THE CITY
Michael R. Bloomberg Mayor
OF
DEPARTMENT OF HEALTH AND MENTAL HYGIENE
NEW YORK
Thomas R. Frieden, M.D., M.P.H. Commissioner
_______________________________________________________________ nyc.gov/health
2008 Health Alert # 18 Shortage of Rabies Vaccine
Please Distribute to All Clinical Staff in Emergency Medicine, Pediatrics, Internal Medicine, Primary Care, Infectious Diseases, Family Medicine, Pharmacy, and Infection Control • • The existing rabies vaccine supply is limited. Several restrictions have been put in place by the two manufacturers of rabies vaccine, Novartis and sanofi pasteur. o Vaccination for pre-exposure prophylaxis is limited to persons in high risk professions (see details below), and is not available for travelers. o Vaccine for post-exposure prophylaxis is only available through sanofi pasteur, maker of Imovax®, and must be ordered on a case by case basis. o Novartis, maker of RabAvert®, will only make vaccine available for post exposure use in patients with severe allergic reactions to Imovax®. Providers should be sure to prescribe rabies post-exposure prophylaxis (PEP) only when indicated. Consult the Bureau of Communicable Disease (BCD, contact information below) if you have questions about whether PEP is indicated. Additional RabAvert® supplies should become available by July or August.
• •
July 1, 2008
Dear Colleagues, Rabies vaccine from sanofi pasteur (Imovax®) for post-exposure prophylaxis is currently available and can be ordered directly from the company. However, vaccine is only available on a case-by-case basis. Orders will be shipped within 24 hours, except on weekends. Each order will consist of five rabies vaccines which will be enough for an entire course of rabies post-exposure prophylaxis. Novartis has no RabAvert® vaccine available for either pre or post-exposure purposes, with certain exceptions (see below). As of May 19, sanofi pasteur announced that Imovax® would no longer be sold for preexposure prophylaxis use in order to maximize current supplies for post-exposure needs. In addition, Rabies vaccine for pre-exposure is not available at this time with the exception of persons engaged in high risk occupations, such as laboratorians working with live rabies virus (see below). If you have a patient with a high risk occupation and need assistance getting vaccine for pre-exposure purposes contact the BCD at 212-788-9830 during regular business hours. If you are having trouble getting rabies vaccine for post-exposure purposes,
contact the BCD during regular business hours; after hours and weekends, call the Poison Control Center at 212-764-7667. A summary of the impact of this vaccine shortage on the usual recommendations for use of rabies vaccine follows: a) Pre-exposure prophylaxis: Rabies vaccine for pre-exposure prophylaxis in the U.S. is temporarily difficult to obtain. Based upon requests and estimates provided by states and discussions with CDC, sanofi pasteur has started to offer for sale some rabies vaccine for pre-exposure prophylaxis of first responders and other workers considered at higher risk for rabies exposure. Arrangements have been made to make rabies vaccine (Imovax®) available on a limited basis for workers in the following order of priority who cannot delay vaccination until vaccine supplies for preexposure become available: 1. Lab personnel working with rabies virus, 2. Animal control officers, 3. Veterinary staff (including students and licensed veterinary technicians), and 4. Wildlife workers. Vaccine is not currently available for pre-exposure prophylaxis for travelers and other persons at risk (cavers, spelunkers etc.) whose activities involving possible exposure to rabies are voluntary, not critical and could be postponed or avoided. Vaccine is not available for a single booster of persons previously vaccinated with a less than adequate virus neutralizing titer (<1:5) as measured by rapid fluorescent focus inhibition test, with the exception of first responders. Vaccine doses will be prioritized on a case-by-case basis according to rabies exposure risk category and occupation type. When vaccine is available, these requests will be prioritized and filled based upon the occupation type until additional RabAvert® supplies become available. b) Post-exposure prophylaxis: Novartis (RabAvert®) has limited doses which are only available for post-exposure prophylaxis in patients with severe allergic reactions to Imovax®. Any requests for RabAvert® must be brought to the attention of the NYC DOHMH to request the vaccine. All other rabies vaccine requests for post-exposure prophylaxis should be directed to sanofi pasteur until additional RabAvert® supplies become available (July or August, according to the Centers for Disease Control and Prevention). Sanofi pasteur vaccine is currently available without any formal health department approval. Providers should consider consulting with the NYC DOHMH about the need for post-exposure prophylaxis first but this is not required. Providers can still order vaccine directly from the company on a case-bycase basis. Vaccine will be shipped typically within 24 hours (but may not be able to be sent on weekends) which may add a slight delay. Providers/hospitals may be able to reduce this delay by using any doses they have in stock (from other persons on the 5 dose schedule or from persons that discontinued the vaccine series) to start the Day 0 dose.
For guidance on the appropriate use of rabies biologics and local epidemiology of rabies in NYC, refer to either the: • • DOHMH’s City Health Information bulletin on “Rabies in New York City and Human Rabies Prevention” available online at http://www.nyc.gov/html/doh/downloads/pdf/chi/chi27-5.pdf National guidelines for rabies prevention, Human Rabies Prevention — United States, 2008 Recommendations of the Advisory Committee on Immunization Practices (ACIP), also available online at: http://www.nyc.gov/html/doh/downloads/pdf/cd/acip-mmwr2008.pdf.
The Bureau of Communicable Disease is available for consultation on rabies post-exposure prophylaxis by calling 212-788-9830 during regular business hours. After hours and on weekends call the NYC Poison Control Center at 212-764-7667. Updates on rabies vaccine availability will be posted on the CDC’s website at www.cdc.gov/rabies. Sincerely,
Sally Slavinski, DVM, MPH Dipl ACVPM, Public Health Veterinarian Bureau of Communicable Disease