Milwaukee protocol

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The Milwaukee protocol, sometimes referred to as the Wisconsin protocol,[1][2] is an experimental course of treatment of an infection of rabies in a human being. The treatment involves putting the patient into a chemically induced coma and administering antiviral drugs.

It was developed and named by Rodney Willoughby, Jr., following the successful treatment of Jeanna Giese.[3] Giese, a teenager from Wisconsin, became the first patient known to have survived rabies without receiving the rabies vaccine.[4]

Case history[edit]

Initial infection[edit]

On September 12, 2004,[5] Jeanna Giese, a 15-year-old student at St. Mary Springs High School, picked up a bat while attending St. Patrick's Church in her hometown of Fond du Lac, Wisconsin.[6] She sustained a small bite on her left index finger from the animal, and having treated it with hydrogen peroxide, the family decided not to seek medical attention.[3][6] Thirty-seven days after the bite, Giese developed neurological symptoms. She was admitted to St. Agnes Hospital with a fever of 102 °F (39 °C), double vision, slurred speech, and jerking in her left arm.[6]

She did not respond to treatment and tested negative for all other diseases. As her condition deteriorated during the visit to the ER, Giese reminded her mother about the bat bite a month before getting sick. She was then diagnosed with rabies and referred to Willoughby at Children's Hospital of Wisconsin in Wauwatosa. The diagnosis was later confirmed by laboratory tests at the Centers for Disease Control and Prevention.[7][8]

Induced coma treatment[edit]

One of the hypotheses about rabies is that rabies deaths are caused by temporary brain dysfunction with little to no damage occurring to the brain itself.[citation needed] Using this information, Willoughby's team devised an experimental treatment for rabies.[6] Giese's parents agreed to the experimental treatment.[6]

Willoughby's goal was to put Giese into an induced coma to essentially protect her brain from the rabies virus with the hope she would survive long enough for her immune system to produce the antibodies to fight off the virus. Giese was given a mixture of ketamine and midazolam to suppress brain activity, and the antiviral drugs ribavirin and amantadine, while waiting for her immune system to produce antibodies to attack the virus.[6] Giese was brought out of the coma after six days, once signs of the immune system's progress became apparent.

After infection[edit]

After 31 days in the hospital, Giese was declared virus-free and removed from isolation. The extent of brain damage she had suffered was of initial concern, but while she had suffered some, the disease (and treatment) seemed to have left her cognitive abilities largely intact. She spent several weeks undergoing rehabilitation therapy and was discharged on January 1, 2005.[9] By early 2005, she was able to walk on her own, had returned to school, and started driver's education, indicating a successful recovery.[10]

Mayo Clinic neurologist Kenneth Mack described her condition as she entered college: "She's recovered 'remarkably well' and should continue to improve."[10] Giese graduated as a biology major from Lakeland College in the spring of 2011, at a ceremony attended by her parents and Willoughby. Giese wrote a thesis on a serious disease affecting bats and hopes to continue her studies and work with animals in some capacity, possibly in research as a biologist or veterinarian. Although she was a very conditioned athlete in high school, because of the neurological complications from the rabies, she still has problems with running and balance.[11]

Giese went on to be an ambassador for the Global Alliance for Rabies Control.[12]

Survival hypotheses[edit]

The reasons for Giese's survival under the Milwaukee protocol remain controversial. While the treatment appears to have worked as planned, her doctors have suggested that Giese might have been infected with a particularly weak form of the virus,[6] or that being bitten in a site far from the brain provided her immune system sufficient time to fight the virus.[citation needed] When admitted to the hospital, no live virus, only antibodies, could be isolated from her body,[13] and the bat was not recovered for testing.[6]

Medical experts disagree about the effectiveness of the Milwaukee treatment, pointing out that a certain antibody type appears in all survivors.[14] This suggests that a genetic or other immunological factor may affect survival.

Clinical trials[edit]

Out of 36 rabies patients treated with the Milwaukee Protocol, 5 have survived. Giese's treatment regimen has undergone revision (the second version omits the use of ribavirin). Two of 25 patients treated under the first protocol survived. A further 10 patients have been treated under the revised protocol, with a further two survivors.[15]

In June 2011, another child survived infection with rabies without receiving the vaccine before showing symptoms. Precious Reynolds, an eight-year-old girl from Willow Creek, California, contracted the disease in April 2011, but did not receive medical care until mid-May, after her grandmother took her to the doctor because of influenza-like symptoms that grew so serious, her grandmother said they resembled polio. The hospital said doctors followed the protocol established for Giese. Reynolds was placed in a drug-induced coma and received antiviral medications. She survived after spending two weeks in intensive care undergoing the treatments.[16]

Some critics say those survivors are due to the patients having a genetic rabies immunity and that the Milwaukee protocol has nothing to do with the survival rate;[17] however this would imply the five patients all happened to coincidentally survive rabies while receiving the Milwaukee protocol—despite no documented survivors before them.

Ketamine has been shown to have a direct effect against the rabies virus.[18]


  1. ^ "Rabies Rescue Protocol Fails in New Cases" accessed 15 January 2012
  2. ^ "Human Rabies --- Indiana and California, 2006" Accessed 15 January 2012
  3. ^ a b Rodney E. Willoughby, Jr., online "A Cure for Rabies?" Scientific American, V. 256, No. 4, April 2007, p. 95
  4. ^ Jordan Lite (2008-10-08). "Medical Mystery: Only One Person Has Survived Rabies without Vaccine--But How?". Scientific American. Retrieved 2008-10-16. 
  5. ^ Pommerville, Jeffrey (2007). Alcamo's Fundamentals of Microbiology (8th ed.). Sudbury, USA: Jones and Bartlett. p. 464. ISBN 978-0-7637-3762-7. 
  6. ^ a b c d e f g h Johnson, Mark; Kawanza Newson (2006-05-11). "Hoping again for a miracle". Milwaukee Journal Sentinel. Archived from the original on July 28, 2006. Retrieved 2008-07-16. 
  7. ^ Monica Murphy; Bill Wasik (July 26, 2012). "Undead: The Rabies Virus Remains a Medical Mystery". Wired. Retrieved August 4, 2012. 
  8. ^ Johnson, Mark; Newson, Kawanza (2005-06-18). "Down to a Prayer". Milwaukee Journal Sentinel. 
  9. ^ "First Unvaccinated Rabies Survivor Goes Home". Daily News Central. 2005-01-03. 
  10. ^ a b "Giese Overcomes Rabies, Heads to College", WEAU, August 30, 2007, Retrieved September 4, 2007
  11. ^ Johnson, Mark. "Rabies survivor Jeanna Giese graduates from college", Milwaukee Journal Sentinel, May 8, 2011. Retrieved June 13, 2011.
  12. ^ "Jeanna Giese remembers her experiences with rabies on her wedding day". Global Alliance for Rabies Control. 11 November 2014. Retrieved 26 March 2017. 
  13. ^ Willoughby, RE; Tieves, KS; Hoffman, GM; Ghanayem, NS; Amlie-Lefond, CM; Schwabe, MJ; Chusid, MJ; Rupprecht, CE (June 2005). "Survival after treatment of rabies with induction of coma" (PDF). New England Journal of Medicine. 352 (24): 2508–14. PMID 15958806. doi:10.1056/NEJMoa050382. 
  14. ^ Jackson AC. (July 2013). "Current and future approaches to the therapy of human rabies.". Antiviral Res. 99 (1): 61–7. PMID 23369672. doi:10.1016/j.antiviral.2013.01.003. 
  15. ^ Willoughby RE (2009). "Are we getting closer to the treatment of rabies?: medical benchmarks". Future Virology. MedScape. 4 (6): 563–570. doi:10.2217/fvl.09.52. 
  16. ^ "UC Davis Children's Hospital patient becomes third person in U.S. to survive rabies". UC Davis Medical Center. Retrieved 3 May 2012. 
  17. ^ "Undead: The Rabies Virus Remains a Medical Mystery". Retrieved May 15, 2015. 
  18. ^ Lockhart BP, Tordo N, Tsiang H (1992). "Inhibition of rabies virus transcription in rat cortical neurons with the dissociative anesthetic ketamine". Antimicrob Agents Chemother. 36 (8): 1750–5. PMC 192041Freely accessible. PMID 1416859. doi:10.1128/AAC.36.8.1750. 

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