Rabies vaccine is a parenteral preparation of inactivated rabies virus used to promote active immunity to rabies in individuals exposed to the disease or virus. Prophylactic doses of rabies vaccine are administered to certain groups of people. Advantages of providing preexposure vaccination include reduced number of doses of the vaccine after a rabies exposure, elimination of need for human rabies immune globulin (RIG) postexposure, possible protection in persons whose postexposure therapy is delayed, and possible protection for persons at risk for inapparent exposures to rabies. Preexposure vaccine is recommended for individuals who are at high risk of exposure to the rabies virus (e.g., physicians, veterinarians, laboratory workers, animal handlers). Preexposure vaccination should also be considered for other persons whose activities involve frequent contact with rabies virus or potentially rabid bats, raccoons, skunks, cats, dogs, or other species at risk for having rabies. Additionally, preexposure vaccination should be evaluated for international travelers who are likely to come in contact with animals in areas where dog rabies is enzootic and immediate access to appropriate medical care, including biologics, might be limited. Postexposure vaccine should be accompanied with human rabies immune globulin (RIG) in all non-immunized individuals following exposure to a rabid animal. Prompt wound care and the administration of RIG plus the rabies vaccine are highly effective in preventing human rabies following exposure, when the recommended treatment protocol is maintained. However, rabies has occasionally developed among humans when key elements of the rabies postexposure prophylaxis regimens were omitted or incorrectly administered. The available vaccine products differ only in the cell culture used to develop the vaccine. Imovax uses human diploid cell (HDC) culture, and RabAvert uses purified chick embryo cell culture. Imovax was approved for use in the US in June 1980; RabAvert was approved for use in October 1997.
General Administration Information
For storage information, see the specific product information within the How Supplied section.
NOTE: According to U.S. federal laws, the health care provider must record in the patient's permanent record the manufacturer, lot number, administration date, and the name and address of the person administering the vaccine.
-Inform the patient, parent, guardian, or responsible adult of the benefits and risks of the vaccine. Provide the Vaccine Information Statements from the manufacturer to the patient, parent, or guardian before each immunization. The action is required by the National Childhood Vaccine Injury Act of 1986.
-If the rabies vaccine has been previously given, question the patient, parent, or guardian about any symptoms or signs of an adverse reaction.
-Complete a Vaccine Adverse Event Reporting System (VAERS) report form if adverse events have been identified. The reporting of events is required by the National Childhood Vaccine Injury Act of 1986. The toll-free number for VAERS is 1-800-822-7967. Also, report an adverse event to the manufacturer of the specific agent administered. Depending on the adverse reaction, a subsequent dose may be contraindicated.
-Health care professionals administering vaccines should take appropriate precautions to prevent allergic reactions in vaccine recipients. The health care professional should have immediate availability of epinephrine (1 mg/mL) injection and other agents used in the treatment of severe anaphylaxis in the event of a serious allergic reaction.
Route-Specific Administration
Injectable Administration
-Administer only via the intramuscular (IM) route; do not inject intravenously, subcutaneously, or intradermally.
-Visually inspect parenteral products for particulate matter and discoloration prior to administration. If either particulate matter or discoloration are present, discard the vaccine vial.-Imovax: The freeze-dried vaccine is creamy white to orange. After reconstitution, it is pink to red.
-RabAvert: The freeze-dried vaccine is white. After reconstitution, it is a clear or slightly opaque, colorless suspension.
-Do not mix rabies vaccine with any other vaccine or product in the same syringe.
Intramuscular Administration
Reconstitution (Imovax)
-Inspect syringe and package for leakage, premature plunger activation, or faulty tip seal before use.
-Screw the plunger rod into the syringe, if it is provided separately.
-Hold the syringe cap in one hand; avoid holding the plunger rod or syringe barrel. Unscrew the syringe tip cap by twisting it counterclockwise.
-Attach the reconstitution needle to the syringe by gently twisting the needle clockwise into the syringe until slight resistance is felt.
-Reconstitute the freeze-dried vaccine by injecting the diluent from the syringe into the vial. Gently swirl the contents of the vial until completely dissolved; the syringe and reconstitution needle should remain attached.
-Prior to withdrawing vial contents and without removing the reconstitution needle from the vial, unscrew the syringe to eliminate negative pressure.
-Reattach the syringe to the reconstitution needle which has remained in the vial.
-Withdraw the entire contents of the vial into the syringe.
-Remove and discard reconstitution needle; attach new needle suitable for intramuscular injection.
-Administer reconstituted vaccine immediately.
Reconstitution (RabAvert)
-The manufacturer supplies a vial of freeze-dried vaccine, a syringe containing 1 mL of sterile diluent, a long needle for reconstitution, and a shorter needle for administration.
-Using aseptic technique, attach the longer of 2 needles provided to the syringe containing the diluent.
-Slowly inject the diluent into the vaccine containing vial at a 45 degree angle. Gently mix until the vaccine has completely dissolved.
-Withdraw the total amount of the dissolved vaccine back into the syringe and replace the long needle with the shorter needle.
-Administer reconstituted vaccine immediately.
Intramuscular (IM) Injection
-Before administration, clean skin over the injection site with a suitable cleansing agent.
-The preferred administration site for adults and children is the deltoid muscle; infants and younger children should receive the injection into the midlateral muscles of the thigh. Do not inject into the gluteal area.
Health care providers are advised NOT to interrupt or discontinue rabies prophylaxis because of local or mild systemic adverse reactions. The manufacturer recommends managing mild adverse events with anti-inflammatory, antihistaminic, and antipyretic agents while continuing prophylaxis with the rabies vaccine.
Local injection site reactions are among the most commonly reported adverse events following administration of the rabies vaccine. During clinical trials, recipients of both Imovax (25%) and RabAvert (up to 45%) have reported symptoms associated with an injection site reaction. These symptoms included pain (up to 23%), erythema, induration, swelling, and pruritus at the injection site. If any of these reactions occur during prophylaxis with the rabies vaccine, health care providers are advised to consider treatment with anti-inflammatory and antipyretic agents.
During clinical trials, mild to moderate systemic adverse reactions were observed in individuals receiving prophylaxis with the rabies vaccine. These non-serious adverse events occurred in recipients of both Imovax and RabAvert and included flu-like symptoms such as abdominal pain, asthenia, chills, dizziness (10-15%), fatigue, fever, headache (20-52%), lymphadenopathy (15%), malaise (15-25%), monoarthritis, myalgia (38-53%), nausea, pain, mild rash (unspecified), sweating, and transient paresthesias. Health care providers are advised to consider treatment with anti-inflammatory, antihistaminic, and antipyretic agents if any of these reactions occur during prophylaxis with the rabies vaccine.
Serious, but quite rare, systemic neuroparalytic reactions occurring during administration pose a treatment dilemma for the treating healthcare provider. Such reactions include Guillain-Barre syndrome, meningitis, myelitis, multiple sclerosis, retrobulbar neuritis, and transient muscle paralysis have been associated with the use of both Imovax and RabAvert. Encephalitis resulting in death is a possible, but extremely rare, reaction. The administration of corticosteroids for these reactions carries the risk of inhibiting active immunity development. Use of the rabies vaccine should NOT automatically be stopped in patients who experience a serious systemic adverse reaction; health care providers are advised to consider the patient's risk of developing rabies prior to discontinuing the rabies vaccination series. The patient's serum should be tested for the development of rabies antibodies. Contact the state health department or the Centers for Disease Control (CDC) for advice and assistance on the management of serious rabies vaccine-associated adverse reactions.
Serious, but rare, systemic allergic and anaphylactoid reactions occurring during administration of rabies vaccine pose a treatment dilemma for the treating healthcare provider. Such reactions include angioedema, Type-III hypersensitivity reactions, bronchospasm, urticaria, pruritus and edema. The administration of corticosteroids for these reactions carries the risk of inhibiting active immunity development. Use of the rabies vaccine should NOT automatically be stopped in patients who experience a serious systemic adverse reaction; health care providers are advised to consider the patient's risk of developing rabies prior to discontinuing the rabies vaccination series. The patient's serum should be tested for the development of rabies antibodies. Contact the state health department or the Centers for Disease Control (CDC) for advice and assistance on the management of serious rabies vaccine-associated adverse reactions. Approximately 6% of persons receiving booster doses with the Imovax brand rabies vaccine have experience an immune complex-like reaction. These reactions are typically observed 2-21 days post-booster and present as generalized urticaria, arthralgia, arthritis, angioedema, and may be accompanied by symptoms such as fever, malaise, and nausea. According to the manufacturer, in no cases have the immune complex-like reactions been considered life-threatening, and the primary series is much less likely to cause immune-complex type events than is the booster dose. Consider use of RabAvert for subsequent booster doses or for postexposure prophylaxis in any person who has experienced an immune complex-like reaction after receiving Imovax.
Adverse events reported during post-marketing surveillance of RabAvert brand rabies vaccine include hot flashes, palpitations, vertigo, and visual impairment. Due to the uncontrolled nature of post-marketing reports, neither the frequency nor a definitive causal relationship to the vaccine can be established.
Presyncope and syncope have been reported postmarketing with rabies vaccine. Syncope can be accompanied by transient neurological signs such as visual disturbance, paresthesia, and tonic-clonic limb movements. Have procedures in place to avoid falling injury and to restore cerebral perfusion after syncope.
Use of the rabies vaccine for preexposure prophylaxis is contraindicated in persons with a history of anaphylaxis to the vaccine or any of the vaccine components; there are no contraindications to the use of the rabies vaccine for postexposure prophylaxis. Products involved in the manufacturing process of RabAvert include chicken fibroblasts, human albumin, bovine gelatin, and antibiotics (neomycin, amphotericin B, and chlortetracycline); therefore, administer RabAvert cautiously to individuals with albumin hypersensitivity, bovine protein hypersensitivity, egg hypersensitivity, and/or neomycin hypersensitivity. Imovax is harvested from infected human cells and thus is not processed with chicken fibroblasts or bovine gelatin; however, Imovax does contain albumin and neomycin and should be used with caution in neomycin or albumin allergic patients. Patients who have developed clinical symptoms of anaphylaxis, such as generalized urticaria, upper airway (lip, tongue, throat, laryngeal, or epiglottal) edema, laryngeal spasm or bronchospasm, hypotension, or shock, after exposure to egg or chicken protein, should only receive the vaccine by personnel with the capability and facilities to manage anaphylaxis post vaccination. As with any biologic product, the prescriber or health care professional should have procedures in place to manage allergic reactions. The healthcare professional should have immediate availability of epinephrine (1 mg/mL) injection and other agents used in the treatment of severe anaphylaxis in the event of a serious allergic reaction to the vaccine.
The rabies vaccine is only indicated for intramuscular administration; do not give via intravenous administration, intraarterial administration, or subcutaneous administration. Systemic adverse reactions, including shock, may occur if the rabies vaccine is accidentally administered intravascularly. Prior to administration, health care personnel should inform the patient, parent, guardian, or responsible adult of the vaccine's benefits and risks. This should include the provision of the vaccine information statement from the manufacturer. The patient or responsible adult should report any adverse reaction following vaccine administration to the health care provider. The US Department of Health and Human Services has established a Vaccine Adverse Event Reporting System (VAERS) to accept all reports of suspected adverse events after the administration of any vaccine. This includes, but is not limited to, the reporting of events required by the National Childhood Vaccine Injury Act of 1986. The toll-free number for VAERS is 800-822-7967.
RabAvert contains albumin, a derivative of human blood. The risk of transmitting infectious agents associated with the albumin formulated rabies vaccine is remote due to effective plasma donor screening for prior exposure to certain viruses, testing for the presence of viruses, and manufacturing processes designed to reduce the risk of transmitting viral infection. However, none of the processes are completely effective. There is also the possibility that unknown infectious agents may be present. A theoretical risk of the transmission of Creutzfeldt-Jakob disease (CJD) is also considered remote. No cases of transmission of viral infections or CJD have ever been identified from albumin.
Patients suffering significant immunosuppression may not have an adequate antibody response to the rabies vaccine. Immunosuppressed persons may include patients with asymptomatic or symptomatic human immunodeficiency virus (HIV) infection or acquired immunodeficiency syndrome (AIDS); severe combined immunodeficiency (SCID); hypogammaglobulinemia; agammaglobulinemia; altered immune states due to diseases such as generalized neoplastic disease; or an immune system compromised by corticosteroid therapy with greater than physiologic doses, alkylating drugs, antimetabolites, or radiation therapy. Short-term (< 2 weeks) corticosteroid therapy or intra-articular, bursal, or tendon injections with corticosteroids should not be immunosuppressive. Avoid use of immunosuppressive agents during postexposure prophylaxis if possible. If postexposure prophylaxis is initiated in an immunosuppressed person, serum antibody titers are recommended on treatment day 14 (day of the 4th vaccination). Preexposure prophylaxis should be given prior to initiation of immunosuppressive therapy or at least 3 months after therapy is discontinued if immune competence has been restored.
The rabies vaccine is indicated for intramuscular administration and, thus, should be given cautiously to persons receiving anticoagulant therapy. Also, patients with thrombocytopenia, coagulopathy (e.g., hemophilia), other bleeding disorders, or vitamin K deficiency should be monitored closely for bleeding at the IM injection site. All steps to avoid hematoma formation are recommended.
Cases of Guillain-Barre syndrome, as well as transient paralysis, neuritis, myelitis, and other neuroparalytic events have been reported during post-marketing use of the rabies vaccine; however, because of the uncontrolled nature of post-marketing reports, a definitive causal relationship to the vaccine cannot be established. Consider the risk to benefit ratio when deciding to vaccinate individuals with a history of Guillain-Barre; advice and assistance may be obtained from the state health department or the Centers for Disease Control (CDC). A patient's risk for developing rabies should be carefully considered before deciding to discontinue immunization.
There are no adequate, well controlled studies in pregnant humans; animal reproduction studies have not been conducted. It is not known if administration of the vaccine can cause fetal harm or affect the reproductive system. Rabies vaccine should be used during pregnancy only if the potential benefit to the mother justifies the potential risk to the fetus. Because of the potential consequences of inadequately treated rabies exposure, pregnancy is not considered a contraindication to postexposure prophylaxis. If the risk of exposure to rabies is substantial, preexposure prophylaxis might be indicated during pregnancy.
It is not known whether rabies vaccine is excreted in human breast milk; however, because of the potential consequences of inadequately treated rabies exposure, the manufacturer does not consider breast-feeding to be a contraindication for postexposure prophylaxis. Additionally, if the risk of exposure to rabies is substantial, preexposure vaccination might also be indicated during nursing. According to the Advisory Committee on Immunization Practices (ACIP), inactivated virus vaccines pose no risk to mothers or their infants. Consider the benefits of breast-feeding, the risk of potential infant drug exposure, and the risk of an untreated or inadequately treated condition. If a breast-feeding infant experiences an adverse effect related to a maternally administered drug, health care providers are encouraged to report the adverse effect to the FDA.
The safety and efficacy of Imovax and RabAvert have not been established in neonates. There is a single case report of one newborn treated with the vaccine post-exposure. Limited safety and efficacy data are available on the use of rabies vaccines in non-newborn infants for pre- and postexposure rabies prophylaxis. Pre-exposure use has been primarily limited to those infants living in select global areas where rabies is enzootic; treatment in infants is usually otherwise reserved for post-exposure use when necessary. The safety and efficacy of both vaccines have been established in children.
Injectable vaccines, including rabies vaccine, have been associated with episodes of syncope and fainting. These events may be accompanied by transient visual disturbance, paresthesia, and tonic-clonic limb movements. Prior to administration of the vaccine, ensure procedures are in place to prevent falls and restore cerebral perfusion.
For rabies prophylaxis:
-for preexposure immunization and booster doses for persons in risk category 1:
NOTE: Preexposure vaccination does not negate the need for postexposure treatment should a potential rabies exposure occur, it simply reduces the doses of treatment needed postexposure.
Intramuscular dosage:
Adults: Primary series of two 1 mL IM injections administered on days 0 and 7. Persons who have an elevated risk for unrecognized and recognized exposures including unusual or high-risk exposures to live rabies should have their serum antibody titers checked every 6 months and be given a booster dose if titers are less than 0.5 International Units/mL. This includes live rabies virus research laboratory workers, rabies biologics production workers, and those performing testing for rabies in diagnostic laboratories. The FDA-approved regimen is a primary series of three 1 mL IM injections administered on days 0, 7, and 21 or 28.
Infants, Children, and Adolescents: Primary series of two 1 mL IM injections administered on days 0 and 7. Persons who have an elevated risk for unrecognized and recognized exposures including unusual or high-risk exposures to live rabies should have their serum antibody titers checked every 6 months and be given a booster dose if titers are less than 0.5 International Units/mL. This includes live rabies virus research laboratory workers, rabies biologics production workers, and those performing testing for rabies in diagnostic laboratories. The FDA-approved regimen is a primary series of three 1 mL IM injections administered on days 0, 7, and 21 or 28.
-for preexposure immunization and booster doses for persons in risk category 2:
NOTE: Preexposure vaccination does not negate the need for postexposure treatment should a potential rabies exposure occur, it simply reduces the doses of treatment needed postexposure.
Intramuscular dosage:
Adults: Primary series of two 1 mL IM injections administered on days 0 and 7. Persons wo have an elevated risk for unrecognized and recognized exposures should have their serum checked for antibody titer every 2 years and be given a booster dose if titers are less than 0.5 International Units/mL. This incudes persons who frequently handle bats, have contact with bats, enter high-density bat environments, or perform animal necropsies. The FDA-approved regimen is a primary series of three 1 mL IM injections administered on days 0, 7, and 21 or 28.
Infants, Children, and Adolescents: Primary series of two 1 mL IM injections administered on days 0 and 7. Persons wo have an elevated risk for unrecognized and recognized exposures should have their serum checked for antibody titer every 2 years and be given a booster dose if titers are less than 0.5 International Units/mL. This incudes persons who frequently handle bats, have contact with bats, enter high-density bat environments, or perform animal necropsies. The FDA-approved regimen is a primary series of three 1 mL IM injections administered on days 0, 7, and 21 or 28.
-for preexposure immunization and booster doses for persons in risk category 3:
NOTE: Preexposure vaccination does not negate the need for postexposure treatment should a potential rabies exposure occur, it simply reduces the doses of treatment needed postexposure.
Intramuscular dosage:
Adults: Primary series of two 1 mL IM injections administered on days 0 and 7. Persons who have an elevated risk for recognized exposures and have sustained risk (more than 3 years after primary vaccination) should have their serum antibody titers checked once during years 1 to 3 after primary series (no sooner than day 21 and no later than 3 years after primary series) and be given a booster dose if titers are less than 0.5 International Units/mL. This includes veterinarians, technicians, animal control officers, students/trainees, persons who handle wildlife reservoir species, spelunkers, and selected high-risk travelers. The FDA-approved regimen is a primary series of three 1 mL IM injections administered on days 0, 7, and 21 or 28.
Infants, Children, and Adolescents: Primary series of two 1 mL IM injections administered on days 0 and 7. Persons who have an elevated risk for recognized exposures and have sustained risk (more than 3 years after primary vaccination) should have their serum antibody titers checked once during years 1 to 3 after primary series (no sooner than day 21 and no later than 3 years after primary series) and be given a booster dose if titers are less than 0.5 International Units/mL. This includes veterinarians, technicians, animal control officers, students/trainees, persons who handle wildlife reservoir species, spelunkers, and selected high-risk travelers. The FDA-approved regimen is a primary series of three 1 mL IM injections administered on days 0, 7, and 21 or 28.
-for preexposure immunization for persons in risk category 4:
NOTE: Preexposure vaccination does not negate the need for postexposure treatment should a potential rabies exposure occur, it simply reduces the doses of treatment needed postexposure.
Intramuscular dosage:
Adults: Primary series of two 1 mL IM injections administered on days 0 and 7. Persons who are at short-term elevated risk for recognized exposures do not require antibody titer testing or booster dosing. This includes veterinarians, technicians, animal control officers, students/trainees, and persons who handle wildlife reservoir species with 3 years or fewer hands on animal care as well as spelunkers and selected travelers with no expected high risk travel 3 years after primary preexposure vaccination. The FDA-approved regimen is a primary series of three 1 mL IM injections administered on days 0, 7, and 21 or 28.
Infants, Children, and Adolescents: Primary series of two 1 mL IM injections administered on days 0 and 7. Persons who are at short-term elevated risk for recognized exposures do not require antibody titer testing or booster dosing. This includes veterinarians, technicians, animal control officers, students/trainees, and persons who handle wildlife reservoir species with 3 years or fewer hands on animal care as well as spelunkers and selected travelers with no expected high risk travel 3 years after primary preexposure vaccination. The FDA-approved regimen is a primary series of three 1 mL IM injections administered on days 0, 7, and 21 or 28.
-for postexposure vaccination of previously unvaccinated immunocompetent persons:
Intramuscular dosage:
Adults: 4-dose series of 1 mL IM on days 0, 3, 7, and 14 in conjunction with RIG on day 0. If RIG is not immediately available at the start of therapy, RIG may be given through the seventh treatment day (i.e., 7 days or less after first vaccine dose). Previous recommendations of the ACIP, as well as the approved product labels, included a 5-dose regimen of 1 mL IM on days 0, 3, 7, 14, and 28.
Infants, Children, and Adolescents: 4-dose series of 1 mL IM on days 0, 3, 7, and 14 in conjunction with RIG on day 0. If RIG is not immediately available at the start of therapy, RIG may be given through the seventh treatment day (i.e., 7 days or less after first vaccine dose). Previous recommendations of the ACIP, as well as the approved product labels, included a 5-dose regimen of 1 mL IM on days 0, 3, 7, 14, and 28.
Neonates: Limited data are available in neonates. However, the data suggest that if needed for post-exposure prophylaxis in an emergent situation, a 1 mL IM dose, given as the traditional 5-dose series (days 0, 3, 7, 14, and 28) may be effective.
-for postexposure vaccination of previously unvaccinated persons with altered immunocompetence:
Intramuscular dosage:
Adults: 5-dose series of 1 mL IM on days 0, 3, 7, 14, and 28 in conjunction with RIG on day 0. If RIG is not immediately available at the start of therapy, RIG may be given through the seventh treatment day (i.e., 7 days or less after first vaccine dose).
Infants, Children, and Adolescents: 5-dose series of 1 mL IM on days 0, 3, 7, 14, and 28 in conjunction with RIG on day 0. If RIG is not immediately available at the start of therapy, RIG may be given through the seventh treatment day (i.e., 7 days or less after first vaccine dose).
-for postexposure vaccination of previously vaccinated persons:
NOTE: Previously vaccinated patients include those who received a complete vaccination series (pre- or postexposure prophylaxis) with a cell-culture vaccine or who previously had a documented adequate rabies virus-neutralizing antibody titer after vaccination with other types of vaccines. If the immune status of a previously vaccinated person is not known, the full post-exposure series is recommended; in such cases, if a protective serum titer (from a sample collected before vaccine administration) can be demonstrated, then the treatment can be discontinued after at least 2 doses.
Intramuscular dosage:
Adults: 1 mL IM on days 0 and 3; do NOT administer RIG.
Infants, Children, and Adolescents: 1 mL IM on days 0 and 3; do NOT administer RIG.
Maximum Dosage Limits:
-Adults
1 ml/dose IM.
-Geriatric
1 ml/dose IM.
-Adolescents
1 ml/dose IM.
-Children
1 ml/dose IM.
-Infants
1 ml/dose IM.
-Neonates
Limited data in newborns; 1 ml/dose IM.
Patients with Hepatic Impairment Dosing
No dosage adjustments are needed.
Patients with Renal Impairment Dosing
No dosage adjustments are needed.
*non-FDA-approved indication
Adalimumab: (Major) If administered concurrently, adalimumab can impair the immunologic response to the rabies vaccine, thereby, decreasing its protective effect. If possible, administration of immunosuppressive mediations, such as adalimumab, should be avoided during use of the rabies vaccine for postexposure prophylaxis. When immunosuppressive therapies must be administered to persons also receiving the rabies vaccine for postexposure prophylaxis, a serum rabies antibody titer should be obtained on day 14 (day of the 4th vaccination) to ensure an acceptable antibody response has been induced.
Albuterol; Budesonide: (Moderate) Patients receiving high-dose corticosteroid therapy may have a diminished response to vaccines. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 2 weeks after discontinuation. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving high-dose corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine.
Antimalarials: (Major) If administered concurrently, antimalarials can impair the immunologic response to the rabies vaccine, thereby, decreasing its protective effect. If possible, administration of antimalarials should be avoided during use of the rabies vaccine for postexposure prophylaxis. When antimalarials must be administered to persons also receiving the rabies vaccine for postexposure prophylaxis, a serum rabies antibody titer should be obtained on day 14 (day of the 4th vaccination) to ensure an acceptable antibody response has been induced.
Artemether; Lumefantrine: (Major) If administered concurrently, antimalarials can impair the immunologic response to the rabies vaccine, thereby, decreasing its protective effect. If possible, administration of antimalarials should be avoided during use of the rabies vaccine for postexposure prophylaxis. When antimalarials must be administered to persons also receiving the rabies vaccine for postexposure prophylaxis, a serum rabies antibody titer should be obtained on day 14 (day of the 4th vaccination) to ensure an acceptable antibody response has been induced.
Atovaquone: (Major) If administered concurrently, antimalarials can impair the immunologic response to the rabies vaccine, thereby, decreasing its protective effect. If possible, administration of antimalarials should be avoided during use of the rabies vaccine for postexposure prophylaxis. When antimalarials must be administered to persons also receiving the rabies vaccine for postexposure prophylaxis, a serum rabies antibody titer should be obtained on day 14 (day of the 4th vaccination) to ensure an acceptable antibody response has been induced.
Atovaquone; Proguanil: (Major) If administered concurrently, antimalarials can impair the immunologic response to the rabies vaccine, thereby, decreasing its protective effect. If possible, administration of antimalarials should be avoided during use of the rabies vaccine for postexposure prophylaxis. When antimalarials must be administered to persons also receiving the rabies vaccine for postexposure prophylaxis, a serum rabies antibody titer should be obtained on day 14 (day of the 4th vaccination) to ensure an acceptable antibody response has been induced.
Betamethasone: (Moderate) Patients receiving high-dose corticosteroid therapy may have a diminished response to vaccines. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 2 weeks after discontinuation. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving high-dose corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine.
Bimekizumab: (Moderate) Patients receiving immunosuppressant medications may have a diminished response to vaccines. When feasible, administer indicated vaccines at least two weeks prior to initiating immunosuppressant medications. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving immunosuppressant medications about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine.
Budesonide: (Moderate) Patients receiving high-dose corticosteroid therapy may have a diminished response to vaccines. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 2 weeks after discontinuation. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving high-dose corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine.
Budesonide; Formoterol: (Moderate) Patients receiving high-dose corticosteroid therapy may have a diminished response to vaccines. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 2 weeks after discontinuation. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving high-dose corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine.
Budesonide; Glycopyrrolate; Formoterol: (Moderate) Patients receiving high-dose corticosteroid therapy may have a diminished response to vaccines. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 2 weeks after discontinuation. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving high-dose corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine.
Chloroquine: (Major) If administered concurrently, antimalarials can impair the immunologic response to the rabies vaccine, thereby, decreasing its protective effect. If possible, administration of antimalarials should be avoided during use of the rabies vaccine for postexposure prophylaxis. When antimalarials must be administered to persons also receiving the rabies vaccine for postexposure prophylaxis, a serum rabies antibody titer should be obtained on day 14 (day of the 4th vaccination) to ensure an acceptable antibody response has been induced.
Corticosteroids (systemic): (Moderate) Patients receiving high-dose corticosteroid therapy may have a diminished response to vaccines. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 2 weeks after discontinuation. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving high-dose corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine.
Corticotropin, ACTH: (Moderate) Patients receiving high-dose corticosteroid therapy may have a diminished response to vaccines. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 2 weeks after discontinuation. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving high-dose corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine.
Cortisone: (Moderate) Patients receiving high-dose corticosteroid therapy may have a diminished response to vaccines. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 2 weeks after discontinuation. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving high-dose corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine.
Deflazacort: (Moderate) Patients receiving high-dose corticosteroid therapy may have a diminished response to vaccines. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 2 weeks after discontinuation. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving high-dose corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine.
Deucravacitinib: (Moderate) Patients receiving immunosuppressant medications may have a diminished vaccine response. When feasible, administer indicated vaccines at least two weeks prior to initiating immunosuppressant medications. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving immunosuppressant medications about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine.
Dexamethasone: (Moderate) Patients receiving high-dose corticosteroid therapy may have a diminished response to vaccines. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 2 weeks after discontinuation. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving high-dose corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine.
Elivaldogene Autotemcel: (Moderate) Patients receiving immunosuppressant medications may have a diminished response to non-live vaccines. When feasible, administer indicated vaccines at least six weeks prior to initiating immunosuppressant medications. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving immunosuppressant medications about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine.
Etanercept: (Major) Etanercept has not been found to act as a general immunosuppressant; however, the patient's underlying disease state may result in the immunosuppression of the patient, thereby, impairing the immunologic response to the rabies vaccine. If possible, administration of etanercept should be avoided during use of the rabies vaccine for postexposure prophylaxis. When etanercept must be administered to persons also receiving the rabies vaccine for postexposure prophylaxis, a serum rabies antibody titer should be obtained on day 14 (day of the 4th vaccination) to ensure an acceptable antibody response has been induced.
Hydrocortisone: (Moderate) Patients receiving high-dose corticosteroid therapy may have a diminished response to vaccines. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 2 weeks after discontinuation. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving high-dose corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine.
Hydroxychloroquine: (Major) If administered concurrently, antimalarials can impair the immunologic response to the rabies vaccine, thereby, decreasing its protective effect. If possible, administration of antimalarials should be avoided during use of the rabies vaccine for postexposure prophylaxis. When antimalarials must be administered to persons also receiving the rabies vaccine for postexposure prophylaxis, a serum rabies antibody titer should be obtained on day 14 (day of the 4th vaccination) to ensure an acceptable antibody response has been induced.
Mefloquine: (Major) If administered concurrently, antimalarials can impair the immunologic response to the rabies vaccine, thereby, decreasing its protective effect. If possible, administration of antimalarials should be avoided during use of the rabies vaccine for postexposure prophylaxis. When antimalarials must be administered to persons also receiving the rabies vaccine for postexposure prophylaxis, a serum rabies antibody titer should be obtained on day 14 (day of the 4th vaccination) to ensure an acceptable antibody response has been induced.
Methylprednisolone: (Moderate) Patients receiving high-dose corticosteroid therapy may have a diminished response to vaccines. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 2 weeks after discontinuation. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving high-dose corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine.
Ocrelizumab: (Moderate) Administer all non-live vaccines at least 2 weeks before ocrelizumab initiation, whenever possible. Ocrelizumab may interfere with the effectiveness of non-live virus vaccines. Attenuated antibody responses to tetanus toxoid-containing vaccine, pneumococcal polysaccharide and pneumococcal conjugate vaccines, and seasonal influenza vaccine were observed in patients exposed to ocrelizumab at the time of vaccination during an open-label study. Infants born to mothers exposed to ocrelizumab during pregnancy may receive non-live vaccines as indicated before B-cell recovery; however, consider assessing the immune response to the vaccine. ACIP recommends that patients receiving any vaccination during immunosuppressive therapy or in the 2 weeks prior to starting therapy should be considered unimmunized and should be revaccinated a minimum of 3 months after discontinuation of therapy. Passive immunoprophylaxis with immune globulins may be indicated for immunocompromised persons instead of, or in addition to, vaccination.
Ofatumumab: (Major) Administer all needed non-live vaccines according to immunization guidelines at least 2 weeks before initiation of ofatumumab. Ofatumumab may interfere with the effectiveness of inactivated vaccines due to its actions, which cause B-cell depletion.
Prednisolone: (Moderate) Patients receiving high-dose corticosteroid therapy may have a diminished response to vaccines. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 2 weeks after discontinuation. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving high-dose corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine.
Prednisone: (Moderate) Patients receiving high-dose corticosteroid therapy may have a diminished response to vaccines. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 2 weeks after discontinuation. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving high-dose corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine.
Primaquine: (Major) If administered concurrently, antimalarials can impair the immunologic response to the rabies vaccine, thereby, decreasing its protective effect. If possible, administration of antimalarials should be avoided during use of the rabies vaccine for postexposure prophylaxis. When antimalarials must be administered to persons also receiving the rabies vaccine for postexposure prophylaxis, a serum rabies antibody titer should be obtained on day 14 (day of the 4th vaccination) to ensure an acceptable antibody response has been induced.
Pyrimethamine: (Major) If administered concurrently, antimalarials can impair the immunologic response to the rabies vaccine, thereby, decreasing its protective effect. If possible, administration of antimalarials should be avoided during use of the rabies vaccine for postexposure prophylaxis. When antimalarials must be administered to persons also receiving the rabies vaccine for postexposure prophylaxis, a serum rabies antibody titer should be obtained on day 14 (day of the 4th vaccination) to ensure an acceptable antibody response has been induced.
Quinine: (Major) If administered concurrently, antimalarials can impair the immunologic response to the rabies vaccine, thereby, decreasing its protective effect. If possible, administration of antimalarials should be avoided during use of the rabies vaccine for postexposure prophylaxis. When antimalarials must be administered to persons also receiving the rabies vaccine for postexposure prophylaxis, a serum rabies antibody titer should be obtained on day 14 (day of the 4th vaccination) to ensure an acceptable antibody response has been induced.
Rabies Immune Globulin, human RIG: (Minor) The rabies immune globulin, human RIG may be administered concurrently with, and up to 8 days after the rabies vaccine. The RIG and the rabies vaccine must be administered via separate syringes and at different anatomical site. Avoid administering RIG if more than 7 days have elapsed since administration of the rabies vaccine as this may impair rabies vaccine-induced active immunity. Additionally, RIG doses greater than the recommended 20 International Units/kg and repeat RIG doses should also be avoided as these too may partially suppress active production of antibodies by the rabies vaccine.
Satralizumab: (Major) Administer all non-live vaccines according to immunization guidelines at least 2 weeks before initiation of satralizumab.
Siponimod: (Moderate) Administer all non-live vaccines at least 2 weeks before siponimod initiation, whenever possible. Vaccines may be less effective if given during siponimod treatment. Patients should be considered unimmunized if vaccinated within a 14-day period before starting immunosuppresive therapy or during immunosuppressive therapy, and should they be revaccinated at least 3 months after therapy is discontinued if immune competence is restored.
Sulfadiazine: (Major) If administered concurrently, antimalarials can impair the immunologic response to the rabies vaccine, thereby, decreasing its protective effect. If possible, administration of antimalarials should be avoided during use of the rabies vaccine for postexposure prophylaxis. When antimalarials must be administered to persons also receiving the rabies vaccine for postexposure prophylaxis, a serum rabies antibody titer should be obtained on day 14 (day of the 4th vaccination) to ensure an acceptable antibody response has been induced.
Tafenoquine: (Major) If administered concurrently, antimalarials can impair the immunologic response to the rabies vaccine, thereby, decreasing its protective effect. If possible, administration of antimalarials should be avoided during use of the rabies vaccine for postexposure prophylaxis. When antimalarials must be administered to persons also receiving the rabies vaccine for postexposure prophylaxis, a serum rabies antibody titer should be obtained on day 14 (day of the 4th vaccination) to ensure an acceptable antibody response has been induced.
Triamcinolone: (Moderate) Patients receiving high-dose corticosteroid therapy may have a diminished response to vaccines. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 2 weeks after discontinuation. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving high-dose corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine.
Ublituximab: (Moderate) Patients receiving immunosuppressant medications may have a diminished response to non-live vaccines. When feasible, administer indicated vaccines at least two weeks prior to initiating immunosuppressant medications. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving immunosuppressant medications about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine.
Vamorolone: (Moderate) Patients receiving high-dose corticosteroid therapy may have a diminished response to vaccines. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 2 weeks after discontinuation. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving high-dose corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine.
The rabies vaccine is manufactured from inactivated strains of the rabies virus. Each dose (1 ml) of the vaccines marketed in the US, ImoVax and RabAvert, contains at least 2.5 international units of rabies antigen. When administered intramuscularly, the rabies antigen induces production of specific neutralizing antibodies against the rabies virus, thereby providing active immunity. The active antibody response requires approximately 7 to 10 days to develop, and detectable rabies virus neutralizing antibodies generally persist for several years. Due to the delay in development of antibodies, post-exposure prophylaxis must include administration of Rabies Immune Globulin (see separate monograph).
The rabies vaccine is administered intramuscularly. Pre-exposure vaccination does not ensure immunity.
The Centers for Disease Control and Prevention (CDC) defines the minimum antibody titer acceptable for seroconversion as a 1:5 dilution (complete inhibition) by rapid fluorescent focus inhibition test (RFFIT); The World Heath Organization (WHO) recommends a titer of at least 0.5 international units/ml. Immunization with the rabies vaccine has been shown to achieve titers above these minimum concentrations within 14 days of initiating the postexposure prophylaxis series in all age groups. In US clinical trials, administering the rabies vaccine for preexposure prophylaxis has resulted in seroconversion (>= 0.5 international units/ml) in all patients by the end of the 28 day vaccination series. The duration of protection is undefined; therefore, persons with continued exposure to rabies should obtain serum titers every 6 months to 2 years (depending on exposure risk) to ensure acceptable antibody concentrations (see Indications).