Frequently Asked Questions about Rabies PEP

• 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 administered by weight of the patient (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 distal 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 the second (day 3) 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 from the time the series was resumed (i.e. the 3^rd 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.
  
  
• A person was bitten a year ago and now asks if rabies is a concern. Since the reported 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 usually referred to a hospital emergency department in order to begin the series. Hospital EDs should be contacted before referring your patient to ensure that RIG and rabies vaccine are in stock.
  
  
• Can primary care clinicians administer follow-up doses of rabies vaccine to their patients? Rabies vaccine in single dose vials is readily available from most pharmaceutical distributors who carry vaccines and can often be delivered overnight. In addition, the rabies vaccine RabAvert can be ordered directly from the manufacturer, Chiron at 1-800-244-7668. Other sources for rabies vaccine include five Safeway Pharmacies in King County (contact David Williams, Pharmacy Care Manager with Safeway, at 425-455-6417), and Public Health Travel Clinics (call ahead to ensure availability-Auburn 206-296-8414; Downtown 206-296-4960 or Northshore 206-296-9816). Please note: Public Health Travel Clinics are not currently able to bill insurance, so patients will have to pay for treatment.
  
  
• My patient’s insurance company does not cover routine vaccinations, and the cost of the vaccine is prohibitive for my patient. Where can I send them? 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. It may be necessary for the patient to obtain pre-approval from their insurance company.  Billing codes which may optimize reimbursement for rabies PEP include CPT^® code = 90675 (rabies vaccine, for intramuscular 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.  The bite wound should be cleaned well, and Td should be administered if the person has not received a tetanus booster within 5 years.

What other rabies resources are available?

• Rabies exposure assessment and rabies vaccine information for clinicians
  
  
• Decision Trees to Assess When a Person Needs Rabies Post-Exposure Prophylaxis
  
  
• Rabies Prevention in Washington State: A Guide for Practitioners

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