day without work [150:<1 mcg of neomycin and trace amounts of chlortetracycline (> <20 ng) and amphotericin B (> <2 ng). 234 Use caution in individuals sensitive to these antibiotics. 234 Weigh possibility of an allergic reaction against the potential risk of contracting rabies if the vaccine is not given. 208 234 Neomycin allergy usually results in delayed-type (cell-mediated) hypersensitivity reactions manifested as contact dermatitis. 211 ACIP and AAP state that vaccines containing trace amounts of neomycin should not be used in individuals with a history of anaphylactic reaction to neomycin, but use of such vaccines may be considered in those with a history of delayed-type neomycin hypersensitivity if benefits of vaccination outweigh the risks. 211 213 Gelatin Allergy PCECV (RabAvert ) contains> <12 mg of polygeline (bovine gelatin). 234 Consider possibility of allergic reactions in individuals sensitive to bovine gelatin. 211 234 Bovine components of the vaccine originate only in the US, Australia, and New Zealand. 234 Allergy to Egg-related Antigens PCECV (RabAvert ) is produced in chick embryo cell culture and may contain minimal amounts of chicken protein. 234 HDCV (Imovax ) is produced in human diploid cells and does not contain chicken protein. 208 Consider possibility that an allergic reaction may occur if PCECV (RabAvert ) is used in individuals allergic to chicken protein. 234 Safety data regarding use of PCECV (RabAvert ) in individuals with egg allergy not available. 234 Experience with other vaccines produced using primary cultures of chick embryo fibroblasts indicate that documented egg hypersensitivity does not necessarily predict an increased likelihood of adverse reactions. 234 No evidence to date that individuals with allergies to chickens or feathers are at increased risk of reaction to vaccines produced in chick embryo fibroblasts. 234 General Precautions Local or Systemic Adverse Effects Once initiated, postexposure prophylaxis for rabies should not be interrupted or discontinued because of local or mild systemic adverse reactions to rabies vaccine. 208 234 236 These reactions generally can be managed with NSAIAs or antipyretic agents (e.g., ibuprofen, acetaminophen). 208 234 236 Serious systemic, anaphylactic, or neuroparalytic reactions pose a therapeutic dilemma. 208 236 Contact state health departments or CDC for advice and assistance regarding management of these individuals. 208 236 Limitations of Vaccine Effectiveness May not protect all vaccine recipients against rabies. 234 May not prevent rabies in individuals who do not achieve adequate antibody titers. 234 236 (For information on adequate antibody titers, see Pre- and Postvaccination Serologic Testing under Cautions.) Duration of Immunity Duration of immunity following the recommended 3-dose preexposure vaccine series (primary immunization) of HDCV (Imovax ) or PCECV (RabAvert ) is 2 years. 213 234 236 Need for additional (booster) doses after primary immunization depends on the nature and category of risk associated with the potential exposure. 236 (See Booster Doses in Children and Adolescents and also see Booster Doses in Adults under Dosage and Administration) Concomitant Illness A decision to administer or delay vaccination in an individual with current or recent febrile illness depends on the severity of symptoms and etiology of the illness. 211 ACIP states that minor acute illness, such as mild diarrhea or mild upper respiratory tract infection (with or without fever) generally does not preclude vaccination. 211 212 213 The manufacturers and ACIP state that preexposure rabies vaccination (but not postexposure prophylaxis) with HDCV (Imovax ) or PCECV (RabAvert ) generally should be deferred in individuals with moderate or severe acute illness until improvement of the condition is noted. 208 211 234 Individuals with Bleeding Disorders Because bleeding may occur following IM administration in individuals with thrombocytopenia or a bleeding disorder (e.g., hemophilia) or in those receiving anticoagulant therapy, use caution in such individuals. 211 ACIP states that vaccines may be given IM to individuals who have bleeding disorders or are receiving anticoagulant therapy if a clinician familiar with the patient's bleeding risk determines that the vaccine can be administered with reasonable safety. 211 In these cases, use a fine needle (23 gauge) to administer the vaccine and apply firm pressure to the injection site (without rubbing) for 2 minutes. 211 If patient is receiving antihemophilia therapy, administer the IM vaccine shortly after a scheduled dose of such therapy. 211 Advise the individual and/or their family about the risk of hematoma from IM injections. 211 Pre- and Postvaccination Serologic Testing If serologic testing for serum antirabies antibody is performed 1 2 weeks after preexposure vaccination or postexposure prophylaxis, ACIP defines an adequate antibody response as complete virus neutralization at a 1:5 serum dilution when determined by rapid fluorescent-focus inhibition test (RFFIT). 236 250 WHO states that an antirabies antibody titer of 0.5 international units/mL can be considered protective. 249 Serologic confirmation of rabies immunity following preexposure vaccination (3-dose primary series) is not necessary in most individuals because of the high rate of response in immunocompetent adults, adolescents, and children when the recommended vaccine regimen is used. 208 212 213 234 236 Postvaccination serologic testing may be particularly important in immunocompromised individuals who receive preexposure vaccination since these individuals may have impaired immune response to vaccination. 208 213 234 236 Manage individuals who fail to seroconvert after the third vaccine dose in the primary series in consultation with appropriate public health officials. 236 (See Individuals with Altered Immunocompetence under Cautions.) To determine the need for preexposure booster doses of rabies vaccine in individuals who received preexposure vaccination with a primary vaccine series, serum antirabies antibody titers should be measured every 6 months in those at continuous risk of rabies exposure and every 2 years for those at frequent risk of rabies exposure. 208 212 213 236 (For ACIP definitions of risk categories and recommendations regarding preexposure vaccination for each category, see Table 1 under Uses.) Serologic testing is not indicated prior to postexposure prophylaxis in previously vaccinated individuals who are exposed to rabies. 236 Such testing is inappropriate because it would delay postexposure prophylaxis and, although antirabies neutralizing antibodies are an important component of immunity, other immune effectors also play a role in disease prevention. 236 Serologic confirmation of rabies immunity following postexposure prophylaxis is not necessary in most individuals because of the high rate of vaccine response among immunocompetent adults, adolescents, and children when the recommended rabies postexposure prophylaxis regimen is used (i.e., proper wound care followed by a single dose of RIG and a 4- or 5-dose regimen of a cell culture-derived rabies vaccine). 208 212 213 236 When postexposure prophylaxis against rabies is indicated in an immunocompromised individual, serologic testing is considered essential after completion of the postexposure prophylaxis regimen to confirm that an adequate antibody response was obtained. 208 213 234 236 This includes individuals receiving immunosuppressive agents (e.g., those receiving corticosteroids for the treatment of life-threatening neuroparalytic reactions to rabies vaccine). 236 (See Individuals with Altered Immunocompetence under Cautions.) Consider serologic testing to confirm that an adequate antibody response was obtained in travelers who received rabies postexposure prophylaxis with regimens and/or preparations not currently recommended by ACIP. 236 (See Postexposure Prophylaxis of Rabies under Uses.) Improper Storage and Handling Improper storage or handling of vaccines may result in loss of vaccine potency and reduced immune response in vaccinees. 211 Do not administer HDCV (Imovax ) or PCECV (RabAvert ) that has been mishandled or has not been stored at the recommended temperature. 211 (See Storage under Stability.) Inspect all vaccines upon delivery and monitor during storage to ensure that the appropriate temperature is maintained. 211 If there are concerns about mishandling, contact the manufacturer or state or local health departments for guidance on whether the vaccine is usable. 211 Specific Populations Pregnancy Category C. 208 234 Manufacturers state that HDCV (Imovax ) and PCECV (RabAvert ) should be given to pregnant women only if clearly needed. 208 234 However, ACIP, CDC, AAP, American College of Obstetricians and Gynecologists (ACOG), and the manufacturers state that pregnancy is not considered a contraindication for postexposure prophylaxis with rabies vaccine because of the potential risks of inadequately treated rabies exposure and because there is no evidence of an association between fetal abnormalities and rabies vaccine. 204 208 212 213 234 236 ACOG recommends that each pregnant woman be considered individually and that public health authorities be consulted. 204 Preexposure vaccination may also be indicated during pregnancy when a substantial risk of rabies exposure is present. 208 236 Lactation Not known whether antigens contained in rabies vaccine are distributed into milk. 234 CDC states that use of rabies vaccine in nursing women should follow the same guidelines as other adults. 212 Because inactivated vaccines do not multiply within the body, the ACIP states that they should not pose any unusual problems for nursing women or their infants. 211 PCECV (RabAvert ): Manufacturer states nursing is not considered a contraindication when the vaccine is indicated for postexposure prophylaxis because of the possible risks of inadequately treated rabies exposure. 234 In addition, use of the vaccine for preexposure vaccination may be indicated in nursing women when a substantial risk of rabies exposure is present. 234 Pediatric Use HDCV (Imovax ): Safety and efficacy in children established. 208 PCECV (RabAvert ): Limited data available regarding safety and efficacy in children. 234 Used effectively for preexposure vaccination in children 2 years of age and for postexposure prophylaxis in children 1 year of age. 234 Children are at higher risk of rabies exposure compared with adults because of increased potential for animal contact and because they are more likely to be bitten on the head, face, and neck leading to more severe injuries. 212 213 237 249 ACIP, CDC, AAP, and the manufacturers recommend that postexposure prophylaxis in children follow the same guidelines as in adults. 208 212 213 234 236 Geriatric Use PCECV (RabAvert ): Insufficient experience in patients 65 years of age to determine whether geriatric patients respond differently to the vaccine than younger adults. 234 Clinical experience with PCECV (RabAvert ) reveals that there are no overall differences in safety between geriatric and younger individuals. 234 Common Adverse Effects HDCV (Imovax ): Local effects at injection site (pain, swelling, erythema, itching), mild systemic reactions (headache, nausea, abdominal pain, muscle aches, dizziness). 208 PCECV (RabAvert ): Local effects at injection site (pain, swelling, erythema, itching), influenza-like symptoms (mild to moderate asthenia, fatigue, fever, myalgia, malaise, headache). 234 Interactions for Rabies Vaccine Other Vaccines HDCV (Imovax ) and PCECV (RabAvert ) rabies vaccines are inactivated viral vaccines; interactions with other inactivated vaccines, live virus vaccines, recombinant vaccines, or toxoids are unlikely. 211 213 Inactivated vaccines can be administered either simultaneously with or at any time before or after inactivated or live vaccines. 211 213 However, each vaccine should be administered using a different syringe and a different injection site. 211 213 Specific Drugs Drug Interaction Comments Immunosuppressive agents (e.g., alkylating agents, antimetabolites, corticosteroids, radiation) Potential for decreased antibody response to rabies vaccine; concomitant administration may predispose patient to rabies infection 208 212 213 233 234 236 Postpone preexposure vaccination and consider avoiding activities for which vaccination is indicated; 212 236 250 if not possible, serologic testing should be performed after preexposure vaccination to document seroconversion 236 250 (see Pre- and Postvaccination Serologic Testing under Cautions) Avoid immunosuppressive therapy during rabies postexposure prophylaxis unless considered essential for treatment of other serious conditions 208 233 234 236 250 If rabies postexposure prophylaxis is indicated in a previously unvaccinated individual receiving immunosuppressive therapy that cannot be discontinued, ACIP states that a 5-dose series (not a 4-dose series) of HDCV (Imovax ) or PCECV (RabAvert ) should be used 250 (see Postexposure Prophylaxis or Rabies under Uses) If rabies postexposure prophylaxis is used in individuals receiving immunosuppressive agents or when corticosteroids are used to treat life-threatening neuroparalytic reactions to rabies vaccine, perform serologic testing for rabies antibody after completion of the regimen to ensure adequate immune response 208 233 234 236 250 (see Pre- and Postvaccination Serologic Testing under Cautions) Rabies immune globulin (RIG) Passively acquired antibody to rabies antigen, which is present in RIG, may partially suppress the active immune response to rabies vaccine; 213 234 236 250 there is evidence that a single RIG dose of 20 international units/kg given at the same time as the first dose of rabies vaccine provides maximum circulating antirabies antibody with minimal interference with the active immune response to the vaccine 246 Neutralization of rabies vaccine may occur if RIG and the vaccine are mixed in the same syringe or administered into the same injection site 211 213 236 If rabies postexposure prophylaxis requires active immunization with rabies vaccine and passive immunization with RIG, a single dose of RIG should be administered simultaneously with the first vaccine dose; 208 213 234 236 250 infiltrate the full RIG dose around the wound(s) if anatomically feasible and administer any remaining portion of the RIG dose IM (using a different syringe and different injection site than rabies vaccine) 213 234 236 250 To minimize potential suppression of the active immune response to the vaccine, do not give single doses of RIG> 20 international units/kg or repeated RIG doses 213 234 236 250 RIG may be administered simultaneously with or through day 7 after the first dose of rabies vaccine without impairing the active immune response to the vaccine 213 234 236 250 RIG is not indicated for postexposure prophylaxis in individuals who previously received recommended preexposure or postexposure regimens of HDCV (Imovax ), PCECV (RabAvert ), Imovax Rabies I.D. (no longer commercially available in the US), or rabies vaccine adsorbed (RVA) (no longer commercially available in the US) or in those who previously received other rabies vaccines and have documented adequate antirabies antibody titers 213 236 250 Stability Storage Parenteral Suspension for IM Injection HDCV (Imovax ): Prior to reconstitution, 2 8 C; avoid freezing. 208 PCECV (RabAvert ): Prior to reconstitution, 2 8 C; protect from light. 234 Must be used immediately after reconstitution; discard if not used immediately. 208 234 HDCV (Imovax ) and PCECV (RabAvert ) do not contain thimerosal or any other preservatives. 208 234 Actions Rabies vaccine is a sterile, freeze-dried vaccine containing inactivated rabies virus antigen ( 2.5 international units/mL). 208 234 Commercially available as human diploid-cell rabies vaccine (HDCV; Imovax ) or purified chick embryo cell culture rabies vaccine (PCECV; RabAvert ). 208 234 HDCV (Imovax ) contains antigen prepared from the Wistar Institute Pitman-Moore strain (PM-1503-3M) of rabies virus propagated in MRC-5 strain of human diploid-cell tissue culture. 208 PCECV (RabAvert ) contains antigens prepared from the fixed-virus strain Flury low egg passage (LEP) of rabies virus propagated in primary cultures of chicken fibroblasts. 234 Stimulates active immunity to rabies by inducing production of antirabies neutralizing antibodies. 208 213 234 236 Antirabies antibodies neutralize rabies virus and are believed to have a primary role in preventing rabies infection. 236 HDCV (Imovax ) and PCECV (RabAvert ) are highly immunogenic in immunocompetent children, adolescents, and adults. 208 234 236 When administered according to the recommended preexposure immunization schedule in clinical studies, 100% of vaccinees achieved protective levels of antirabies antibody. 208 234 Following IM administration of rabies vaccine, antirabies antibody levels are detectable in serum within 7 10 days and persist for several years. 236 Development of immunity and protection from rabies infection are evaluated by appearance of antirabies antibody in serum. 236 Minimum titers of antirabies antibodies indicating protection against rabies have not been definitely established to date (varies among laboratories and by type of test performed). 236 ACIP considers antirabies antibody titers 1:5 as determined by RFFIT to be indicative of an adequate response to rabies immunization. 236 250 WHO states that an antirabies antibody titer of 0.5 international units/mL can be considered protective. 249 Following rabies exposure and inoculation, the virus remains close to the wound for an indeterminate time and can be partially neutralized with RIG while at this site. 213 In susceptible individuals, the virus is transported to the CNS via the peripheral nerves. 249 Following entrance into the CNS, the virus is unlikely to be affected by antirabies antibodies and a fatal encephalomyelitis almost always develops. 234 249 Incubation period for rabies infection in humans can range from days to years (usually 1 3 months). 212 213 234 236 250 After severe bites to the face, neck, or arms, the incubation period may be as short as 10 days. 246 Common prodromal symptoms of rabies infection include malaise, anorexia, fatigue, headache, and fever followed by pain or paresthesia at the site of exposure. 234 249 Anxiety, agitation, and irritability may also occur during the prodromal stage followed by hyperactivity, disorientation, seizures, aerophobia, hydrophobia, hypersalivation, and eventually paralysis, coma, and death. 212 213 234 249 Following appearance of clinical symptoms of rabies, use of rabies vaccine or RIG will not improve the prognosis and may be detrimental; there is no specific proven effective treatment for rabies once symptoms develop. 212 213 236 249 There have been no cases of rabies in the US in previously unvaccinated individuals who received the recommended postexposure prophylaxis regimen (i.e., proper wound care followed by a single dose of RIG and a 4- or 5-dose regimen of HDCV [Imovax ] or PCECV [RabAvert ] rabies vaccine). 236 246 250 Advice to Patients Prior to administration of each vaccine dose, provide a copy of the appropriate CDC Vaccine Information Statement (VIS) to the patient or patient's legal representative as required by the National Childhood Vaccine Injury Act (VISs are available at ). 244 Advise the patient and/or patient's parent or guardian of the risks and benefits of vaccination with rabies vaccine. 208 234 Advise the patient and/or patient's parent or guardian that rabies vaccine is used to prevent rabies and is given to persons at high risk of exposure to rabies as a result of employment, travel, or hobbies (e.g., certain laboratory workers, veterinarians, animal control and wildlife workers, spelunkers, hunters). 208 234 Advise the patient and/or patient's parent or guardian that rabies vaccine is also used to prevent rabies in individuals who have been bitten, scratched, or licked on an open wound by an animal known or suspected of having rabies. 208 234 When rabies preexposure vaccination is indicated, importance of completing the 3-dose primary vaccination series. 213 236 When rabies postexposure prophylaxis is indicated in previously unvaccinated individuals, importance of completing a 4- or 5-dose series of rabies vaccine and receiving a single dose of RIG as soon as possible following rabies exposure. 208 213 234 236 When rabies postexposure prophylaxis is indicated in previously vaccinated individuals, importance of receiving a 2-dose regimen of rabies vaccine as soon as possible following rabies exposure. 208 213 234 236 Importance of informing clinicians if the patient has a weakened immune system (e.g., cancer, HIV/AIDS) or receives treatment that may weaken the immune system (e.g., corticosteroids, cancer treatment). 208 234 Importance of informing clinicians if a patient has a fever or serious illness. 208 234 Advise patient that preexposure vaccination may be deferred if they are moderately or severely ill, but that rabies postexposure prophylaxis will still be administered, regardless of any other illness they may have. 244 Importance of informing clinicians if any serious adverse reactions (e.g., hypersensitivity, neurologic reactions) occur. 208 234 Clinicians or individuals can report any adverse reactions that occur following vaccination to the Vaccine Adverse Event Reporting System (VAERS) at 800-822-7967 or . 208 213 234 Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs, and any concomitant illnesses. 208 234 Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed. 208 234 Importance of informing patients of other important precautionary information. 208 234 (See Cautions.) Preparations Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details. Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations. Rabies Vaccine (Human Diploid-cell) Routes Dosage Forms Strengths Brand Names Manufacturer Parenteral For injectable suspension, for IM use only 2.5 units (of rabies antigen) Imovax Rabies Sanofi Pasteur Rabies Vaccine (Purified Chick Embryo Cell Culture) Routes Dosage Forms Strengths Brand Names Manufacturer Parenteral For injectable suspension, for IM use only 2.5 units (of rabies antigen) RabAvert Novartis AHFS DI Essentials. Copyright 2017, Selected Revisions September 1, 2010. American Society of Health-System Pharmacists, Inc., 4500 East-West Highway, Suite 900, Bethesda, Maryland 20814. References 200. Connaught. Imovax rabies I.D. (rabies vaccine human diploid cell) prescribing information. Swiftwater, PA; 1991 Jul. 204. American College of Obstetricians and Gynecologists. Immunization during pregnancy. Committee opinion No. 282. Obstet Gynecol . 2003; 101:207-12. [PubMed 12517674] 208. Sanofi Pasteur. Imovax rabies (rabies vaccine human diploid cell) prescribing information. Swiftwater, PA; 2005 Dec. 209. Fishbein DB, Sawyer LA, Reid-Sanden FL et al. Administration of human diploid-cell rabies vaccine in the gluteal area. N Engl J Med . 1988; 318:124-5. [PubMed 3336395] 210. Shill M, Baynes RD, Miller SD. Fatal rabies encephalitis despite appropriate post-exposure prophylaxis: a case report. N Engl J Med . 1987; 316:1257-8. [PubMed 3574385] 211. Centers for Disease Control and Prevention. General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep . 2006; 55(RR-15):1-47. 212. US Centers for Disease Control and Prevention. Health information for international travel, 2010. Atlanta, GA: US Department of Health and Human Services; 2010. Updates available from CDC website (). 213. American Academy of Pediatrics. Red Book: 2009 Report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009. 214. Bernard KW, Mallonee J, Wright JC et al. Preexposure immunization with intradermal human diploid cell rabies vaccine: risks and benefits of primary and booster vaccination. JAMA . 1987; 257:1059-63. [PubMed 3806894] 215. Fishbein DB, Pacer RE, Holmes DF et al. Rabies preexposure prophylaxis with human diploid cell rabies vaccine: a dose-response study. J Infect Dis . 1987; 156:50-55. [PubMed 3598225] 216. Baer GM, Fishbein DB. Rabies post-exposure prophylaxis. N Engl J Med . 1987; 316:1270-2. [PubMed 3574388] 217. Nicholson KG, Burney MI, Ali S et al. Stability of human diploid-cell-strain rabies vaccine at high ambient temperatures. Lancet . 1983; 1:916-8. [PubMed 6132229] 218. Wasi C, Chaiprasithikul P, Thongcharoen P. Stability of human diploid cell rabies vaccines. Lancet . 1983; 1:1272. [PubMed 6134059] 219. Centers for Disease Control. Systemic allergic reactions following immunization with human diploid cell rabies vaccine. MMWR Morb Mortal Wkly Rep . 1984; 33:185-7. [PubMed 6423947] 220. Centers for Disease Control. Rabies postexposure immunization regimens Thailand. MMWR Morb Mortal Wkly Rep . 1990; 39:759-62. [PubMed 2120574] 221. Centers for Disease Control. Human rabies despite treatment with rabies immune globulin and human diploid cell rabies vaccine Thailand. MMWR Morb Mortal Wkly Rep . 1987; 36:759-60,765. [PubMed 3118174] 222. Rupprecht CE, Smith JS, Fekadu M et al. The ascension of wildlife rabies: a cause for public health concern or intervention? Emerg Infect Dis. 1995 (Oct-Dec); 1:107-14. 223. Chutivongse S, Wilde H, Supich C et al. Postexposure prophylaxis for rabies with antiserum and intradermal vaccination. Lancet . 1990; 335:896-8. [PubMed 1969993] 224. Michigan Department of Public Health. Rabies vaccine adsorbed prescribing information. Lansing, MI; 1988 Mar. 225. Fishbein DB, Dreesen DW, Holmes DF et al. Human diploid cell rabies vaccine purified by zonal centrifugation: a controlled study of antibody response and side effects following primary and booster pre-exposure immunizations. Vaccine . 1989; 7:437-42. [PubMed 2815979] 226. Berlin BS. Rabies vaccine adsorbed: neutralizing antibody titers after three-dose pre-exposure vaccination. Am J Public Health . 1990; 80:476-7. [PubMed 2316774] 227. Reid-Sanden FL, Fishbein DB, Stevens CA et al. Administration of rabies vaccine in the gluteal area: a continuing problem, Arch Intern Med . 1991; 151:821. Letter. 228. Anon. Rabies vaccine, adsorbed: a new rabies vaccine for use in humans. MMWR Morb Mortal Wkly Rep . 1988; 37:217-23. [PubMed 3127674] 229. Berlin BS, Mitchell JR, Burgoyne GH et al. Rhesus diploid rabies vaccine (adsorbed), a new rabies vaccine. JAMA . 1982; 247:1726-8. [PubMed 7038159] 230. Berlin BS, Mitchell JR, Burgoyne GH et al. Rhesus diploid rabies vaccine (adsorbed), a new rabies vaccine. JAMA . 1983; 249:2663-5. [PubMed 6341639] 231. Burgoyne GH, Kajiya KD, Brown DW et al. Rhesus diploid rabies vaccine (adsorbed): a new rabies vaccine using FRhL-2 cells. J Infect Dis . 1985; 152:204-10. [PubMed 4008986] 232. Berlin BS, Goswick C. Rapidity of booster response to rabies vaccine produced in cell culture. J Infect Dis . 1984; 150:785. [PubMed 6491383] 233. Centers for Disease Control and Prevention. Recommendations of the Advisory Committee on Immunization Practices (ACIP): use of vaccines and immune globulins in persons with altered immunocompetence. MMWR Recomm Rep . 1993; 42(RR-4):1-18. 234. Novartis Vaccines and Diagnostics, Inc. RabAvert rabies vaccine for human use prescribing information. Emeryville, CA; 2006 Oct. 235. Anon. Availability of new rabies vaccine for human use. MMWR Morb Mortal Wkly Rep . 1998; 47:12,19. [PubMed 9450724] 236. Centers for Disease Control and Prevention. Human rabies prevention United States, 2008. Recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep . 2008; 57(RR-3):1-27. 237. Anon. Advice for travelers. Med Lett Treat Guidel . 2009; 7:83-94. 238. Aventis Pasteur, Swiftwater, PA: Personal communication. 242. Centers for Disease Control and Prevention. Human rabies-Florida, 2004. MMWR Morb Mortal Wkly Rep . 2005; 54:767-9. [PubMed 16094285] 244. US Centers for Disease Control and Prevention. Rabies vaccine information statement. 2009 Oct 6. From CDC website (). 245. Department of Health and Human Services, Food and Drug Administration, Center for Biologics Evaluation and Research (CBER). Guidance for industry. Revised preventive measures to reduce the possible risk of transmission of Creutzfeldt-Jacob disease (CJD) and variant Creutzfeldt-Jacob disease (vCJD) by blood and blood products. January 2002. From FDA website () Accessed 2008 Feb 20. 246. Sanofi Pasteur. Imogam Rabies-HT (rabies immune globulin [human] USP, heat treated) prescribing information. Swiftwater, PA; 2005 Dec. 249. World Health Organization. Rabies vaccines WHO position paper. Wkly Epidemioll Rec . 2007; 82: 425 35. From WHO website (). 250. Centers for Disease Control and Prevention. Use of a reduced (4-dose) vaccine schedule for postexposure prophylaxis to prevent human rabies. Recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep . 2010; 59(RR-2):1-9. 251. Centers for Disease Control and Prevention (CDC). Human rabies - Kentucky/Indiana, 2009. MMWR Morb Mortal Wkly Rep . 2010; 59:393-6. 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