in those at continuous or frequent risk of rabies, but not in those at infrequent or rare risk.208 213 234 236 (For ACIP definitions of risk categories and recommendations regarding preexposure vaccination for each category, see Table 1 under Uses.)
In those at continuous risk of rabies, perform serologic testing every 6 months and administer booster dose if necessary.208 212 213 236 (See Pre- and Postvaccination Serologic Testing under Cautions.)
In those at frequent risk, perform serologic testing every 2 years and administer booster dose if necessary.208 212 213 236 (See Pre- and Postvaccination Serologic Testing under Cautions.)
Postexposure prophylaxis in previously unvaccinated individuals consists of active immunization with a series of 4 or 5 doses of rabies vaccine in conjunction with passive immunization with a single dose of RIG.208 213 234 236 250
Although the manufacturers recommend a 5-dose regimen of rabies vaccine in conjunction with RIG for postexposure prophylaxis in all previously unvaccinated individuals,208 234 the ACIP states that a 4-dose regimen of rabies vaccine in conjunction with RIG is sufficient for previously unvaccinated individuals who are immunocompetent and that a 5-dose vaccine regimen in conjunction with RIG should be used in those with altered immunocompetence.250
Immunocompetent adults: ACIP recommends first vaccine dose as soon as possible after exposure (day 0); give 3 remaining doses on days 3, 7, and 14, respectively, after first dose.250 Each dose consists of the entire contents (1 mL) of a reconstituted single-dose vial.208 234 236 250
Immunocompromised adults: ACIP recommends first vaccine dose as soon as possible after exposure (day 0); give 4 remaining doses on days 3, 7, 14, and 28, respectively, after first dose.250 Each dose consists of the entire contents (1 mL) of a reconstituted single-dose vial.208 234 236 250
Administer RIG dose preferably at the time of the first dose of rabies vaccine.208 213 234 236 250 If rabies vaccine is not immediately
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