Because of a recent decrease in human rabies vaccine supplies,¹ vaccine must now be ordered from the only current manufacturer on a case-by-case basis for each patient. This document contains updated information on ordering and administering rabies post-exposure prophylaxis (PEP). Of the two rabies vaccines distributed in the United States (RabAvert by Novartis, and Imovax by Sanofi Pasteur) only RabAvert is currently available from the manufacturer. Sanofi Pasteur reports that Imovax may become available again in late September or early October. Online information on rabies risk assessment and rabies PEP is listed at the bottom of the other side of this page.  Please review indications for rabies PEP to ensure that rabies vaccine is only used when truly indicated. Contact Public Health at 206-296-4774 to report possible rabies exposures and discuss the need for PEP.

Frequently asked questions on ordering rabies vaccine:

• Where do I get rabies vaccine for my patients? For human rabies PEP, rabies vaccine is available only from Novartis, the producer of RabAvert rabies vaccine. To obtain vaccine, health care providers may either (1) order vaccine from a wholesaler or distributor and have it drop-shipped directly to the clinic or hospital, or (2) order vaccine directly from Novartis.
• How do I order rabies vaccine from Novartis? Call Novartis 1-800-244-7668, option 2. A health department confirmation code is necessary to order vaccine. We recommend that you order the entire series of 5 doses at one time. Shipment will ordinarily require a few days. Because rabies PEP is a medical urgency and not an emergency, this delay should not represent an increased risk to most patients.
• What if my patient needs rabies vaccine urgently? Clinicians should inform Novartis of especially high risk exposures, including bites to the head, face and neck, and request expedited shipment in such cases.

Frequently asked questions on administering rabies PEP:

• What is Public Health’s role in rabies PEP? Public Health’s roles are to:
  • Ensure that health care providers and the public have up to date information on rabies and rabies PEP
  • Offer consultation to health care providers when assessing patients for rabies PEP
  • Conduct surveillance for animal bites and rabies PEP administration
  • Serve as a safety net by coordinating rabies PEP for patients who do not have access to health care
  • Ensure rabies PEP is administered appropriately based on current national guidelines - see 2008 recommendations on rabies prevention from the Advisory Committee on Immunization Practices (ACIP)
    
    
• What is the schedule for rabies PEP? In the US, rabies PEP consists of one dose of rabies immune globulin (RIG) and five doses of rabies vaccine over a 28-day period (in people who have never had rabies vaccine before). Rabies immune globulin and the first dose of rabies vaccine are given as soon as possible after exposure. Additional doses of rabies vaccine are given on days 3, 7, 14, and 28 after the first vaccination. RIG is dosed by patient weight (20 IU/kg) and should be infiltrated as much as possible at the site of exposure. The remaining volume should be given IM, at a location distant to the site of vaccine administration. Please note that administration of rabies PEP is reportable to Public Health within three working days by calling 206-296-4774.
  
  
• If a patient missed a dose of PEP, what should be done about subsequent doses? Rabies vaccine should be administered following the recommended schedule precisely. If a dose is missed, do not omit any doses. Resume the schedule maintaining the recommended intervals between doses (i.e. the 3rd dose would be four days after the missed dose is administered, not 7 days after the initial dose).
  
  
• What about patients bitten in other countries? In general, anyone bitten by a wild animal in a country where rabies is endemic should receive PEP.
  
  
• Is rabies still a concern for a patient bitten more than a year ago? Yes - because the documented incubation period for rabies ranges from 9 days to 7 years, all rabies exposures should receive PEP regardless of the time since the exposure.
  
  
• Where can my patient obtain the first dose of rabies vaccine and RIG? Many primary care sites (including Public Health clinics) do not normally carry RIG, therefore persons needing rabies PEP are often referred to a hospital emergency department. Before referring your patient, contact the hospital ED to inquire if RIG and rabies vaccine are in stock. Hospital EDs need to order rabies vaccine from Novartis for each patient requiring PEP. Therefore a hospital ED may not have vaccine in stock on the day of referral, and may require a patient to return for the first dose of vaccine after the ED receives it from the manufacturer. When you refer a patient to another facility for rabies PEP, clarify with that facility if you are requesting that it see the patient for part or all of the rabies vaccine series.
  
  
• Can primary care clinicians administer follow-up doses of rabies vaccine to their patients? Yes - physicians can order rabies vaccine for PEP for their patients directly from Novartis by calling 1-800-244-7668.
  
  
• What if my patient’s insurance company does not cover routine vaccinations? Because rabies vaccine when administered as PEP is a treatment for a disease exposure rather than a routine vaccination, it is often covered by medical insurance. Pre-approval from the patient’s insurance company may be necessary. Billing codes that have been used to obtain reimbursement for rabies PEP include CPT^® code = 90675 (rabies vaccine, for IM use), and ICD-9 code = V01.5 (contact with or exposure to communicable diseases, specifically rabies).
  
  
• What animals are generally not considered a concern for rabies in Washington State? Wild and pet rats, mice, squirrels, hamsters, gerbils, and rabbits.
  
  
• What other considerations besides rabies are there for animal bites? The bite wound should be cleaned well, and a tetanus-containing vaccine should be administered if the person has not received a tetanus booster within 5 years. Public Health recommends that when a tetanus containing vaccine is indicated, Tdap be used for persons 11 years and older who have not received Tdap previously.

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Rabies resources for health care professionals:

• Public Health rabies webpage for health care providers, including guidelines for clinical assessment and management of possible rabies exposures, reporting instructions, decision trees, and factsheets for patients.
  
  
• 2008 recommendations on rabies prevention from the Advisory Committee on Immunization Practices (ACIP).
  
  
• Rabies information from Washington State Department of Health (WA DOH) including statistics on animals and bats tested for rabies in Washington State between 1988 and 2007.