Editing Rabies (section)

==Treatment==
===After exposure===
[[postexposure prophylaxis|Treatment after exposure]] can prevent the disease if given within 10 days. The rabies vaccine is 100% effective if given early, and still has a chance of success if delivery is delayed.<ref name=Sherris/><ref name="CDC_Rabies_PEP"/><ref name="Lite2009">{{cite magazine|url=http://www.scientificamerican.com/article.cfm?id=jeanna-giese-rabies-survivor |title=Medical Mystery: Only One Person Has Survived Rabies without Vaccine—But How? |magazine=[[Scientific American]] | first = Jordan | last = Lite | name-list-style = vanc |date=8 October 2008 |access-date=2010-01-30 |url-status=live |archive-url= https://web.archive.org/web/20091105091606/http://www.scientificamerican.com/article.cfm?id=jeanna-giese-rabies-survivor |archive-date=5 November 2009 }}</ref> Every year, more than 15&nbsp;million people get vaccinated after potential exposure. While this works well, the cost is significant.<ref>{{Cite web|url=https://www.who.int/neglected_diseases/news/human_rabies_better_coordination_and_emerging_technology/en/ |title=Human rabies: better coordination and emerging technology to improve access to vaccines |website=World Health Organization |language=en-GB |access-date=2017-02-23 |url-status=live |archive-url=https://web.archive.org/web/20170224131644/http://www.who.int/neglected_diseases/news/human_rabies_better_coordination_and_emerging_technology/en/ |archive-date=24 February 2017 }}</ref> In the US it is recommended people receive one dose of human rabies [[immunoglobulin]] (HRIG) and four doses of rabies vaccine over a 14-day period.<ref>[https://www.cdc.gov/mmwr/pdf/rr/rr5902.pdf "Use of a Reduced (4-Dose) Vaccine Schedule for Postexposure Prophylaxis to Prevent Human Rabies"] {{webarchive|url=https://web.archive.org/web/20110725112251/http://www.cdc.gov/mmwr/PDF/rr/rr5902.pdf |date=25 July 2011 }}. [[Centers for Disease Control and Prevention]] (CDC).</ref> HRIG is expensive and makes up most of the cost of post exposure treatment, ranging as high as several thousand dollars.<ref>{{cite web|url=https://www.cdc.gov/rabies/location/usa/cost.html |title=Cost of Rabies Prevention |url-status=live |archive-url=https://web.archive.org/web/20160329143011/http://www.cdc.gov/rabies/location/usa/cost.html |archive-date=29 March 2016 |date=11 June 2019 }}</ref> As much as possible of this dose should be injected around the bites, with the remainder being given by deep intramuscular injection at a site distant from the vaccination site.<ref name="CDC_Rabies_PEP">{{cite web |url=https://www.cdc.gov/rabies/exposure/postexposure.html |title=Rabies Post-Exposure Prophylaxis |publisher=[[Centers for Disease Control and Prevention]] (CDC) |date=23 December 2009 |access-date=2010-01-30 |url-status=dead |archive-url=https://web.archive.org/web/20100201085054/http://www.cdc.gov/rabies/exposure/postexposure.html |archive-date=1 February 2010 }}</ref>

People who have previously been vaccinated against rabies do not need to receive the immunoglobulin, only the postexposure vaccinations on days 0 and 3.<ref>Park's textbook of Community medicine, 22nd edition, 2013, p 254.</ref> The side effects of modern [[cell-based vaccine]]s are similar to the side effects of flu shots. The old nerve-tissue-based vaccination required multiple injections into the abdomen with a large needle but is inexpensive.<ref name="Ly2009"/> It is being phased out and replaced by affordable World Health Organization intradermal-vaccination regimens.<ref name="Ly2009"/> Intramuscular vaccination should be given into the [[deltoid muscle|deltoid]], not the [[gluteal muscles|gluteal area]], which has been associated with vaccination failure{{Citation needed|date=May 2020}} due to injection into fat rather than muscle. In children less than a year old, the lateral thigh is recommended.<ref>{{cite web|url=https://www.who.int/ith/vaccines/rabies/en/ |title=Rabies |website=www.who.int |publisher=[[World Health Organization]] |access-date=1 February 2015 |url-status=live |archive-url=https://web.archive.org/web/20150215014809/http://www.who.int/ith/vaccines/rabies/en/ |archive-date=15 February 2015 }}</ref> Thoroughly washing the wound as soon as possible with soap and water for approximately five minutes is effective in reducing the number of viral particles.<ref>{{cite web |url=http://www.health.vic.gov.au/ideas/bluebook/rabies_info |title=Rabies & Australian bat lyssavirus information sheet |publisher=Health.vic.gov.au |access-date=2012-01-30 |url-status=dead |archive-url=https://web.archive.org/web/20110818081218/http://www.health.vic.gov.au/ideas/bluebook/rabies_info |archive-date=18 August 2011 }}</ref> [[Povidone-iodine]] or alcohol is then recommended to reduce the virus further.<ref>{{cite web |author1=National Center for Disease Control |title=National Guidelines on Rabies Prophylaxis |url=http://nicd.nic.in/Rabies_guidelines2014.pdf |access-date=5 September 2014 |year=2014 |url-status=dead |archive-url=https://web.archive.org/web/20140905235321/http://nicd.nic.in/Rabies_guidelines2014.pdf |archive-date=5 September 2014 }}</ref>

Awakening to find a bat in the room, or finding a bat in the room of a previously unattended child or mentally disabled or intoxicated person, is an indication for [[post-exposure prophylaxis]] (PEP). The recommendation for the precautionary use of PEP in bat encounters where no contact is recognized has been questioned in the medical [[literature]], based on a [[cost–benefit analysis]].<ref>{{cite journal | vauthors = De Serres G, Skowronski DM, Mimault P, Ouakki M, Maranda-Aubut R, Duval B | title = Bats in the bedroom, bats in the belfry: reanalysis of the rationale for rabies postexposure prophylaxis | journal = Clinical Infectious Diseases | volume = 48 | issue = 11 | pages = 1493–9 | date = June 2009 | pmid = 19400689 | doi = 10.1086/598998 | doi-access = free }}</ref> However, a 2002 study has supported the protocol of precautionary administering of PEP where a child or mentally compromised individual has been alone with a bat, especially in sleep areas, where a bite or exposure may occur with the victim being unaware.<ref>{{cite journal | vauthors = Despond O, Tucci M, Decaluwe H, Grégoire MC, S Teitelbaum J, Turgeon N | title = Rabies in a nine-year-old child: The myth of the bite | journal = The Canadian Journal of Infectious Diseases | volume = 13 | issue = 2 | pages = 121–5 | date = March 2002 | pmid = 18159381 | pmc = 2094861 | doi = 10.1155/2002/475909 }}</ref>

{{anchor|Jeanna Giese}}

==={{anchor|Jeanna Giese}}After onset===
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At least two treatment schemes have been proposed to treat rabies after the onset of disease, namely the Milwaukee Protocol and the Recife Protocol. The Milwaukee Protocol initially came into use in 2003, when it was tested on Jeanna Giese. Subsequently, the teenager from Wisconsin became the first person known to have survived rabies without preventive treatments before symptom onset. The basic idea is to put a person into a chemically induced coma and to use antiviral medications to prevent fatal [[dysautonomia]]. However, the overall protocol is complex. The sixth version of the protocol last updated in 2018 consists of 17 pages with 22 steps of treatment, detailed monitoring and a timeline of expected complications.<ref>{{Cite web |title=Milwaukee Protocol, version 6 (updated November 2018) |url=https://www.mcw.edu/-/media/MCW/Departments/Pediatrics/Infectious-Diseases/Milwaukee_protocol.pdf?la=en}}</ref> The Recife Protocol follows the same principle but differs in details like termination of sedation and supplementary medication.<ref name="ncbi">{{Cite journal |title=Comparing clinical protocols for the treatment of human rabies: the Milwaukee protocol and the Brazilian protocol (Recife) |year=2020|pmc=7670764|last1=Ledesma|first1=L. A.|last2=Lemos|first2=E. R.|last3=Horta|first3=M. A.|journal=Revista da Sociedade Brasileira de Medicina Tropical|volume=53|pages=e20200352|doi=10.1590/0037-8682-0352-2020|pmid=33174958}}</ref> Some experts assessed the Milwaukee Protocol as an ineffective treatment with concerns related to the costs and ethics. Yet a study published in 2020 found 38 case reports for the Milwaukee Protocol and only one for the Recife Protocol with a total of 11 known survivors with varying sequelae.<ref name="ncbi" />