FAQs ON RABIES (101-155) FOR VETERINARIANS
by-DR RAJESH KUMAR SINGH ,JAMSHEDPUR,JHARKHAND, INDIA,
9431309542,rajeshsinghvet@gmail.com
All veterinarians, from those who work with farm animals to pets to wild animals, play a crucial role in protecting human health as well by managing crises such as diseases and zoonoses and foodborne diseases. Cross-border collaboration, communication and cooperation between veterinarians, represented by various vet org, and the various animal and human health-focussed agencies and industries they work with, such as the OIE, FAO and WHO, are important parts of global health initiatives-ONE WORLD ONE HEALTH..
The work these veterinarians undertake has been integral to the containment and eradication of several major diseases that have harmful effects on both human and animal health. One of the most well-known cases is rabies, which can be deadly in both humans and animals. The responsibility for controlling rabies and preventing transmission of this deadly viral disease is associated with vets. Vets are being asked several questions from the common people of society about Rabies.By providing detail knowledge about rabies , we can make our people aware about the deadly Rabies. On the occasion of the WORLD RABIES DAY I.E 27TH OCTOBER , I thought to post some most crucial informations which are not only useful to common people but also to vets.In this post I have compiled 155 faqs on behalf of common people from vets, It is not possible to post all at a times so it will be posted subsequently
101.How to calculate the total dose of HRIG/ERIG?
• Dosage of RIGs: Dosage for administration is decided on the basis of body weight.
For HRIGs: Dosage is 20 IU per kg body weight subject to a maximum of 1500 IU. HRIG has a longer half-life (about 21 days).
For ERIGs: Dosage is 40 IU per kg body weight subject to a maximum of 3000 IU.
102.What are the various brands of RIG available in India?
• Availability of different RIGs in India:- HRIG Brands
1. BERIRAB-P- manufactured by CSL Behring GmbH, Germany and marketed by Bharat Serum & Vaccines Ltd.
2. KAMRAB – manufactured by Kamada Ltd., Israel and marketed by Synergy.
ERIG Brands
1. Anti Rabies Serum – manufactured by CRI – Kasauli.
2. EQUIRAB – manufactured and marketed by Bharat Serum & Vaccines Ltd.
3. ABHAYRIG – manufactured by VINS Bioproducts and marketed by Human Biologicals Ltd.
4. VINIRIG – manufactured and marketed by VINS Bioproducts.
1o3.When should RIG be administered? What should be the time gap between RIG and vaccination?
• RIG is more effective if infiltrated immediately or within 24 hours of animal bite along with first dose of vaccine. If vaccine alone was started, then RIG can be given up to 7 days after starting first dose of vaccine. Ideally, rabies vaccine should precede RIG. However, in exceptional situations, approximately within 1 hour after administering RIG, the vaccine must be given
104.What are the precautions to be taken while administering RIGs?
• 1. Patient should not be on an empty stomach.
2. RIGs vial taken out from the refrigerator should be kept outside for a few minutes to warm it to room/body temperature.
3. While infiltrating RIGs into the bite wound, care must be taken to avoid injecting into blood vessels and nerves.
4. While injecting into finger tips, care must be taken to avoid compartment syndrome.
5. All emergency drugs and facilities for managing any adverse reactions must be available.
6. For ERIG, keep the patient under observation for at least one hour after ERIG administration and then send home.
7. RIGs can be infiltrated even to already sutured wounds without disturbing the sutures.
105.Can RIG and rabies vaccine be administered in the same syringe?
• RIG should never be administered in the same syringe or at the same anatomical site as vaccine administration.
106.Can RIGs be safely injected into already infected animal bite wounds?
• RIGs can be safely injected into already infected animal bite wounds following proper wound cleansing and administration of appropriate antibiotics.
106.Is it essential to perform skin sensitivity test prior to the administration of ERIG?
• Majority of reactions to ERIG result from complement activation and are not IgE mediated and will not be predicted by skin testing.
The recent WHO recommendation states that there are no scientific grounds for performing a skin test prior to the administration of ERIG, because testing does not predict reactions and ERIG should be given whatever the result of the test.
However skin test is mandatory to avoid any possible litigation under consumer protection Act (COPRA) in India.
107.How skin sensitivity test is performed?
• Inject 0.1 ml ERIG diluted 1:10 in physiological saline intra-dermally into the flexor surface of the forearm to raise a bleb of about 3-4 mm diameter.
Inject an equal amount of normal saline as a negative control on the flexor surface of the other forearm After 15 minutes an increase in diameter to > 10 mm of indurations surrounded by flare is taken as positive skin test, provided the reaction on the saline test was negative.
An increase or abrupt fall in blood pressure, syncope, hurried breathing, palpitations and any other systemic manifestations should be taken as positive test.
A negative skin test must never reassure the physician that no anaphylactic reaction will occur. Those administering ERIG should always be ready to treat early anaphylactic reactions with adrenalin. The dose is 0.5 ml of 0.1 percent solution (1 in 1000, 1mg/ml) for adults and 0.01 ml/kg body weight for children, injected subcutaneously or IM. If patient is sensitive to ERIG, HRIG should be used.
Most ERIGs that are manufactured presently are highly purified and the occurrence of adverse events has been significantly reduced. Unlike the original unpurified rabies antisera which resulted in adverse reactions in as many as 40% of recipients, the adverse-reaction rate of patients receiving highly purified ERIGs has been reduced to <1-2%. However adverse event like anaphylaxis cannot be completely ruled out.
108.What are the common adverse reactions to HRIG?
• In rare cases the following adverse reactions may occur:
1. Allergic reactions including fall in blood pressure, dyspnoea, cutaneous reactions, in isolated cases reaching as far as anaphylactic shock, even when the patient has shown no hypersensitivity to previous administration of Immunoglobulins.
2. Generalized reactions such as chills, fever, headache, malaise, nausea, vomiting, arthralgia and moderate back pain
3. Cardiovascular reactions particularly if HRIG is inadvertently injected intravascularly.
Local reactions:
At the injection site local pain, tenderness or swelling can be observed in rare cases.
109.If the skin test is positive to ERIG, what should be done?
• If skin test is positive, it is better to switch over to HRIG.
110.How adverse reactions to ERIGs are managed?
• Anti-sera of equine origin may cause anaphylactic shock and thus sensitivity testing is mandatory before giving ERIG. A negative skin test must never reassure the physician that no anaphylactic reaction will occur.
Management if anaphylactic reaction occurs:
1. Adrenaline: The dose is 0.5 ml of 0.1 percent solution (1 in 1000, 1mg/ml) for adults and 0.01ml/kg body weight for children, injected intramuscularly (IM).
2. Inj Hydrocortisone: 100 mg stat and 6 hourly I/V.
3. Inj Chlorphinaramine I/V.
4. Inj Ranitidine I/V.
If patient is sensitive to ERIG, HRIG should be used. Patient who had prior exposure of anti-sera (e.g.-Anti-tetanus serum, anti-diphtheria serum) should receive subcutaneous dose of Inj adrenaline (the requirement will be half dose of that required for treatment for anaphylaxis).
Tolerance and side effects:
1. There may be transient tenderness at the injection site.
2. Brief rise in body temperature.
3. Skin reactions are extremely rare.
4. RIG must never be given intravenously since this could produce symptoms of shock, especially in patients with antibody deficiency syndromes.
5. Serum sickness occurs in 1% to 6% of patients usually 7 to 10 days after injection of ERIG, but it has not been reported after treatment with HRIG.
ERIG should preferably be given in a hospital setting.
111.How to inject RIGs locally? What is the mode of administration of full dose of RIGs?
• It is important to infiltrate all wounds with RIGs. Intra-muscular (IM) administration of RIGs is of very little value. The previous recommendation was to give anti rabies serum half into wounds and half IM, which is no longer recommended and may lead to treatment failure. As much of the calculated dose of RIG, as is anatomically feasible, should be infiltrated into & around all the wounds. In the event that some volume of RIGs is left over after all wounds have been infiltrated, it should be administered by deep IM at a site distant from the vaccine injection site.
If the calculated dose of RIG is insufficient to infiltrate all wounds, sterile saline can be used to dilute it 2 or 3 fold to permit thorough infiltration.
112.Can RIG be given locally to a healed wound?
• Yes. If anti-rabies vaccination is not started, without disturbing the scab, RIG can be given locally.
113.If RIG is inadequate to infiltrate extensive wounds, what should be done?
• If RIG is inadequate to infiltrate extensive wounds, the RIG should be diluted with normal saline. This is a particular issue in children, whose body weight may be small in relation to the size and number of wounds.
114.If HRIG is not available, can human normal immunoglobulin (polyvalent) be given?
• Human normal immunoglobulin cannot be a substitute for HRIG.
115.What should be done to a person who has consumed milk of a rabid animal?
• If a person has consumed milk of a rabid animal, counseling should be done. If counseling is not effective, then PrEP by IM or ID route or as a last resort a course of PEP (only vaccine) should be given.
If the milk is boiled or heated then only counseling or at the most a course of PrEP should be given only due to compulsions in medical practice in Indian setting.
116.Can rabies be transmitted through sexual intercourse?
• Rabies virus is present in the semen and to some extent in vaginal secretions. Priapism, increased sexual libido and indulgence are seen both in male and female rabies cases. Hence, in the exposed person, a full course of rabies post-exposure vaccination either by Intramuscular (IM) or Intradermal (ID) route should be given. If there is any doubt of category III exposures, that is, abrasion on penis or in vagina, then even RIG must also be given by IM route.
117.Does kissing of a rabies patient call for anti-rabies vaccination?
• Kissing a rabies patient may transmit disease because there may be contact with rabies patient’s saliva. Full post-exposure immunization must be given either by Intramuscular (IM) or Intradermal (ID) route.
If there are ulcers in the mouth of the exposed person, then RIGs must be given by IM route
118.A person has handled or eaten the raw meat of a rabid animal. What should be done?
• If a person has handled or eaten the raw meat of a rabid animal, he should receive full course of rabies vaccine. If the person has eaten raw meat of a rabid animal and has oral ulcers/lesions, he may be given RIGs in thigh IM on day 0 along with first dose of vaccine.
119.If the rabid animal`s saliva falls into the eyes, what should be done?
• If the rabid animal`s saliva falls into the eyes, the eyes should be washed with water/saline and then RIGs can be instilled as eye drops, after dilution (1:1) with sterile normal saline along with full course of anti-rabies vaccination.
120.How should you approach a patient requiring RIGs, when none is available?
• 1. Thorough wound cleansing.
2. ESSEN IM vaccination with double dose on day 0 and refer the patient to RIG center.
121.Do antibodies from rabies vaccination cross an intact blood-brain barrier?
• No. Antibodies from vaccination do not cross an intact blood-brain barrier.
122.What should be done to a pet dog that is bitten by a stray dog?
• If a pet dog is bitten by a stray dog, wounds should be thoroughly washed and povidone iodine should be applied. Consult veterinarian for anti-rabies vaccination.
123.We often hear that the patient died of rabies but the biting dog was still alive. Is it possible?
• It is not possible
124.What is the incubation period in animals?
• In dogs and cats, the incubation period is 10 days to 6 months; most cases become apparent between 2 weeks and 3 months. In cattle, an incubation period from 25 days to more than 5 months has been reported (in vampire bat-transmitted rabies).
125.What are the signs of rabies in dogs/cats?
• 1. Any change in normal behavior suggesting either undue aggression or depression.
2. Running aimlessly and attacking others without provocation.
3. Becomes too drowsy and withdraws to a corner.
4. Change in voice/bark.
5. Excessive salivation.
6. Refusal to feed or eating objects like stone, paper, wood, metal pieces etc
126.What is the clinical course of rabies in animals?
• The clinical course of rabies in animals is divided into three phases:-
1. Prodromal,
2. Excitative
3. Paralytic.
However, the signs are variable and the lengths of phases may be irregular.
127.What are the signs of rabies during the prodromal phase in animals?
• Prodromal phase may last for 1-3 days and the animal may show only vague CNS signs, which intensify rapidly and death is virtually certain within 10 days after the initial onset of signs.
128.What is “furious form” of rabies in animals?
• The excitative phase follows the prodromal phase in some animals. The animal becomes irrational and may aggressively use its teeth, claws, horns, or hooves. The expression is one of anxiety with dilated pupils. Noise invites attack. Rabid animal roam extensively and attack other animals, including humans and any moving object. Cats usually manifest furious type of rabies.
129.What is “paralytic form” of rabies in animals?
• Paralytic or dumb rabies refers to animals in which the behavioral changes are minimal or absent and the disease is manifested mainly by paralysis. This is first manifested by paralysis of the throat and masseter muscles, often with profuse salivation and inability to swallow. Dropping of lower jaw is common in dogs. The animals are not vicious and rarely attempt to bite. The paralysis progresses rapidly to all parts of the body leading to coma and death follows in a few hours.
130.What is the cause of death in a rabid animal?
• Death in rabid animal is due to progressive paralysis.
131.Is hydrophobia a sign of rabies in dogs?
• Hydrophobia is not a sign of rabies in dogs. Rabid dogs can drink water and even swim in water. If a rabid dog is not able to drink water, it is because of paralysis of jaw muscles and not due to hydrophobia.
132.Are there any variations in signs of rabies between different species of animals?
• There are few variations in signs of rabies between different species of animals. Cattle with furious rabies attack man and other animals. A common clinical sign is a characteristic abnormal bellowing.
Head butting is a characteristic sign in case of rabies in cattle, sheep and goats.
133.Should modern rabies vaccines meant for use in man be given to animals?
• It is advisable to use human vaccines for human use and use the veterinary vaccines for animals
134.If vaccination is required for a person bitten by a vaccinated dog, then why vaccinate the dog at all?
• Vaccinating the pet dog is primarily to protect it against contracting rabies following bites by stray rabid dogs/animals. No veterinary vaccine offers 100% protection against rabies. Rabies is enzootic in our stray animal/dog population. The facility of protective antibody titre test (in vaccinated dog) is available only at a few centers in the country. The facility to quarantine the bitten vaccinated pet is limited and difficult. In view of the above facts and practical realities, rabies being 100% fatal, we take no chances and start PEP (immunization) in the bitten person and presume the vaccinated dog to be incubating rabies (and infective) and simultaneously observe the dog.
However, in extremely rare situations exception to the above thumb rule can be made at the professional discretion of the treating physician.
135.Can a vaccinated dog transmit rabies? How effective is dog vaccine?
• If a potent veterinary vaccine is given correctly as per pre-exposure schedule, it will mostly prevent rabies in the vaccinated dog, unless the exposure is severe. Ideally, its sera should be tested for protective antibody titre level but this is rarely practicable due to scare facilities in our country. Consequently, PEP vaccination is recommended following bites even by vaccinated dogs. It has been noted that:-
1. 6% of dogs found rabid have a reliable pre-exposure rabies vaccine history and that
2. 40% of dogs’ vaccinated only one time lost most of their immunity 4-6 months later.
3. Post Exposure Prophylaxis (PEP) vaccination is not very successful in dogs.
136.What is important for the success of Animal Birth Control (ABC) program?
• The success of this program hinges on the sterilization of 70% of the strays in a given geographic area within 6 months, before the next reproductive cycle begins; otherwise the entire effort is negated.
137.A pet dog died of sudden unexplained death. What should be done?
• If facilities are available post-mortem of the dog for confirmation of rabies is required. If not possible, (or if the post mortem proves rabies) all those who came in contact with the saliva of the animal (directly or through its fomites) should be given PEP.
138.Does treatment of provoked bites differ from unprovoked bites?
• Provocation is subjective & relative and specific to each dog/cat. However, obvious gross provocation viz., stamping, hitting, chasing, etc possibly suggest that the animal may not be rabid. However, the wound treatment of animal bites is the same.
139.An unvaccinated or partially vaccinated pet dog or cat is bitten by a stray dog. What should be done?
• If an unvaccinated or partially vaccinated pet dog or cat is bitten by a stray dog, wounds should be thoroughly washed with water and povidone iodine should be applied. If the stray dog is suspected to be rabid, then the pet dog should be put to sleep (Euthanasia). But if the owner is not ready or the rabid status of the stray dog is not known, post-exposure vaccination of the pet with cell culture vaccine and simultaneous careful observation of the pet are recommended for up to 2 months (up to six months is desirable) for possible signs of rabies in the pet. During this period for any sickness in dog, the owner should take the dog to the veterinarian to get rabies ruled out at the first instance. It should be noted that post-exposure vaccination is not very successful in dogs. Simultaneously, pre-exposure vaccination of all household members is necessary.
140.Can unvaccinated pet dog/cat pose danger to the family?
• As rabies is enzootic, that is, widely prevalent in stray dogs in India, if unvaccinated pet dog/cat is bitten by a stray dog, the pet may develop rabies and later pose threat at home to all family members.
Dogs effectively vaccinated against rabies ordinarily do not suffer and transmit the disease. But it is very difficult to say with certainty that a particular dog immunized with a specific vaccine is immune against rabies. If a tissue culture vaccine is regularly given to a healthy dog, it should develop sufficient protection. However, following severe and extensive bites (challenge dose of virulent virus infection) by a rabid dog, it may still succumb to rabies.
141.A vaccinated pet dog is bitten by a rabid animal. What should the owner do?
• Ideally, the pet dog should be put to sleep (Euthanasia). The usual method of euthanasia for dogs is by IV injection of either concentrated Magnesium Sulphate solution or concentrated pentabarbitone.
142.Is age of biting dog important in transmission of rabies?
• No. Neither the age nor the breed or sex of the dog is important in transmission of rabies.
143.How should the animal causing the bite be handled?
• It is important to establish if the biting animal is healthy or diseased, bearing in mind that a rabid animal excretes the virus in its saliva not just throughout the illness but also several days before the appearance of the first signs. An unknown animal, which has disappeared, must be considered as rabid and full course of PEP must be given. Cats and dogs, which can be identified, must be kept under observation. The risk of rabies can be considered as slight if the animal shows no sign of disease after 5 days, and non-existent if the animal is still healthy on the 10th day (The European Standards recommend an observation period of 15 days).
All wild animals, and those domestic animals suspected of having rabies must be put down and the rabies diagnosis must be carried out in the laboratory.
If it is proven that the animal is not rabid – and only then – the anti-rabies treatment may be halted.
144.Can rabies be transmitted to a dog that has eaten the flesh of a dead rabid cow or buffalo?
• Yes. The rabies virus after multiplying in the brain spreads to other organs of the body like the heart, muscles, skin, etc. So the dog can definitely get infected because the virus can spread through oral mucous membrane.
145.Can vaccinated dog succumb to rabies following bite by rabid animal?
• Following severe and extensive bites which mean injection of very high challenge dose of virulent virus by a rabid dog, a vaccinated dog can still succumb to rabies.
146.If the pet is immunized, do family members need pre-exposure vaccination?
• A dog effectively vaccinated against rabies ordinarily will not suffer and transmit rabies. But it is very difficult to say with certainty that a particular dog immunized with specific vaccine is immune against rabies, more so in a rabies-endemic area.
Animal lovers and pet owners are always at high risk of rabies, and therefore, pre-exposure vaccination is recommended for all the family members
147.When is World Rabies Day observed?
• “World Rabies Day” is on 28th September.
148.What humanizing your dog means?
• 1. Talking to your dog like he/she is a person.
2. Treating your dog like he/she is a person.
3. Allowing dogs to do what they want because it will hurt their “feelings.”
4. Dressing them up in little doggie clothes.
Remember, humanizing your dog is fulfilling your own human needs, not your dogs. Humanizing dogs does more harm than good.
149.What are the rules every dog owner should follow?
• 1. The number one way to communicate to a dog that you are his pack leader is to take him or her for a Pack walk daily, where the dog is made to heel beside or behind the human who is holding the lead. This is most important for all dogs, as in a dog’s mind, the leader always leads the way.
aA dog must not be allowed to sniff or eliminate anywhere he wishes, but where you allow him.
bThe dog should be concentrating on following the human.
2. All humans must eat before the dogs.
3. No table scraps should be fed to the dogs during a meal.
4. Feedings must be at a scheduled time.
5. Humans must not let the dog go through any doorways first.
6. When you have left the house or the room, even for a minute and come back, ignore the dog for a few minutes.
7. A simple obedience command should be given before any pleasurable interaction with the dog. A child in the house should give the dogs command at least once a day and reward with a treat when the command is followed.
8. You should not lie on the floor to watch TV when the dog is around, as a human should never put himself in an equal or lesser height position than the dog.
9. You are the first one who greets new comers; the dog is the last that gets attention.
10. If a dog is lying in your path, do not walk around the dog, either make the dog move or step over the dog.
11. If you establish eye contact with the dog, the dog must avert his gaze first. Tell the children not to have staring contest with the dog.
12. Dogs must not sleep in your bed.
13. Games of fetch or play with toys must be Started and Ended by the Human.
14. Dog should not be allowed to lie on your furniture.
15. No tug-of-war, as this is a game of power and you may lose the game giving the dog reinforcement (in the dog’s mind) of top dog.
16. Dogs need to be taught a drop it or release command.
17. Dogs should not be allowed to pull on the leash.
18. When you put his food dish down, he must wait until you give the “OK” to eat it.
19. Small dogs or puppies who demand to be picked up or put down should not get what they want until they sit or do another acceptable quiet behavior.
20. Dogs should never be left unsupervised with children or anyone who cannot maintain leadership over the dog.
21. Last but certainly not least… when you are around your dog avoid emotions. Your dog can sense these emotions and will see you as weak.
150.Why dogs always keep their mouth open with tongue protruding out?
• Dogs do not sweat through the skin. They exchange most of their heat through the mouth, and extend the tongue to increase the surface exposed to the air.
151.What is the latest news about Rabies disease?
• 1. Study of passive immunity in the prevention of rabies discusses the advances in passive immunoprophylaxis, most notably the shift from the recommended polyclonal human or equine immunoglobulin to monoclonal antibody therapies. The first rabies-specific monoclonal antibodies are undergoing clinical trials, so passive immunization might finally become an accessible, affordable, and routinely used part of global health practices for rabies.
2. A report on use of a reduced (4-dose) vaccine schedule for post exposure prophylaxis to prevent human rabies summarized new recommendation and updates previous recommendations of the Advisory Committee on Immunization Practices (ACIP) for post exposure prophylaxis (PEP) to prevent human rabies.
3. Human rabies can be very effectively prevented, and animal control is an important component in reducing the public health risk to humans. Dog rabies can be eliminated by well established control methods and routine dog rabies vaccination programs.
152.Can a Rabies patient make a valid will?
• A rabies patient can make a valid will.
According to Section 59 in the Indian Succession Act, 1925
Person capable of making will:- 1. Every person of sound mind not being a minor may dispose of his property by will.
2. A married woman may dispose by will of any property which she could alienate by her own act during her life.
3. Persons who are deaf or dumb or blind are not thereby incapacitated for making a will if they are able to know what they do by it.
4. A person who is ordinarily insane may make a will during interval in which he is of sound mind.
5. No person can make a will while he is in such a state of mind, whether arising from intoxication or from illness or from any other cause that he does not know what he is doing.
153.What are monoclonal antibodies?
• Monoclonal antibodies (mAb) are important reagents used in biomedical research, in diagnosis of diseases, and in treatment of such diseases as infections and cancer. These antibodies are produced by cell lines or clones obtained from animals that have been immunized with the substance that is the subject of study. The cell lines are produced by fusing B cells from the immunized animal with myeloma cells.
154.What is the role of monoclonal antibodies in Rabies?
• Monoclonal antibodies against rabies virus have been widely used in the diagnosis and immunological analysis of rabies. Human monoclonal antibodies to rabies virus G protein are also expected to be used as a replacement for rabies immunoglobulin (RIG) in the post-exposure treatment of rabies. In 1978, Wiktor reported the preparation of rabies virus monoclonal antibodies. Since then, rabies virus monoclonal antibody (mAb) technology has been more and more widely used in basic research and diagnosis of rabies.
155.What is Milwaukee protocol?
• The Milwaukee protocol is an experimental course of treatment of an acute 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 Dr. Rodney Willoughby, following the successful treatment of Jeanna Giese, a teenager from Wisconsin who became the first of only six patients known to have survived symptomatic rabies without receiving the rabies vaccine.
Medical history has shown most rabies deaths are caused by temporary brain dysfunction with little to no damage occurring to the brain itself. Using this information, Willoughby’s team devised an experimental treatment for rabies. Giese’s parents agreed to the experimental treatment. Dr. Willoughby’s goal was to put Giese into an induced coma to essentially protect herself from her brain, 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. Giese was brought out of the coma after six days, once signs of the immune system’s progress became apparent. After 31 days in the hospital, Giese was declared virus-free and removed from isolation.The reasons for Giese’s survival under the Milwaukee protocol remain controversial.
Recent WHO expert consultation did not recommend this protocol to be tried.
