6 ms·

Why is it no longer recommended? Is it not the only viable way to save someone infected to life, when the disease has progressed far enough?

by mongol 8y ago

NeedMoreTea 8y ago
Because it has saved just one life. It's since been claimed that person may have had natural immunity or been unrepresentative in some other way. https://www.sciencedirect.com/science/article/pii/S0166354213000181 https://www.sciencedirect.com/science/article/pii/S016635421...
- voidlogic 8y ago
  You mean 13 lives. It has a 8% success rate.
  - jacurtis 8y ago
    Regardless... it is no where even close to statistically significant.
    - ALittleLight 8y ago
      But we might get the data to make statistically significant claims if we keep applying the protocol. By abandoning it, it seems we won't. If I were there patient and my options were medicated coma that possibly has an 8% chance of healing me and possibly has no benefit, I'd prefer that to the excruciating death by rabies I'd be facing otherwise.
    - raverbashing 8y ago
      One success on top of a solid 100% fatality rate is extremely significant
      - lbriner 8y ago
        You need to read the comments. The whole point is that it was not necessarily a success because subsequent tests showed it didn't work, there are several reasons why Ms Giese might have survived including the reasons why previous survivors who didn't get the protocol also survived.
  - NeedMoreTea 8y ago
    Of the 29 cases from 2005 to December 2014, "Therapy failed in all; the only survivor (Case No. 14) did not have neutralizing anti-rabies virus antibodies and likely did not have rabies" https://www.cambridge.org/core/journals/canadian-journal-of-neurological-sciences/article/critical-appraisal-of-the-milwaukee-protocol-for-rabies-this-failed-approach-should-be-abandoned/8A47C583B24B2B2E43248770F78CC35A/core-reader https://www.cambridge.org/core/journals/canadian-journal-of-... So where does 13 come from?
    - raverbashing 8y ago
      Not sure about 13, but the "only one success" is old news https://www.dailymail.co.uk/health/article-5258433/Brazilian-teen-14-fifth-person-cured-rabies.html https://www.dailymail.co.uk/health/article-5258433/Brazilian...
      - vidarh 8y ago
        It's not clear even all of those were successes at all, though - at least a couple of the claimed successfully treated patients subsequently died. Several others had completed most or all of the PEP treatments, and it's not clear if the MP had anything to do with their survival, given other patients have survived without MP in similar circumstances.
    - vorpalhex 8y ago
      This NCBI article claims 13: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4947331/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4947331/
      - vidarh 8y ago
        13 survivors total, not 13 saved by the Milwaukee protocol. Notably: > Prior to 2004, there were only five documented human survivors, all of whom had received the PEP, albeit incomplete or late [5] > In 2004, the first survivor without PEP was reported after this individual had undergone the MP. However, the use of the MP did not increase survival in subsequent cases [6]. Our patient was managed with aggressive supportive care without the MP or steroids. Our patient survived the acute phase of rabies encephalitis and was discharged after five months of intensive nursing care in the hospital. And: > Out of the seven reported rabies survivors until 2008, only the index case that used the MP did not receive PEP. Rabies virus was detected in only one case in all of the others that were diagnosed using only the rabies antibody [9]. Our case was diagnosed using both the rabies antibody and highly specific rabies antigen detection tests. The article points out a number of confounding factors that makes it hard to determine what saved the patient, including potential effects of use of PEP even if unsuccessful in stopping the disease completely (e.g. note that the virus itself was only found in one of the cases of survivors discussed by this article), the high level of other interventions to manage the disease, as well as the potential for genetic variations and the possibility that some of them didn't have Rabies in the first case
voidlogic 8y ago
You are right, its probably no longer recommended because they use a "modified Milwaukee protocol" now. That being said the MP is a last ditch effort and often fails. Its just the best option we have if someone is outside of the window for post-exposure prophylaxis (PEP). Treatment success rates: Vaccination: ~100% PEP: ~100% MP: ~8% So MP provides a slightly less than 1/10 chance for life when the patient would face otherwise certain death. You might find this interesting: http://www.mjdrdypu.org/article.asp?issn=0975-2870;year=2017;volume=10;issue=2;spage=184;epage=186;aulast=Agarwal http://www.mjdrdypu.org/article.asp?issn=0975-2870;year=2017...
durzagott 8y ago
According to a study [1] it has never been a viable treatment. The treatment has been repeated on at least 12 patients since the original case (Jeanna Giese) and has been a failure every time. No-one know why Ms Giese survived, but the Milwaukee protocol does not seem to have been the reason. Or if it was, it is not repeatable on other patients. [1] https://www.cambridge.org/core/journals/canadian-journal-of-neurological-sciences/article/critical-appraisal-of-the-milwaukee-protocol-for-rabies-this-failed-approach-should-be-abandoned/8A47C583B24B2B2E43248770F78CC35A/core-reader https://www.cambridge.org/core/journals/canadian-journal-of-...
- p49k 8y ago
  Sure, but I don't understand what the harm would be in trying the treatment for a patient who will otherwise have a 100% chance of dying in a very short timeframe. I mean, if the Milwaukee protocol did help the one patient, then the treatment has a 5% success rate, which is better than 0, no?
  - david-gpu 8y ago
    The outcome of an aggressive medical treatment can be much worse than death, not even taking economic or opportunity costs into account.
  - vidarh 8y ago
    The harm is that these patients and their families lose the tiny amount of time together they'd otherwise have left, because the patient is put in a coma. It's a difficult trade-off for a lot of high risk medical interventions to judge the relative worth of the potential chance of survival vs. that last remaining time, and it's certainly not a choice we can objectively make on behalf of other people. In this case it's not certain the protocol have helped any patients. If it did help, then the success rate is so low that there are ethical issues with overselling the potential vs. giving people that extra time together. If a patient wants to try, I'd be all for giving them that choice. But there's a big gap from letting a patient ask for something and promoting it as the recommended course of action without evidence of any efficacy.

Why is it no longer recommended? Is it not the only viable way to save someone infected to life, when the disease has progressed far enough?

by mongol 8y ago

Why is it no longer recommended? Is it not the only viable way to save someone infected to life, when the disease has progressed far enough?

NeedMoreTea 8y ago

Because it has saved just one life. It's since been claimed that person may have had natural immunity or been unrepresentative in some other way. https://www.sciencedirect.com/science/article/pii/S0166354213000181 https://www.sciencedirect.com/science/article/pii/S016635421...

voidlogic 8y ago
You mean 13 lives. It has a 8% success rate.
- jacurtis 8y ago
  Regardless... it is no where even close to statistically significant.
  - ALittleLight 8y ago
    But we might get the data to make statistically significant claims if we keep applying the protocol. By abandoning it, it seems we won't. If I were there patient and my options were medicated coma that possibly has an 8% chance of healing me and possibly has no benefit, I'd prefer that to the excruciating death by rabies I'd be facing otherwise.
  - raverbashing 8y ago
    One success on top of a solid 100% fatality rate is extremely significant
    - lbriner 8y ago
      You need to read the comments. The whole point is that it was not necessarily a success because subsequent tests showed it didn't work, there are several reasons why Ms Giese might have survived including the reasons why previous survivors who didn't get the protocol also survived.
- NeedMoreTea 8y ago
  Of the 29 cases from 2005 to December 2014, "Therapy failed in all; the only survivor (Case No. 14) did not have neutralizing anti-rabies virus antibodies and likely did not have rabies" https://www.cambridge.org/core/journals/canadian-journal-of-neurological-sciences/article/critical-appraisal-of-the-milwaukee-protocol-for-rabies-this-failed-approach-should-be-abandoned/8A47C583B24B2B2E43248770F78CC35A/core-reader https://www.cambridge.org/core/journals/canadian-journal-of-... So where does 13 come from?
  - raverbashing 8y ago
    Not sure about 13, but the "only one success" is old news https://www.dailymail.co.uk/health/article-5258433/Brazilian-teen-14-fifth-person-cured-rabies.html https://www.dailymail.co.uk/health/article-5258433/Brazilian...
    - vidarh 8y ago
      It's not clear even all of those were successes at all, though - at least a couple of the claimed successfully treated patients subsequently died. Several others had completed most or all of the PEP treatments, and it's not clear if the MP had anything to do with their survival, given other patients have survived without MP in similar circumstances.
  - vorpalhex 8y ago
    This NCBI article claims 13: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4947331/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4947331/
    - vidarh 8y ago
      13 survivors total, not 13 saved by the Milwaukee protocol. Notably: > Prior to 2004, there were only five documented human survivors, all of whom had received the PEP, albeit incomplete or late [5] > In 2004, the first survivor without PEP was reported after this individual had undergone the MP. However, the use of the MP did not increase survival in subsequent cases [6]. Our patient was managed with aggressive supportive care without the MP or steroids. Our patient survived the acute phase of rabies encephalitis and was discharged after five months of intensive nursing care in the hospital. And: > Out of the seven reported rabies survivors until 2008, only the index case that used the MP did not receive PEP. Rabies virus was detected in only one case in all of the others that were diagnosed using only the rabies antibody [9]. Our case was diagnosed using both the rabies antibody and highly specific rabies antigen detection tests. The article points out a number of confounding factors that makes it hard to determine what saved the patient, including potential effects of use of PEP even if unsuccessful in stopping the disease completely (e.g. note that the virus itself was only found in one of the cases of survivors discussed by this article), the high level of other interventions to manage the disease, as well as the potential for genetic variations and the possibility that some of them didn't have Rabies in the first case

voidlogic 8y ago

You are right, its probably no longer recommended because they use a "modified Milwaukee protocol" now. That being said the MP is a last ditch effort and often fails. Its just the best option we have if someone is outside of the window for post-exposure prophylaxis (PEP). Treatment success rates: Vaccination: ~100% PEP: ~100% MP: ~8% So MP provides a slightly less than 1/10 chance for life when the patient would face otherwise certain death. You might find this interesting: http://www.mjdrdypu.org/article.asp?issn=0975-2870;year=2017;volume=10;issue=2;spage=184;epage=186;aulast=Agarwal http://www.mjdrdypu.org/article.asp?issn=0975-2870;year=2017...

durzagott 8y ago

According to a study [1] it has never been a viable treatment. The treatment has been repeated on at least 12 patients since the original case (Jeanna Giese) and has been a failure every time. No-one know why Ms Giese survived, but the Milwaukee protocol does not seem to have been the reason. Or if it was, it is not repeatable on other patients. [1] https://www.cambridge.org/core/journals/canadian-journal-of-neurological-sciences/article/critical-appraisal-of-the-milwaukee-protocol-for-rabies-this-failed-approach-should-be-abandoned/8A47C583B24B2B2E43248770F78CC35A/core-reader https://www.cambridge.org/core/journals/canadian-journal-of-...

p49k 8y ago
Sure, but I don't understand what the harm would be in trying the treatment for a patient who will otherwise have a 100% chance of dying in a very short timeframe. I mean, if the Milwaukee protocol did help the one patient, then the treatment has a 5% success rate, which is better than 0, no?
- david-gpu 8y ago
  The outcome of an aggressive medical treatment can be much worse than death, not even taking economic or opportunity costs into account.
- vidarh 8y ago
  The harm is that these patients and their families lose the tiny amount of time together they'd otherwise have left, because the patient is put in a coma. It's a difficult trade-off for a lot of high risk medical interventions to judge the relative worth of the potential chance of survival vs. that last remaining time, and it's certainly not a choice we can objectively make on behalf of other people. In this case it's not certain the protocol have helped any patients. If it did help, then the success rate is so low that there are ethical issues with overselling the potential vs. giving people that extra time together. If a patient wants to try, I'd be all for giving them that choice. But there's a big gap from letting a patient ask for something and promoting it as the recommended course of action without evidence of any efficacy.