The Man Who Survived Rabies

8 May

The Milwaukee Protocol and Its Impact on Modern Medicine

A handful of people have survived rabies, one of the deadliest viruses known to humans, thanks in part to an experimental treatment called the Milwaukee Protocol. Traditionally, rabies is nearly always fatal once symptoms appear, but this medical approach challenged that grim expectation and brought hope for both doctors and patients.

The Milwaukee Protocol involves placing patients in a medically induced coma and administering antiviral drugs, aiming to give the body a chance to fight off the virus. Interest in this protocol surged after a documented case where a person survived symptomatic rabies without prior vaccination, an outcome previously considered impossible.

The survival story that captured global attention prompted debate and further study of the protocol's effectiveness, as only a few individuals have walked away from rabies after its symptoms began. This case continues to influence the medical community’s ongoing efforts to find successful treatments for rabies and other severe viral infections.

Understanding Rabies

Rabies is a severe infectious disease caused by a virus that can affect both animals and humans. The disease is almost always fatal once symptoms begin, making awareness and timely prevention critical.

What Is Rabies

Rabies is caused by the rabies virus, a member of the lyssavirus genus. It primarily infects mammals and is best known for affecting the central nervous system. Once inside the body, the virus travels along nerves toward the brain, eventually leading to inflammation of the brain and spinal cord.

Rabies is classified as a zoonotic disease, meaning it is transmitted from animals to humans. The disease is present worldwide, except in a small number of countries that have eradicated it through strict animal control and vaccination programs. Human rabies can result from direct contact with infected saliva, most commonly through bites.

How Rabies Virus Spreads

Transmission of the rabies virus occurs almost exclusively through the bite or scratch of an infected animal. The virus is present in the saliva and nervous tissue of affected animals.

Common carriers include dogs, bats, raccoons, skunks, and foxes. In many regions, domestic dogs are the main source of human rabies cases. After entering the body, the virus migrates from the exposure site to the nervous system. Rare cases of transmission have occurred via organ transplantation or exposure to aerosolized virus in laboratory settings.

Immediate thorough washing of bite wounds and prompt medical attention can greatly reduce the risk of developing rabies. Post-exposure prophylaxis, if administered before symptoms appear, is highly effective at preventing the disease.

Symptoms of Rabies

Symptoms of rabies usually develop after an incubation period that ranges from several weeks to months. Early signs often resemble the flu, with fever, headache, and general weakness.

As the infection progresses, more specific symptoms develop, including anxiety, confusion, agitation, hallucinations, and difficulty swallowing. Patients may also experience hydrophobia, an intense fear of water due to trouble swallowing. Paralysis and coma follow as the virus spreads through the central nervous system.

The appearance of symptoms marks the near-certainty of death from rabies, as there is no effective treatment once the disease is established. The progression from initial symptoms to coma and death typically occurs within days to weeks.

Rabies Fatality Rate

Rabies is considered one of the deadliest infectious diseases known. Once symptoms of rabies begin, the fatality rate is greater than 99% in humans.

According to recent case reports, only a handful of individuals have survived symptomatic rabies, often due to aggressive medical intervention such as the Milwaukee Protocol. Globally, rabies causes tens of thousands of deaths each year, mainly in areas where vaccination and animal control are insufficient.

Prevention through vaccination of pets and timely post-exposure prophylaxis in humans remains the most effective method to fight rabies deaths.

Conventional Rabies Treatment and Prevention

Rabies is almost always fatal after symptoms appear, but modern medical approaches have made prevention highly effective. Vaccines, prompt medical care, and antibody-based treatments form the core of rabies management.

Rabies Vaccine

The rabies vaccine is a crucial tool for both pre-exposure and post-exposure protection. It contains inactivated rabies virus, which stimulates the immune system to prepare for future contact with the virus.

Pre-exposure vaccination is recommended for veterinarians, laboratory workers, travelers to high-risk regions, and anyone regularly at risk. The vaccine is generally administered in a series of three shots over three to four weeks.

In most cases, the body develops long-lasting immunity, supported by studies that show antibody levels remain protective for years. Boosters may be advised based on risk and antibody titer tests, especially in occupational settings.

Post-Exposure Prophylaxis

Post-exposure prophylaxis (PEP) is the standard response to a confirmed or suspected rabies exposure, such as an animal bite. PEP involves immediate wound cleaning and a series of rabies vaccine injections.

This approach is highly effective if started before the virus reaches the central nervous system. PEP typically includes rabies immunoglobulin (RIG) administered around the wound for previously unvaccinated individuals, providing passive antibodies.

Timeliness is critical. According to public health guidelines, starting PEP as soon as possible after exposure is essential, as delays can reduce protection.

Antibodies and Immune Response

Antibodies are proteins produced by the immune system in response to rabies virus antigens. The rabies vaccine and RIG both stimulate the body’s production of virus-neutralizing antibodies.

These antibodies prevent the virus from entering nerve tissue, which is key since rabies becomes nearly untreatable once established in the nervous system. The immune response generated after vaccination helps the body quickly destroy introduced viral particles.

Measurement of neutralizing antibody levels after vaccination guides booster requirements. Individuals with persistent risk are monitored to ensure adequate immunity using standardized antibody titer testing.

Vaccination Strategies

Vaccination strategies are tailored to risk level and regional needs. Routine vaccination is advised for pets and livestock, which limits the virus's spread to people. Wildlife vaccination programs often use oral vaccine baits to control infection among wild animals, reducing spillover to humans.

In high-risk occupational settings, regular booster doses and antibody monitoring are standard. International travelers headed to areas with endemic rabies may receive vaccine series prior to travel.

Public health campaigns emphasize pet vaccination, prompt wound care, and awareness of rabies risks. These coordinated strategies help minimize human cases and support broader disease control efforts.

The Jeanna Giese Case: Surviving Rabies

Jeanna Giese became internationally known after she survived rabies without receiving the vaccine. Her experience changed expectations for rabies patients and influenced treatment approaches in critical care settings.

Background of Jeanna Giese

Jeanna Giese grew up in Fond du Lac, Wisconsin, where she lived with her family. She attended high school locally and was active in her community. Before her illness, she was in good health with no underlying medical issues.

At the time of her infection, she was just 15 years old. Fond du Lac, a small city in Wisconsin, became the focus of global medical attention after Jeanna’s story emerged. Her case was soon recognized as historic in the study and treatment of rabies.

Bat Bite Incident

Jeanna Giese’s rabies infection began after a bat entered her local church in Fond du Lac in September 2004. The bat was flying around and was eventually caught. During the incident, Jeanna was bitten on her left index finger while helping to remove the bat from the building.

She initially did not tell her parents about the bite. The wound seemed minor, and she did not seek medical care or report the event at that time. She did not receive rabies post-exposure prophylaxis, which is the standard protocol after potential rabies exposure.

Initial Hospitalization

About a month after the bite, Jeanna started to experience symptoms of illness. She was admitted to Children’s Hospital of Wisconsin after complaints of fatigue, tingling, and numbness in her arm. Her symptoms progressed rapidly, including difficulty walking, confusion, and slurred speech.

Doctors ran several tests but could not initially determine the cause of her symptoms. Her condition started to deteriorate further as she developed trouble swallowing and experienced hallucinations. The possibility of rabies was not immediately considered due to the rarity of survival in confirmed cases.

Rabies Diagnosis and Symptoms

Once rabies was suspected, doctors investigated recent animal exposures. Jeanna’s parents recalled the bat bite incident, prompting further testing. Laboratory confirmation established that she was indeed infected with the rabies virus.

Jeanna’s symptoms included fever, neurological changes, and eventually respiratory distress. Rabies has an almost 100% fatality rate once symptoms appear. Doctors at the Children’s Hospital of Wisconsin decided to place her into a medically induced coma, attempting to suppress brain activity while her immune system responded—this became known as the Milwaukee Protocol.

Symptoms such as agitation, paralysis, and hydrophobia were documented. Despite the grim prognosis, Jeanna survived, making her the first documented rabies survivor who did not receive the vaccine. Her recovery contributed significant insights into rabies care and inspired further research on treatment protocols.

The Milwaukee Protocol: Experimental Life-Saving Procedure

The Milwaukee Protocol was one of the first documented attempts to treat symptomatic rabies, a condition almost universally regarded as fatal. By combining medically induced coma, targeted sedation, antiviral drugs, and intensive supportive care, the protocol aimed to give the immune system time to fight the rabies virus.

Development of the Milwaukee Protocol

The Milwaukee Protocol was developed in 2004 at Children's Hospital of Wisconsin. Doctors designed it after a teenage girl named Jeanna Giese became the first known person to survive symptomatic rabies without prior vaccination.

This experimental treatment arose from the understanding that rabies causes widespread brain dysfunction, but that the damage might be reversible if brain activity is suppressed during the early critical period. Physicians theorized that careful management of brain activity and controlling inflammation could offer a chance for survival.

Initial versions of the protocol involved placing the patient in a medically induced coma soon after diagnosis. Intensive monitoring and individualized adjustments became central features of the protocol as cases progressed. Over time, clinicians have revised the original approach based on subsequent patient experience and outcomes. The Milwaukee Protocol remains rare and controversial due to variable results.

Induced Coma and Sedation

A cornerstone of the Milwaukee Protocol is the use of a medically induced coma. Doctors employed sedatives such as ketamine and midazolam to suppress brain activity during the acute phase of the infection.

The aim was to protect the patient’s brain by limiting overstimulation caused by the rabies virus. Sedation also sought to control agitation, seizures, and other neurological symptoms that commonly manifest as the disease progresses.

Patient monitoring during this period is intensive. Cerebral activity, vital signs, and metabolic parameters are all watched closely. Adjustments to sedative doses are frequently needed to maintain a delicate balance between adequate brain suppression and general physiological stability.

Administration of Antiviral Drugs

The Milwaukee Protocol combines induced coma with a regimen of antiviral drugs. Medications like ribavirin and amantadine have typically been used, although the exact drug combinations have varied in different cases.

Antivirals aim to slow the replication of the rabies virus within the body. The drugs are generally started as soon as rabies is suspected or confirmed, and they are continued throughout the course of coma and recovery.

Despite this approach, there is limited evidence supporting the success of available antiviral agents against rabies in humans. This aspect of the protocol is considered experimental, and no standard antiviral regimen has yet been established.

Role of Supportive Care

Supportive care is vital during the Milwaukee Protocol. Patients require close monitoring in an intensive care unit (ICU), often for several weeks. Life-support measures may be necessary.

Supportive interventions include mechanical ventilation, management of electrolyte imbalances, and treating secondary infections. Nutritional support, hydration, and physical therapy are also part of daily care to prevent complications from immobility and prolonged sedation.

Multidisciplinary ICU teams—physicians, nurses, respiratory therapists, and others—coordinate to react promptly to complications. The complexity and intensity of this care highlight the challenges of attempting to treat rabies after symptoms appear.

Recovery Journey and Rehabilitation

Patients who survive rabies, such as those treated with the Milwaukee Protocol, face an extended and complex path to recovery. Their experience includes intensive rehabilitation, frequent neurological assessments, and monitoring for both immediate and long-lasting complications.

Rehabilitation Process

After initial stabilization, survivors of rabies infection require a multidisciplinary rehabilitation approach. Physical, occupational, and speech therapists work closely with patients to address motor skill deficits and regain basic functions.

Patients may undergo daily physiotherapy targeting muscle coordination, as muscle weakness and movement disorders are common after encephalitis. Cognitive rehabilitation aims to restore memory, attention, and problem-solving skills, while speech therapy helps those who struggle with communication due to neurological impairments.

Key areas of focus include:

Motor skills restoration
Speech and language recovery
Psychological support and adaptation

Progress is variable. Some regain most abilities, while others require ongoing care.

Long-Term Recovery

Long-term recovery from rabies is unpredictable, partly due to the intensity of viral encephalitis and individual response to treatment. Neurological follow-up can extend for months or years, with frequent outpatient appointments to track improvement or identify new issues.

Survivors may experience persistent fatigue, attention difficulties, or depression. Brain imaging and neuropsychological tests are regularly used to monitor healing and spot emerging problems. Long-term recovery demands both medical and psychosocial support, with adaptations in schooling, employment, or daily routines.

Ongoing education for families and caregivers is essential. This equips them to recognize changes in mood or function that may require medical attention.

Complications and Neurological Outcome

Rabies survivors often experience lasting neurological complications due to viral damage and the effects of acute encephalitis. These can include seizures, peripheral neuropathy, involuntary movements, or learning disabilities.

The severity of complications often depends on how early treatment began and the extent of brain injury. Some patients recover enough to lead semi-independent lives, while others require permanent assistance for basic tasks.

Possible neurological outcomes:

Complication Frequency Cognitive deficits Common Motor dysfunction Frequent Seizure disorders Occasional Speech/language impairment Variable

Early and tailored rehabilitation improves quality of life, but prevention of rabies exposure remains critical, as survival with minimal brain damage is still extremely rare.

Impact on Rabies Treatment Worldwide

The survival of a rabies patient using the Milwaukee Protocol challenged established beliefs about the disease’s fatality. Subsequent experience with the protocol generated changes, debate, and new protocols for managing rabies around the globe.

Changes in Rabies Management

The first reported rabies survivor to be treated with the Milwaukee Protocol drew international attention. This approach involved inducing a therapeutic coma and administering antiviral medications, shifting practices previously centered solely on prevention and palliative care.

Clinicians in multiple countries started considering the protocol for some acute rabies cases, especially those who had already shown symptoms. Pediatric infectious disease specialists and general practitioners re-examined their management strategies, with some hospitals adopting new guidelines for potential rabies patients.

Despite these changes, traditional rabies management—especially timely post-exposure vaccination—remained the cornerstone for prevention. The Milwaukee Protocol did not replace these measures but rather supplemented care in very rare situations.

Controversies Around the Milwaukee Protocol

The efficacy and safety of the Milwaukee Protocol soon came under scrutiny. Some researchers argued that its use might have been coincidental in the case of the original rabies survivor, as later attempts rarely succeeded.

Adverse effects were noted in several patients, including complications from the induced coma and side effects of antivirals. Reviews and mini-reviews reported inconsistent results, questioning whether survivors were actually cured of rabies due to the protocol.

Medical communities debated whether the protocol should be recommended for pediatric or adult rabies cases, given the high risk and uncertain benefit. Ethical concerns about offering a risky and unproven therapy to gravely ill patients were also raised.

Application in Later Rabies Cases

After the initial case, the Milwaukee Protocol was attempted in dozens of subsequent rabies patients worldwide. Success rates remained very low; most patients did not survive or experienced severe complications. Survivorship did not clearly correlate with the use of the protocol alone.

Most notably, there have been several cases—some in pediatric patients—who did not respond to the Milwaukee Protocol. In some reports, individuals who survived rabies appeared not to have received the full protocol or had atypical disease courses.

Hospitals and public health bodies have now largely scaled back use of the protocol. Attention shifted back to rabies prevention and rapid treatment after exposure as the most reliable ways to avoid fatal outcomes.

Risks of Rabies Transmission from Vampire Bats

Rabies is a fatal viral disease, and transmission through vampire bats poses specific dangers, especially in certain regions. Humans in close contact with these bats or living in affected areas face unique risks due to the animal’s feeding behavior and disease prevalence.

Vampire Bats as Vectors

Vampire bats (genus Desmodus) are native to the Americas and are significant vectors for rabies virus transmission. Unlike other bats, vampire bats feed on the blood of mammals, including humans and livestock, increasing the probability of a bat bite transmitting the disease.

A vampire bat bite introduces the virus directly into the bloodstream through saliva, making rabies transmission highly efficient. These bats are mostly active at night, and their painless bites may go unnoticed, leading to delayed treatment initiation.

Surveillance studies have documented rabies outbreaks linked specifically to vampire bat populations. The repeated feeding behavior of these bats can result in multiple exposures within a community. This characteristic makes their role as vectors particularly concerning in rural or remote areas where preventive measures are limited.

Outbreaks in South America

Vampire bat-transmitted rabies is a documented public health issue in South America, particularly in countries like Peru and Brazil. Indigenous populations and rural communities are at greater risk, as they often live close to bat habitats and have limited access to vaccination or post-exposure prophylaxis.

Reports from the Amazon suggest that up to 10% or more of some populations may have been exposed to rabies by vampire bats. Outbreaks typically occur after periods of increased bat activity or changes to the bats’ ecosystem, such as deforestation or shifts in livestock availability.

In affected regions, clusters of human rabies cases often follow incidents where bat bites go untreated or are not recognized in time. Local health agencies have responded by implementing bat control measures, educational programs, and targeted vaccination campaigns to reduce new transmissions.

The Role of Medical Teams and Neurologists

Survival from rabies once symptoms have begun is exceptionally rare. The Milwaukee Protocol brought together physicians, specialists, and hospital staff in a coordinated effort with a focus on neurology and critical care.

Multidisciplinary Care

A dedicated team at the Children’s Hospital of Wisconsin led the response for the first known survivor of symptomatic rabies treated with the Milwaukee Protocol. This group included emergency doctors, infectious disease experts, neurologists, intensive care specialists, nurses, and pharmacists.

Care was highly structured, with daily collaboration between neurologists and other team members. Critical decisions, such as inducing a medically controlled coma and closely monitoring brain function, depended on the expertise of neurology professionals.

The pharmacists managed complex antiviral treatments, while nurses oversaw patient stability and round-the-clock observation. Infectious disease doctors monitored the virus’s progress and advised on post-exposure protocols for staff.

Key Contributions to Recovery

Neurologists played a central role by continually assessing brain activity and managing symptoms of encephalitis. Their judgment guided the depth and duration of the coma used as a protective measure for the patient’s brain.

In patient monitoring, laboratory staff provided frequent test results allowing medical teams to detect complications early. The collaborative approach meant medication adjustments and new interventions could be implemented immediately.

Intensive care staff maintained respiratory and cardiovascular stability during the protocol. Their attention to detail prevented complications commonly involved with prolonged coma and supported gradual recovery.

The expertise and round-the-clock involvement of the multidisciplinary team at Children’s Hospital of Wisconsin were essential components in the outcome. Their coordinated actions and specialist insight transformed what was once a uniformly fatal diagnosis into a case with hope for recovery.

Ijaz Malik

The Man Who Survived Rabies

The Milwaukee Protocol and Its Impact on Modern Medicine