JIACM 2006; 7(1): 39-46
REVIEW ARTICLE
Post-exposure Prophylaxis for Rabies
C Shayam*, AK Duggal**, Ulka Kamble***, AK Agarwal****
Rabies (rage or madness in Latin) has been the subject
of fear ever since the disease was recognised.
Worldwide the number of deaths annually, due to
rabies, is estimated to be between 35,000 to 50,000
approximately1. The highest incidence of rabies is in
India with approximately 30,000 cases of rabies
reported annually2. The causative agent of rabies is a
Lyssavirus type 1. It is a bullet shaped virus and is found
in the wild as well as some domestic animals3. Rabies
is essentially a zoonotic disease with man being the
dead-end host. Rabies is transmitted to man most
commonly as a result of bites or scratches by a rabid
animal but there are some other uncommon modes
of transmission of rabies as listed in Table I. Since rabies
is 100% fatal (only six cases reported so far where
survival occurred after developing clinical rabies),
prevention of rabies is the best and only option for
cure4, 5. Post-exposure rabies vaccination forms the
most integral part of prevention of rabies. This article
discusses the various available vaccines for rabies
prophylaxis and their schedules.
Table I: Modes of transmission of Rabies.
Animal to man
1. Bites of rabid animals.
2. Scratches by rabid animals.
3. Licks on abraded skin or mucous membranes.
Aerosols
1. In caves harbouring rabies infested bats.
2. In laboratories handling rabies infected neural tissue*.
Oral**
1. Drinking unboiled raw milk of rabies infected cow or
goat.
2. Eating meat of rabid animal can theoretically lead to
rabies.
Man to man
1. Corneal transplant from an infected person.
* Chief Medical Officer, ** Medical Officer, *** Medical Specialist and Assistant Professor,
**** Consultant, Professor and Head, Department of Internal Medicine,
Dr. Ram Manohar Lohia Hospital, New Delhi - 110 001.
2. Solid organ transplant (liver, kidney) from an infected
person.
3. Bite from a rabid human; theoretical risk but no
confirmed cases reported as yet.
4. Kissing an infected person; theoretical risk but no
confirmed case reported as yet.
* Contact with body fluids other than saliva and neural tissue (i.e.,
blood, urine or faeces) is not considered an exposure.
** Rabies virus is inactivated by desiccation, UV radiation and
heating or cooking at > 60. Thus, dry material from a rabid animal
can be considered non-infectious.
Antirabies vaccines are of 2 types-Neural and Non-neural
vaccines (Figure 1).
Neural vaccines
Although WHO has directed its member nations not to use
the neural tissue vaccines, still many developing nations
use neural vaccines because of their low cost.
1. Semple Vaccine was developed by Semple at Central
Research Institute, Kasauli, and it has been the most
widely used vaccine for over half-a-decade. It is a 5%
suspension of sheep brain infected with fixed virus and
inactivated with phenol at 37C6.
2. Beta propionilactione vaccine (BPL) is a modification
of the Semple vaccine in which BPL is used as an
inactivating agent instead of phenol. It is believed to
be more antigenic, so a smaller dose is required7.
3. Suckling mouse brain vaccine was developed with the
aim to reduce the encephelitogenic properties of the
rabies vaccine. The infant mice (< 9 days old) are used
for vaccine production. The amount of myelin in infant
brain is scanty and this results in a lower incidence of
neuroparalytic side effects8.
Neural tissue vaccines (NTV) have many disadvantages:
 Fig. 1: Type of anti rabies vaccine
Antirabies vaccines
Neural (nerve tissue) vaccines
Semple vaccine
BPL vaccine
Suckling mouse brain vaccine
Duck embryo vaccine
1) poor immunogenecity as they contain mostly
nucleocapsid antigen with only small quantities of
glycoprotien G which is the sole protective agent; 2) they
may contain infectious agent which may not be
inactivated during vaccine production and storage; 3)
the neuroparalytic adverse effects9. NTV contain myelin,
which is responsible for the neuroparalytic side effects
of these vaccines (Table II) 10. The incidence of neural
complications with vaccines prepared from brains of
adult animals is between 1:200 and 1:2,000 and from that
of infant mice is 1:3,000 to 1:24,000 8,10. These
complications usually occur after the sixth or seventh
injection of the vaccine. The onset of symptoms is usually
within 30 days (88% within 20 days). The condition may
result in serious residual paralysis and even death8. There
is no definite treatment of these neuroparalytic
complications, but high dose corticosteroids, plasma
exchange and immunoglobulins have been used with
variable results8.
Because of the above reasons, WHO has recommended
phasing out of NTVs by the year 200611. The Government
of India has discontinued the use of NTV from December,
2004.
Table II: Neuroparalytic complications of neural
vaccines.
1. Meningoencephalitis
2. Meningoencephelomyelitis
3. Mononeuritis multiplex
4. Dorso-lumbar transverse myelitis
5. Ascending paralysis of Landrys type
40 Journal, Indian Academy of Clinical Medicine
Non-neural vaccines
Cell Culture vaccine
1st generation: HDCV
2nd generation: PCECV
PVRV
RVA
PHKV
Non-neural vaccines
Non-neural vaccines were developed with the aim of
reducing the neuroparalytic complications associated with
the nervous tissue vaccines. They are of 2 types: avian embryo
vaccines and primary cell culture vaccines.
Avian embryo vaccines: the prototype avian embryo
vaccine is the duck embryo vaccine that was first made
available in 1957. It was widely used before the first
generation cell culture vaccines became available. This
vaccine contains no detectable myelin protein but contains
traces of avian antigens. The chief disadvantages of use of
duck embryo vaccine are poor immunogenecity and
presence of avian antigens that could lead to anaphylactic
reaction12.
Primary cell culture vaccines: modern cell culture
vaccines were first developed in 1964 but were beset with
tolerability problems9.
1. Human diploid cell vaccine (MIRV-HDC in India): the
vaccine is prepared from Pitman Moore strain of
rabies virus grown on MRC-5 human diploid cell
culture line, concentrated by ultrafiltration and
inactivated by BPL13. It is supplied in two forms:
a) Intramuscular administration: a single dose vial
containing lyophilised vaccine that is
reconstituted in the vial with the accompanying
diluent to a volume of 1 ml.
b) Intradermal administration: a single dose syringe
containing lyophilised vaccine that is
reconstituted in the syringe to a final volume of

Vol. 7, No. 1
January-March, 2006
 0.1 ml before administration14.
The WHO regards the HDCV as the gold standard
among all rabies vaccines. In one of studies in Iran, none
of the 45 persons who received HDCV developed rabies
following severe bites by rabid dogs or wolves15.
2. Purified chick embryo cell vaccine (PCECV- RabipurTm):
PCECV is prepared from fixed rabies virus strain FLURY
LEP grown in primary cultures of chicken fibroblasts9.
The vaccine was first marketed in 1984 and is now
available in more than 70 countries and more than
30 million doses of PCECV have been administered
worldwide. It is available as a single dose vial
containing lyophilised vaccine that is reconstituted
with diluent to a final volume of 1 ml. Various studies
have shown that PCECV is atleast as effective as the
HDCV16-18. It is cheaper than HDCV.
3. Purified Vero Cell Rabies Vaccine (PVCV AbhayrabTm,
VerorabTm): PVCV contains Wistar strain of virus, with
the vero cell line as the substrate, which is a continuous
cell line9. The vaccine induces a good immune
response after primary as well as secondary
immunisation, the results being comparable to those
of HDCV19. But the continuous cell lines like vero cell
line are abnormal, as their genetic make-up has been
altered to allow continuous replication. Therefore they
may contain potentially oncogenic substances and
vaccines produced in such cell lines must be
monitored for residual DNA that is present in each
dose. According to European Pharmacopoeia, the
content of residual DNA per human dose should be
less than 100 pg. The FDA, USA has not yet approved
the is vaccine for use in USA.
4. Rabies Vaccine Adsorbed (RVA): is prepared from
Kissling strain of challenge virus standard (CVS) rabies
virus adapted to foetal rhesus lung diploid cell culture20.
The vaccine virus is inactivated by BPL and
concentrated by adsorption to aluminum phosphate.
It is a liquid rather than lyophilised vaccine and is
approved only for Intramuscular use as a 1 ml dose9.
5. Primary Hamster Kidney Cell Vaccine (PHKCV): this
vaccine is used in China and Russia locally. The virus is
propagated in primary kidney cells of Syrian hamsters6.
Journal, Indian Academy of Clinical Medicine
Vol. 7, No. 1
Potency of anti rabies vaccines
WHO recommends that the rabies vaccine for human use
must have a potency of at least 2.5 IU/dose using the NIH
test21 for NTVs the minimum potency is 0.3 antigenic value.
All WHO recommended modern cell vaccines are safe and
effective. To be effective in preventing rabies, specimens
collected 2 - 4 weeks after post-exposure prophylaxis
should completely neutralise challenge virus at a 1:5
serum dilution by the RFFIT4.
Adverse effects of cell culture vaccines: the modern cell
culture vaccines are generally considered safe and have
very few adverse effects. Table III enlists the common
adverse effects associated with modern cell culture
vaccines4.
Table III: Adverse effects of cell culture vaccines.
1. Local: pain, erythema, swelling, or induration (in 15 to
74 per cent of recipients)
2. Itching
3. Local lymphadenopathy
4. Headache, malaise, myalgia, or dizziness (10 to 25 per
cent)
5. Gastrointestinal symptoms (in less than 10 percent);
6. Allergic reactions during primary vaccination (in 0.1
per cent [less than 10 per cent of whom have
anaphylactic reactions]).*
7. Type III hypersensitivity reactions (in 6 to 10 per cent
after booster doses of human diploid cell vaccine and
in fewer during primary vaccination).
*Allergic reactions are fewer with 2nd generation cell culture
vaccines.
Dosage and schedule of cell culture vaccines
Rabies post-exposure prophylaxis (PEP) is an emergency and
as a rule should not be delayed or deferred. There are no
contraindications if modern cell culture vaccines are used.
Indications for Antirabies vaccination: post-exposure
prophylaxis
a. In endemic countries like India where terrestrial rabies
is rampant, post-exposure prophylaxis should be given
to all patients with animal bites except if the dog at

January-March, 2006 41
 the time of exposure is more than a year old and has a i. Bite by a wild animal
vaccination certificate indicating that it has received at ii. Unprovoked bites
least 2 doses of a potent vaccine, the first not earlier
iii. If the biting animal cannot be traced
than 3 months of age and another within 6 - 12
months later. In this case the dog may be observed iv. Laboratory tests of the brain of the animal are
for 10 days and if the dog shows any sign of illness positive for rabies
during the observation period, the patient should
PEP for rabies is not indicated if the biting animal is a small
receive full post exposure prophylaxis11.
rodent or rabbit22. Larger rodents like the woodchuck are
b. In other areas where rabies is not terrestrial, more frequently reported to be rabid4. Figure 2 shows a
indications for post-exposure prophylaxis are8: suggested algorithm for post-exposure prophylaxis of rabies4.

Did an exposure to rabies occur ?

Did an animal bite the patient, or did
a potentially unrecognised exposure
occur ?
Was there direct contact of the patients
open bleeding wound, broken skin,
or mucous membranes with potentially
infectious material such as animal saliva Yes Was the animal a mammal ?
No No Yes

No PEP Yes Was the animal a small rodent or rabbit ?

No

Observe the animal Yes Is the animal available Yes Was the animal a dog, cat, or ferret ?
for 10 days. Does it for observation ?
exhibit signs of rabies ? No
No

Consult public health Yes Was the animal domestic livestock ?

No Yes officials for local rabies
epidemiology. No
Was the animal a bat,
or is terrestrial rabies
present ? No Is the animal (brain) available for testing ?
No
No
Yes
Did the animal Negative for rabies Positive for rabies
exhibit any
signs of rabies ?

No
Yes
No PEP PEP No PEP PEP No PEP PEP

Fig. 2: Algrithm for post-exposure prophylaxis (PEP) of rabies.

42 Journal, Indian Academy of Clinical Medicine
Vol. 7, No. 1
January-March, 2006

Indications for Antirabies vaccination: pre-exposure
prophylaxis pre-exposure vaccination is recommended
for persons at risk: laboratory workers, diagnosticians,
veterinarians and their staff, animal control officers, rabies
researchers, and some travellers to endemic areas where
rabies is prevalent23. WHO recommends that toddlers and
children in highly endemic areas may also be considered
for rabies pre exposure vaccination.
Categorisation of bites (WHO)11
Category I: touching or feeding of animals or licks on
intact skin. In such a case if the history is reliable no
treatment is required as there is no exposure to the
rabies virus.
Category II: minor scratches or abrasions without bleeding,
or licks on broken skin and nibbling of skin. This requires a
full course of antirabies vaccine.
Category III: single or multiple transdermal bites or
contamination of mucous membrane with saliva. In this
case both immunoglobulin and vaccine should be used.
Schedule for pre-exposure vaccination
Pre-exposure vaccination simplifies the management
of subsequent exposure as fewer doses of vaccine are
required and rabies immunoglobulin is not required23.
Three doses of vaccine are given on day 0, 7, and 28
by intramuscular route23. Alternatively, 0.1 ml of HDCV
may be injected intradermally also24. Of note here is
the interference of chloroquine with the immune
response of anti-rabies vaccines. So HDCV should not
be given intradermally if the person is receiving
chloroquine25. The need for booster vaccination may
be monitored by serologic testing performed every
six months to 2 years and booster dose is given when
titres fall below 0.5 IU/ml23.
Schedule for post-exposure vaccination
Traditionally, modern cell culture vaccines are given
intramuscularly. The vaccines should not be administered
in the gluteus muscle to avoid injury to the sciatic nerve
and to lessen the delivery of vaccine to the adipose tissue26.
Two regimens are used:
Journal, Indian Academy of Clinical Medicine
Vol. 7, No. 1
a. Classic 5 dose intramuscular regimen (Essen regimen)
in which one dose of vaccine, i.e., 1 ml of HDCV, PCECV
or 0.5 ml of PVEV is administered on day 0, 3, 7, 14,
and 28.
b. Alternate 2 - 1 - 1 regimen in which 2 doses of vaccine
are given on both deltoids on day 0 and then one dose
each on day 7 and 2111.
Since the cell culture vaccines are very expensive,
developing countries like India cannot afford the
universal use of cell culture vaccines as recommended
by the WHO11. In India alone, approximately 2.5 million
animal bites occur annually. If RabipurTm (PCECV) is used
then the annual cost would be approximately Rs. 8.7
billion. The WHO therefore recommends the use of cell
culture vaccines by intradermal route. Intradermal
vaccination reduces the volume of vaccine required and
the cost of vaccination by 60 - 80%11. The efficacy and
immunogenecity of the intradermal regimen has been
established by various studies in Thailand, Sri Lanka and
India27, 28. However, certain precautions are required that
include proper staff training, use of appropriate 1 ml
syringe and short hypodermic needles. Two regimens
are used, the 8 site Oxford regimen and the 2 site Thai
Red Cross regimen8 (Table IV).
Efficacy of post-exposure rabies prophylaxis
The modern cell culture vaccines are highly effective.
Various studies done with the cellular vaccines have
shown that the seroconversion rate (i.e., an antibody
titre of > 0.5 IU/ml) after 14 days is 100%30-32. On the
other hand, the amount of glycoprotein antigen in NTVs
is much less. So patients receiving NTVs may
seroconvert late or may not seroconvert at all. In a study
comparing NTV with PCECV, 14% of patients receiving
NTV did not seroconvert, and the average antibody titres
in NTV group (3.2 IU/ml) was much less than the PCECV
group (13.4 IU/ml)33.
The cellular vaccines have been in use for over 40 years
now. In USA there have been no reported failures after
post-exposure prophylaxis with the cellular vaccines. But in
South-east Asia and India there have been failures even
with the use of cellular vaccines34, 35. Most of these failures
have occurred when there have been deviations from the

January-March, 2006 43
recommended schedule and guidelines. Of importance
here is the proper management of the wound and use of
ARG especially in severe category III bites34.
Table IV: Regimens for post-exposure vaccination for rabies.
Oxford regimen
8 site intradermal regimen
1. Vaccines used: HDCV, PCECV
2. Dose: 0.1 ml of HDCV OR PCECV
3. Schedule: (8 - 0 - 4 - 0 - 1 - 1)
0.1 x 8 0.1 x 4 0.1 0.1
day 0 day 7 day 28 day 90
4. Particularly useful in emergency situations
where no RIG is available because antibody
response at 7 days is greater29.
5. Total of less than 2 vials used on 4 visits.
Antirabies serum (ARS)/rabies
immunoglobulin (RIG) treatment
Even with the more potent cellular vaccines, the protective
antibody levels are achieved only after 10 - 14 days35. Thus
ARS/RIG are needed to cover this vulnerable short
incubation period in class III exposures or severe wounds
from high-risk category of animals. It provides a short
immunity with half-life of 21 days36. The failure of modern
cellular vaccines in most cases has been because ARS/RIG
was not used in high-risk category III cases34. RIG or ARS are
made of readymade antirabies antibodies, which provide
passive immunity and immediate protection. Two types of
ARS/RIG are available:-
1. ARS or Equine Rabies Immunoglobulin (ERIG): Potent
antirabies serum has been prepared in horse and
other animals. ERIG is widely used in India. It should
be given as early as possible, preferably on day 0. It
can however be given irrespective of the interval
between time of exposure and initiation of
treatment. It should never be given alone without
concomitant use of antirabies vaccine. It can be given
within 7days of starting antirabies vaccine37. Beyond
the seventh day, RIG is not indicated since an
antibody response to cell culture vaccine is presumed
44 Journal, Indian Academy of Clinical Medicine
to have occurred. Because RIG can partially suppress
active production of antibody, no more than the
recommended dose should be administered34.
Thai Red Cross regimen
2 site intradermal regimen
1. PVRVORPCECV
2. Dose: 0.1 ml of PVRV or 0.2 ml of PCECV
3. Schedule: (2 - 2 - 2 - 0 - 1 - 1)
0.1 x 2 0.1 x 2 0.1 x 2 0.1 x 1 0.1 x 1
day 0 day 3 day 7 day 28 day 90
4. To be avoided in emergency situation
5. Total of less than 2 vials used on 5 visits.
Prior to administration, a skin test should be done. A
test dose of 0.1 ml of 1 in 10 diluted ERIG is injected
intradermally into the left forearm. An equivalent
intradermal injection of physiological saline is used as
control. An induration of > 10 mm is taken as positive38.
The problem however is that a positive skin sensitivity
test does not accurately predict anaphylaxis or serum
sickness like reactions39. The immediate reactions that
occur after use of heterologous sera are either IgE
mediated (anaphylactic) or complement mediated
(anaphylactoid). The skin test detects the anaphylactic
reactions but not the anaphylactoid reactions40. WHO
in 1995 had recommended that skin test may not be
done prior to ERIG administration39. In Brazil a study
was done in which none of the 1,054 patients who
were given ERIG were subjected to skin sensitivity test.
They were however given ERIG under the cover of
antihistamines (anti H1+ anti H2 ) and corticosteroids.
All the patients were observed for 60 - 180 minutes.
None of the patients showed any adverse effects41. In
1997 WHO recommended that if the skin test is positive,
preferably HRIG should be used. However, if HRIG is not
available then desensitisation for horse serum may be
considered. Alternatively, ERIG may be given under
cover of antihistamines and intramuscular adrenaline/

Vol. 7, No. 1
January-March, 2006
 epinephrine42. If however, ERIG cannot be given, then
after proper wound toilet the patient should preferably
be given 2 doses of a cellular vaccine on day 0 in both
deltoids.
Dose of ERIG is 40 IU/Kg of body weight. As much as
possible ERIG should be infiltrated around and into the
wound(s), even if the lesion has begun to heal. If the
calculated dose of ERIG is insufficient, then sterile saline
can be used to dilute it 2 - 3 times to permit thorough
infiltration. Any remaining ERIG is injected
intramuscularly at a site distant from the site of vaccine
administration.
With the use of purified ERIG, the incidence of adverse
effects has been low (0.8 - 6%)43-45. The incidence of
early manifestations is calculated to be less than
1:35,000 treatments38. The adverse effects are of 2
types:
Immediate or anaphylactoid reactions: include
hypotension, dyspnoea, syncope, and urticaria.
Anaphylaxis is rare (< 1%) with modern purified and
pepsin-digested equine rabies immunoglobulins38. This
type of reaction is treated with adrenaline, oxygen,
hydrocortisone, and antihistaminics.
Delayed or serum sickness like reactions may occur
after 6 days. The incidence is < 3%45. This is a type III
hypersensitivity reaction and symptoms include fever,
pruritis, rash, adenopathy, and arthralgias. These are
treated with Nonsteroidal anti-inflammatory agents and
antihistamines.
2. Human rabies immunoglobulin (HRIG): HRIG has
replaced ERIG in most developed countries. In
developing countries the use is limited because of
prohibitively high costs of HRIG. The dose is 20 IU/Kg
body weight and use is similar to ERIG. It is free from
anaphylactic and serum sickness like adverse effects23.
Future vaccines: DNA vaccines have shown efficacy in
preclinical animal models in preventing or even treating
a variety of diseases caused by infectious organisms.
One of the main perceived advantages of DNA vaccines
is the low cost. However, in general, immune responses
elicited by DNA vaccines are less potent. Although DNA
vaccines have shown good efficacy in preventing rabies
Journal, Indian Academy of Clinical Medicine
Vol. 7, No. 1
in animals, their efficacy in phase I human trials has
largely been disappointing46.
To conclude, although post-exposure vaccination forms
an integral part of rabies control, control of rabies can
only be achieved by health education and vaccination
of dogs and cats. However availability of cheap and
effective human rabies vaccine is of prime importance
for preventing mortality from rabies in a country like
India.
References
1. WHO: the world health report, Geneva. World Health
Organisation 1996; 57.
2. WHO: the health situation in South-East Asia Region. New
Delhi Regional office of SEAR 1994-7.
3. King AA, Meredith CD, Thomson GR. The biology of southern
African lyssavirus variants. Curr Top Microbiol Immunol 1994;
187: 267-95.
4. Rupprecht CE, Gibbons RV. Prophylaxis against Rabies. N
Engl J Med 2004; 351 (25): 2626-35.
5. Willoughby RE Jr, Tieves KS, Hoffman GM et al. Brief report:
Survival after treatment of rabies with induction of coma.
N Engl J Med 2005; 352: 2508-14.
6. Meslin FX, Kaplan MM., Koprowski H. Laboratory techniques
in rabies; 4th edition; World Health Organization, Geneva,
1996.
7. Mahajan BK, Gupta MC. Textbook of Preventive and Social
Medicine 2nd ed. Delhi. Jaypee Brothers, 1995; 351.
8. Park K. Parks Textbook of Preventive and Social Medicine
17th ed. Jabalpur. M/s Banarsidaas Bhanot 2002; 207-15.
9. Briggs DJ, Dreesen DW, Wunner WH. Vaccines. In: Jackson
AC, Wunner WH, eds. Rabies. San Diego, USA: Academic
Press, 2002; 371-400.
10. Bahri E,Letaief A, Emez M et al. Neurological complictions
in adults given post exposure Semple type rabies vaccine.
Presse Med 1996; 25: 491-3.
11. Current WHO guide for Rabies Pre- and Post-exposure
treatment in humans. WHO Department of
Communicable Diseases Surveillance and Response.
(Accessed July 29, 2005, at http://www.who.int/rabies/en/
WHO_guide_rabies_pre_post_exp_treat_humans.pdf).
12. King AA, Turner GS. Rabies: a review. J Comp Pathol 1993;
108: 1-39.
13. Wiktor TJ, Plotkin SA, Koprowski H. Development and clinical
trials of the new human rabies vaccine of tissue culture
(human diploid cell) origin. Dev Biol Stand 1978; 40: 3-9.
14. CDC. Rabies prevention: supplementary statement on the
pre-exposure use of human diploid cell rabies vaccine by
the intradermal route. MMWR 1986; 35: 767-8.
15. Bahmanyar M. Results of rabies post-exposure treatment
with antirabies serum and the human diploid cell vaccine

January-March, 2006 45
 in Iran. Dev Biol Stand 1978; 40:163-5.
16. Sehgal S, Bhattacharya D, Bhardwaj M. Ten-year
longitudinal study of efficacy and safety of purified chick
embryo cell vaccine for pre- and post-exposure
prophylaxis of rabies in Indian population. J Commun Dis
1995; 27 (1): 36-43.
17. Natrajan M, Mukandan P, John TJ. Immune response to
purified chick embryo cell culture rabies vaccine
manufactured in India. Indian J Med Res 1992; 95: 51-3.
18. Bijok U, Vodopija I, Smerdel S et al. Purified chick embryo
cell (PCEC) rabies vaccine for human use: clinical trials.
Behring Inst Mitt 1984; 76: 155-64.
19. Sampath G, Reddy SV, Rao ML et al. An immunogenicity
study of a newly introduced purified Vero cell rabies
vaccine (AbhayrabTm) manufactured in India. Vaccine 2005;
23 (7): 897-900.
20. Burgoyne GH, Kajiya KD, Brown DW, Mitchell JR. Rhesus
diploid rabies vaccine (adsorbed): a new rabies vaccine
using FRhL-2 cells. J Infect Dis 1985; 152: 204-10.
21. WHO Expert Committee on Rabies, 8th report. Geneva:
World Health Organisation, 1992; TRS 824.
22. Childs JE, Colby L, Krebs JW et al. Surveillance and
spatiotemporal associations of rabies in rodents and
lagomorphs in the United States, 1985-1994. J Wildl Dis 1997;
33: 20-7.
23. Human rabies prevention United States, 1999:
Recommendations of the Immunisation Practices Advisory
Committee (ACIP). MMWR Recomm Rep 1999; 48 (RR1): 1-21.
24. 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: 50-5.
25. Pappaioanou M, Fishbein DB, Dreesen DW et al. Antibody
response to preexposure human diploid-cell rabies vaccine
given concurrently with chloroquine. N Engl J Med 1986; 314:
280-4.
26. Nicholson KG. Rabies. Lancet 1990; 335: 1201-5.
27. Quiambao BP, Dimaaano EM, Ambas C et al. Cross post-
exposure regimen in patients severely exposed to
laboratory-confirmed rabid animals. Vaccine 2005; 23 (14):
1709-14.
28. Madhusudana SN, Anand NP, Shamsundar R. Economical
multi-site intradermal regimen with purified chick embryo
cell vaccine (RabipurTm) prevents rabies in people bitten by
confirmed rabid animals. Int J Infect Dis 2002; 6 (3): 210-4.
29. Madhusudana SN, Anand NP, Shamsundar R. Evaluation
of two intradermal vaccination regimens using purified
chick embryo cell vaccine for post-exposure prophylaxis
of rabies. Natl Med J India 2001; 14 (3): 145-7.
30. Wang XJ, Lang J, Tao XR et al. Immunogenicity and safety
of purified Vero-cell rabies vaccine in severely rabies-
exposed patients in China. Southeast Asian J Trop Med Public
Health 2000; 31 (2): 287-94.
31. Nicholson KG, Turner GS, Aoki FY. Immunisation with a
46 Journal, Indian Academy of Clinical Medicine
human diploid cell strain of rabies virus vaccine: Two
year results. J Infect Dis 1978; 137: 783-8.
32. Sehgal S, Bhattacharya D, Bhardwaj M. Ten-year
longitudinal study of efficacy and safety of purified chick
embryo cell vaccine for pre- and post-exposure
prophylaxis of rabies in Indian population. J Commun Dis
1995; 27: 36-43.
33. Deshpande AK, Londhe VA, Akarte S, Briggs D. Comparative
evaluation of immunogenicity, reactogenecity and safety
of purified chick embryo cell rabies vaccine and neural
tissue rabies vaccine. J Assoc Physicians India 2003; 51: 655-
8.
34. Wilde H, Sirikawin S, Sabcharoen A et al. Failure of
postexposure treatment of rabies in children. Clin Infect
Dis 1996; 22 (2): 228-32.
35. Arya SC. Therapeutic failures with rabies vaccine and rabies
immunoglobulin. Clin Infect Dis 1999; 29 (6): 1605.
36. Cabasso VJ, Loofbourow JC, Roby RE,Anuskiewicz W. Rabies
immune globulin of human origin: preparation and dosage
determination in non-exposed volunteer subjects. Bull
World Health Organ 1971; 45: 303-15.
37. Helmick CG, Johnstone C, Sumner J et al. A clinical study of
Merieux human rabies immune globulin. J Biol Stand 1982;
10: 357-67.
38. Tantawichien T, Benjavongkulchai M, Wilde H et al. Value
of skin testing for predicting reactions to equine rabies
immune globulin. Clin Infect Dis 1995; 21 (3): 660-2.
39. WHO Report of a WHO consultation on intradermal
application of human rabies vaccines; March 13-14, 1995.
Geneva, World Health Organization, 1995.
40. Atkinson TP, Kaliner MA. Anaphylaxis. Med Clin N Amer 1992;
76: 841-55.
41. Cupo P, de Azevedo-Marques MM, Sarti W, Hering SE.
Proposal of abolition of the skin sensitivity test before
equine rabies immune globulin application. Rev Inst Med
Trop Sao Paulo 2001; 43 (1): 51-3.
42. WHO Recommendations on rabies post-exposure
treatment and the correct technique of intradermal
immunisation against rabies. Geneva, World Health
Organization, 1997.
43. Wilde H, Chomchey P, Prakongsri S, Punyaratbandhu P.
Safety of equine rabies immune globulin. Lancet 1987; 2:
1275.
44. Wilde H, Chutivongse S. Equine rabies immune globulin: a
product with an undeserved poor reputation. Am J Trop Med
Hyg 1990; 42 (2): 175-8.
45. Wilde H, Chomchey P, Punyaratabandhu P et al. Purified
equine rabies immune globulin: a safe and affordable
alternative to human rabies immune globulin. Bull World
Health Organ 1989; 67 (6): 731-6.
46. Lodmell DL. Rabies DNA vaccines for protection and
therapeutic treatment. Expert Opin Investig Drugs 1999; 8
(2): 115-22.

Vol. 7, No. 1
January-March, 2006