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ACIP: Rabies - Continued

tion. Additional experience with this vaccine is needed to define more clearly the risk of these adverse reactions.

Vaccines in Other Countries

Many developing countries use inactivated nerve tissue vaccines (NTV) or inactivated suckling mouse brain vaccine (SMBV). NTV is reported to provoke neuroparalytic reactions at a rate of about 1/2,000 vaccinees; the rate for SMBV is about 1/8,000.

Rabies Immune Globulin, Human

Local pain and low-grade fever may follow receipt of RIG. Although not reported specifically for RIG, angioneurotic edema, nephrotic syndrome, and anaphylaxis have been reported after injection of immune serum globulin (ISG). These reactions occur so rarely that the causal relationship between ISG and these reactions is not clear.

Antirabies Serum, Equine

ARS produces serum sickness in at least 40% of adult recipients; reaction rates for children are lower. Anaphylactic reactions may occur. When RIG is not available, and ARS must be used, the patient should be tested for sensitivity to equine serum. (See package circular for details.)

Because adverse reactions are associated more frequently with ARS than with RIG, and ARS might sensitize recipients to equine protein, ARS should be used only when RIG cannot be obtained.

Management of Adverse Reactions

Once initiated, rabies prophylaxis should not be interrupted or discontinued because of local or mild systemic adverse reactions to rabies vaccine. Usually such reactions can be successfully managed with anti-inflammatory and antipyretic agents (aspirin, for example).

When a person with a history of hypersensitivity must be given rabies vaccines, antihistamines may be given; epinephrine should be readily available to counteract anaphylactic reactions, and the person should be carefully observed immediately after immunization.

Serious systemic anaphylactic or neuroparalytic reactions occurring during the administration of rabies vaccines pose a serious dilemma for the attending physician. A patient's risk of developing rabies must be carefully considered before deciding to discontinue vaccination. Moreover, the use of corticosteroids to treat life-threatening neuroparalytic reactions carries the risk of inhibiting the development of active immunity to rabies. It is especially important in these cases that the serum of the patient be tested for rabies antibodies. Advice and assistance on the management of serious adverse reactions in persons receiving rabies vaccines may be sought from the state health department or CDC.

All serious systemic neuroparalytic or anaphylactic reactions to a rabies vaccine should be immediately reported to the state health department or the Division of Viral Diseases, Center for Infectious Diseases, CDC ([404] 329-3095 during working hours, or [404] 329-2888 at other times).

PRECAUTIONS AND CONTRAINDICATIONS
Immunosuppression

Corticosteroids, other immunosupressive agents, and immunosuppressive illnesses can interfere with the development of active immunity and predispose the patient to developing rabies. Immunosuppressive agents should not be administered during postexposure therapy, unless essential for the treatment of other conditions. When rabies postexposure prophylaxis is administered to persons receiving steroids or other immunosuppressive therapy, it is especially important that serum be tested for rabies antibody to ensure that an adequate response has developed.

ACIP: Rabies - Continued

Pregnancy

Because of the potential consequences of inadequately treated rabies exposure and limited data that indicate that fetal abnormalities have not been associated with rabies vaccination, pregnancy is not considered a contraindication to postexpsoure prophylaxis. If there is substantial risk of exposure to rabies, preexposure prophylaxis may also be indicated during pregnancy.

Allergies

Persons with histories of hypersensitivity should be given rabies vaccines with caution. When a patient with a history suggesting hypersensitivity to HDCV must be given that vaccine, antihistamines can be given; epinephrine should be readily available to counteract anaphylactic reactions, and the person should be carefully observed.

SELECTED BIBLIOGRAPHY

Anderson LJ, Nicholson KG, Tauxe RV, Winkler WG. Human rabies in the United States, 1960 to 1979: epidemiology, diagnosis, and prevention. Ann Intern Med 1984;728-35.

Anderson LJ, Sikes RK, Langkop CW, et al. Postexposure trial of a human diploid cell strain rabies vaccine. J Infect Dis 1980;142:133-8.

Baer, GM, ed. The natural history of rabies. New York: Academic Press, 1975.

(Continued on page 407)

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TABLE 1. Summary-cases specified notifiable diseases, United States

Disease

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'One of the 12 reported cases for this week was imported from a foreign country or can be directly traceable to a known internationally imported case within two generations.

TABLE III. Cases of specified notifiable diseases, United States, weeks ending
July 14, 1984 and July 16, 1983 (28th Week)

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small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][ocr errors][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][ocr errors][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][ocr errors][merged small][merged small][merged small][merged small][merged small][ocr errors][subsumed][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][subsumed][merged small][merged small][merged small][merged small][merged small][merged small][subsumed][merged small][merged small][merged small][subsumed][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][subsumed][merged small][merged small][merged small][merged small][subsumed][merged small][merged small][merged small][merged small][merged small][subsumed][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged 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small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][ocr errors][merged small][merged small][merged small][ocr errors][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][ocr errors][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small]

TABLE III. (Cont'd.) Cases of specified notifiable diseases, United States, weeks ending
July 14, 1984 and July 16, 1983 (28th Week)

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small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][ocr errors][subsumed][merged small][merged small][subsumed][subsumed][subsumed][merged small][merged small][merged small][merged small][merged small][merged small][merged small][ocr errors][subsumed][merged small][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][merged small][ocr errors][merged small][merged small][merged small][merged small][subsumed][merged small][subsumed][merged small][merged small][merged small][merged small][merged small][subsumed][merged small][merged small][merged small][subsumed][merged small][merged small][subsumed][merged small][merged small][subsumed][merged small][merged small][merged small][merged small][subsumed][merged small][merged small][merged small][merged small][merged small][merged small][merged small][subsumed][merged small][subsumed][merged small][merged small][merged small][merged small][subsumed][merged small][subsumed][merged small][merged small][merged small][merged small][merged small][merged small][subsumed][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][ocr errors][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][subsumed][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][ocr errors][subsumed][merged small][merged small][merged small][merged small][merged small][subsumed][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][ocr errors][merged small][ocr errors][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small]

TABLE III. (Cont'd.) Cases of specified notifiable diseases, United States, weeks ending
July 14, 1984 and July 16, 1983 (28th Week)

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