COMMONWEALTH of VIRGINIA
New River Health District
J. Henry Hershey, M.D., M.P.H.
Director
Headquarters Office
Floyd County Health Department
P.O. Box 157
Floyd, VA 24019
(540) 745-2141
FAX (540) 745-4929
Montgomery County Health Department
210 S. Pepper St., Suite A
Christiansburg, VA 24073
Giles County Health Department
120 North Main St.
Pearisburg, VA 24134
(540) 921-2891
FAX (540) 921-1335
Montgomery County Health Department
210 S. Pepper St., Suite A
Christiansburg, VA 24073
(540) 381-7100
FAX (540) 381-7104
Pulaski County Health Department
170 4th St, NW
Pulaski, VA 24301
(540) 994-5030
FAX (540) 994-5036
Radford City Health Department
212 Third Avenue
Radford, VA 24141
(540) 831-5774
FAX (540) 831-6109
MEMORANDUM
TO:
All Physicians and Group Practices, Nurse Practitioners, Physician Assistants, Hospital
Infection Control Nurses, Hospital Laboratory Directors, Head Nurses of Emergency
Rooms, Hospital CEOs/Administrators, Student Health Services, Edward Via Virginia
College of Osteopathic Medicine
FROM:
J. Henry Hershey, M.D., M.P.H., Director
DATE:
May 20, 2008
SUBJECT:
Rabies Biological Supply (IMOVAX)
Effective May 19, 2008, Sanofi Pasteur maker of IMOVAX Rabies (Rabies Vaccine) will,
temporarily, only be available for post-exposure prophylaxis (PEP). Sanofi Pasteur will continue to
supply their vaccine to health care providers to treat patients who have had documented rabies exposures.
Providers should consult local public health officials, as needed, with any questions regarding PEP.
These measures will allow responsible management of currently limited supplies of this vaccine. A letter
from the manufacturer explaining this change should have been released to you on Monday.
Novartis, the other supplier of rabies vaccine in the United States, currently has limited amounts of rabies
vaccine, RabAvert, which is available for postexposure prophylaxis use only. It is expected that
additional RabAvert will be available to the market by approximately July 2008. It is hoped that the
demand for pre-exposure vaccine supplies will be met at this time. Discussions among federal, state, and
local public health personnel are ongoing to review additional strategies to handle pre-exposure
vaccination needs (Pre-EP).
Pre-EP should be delayed until vaccine is available. It is expected that additional vaccine will be
available again approximately in July 2008. Persons at increased risk for rabies exposure should take
appropriate precautions to avoid rabies exposure (http://www.cdc.gov/rabies/exposure/).
I am attaching general rabies awareness and prevention messages (e.g., avoid wildlife contact, vaccinate
pets/livestock, etc.) for your use and to provide to your patients. Additionally, I am including
two other documents that might be helpful to you--(1) questions and answers on the current
vaccine supply issue and (2) the PEP vaccination section from the Virginia Guidelines for
Rabies
Prevention
and
Control.
The
complete
Guidelines
can
be
found
at:
http://www.vdh.virginia.gov/epidemiology/DEE/Rabies/vgrpc.htm.
As always, any questions regarding PEP should be directed to Reba Hite, RN, District Nurse
Epidemiologist, Paige Bordwine, District Epidemiologist, or me at 381-7100 ext. 196, ext. 152, or 156
respectively during normal business hours (8:00 a.m. - 4:30 p.m, M-F). After normal business hours, you
may direct emergency rabies questions through the New River Health District’s Emergency Event
Reporting System at 381-7100 ext.183 by leaving a message containing contact information, subject, and
a brief message. Public inquiries may be made to the Centers for Disease Control and Prevention at
1-800-CDC-INFO.
Attachments
GENERAL RABIES PREVENTION MESSAGES
Post-exposure prophylaxis:
 Post-exposure prophylaxis (PEP) is indicated for persons exposed to a rabid animal.
 Exposures include animal bites or mucous membrane contamination with infectious tissue or
fluids such as saliva. Blood, feces and urine do not contain the virus and are not infectious. (For
more information on types of exposures, see the 2008 ACIP Guidelines:
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr57e507a1.htm).
 PEP should begin as soon as possible after an exposure. Administration of rabies PEP is a
medical urgency, not a medical emergency. There have been no vaccine failures in the United
States (i.e., someone who developed rabies after vaccination) when PEP was given promptly and
appropriately after an exposure.
 Physicians should evaluate each possible exposure to rabies and, as necessary, consult with local
public health officials regarding the need for rabies PEP.
Post-exposure prophylaxis regimen:
 In the United States, PEP for previously unvaccinated persons consists of a regimen of one dose
of rabies immune globulin and five doses of rabies vaccine over a 28-day period.
 The immune globulin and first dose of vaccine should be given as soon as possible after
exposure.
 Additional doses of rabies vaccine should be given on days 3, 7, 14, and 28 after the first
vaccination.
 Current vaccines are relatively painless and are given in the arm, like an influenza or tetanus
vaccine.
Pre-exposure vaccination series:
 When available again for this purpose, pre-exposure vaccination should be offered to persons in
high-risk groups, such as rabies diagnostic workers, veterinarians, and animal handlers that work
in rabies enzootic areas,.
 When available again for this purpose, pre-exposure vaccination also should be considered for
other persons 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.
 The pre-exposure series consists of three doses of rabies vaccine administered on days 0, 7 and 21
or 28.
Messages for the general public on rabies prevention:
 All dogs, cats and ferrets should be vaccinated against rabies. Consider vaccinating valuable
livestock and horses. Animals that have frequent contact with humans should be vaccinated.
 Pet owners can reduce the possibility of pets being exposed to rabies by not letting them roam
free.
 Spaying or neutering your pet will prevent unwanted pregnancies and reduce contributions to dog
and cat overpopulation.
 Don’t feed or water your pets outside. Empty bowls can attract wild and stray animals.
 Keep your garbage securely covered. Open garbage will attract wild or stray animals.
 Wild animals should not be kept as pets.
 Enjoy all wild animals from a distance and teach children never to handle unfamiliar animals-even if they appear friendly.
 If you see a wild animal acting strangely, report it to city or county animal control officials.
 Bat-proof your home in the fall and winter.
 Contact your local or state health department for assistance with animal diagnostic testing and
medical advice.
New River Health District, May 20, 2008
GENERAL RABIES PREVENTION MESSAGES
(continued)
What to do when your pet bites someone:
 Contact your local health department or local animal control.
 A dog, cat or ferret that bites a human, needs to be examined by a licensed veterinarian
immediately.
 The local public health official may require monitoring the pet at home or at a veterinary clinic
for 10 days.
 Report any illness or unusual behavior by your pet to the local health department and to your
veterinarian immediately.
What to do when your pet gets bitten by another animal:



Consult your veterinarian immediately and have your veterinarian examine your pet and assess
your pet’s medical and vaccination needs.
Contact local animal control if the bite was from a stray or wild animal.
Monitor your pet at home or in a veterinary clinic for a specified time period by state law
or local ordinance (usually at least 45 days) if an unvaccinated or wild animal bit your
pet.
What to do if you are bitten by an animal:




Wash the wound thoroughly with soap and water for at least 15 minutes.
Contact your physician immediately.
Report the bite to your local health department and local animal control. If necessary, you will be
assessed for rabies post-exposure prophylaxis.
Prompt and appropriate action after being bitten and before the disease develops can stop rabies
infection and prevent the disease.
Useful Websites:
CDC Rabies Website:
www.cdc.gov/rabies
2008 ACIP Human Rabies Prevention:
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr57e507a1.htm or
http://www.cdc.gov/mmwr/pdf/rr/rr57e507.pdf
NASPHV Compendium of Animal Rabies Control and Prevention:
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5702a1.htm or
http://www.cdc.gov/mmwr/pdf/rr/rr5702.pdf
New River Health District, May 20, 2008
RABIES BIOLOGICAL SUPPLY
Questions and Answers
Why is there an interruption in supply?
Starting in June 2007, Sanofi Pasteur began renovating its IMOVAX Rabies vaccine production facility in
France to maintain compliance with the most current requirements from FDA and the French regulatory
body. Prior to these renovations, Sanofi Pasteur established an inventory based on historical levels of
sales and projected market demand. The facility is scheduled to be approved and operational by mid-tolate 2009. Until the facility is operational, Sanofi Pasteur has a finite amount of IMOVAX Rabies
vaccine. After the renovations began, Novartis, the other supplier of rabies vaccine for the United States,
was unable to meet projected rabies vaccine supplies. Since early 2008, Novartis has been supplying its
rabies vaccine, RabAvert, for post-exposure use only. Consequently, Sanofi Pasteur has been supplying
nearly all of the market for rabies vaccine. The increase in demand for IMOVAX is outpacing the
company’s historical levels of supply.
How long will vaccine for pre-exposure prophylaxis (Pre-EP) not be available?
We are unsure how long rabies Pre-EP will not be available. We are hopeful that supplies will begin to
improve in approximately July 2008.
What do I do for someone that is in the middle of a Pre-EP regimen?
Pre-EP should only begin only if adequate supply of vaccine is available. If it has already begun, it would
be better to complete the Pre-EP regimen; however, additional stocks may not be released for this
purpose. Completion of the regimen will have to be done using already purchased stocks. If this is not
possible, the Pre-EP should be discontinued, and the person considered as non-vaccinated. If needed, the
Pre-EP course in such persons should be restarted when the adequate vaccine supply for Pre-EP is
available.
Will vaccine be available for persons that had Pre-EP and now have a low titer?
No. No additional stocks of rabies vaccine will be released for Pre-EP usage. Persons at increased risk
for rabies exposure should take appropriate precautions to avoid rabies exposure. Individuals who are
concerned about their titer should request a rapid fluorescent focus inhibition test (RFFIT) (used by ACIP
as an indicator of an adequate adaptive immune response).
Does this change affect all risk groups for Pre-EP or just the lower risk group (i.e.,
infrequent or travelers)?
Yes, this change affects all risk groups. Individuals who are traveling should limit travel to high rabies
risk areas unless otherwise necessary. Travelers should be aware of anti-rabies vaccination options in that
country in case exposure is likely.
How does this affect providers that purchase/provide rabies vaccine?
Sanofi does not have any vaccine for stockpiles; therefore, the provider will have to call and place an
order for each patient that needs PEP. Sanofi will fax the attending physician a form that must be
completed and returned before the vaccine can be sent. (The signed form is for tracking purposes.) The
vaccine will then be shipped in 24 hours. Rabies vaccine that providers presently have in stock can be
used for pre-exposure if desired. However, at the current time, providers that purchase vaccine directly
will only be able to purchase it for PPE usage.
New River Health District, May 20, 2008
Virginia Department of Health. Virginia Guidelines for Rabies Prevention and Control, August 2006, pages 11-12.