Medicine for the Outdoors
Medicine for the Outdoors

Dr. Paul Auerbach is the world's leading outdoor health expert. His blog offers tips on outdoor safety and advice on how to handle wilderness emergencies.

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Rabies Vaccine Shortage

The American College of Emergency Physicians has just alerted emergency physicians that because of a shortage of rabies vaccine, they need to obtain a confirmation code from their state health department before ordering doses of the vaccine for post-exposure prophylaxis.

Here is some information about rabies:

Rabies virus infection occurs more frequently in wild than in domestic animals. In some foreign countries where immunization of animals is infrequently practiced, the risk is great even in domesticated animals. The virus is carried in saliva and is transmitted by bite or lick (if the skin is broken). It has been transmitted by bats in caves either by aerosolized saliva or undetected bites. Raccoons, dogs, cats, foxes, coyotes, skunks, wolves, bats, woodchucks, and groundhogs are the most common carriers. Rabies has not been reported in bears. Although rabbits, hares, mice, squirrels, chipmunks, rats, guinea pigs, and ferrets may be rabid, they are rarely involved in the transmission of rabies to humans. Domestic animals such as cattle, horses, and sheep become infected in regions where skunk or raccoon rabies is found. In developing countries in Asia, Africa, and South and Central America, dogs are the most common carriers.

Animals with rabies show abnormal behavior. In the “furious” phase, they are hyperactive, may have a fever, are overtly aggressive, and salivate excessively. With “dumb” rabies, they appear tired, lack coordination, and may become paralyzed.

Because of rabies risk, all wild animal bites or scratches, and bites or scratches of unregistered or strangely behaving cats and dogs, should be reported to the appropriate public health authority. If the animal is a pet with otherwise normal behavior, it should be observed for 10 days. If the animal is rabid, it will become very ill or die during that time, and its brain tissue can be analyzed for the presence of rabies. If the animal is a pet with unusual behavior, or a captured high-risk wild animal, it should be killed and examined. If it is a high-risk animal and cannot be captured, it must be presumed to be rabid.

Immediately scrub an animal bite wound or a wound that has been licked by a potentially rabid animal vigorously with soap and water. If benzalkonium chloride 1% (Zephiran); 10% povidone iodine (Betadine) solution (less effective); or, in a pinch, Bactine (benzalkonium 0.13%) antiseptic is available, one of these should be used to irrigate and deeply swab the wound, since they may kill rabies virus.

The standard instructions in times of plentiful rabies vaccine supply are:

If rabies is a consideration, the victim should seek the assistance of a physician, who will determine the need for postexposure rabies vaccination (a series of five injections) and injection of antirabies serum (human rabies immune globulin; as much as possible is injected around the bite wound, and the remainder intramuscularly). A person who has been previously immunized against rabies still needs two booster doses of rabies vaccine after high-risk contact with a rabid animal. In countries (Africa, Asia) where rabies in very prevalent in dogs and cats, the vaccination status of the biting animal should be ignored, because the vaccination may not have occurred or may have been ineffective. Begin vaccination and then discontinue after 10 days if the animal is observed to remain healthy during that time period.

Preexposure vaccination against rabies should be administered to people at high risk of exposure (animal handlers, cavers, hunters, and trappers in rabies-endemic areas, along with travelers to certain foreign countries). This is given as a series of three intramuscular injections over 28 days, although a newer 1 week schedule for the injections appears to be quite effective. An intradermal regimen can be used for immunization, but this technique may result in lower antibody level.

The incubation period of rabies ranges from 9 days to more than 1 year, but is usually between 2 and 16 weeks. The first symptoms are fatigue, weakness, anxiety, irritability, fever, headache, nausea and vomiting, sore throat, abdominal pain, and loss of appetite. Some victims complain of numbness and tingling where they were initially bitten. After a few days to 2 weeks, the virus shows its devastating effect upon the nervous system, with symptoms of increased agitation, hyperactivity, seizures, hallucinations, uncontrollable behavior, and inability to drink (hydrophobia) due to muscle spasms in the throat. This constellation is called “furious rabies.” With “dumb” rabies, a person becomes progressively weak, uncoordinated, and paralyzed. Unfortunately, rabies is virtually always fatal, with the terminal events being one or more of coma, respiratory failure, seizures, abnormal heart rhythms, paralysis, and pneumonia.

To avoid rabies, be certain that all pets and livestock are properly vaccinated, do not feed or handle wild animals, do not feed or touch stray animals, avoid sick or strange-acting animals, keep garbage and food (including feed for animals) covered and away from wild animals, do not keep wild animals as pets, do not touch or pick up dead animals, and do not handle bats.

With the current vaccine shortage, the protocol for post-exposure vaccination has been modified. Complete details are found at the CDC website dedicated to information about rabies. To emphasize some of the information:

As of August 29, 2008, Sanofi Pasteur in coordination with the Centers for Disease Control and Prevention (CDC) will resume shipping IMOVAX® Rabies, Rabies Vaccine for post-exposure prophylaxis only. Novartis Vaccines will no longer be shipping supplies of RabAvert®.

For a physician to obtain IMOVAX rabies vaccine, he or she must first contact the appropriate Rabies State Health Official so that a risk-assessment can be conducted for the suspected exposure. If the Official determines that post-exposure prophylaxis is required, the inquiring physician will be provided with a pass code to place on the Sanofi Pasteur Rabies Post-Exposure Form. The form must be filled out in its entirety, including the required physician’s signature and pass code provided by the Rabies State Health Official. Sanofi Pasteur may be contacted at 1-800-VACCINE to obtain the required form.

Vaccine availability for pre-exposure vaccination continues to be limited, and will be distributed on approval from state and federal public health authorities for those first responders with a critical need and in consideration of available supplies. These measures will allow responsible management of currently limited supplies of this vaccine for individuals at highest risk of exposure.

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-to-late 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.

Persons at increased risk for rabies exposure should take appropriate precautions to avoid rabies exposure. Vaccine is available for pre-exposure prophylaxis, and providers should consult with their local or state public health department to ensure appropriate use of such prophylaxis. General rabies awareness and prevention messages should be emphasized to avoid exposure (e.g., avoid wildlife contact, vaccinate pets/livestock, capture/observe/test exposing animal, etc.).

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About the Author

Dr. Paul S. Auerbach is the world’s leading authority on wilderness medicine.