Imovax

Pre-exposure Rabies Prophylaxis Guide

• Administer IM in the deltoid for adults and older children, and the anterolateral aspect of the thigh may be preferable for infants and small children depending on age and body mass.

• Primary vaccination: 

• Give three 1.0mL doses of Imovax via one IM injection per day on Days 0, 7, and 21 or 28.

• Booster dose:

• Give one injection of 1.0mL of Imovax.

• Check titers periodically to ensure the presence of a primed immune response in persons at higher than normal risk for exposure.

• For persons who have experienced “immune complex-like” hypersensitivity reactions: do not give further doses of Imovax unless they are exposed to rabies or are truly likely to be apparently and/or unavoidably exposed to rabies and have unsatisfactory antibody titers.

• For immunosuppressed persons: postpone pre-exposure vaccinations and consider avoiding activities for which rabies pre-exposure prophylaxis is indicated. If unavoidable, immunosuppressed persons who are at risk for rabies should have their viral neutralizing antibody titers checked after completing the pre-exposure series.

Pre-exposure Rabies Prophylaxis Guide

• Risk category: Continuous. 

• Nature of risk: Virus present continuously and often in high concentrations. Specific exposures likely to go unrecognized. Bite, nonbite, or aerosol exposure.

• Typical populations: Rabies research laboratory workers; rabies biologics production workers.

• Pre-exposure recommendations: Primary course. Serologic testing every 6 months; booster vaccination if antibody titer is below acceptable level (minimum acceptable antibody level is complete virus neutralization at a 1:5 serum dilution by the rapid fluorescent focus inhibition test).

• Risk category: Frequent.

• Nature of risk: Exposure usually episodic, with source recognized, but exposure also might be unrecognized. Bite, nonbite, or aerosol exposure.

• Typical populations: Rabies diagnostic laboratory workers, cavers, veterinarians and staff, and animalcontrol and wildlife workers in areas where rabies is enzootic. All persons who frequently handle bats.

• Pre-exposure recommendations: Primary course. Serologic testing every 2 years; booster vaccination if antibody titer is below acceptable level (minimum acceptable antibody level is complete virus neutralization at a 1:5 serum dilution by the rapid fluorescent focus inhibition test).

• Risk category: Infrequent (greater than population at large).

• Nature of risk: Exposure nearly always episodic with source recognized. Bite or nonbite exposure.

• Typical populations: 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 including biologics is limited.

• Pre-exposure recommendations: Primary course. No serologic testing or booster vaccination.

• Risk category: Rare (population at large).

• Nature of risk: Exposure always episodic with source recognized. Bite or nonbite exposure.

• Typical populations: US population at large, including persons in areas where rabies is epizootic.

• Pre-exposure recommendations: No vaccination necessary.

Post-exposure Treatment

Post-exposure dosage for previously unimmunized persons

• Administer IM in the deltoid for adults and older children, and the anterolateral aspect of the thigh may be preferable for infants and small children depending on age and body mass.

• Give five IM doses of 1.0mL each of Imovax on Day 0 (immediately after exposure) and one dose at 3, 7, 14, and 28 days later.

• Administer rabies immune globulin (RIG) 20 IU/kg on Day 0 in conjunction with the first vaccine dose. If possible, administer the full dose of RIG to infiltrate the wound(s); if not possible, administer the remaining dose via IM at a different site from the site used to administer the vaccine.

Post-exposure dosage for previously immunized persons

• Administer IM in the deltoid for adults and older children, and the anterolateral aspect of the thigh may be preferable for infants and small children depending on age and body mass.

• For an immunized person who previously was vaccinated using the recommended pre-exposure regimen or a prior post-exposure regimen with a cell culture vaccine or who had previously demonstrated rabies antibody is exposed to rabies: 

• Give two IM doses of 1.0mL each of Imovax on Day 0 (immediately after exposure) and one dose 3 days later.

• Do not administer RIG to these patients.

• If the immune status of a previously vaccinated persons who did not receive the recommended HDCV regimen is not known, may need to administer the full primary post-exposure antirabies treatment (RIG plus 5 doses of HDCV).

• If antibody levels of greater than 1:5 dilution by a RFFIT can be reported in a serum sample collected before vaccine is given, discontinue treatment after at least 2 doses of HDCV.

Local Treatment of Wounds

• Thoroughly wash and flush all bite wounds and scratches immediately or as early as possible for about 15 minutes (if possible) with soap or a cleansing agent and copious amounts of water. If available, apply an iodine-containing, or similarly viricidal, topical preparation to the wound.

• Give as indicated tetanus prophylaxis and measures to control bacterial infection.

Specific Treatment

• Post-exposure antirabies vaccination should always include both passive antibody and vaccine, with the exception of persons who have every previously received complete vaccination regimens (pre-exposure or post-exposure) with a cell culture vaccine or persons who have been vaccinated with other types of vaccines and have previously had a documented rabies virus neutralizing antibody titer. Only administer the vaccine for post-exposure for a person previously vaccinated.

• The combination of RIG and vaccine is recommended for both bite and nonbite exposures reported by persons who have never been previously vaccinated for rabies, regardless of the interval between exposure and initiation of prophylaxis.

• If post-exposure prophylaxis has been initiated and appropriate laboratory diagnostic testing (ie, the direct fluorescent antibody test) indicates that the exposing animal was not rabid, post-exposure prophylaxis can be discontinued.

Treatment Outside the United States

• If post-exposure is begun outside the United States with locally produced biologics, it may be desirable to provide additional treatment when the patient reaches the US. State or local health departments should be contacted for specific advice in such cases.

Post-exposure Treatments Guide

• Animal type: Dogs, cats, and ferrets.

• Evaluation and disposition of animal: Healthy and available for 10 days observation. Rabid or suspected rabid. Unknown (eg, escaped).

• Post-exposure prophylaxis recommendations: Persons should not begin prophylaxis unless animal develops clinical signs of rabies. Immediately begin prophylaxis. Consult public health officials.

• Animal type: Skunks, raccoons, foxes, and most other carnivores. Bats.

• Evaluation and disposition of animal: Regard as rabid unless animal proven negative by laboratory tests.

• Post-exposure prophylaxis recommendations: Consider immediate prophylaxis.

• Animal type: Livestock, small rodents (rabbits and hares), large rodents (woodchucks and beavers), and other mammals.

• Evaluation and disposition of animal: Consider individually.

• Post-exposure prophylaxis recommendations: Consult public health officials. Bites from squirrels, hamsters, guinea pigs, gerbils, chipmunks, rats, mice, other small rodents, rabbits, and hares almost never require anti-rabies post-exposure prophylaxis.