SYMHC Classics: Rabies

This 2022 episode discusses how modern rabies prophylaxis is almost 100% effective at preventing human death from the bite of a rabid animal. How did people come to understand rabies, and then develop a vaccination for it?

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Episode Transcript

Speaker 1 (00:02):
Happy Saturday. Our episode on the Dick and Metal had
a brief mention of efforts to keep the UK free
of rabies, and we also just got an email from
listener Whitney on the subject of a mass rabies exposure
in the news, and we have been working on plans
for our trip to Morocco in November, which is a
country considered to be a high risk for dog rabies. Basically,

(00:24):
we're just thinking a lot about rabies right now, so
seemed like a good time to replay our May ninth,
twenty twenty two episode on the history of rabies. Enjoy
Welcome to Stuff You Missed in History Class, a production
of iHeartRadio. Hello, and welcome to the podcast. I'm Tracy V.

(00:51):
Wilson and I'm Holly Frye. Foxes are one of many
wild animals that share cities and other places with human beings,
and in April, one of them made headlines after biting
at least nine people around the US capital. When this
story crossed my Twitter feed, I became incredibly invested in

(01:12):
whether everybody who got bitten by this fox had gotten
their raby shots. Afterward, news articles were not telling me
the answer to this information some of them were talking
about a specific reporter or a specific congress person, but
I was like, no, everybody, everybody needs to get the
raby shots because foxes can carry rabies. Rabies is virtually

(01:36):
always fatal once people develop symptoms, once anyone develops symptoms,
but today's rabies profile axis is almost one hundred percent
effective at preventing that from happening. It is, I think,
the most effective vaccine that we have in existence. So
then when news broke that yes, this fox did have rabies,
it was like just a big flashing, screaming sign in

(01:57):
my brain, like raby shots, raby shots, Please tell me
everyone got their rabies shots. Of course, then that made
me want to do a podcast on rabies and the
vaccine that prevents it, something that somehow I thought we
already had stuff on. We don't, or if we do,
I failed to find it. The vast majority of our

(02:18):
listeners live in places where rabies deaths and humans are
extremely rare. Some parts of the world are rabies free,
and here in the United States there were only five
human deaths from rabies and twenty twenty one that was
the highest number of annual rabies deaths in the United
States in a decade. There are also places, though, where

(02:40):
rabies is still endemic, and globally about fifty six thousand
people die from it every year. That is a not
a like. That's a small number compared to something like
the current pandemic, but they're fifty six thousand totally preventable deaths,
like we have right what we need to prevent this,
so I want to talk about that adds up though

(03:02):
there's a lot of animal experimentation in this episode and deaths. Obviously,
Rabi's is caused by Rabi's lyssavirus, which probably originated in
Old World bats. This virus has existed on every continent
except Antarctica and Australia for millennia, and although Australia is

(03:22):
Raybi's free, it's home to a closely related virus called
bat Lissa virus. But in spite of the virus's connection
to bats, humanity's connection to Rabi's has mainly been through dogs.
That connection shows up in the first written reference we
have of rabies, that's in the Eshnuna code from roughly

(03:43):
two thousand BCE. Eshnuno was a city in what's now Iraq,
and some of its laws have survived on a pair
of broken tablets that were found at an archaeological site
near Baghdad. Here's one of the laws quote if a
dog is mad, and the authority have brought the fact
to the knowledge of its owner, if he does not

(04:03):
keep it in, and it bites a man and causes
his death, then the owner shall pay two thirds of
a mina of silver. If it bites a slave and
causes his death, he shall pay fifteen shekels of silver.
The first written reference to rabies in China is from
the Zuo tradition, sometimes called the Zoo Commentary. This is

(04:24):
a commentary on the Spring and Autumn Annals, which chronicles
a period of Chinese history stretching from seven twenty two
to four eighty one BC. One passage in the Tzuo
tradition describes people of the capital city of Sung chasing
a rabid dog. The dog ran into the home of
a minister named Huachen, and the people chased after it.

(04:46):
Quachen was afraid and fled the city. In about the
fourth century BCE, Aristotle wrote this in his History of Animals.
Quote dogs suffer from three diseases, es, quincy, and sore feet.
Rabies drives the animal mad, and any animal whatever, excepting man,
will take the disease if bitten by a dog so afflicted,

(05:10):
the disease is fatal to the dog itself and to
any animal it may bite. Man accepted. So this translation
makes it sound like Aristotle was saying that humans don't
get rabies, but it's also been interpreted as meaning that
people don't always develop rabies when bitten by a rabid dog,
and that is true, or that people don't always die

(05:32):
from the disease if they contract it, which is almost
never true. People have known that rabies was essentially always
fatal for thousands of years, though Roman court physicians Scribonius
largest described rabies as incurable in the first century CE.
In addition to being lethal, rabies progresses in a way

(05:52):
that can be really terrifying. The exact symptoms can vary,
but there are two broad categories, both of which end
in coma and death. Paralytic rabies involves lethargy, weakness, and paralysis,
and furious rabies involves agitation, aggression, and hyperactivity. The word

(06:13):
rabies reflects this latter type that comes from the Latin
for two rage, which may have roots in a Sanskrit
word meaning to do violence. Lisavirus has a similar root.
It comes from a Greek word meaning frenzy or madness,
which was used to describe rabies as well as to
describe irrational rage. Rabi shows up a lot in popular culture,

(06:37):
and that goes back thousands of years as well, including
the use of rabies or rabid dogs as a metaphor
for being mad or uncontrollable. For example, in the Iliad,
which was written in about the eighth century BCE, Homer
describes Hector as a rabid dog. Rabies can also cause
paralysis and spasms in the throat that make it impossible

(06:59):
to swallow water. That's why it's also known as hydrophobia.
In the second century CE, Roman philosopher Celsus used the
word hydrophobia in his description of the disease. Celsus also
recognized that something was present in saliva that transmitted this illness,
and he recommended a range of techniques to draw this

(07:22):
substance out of wounds. Like the connection between Rabi's and
aggressive rage, the connection between rabies and hydrophobia made its
way into literature centuries ago. For example, in about the
year five hundred, Kayleius Aurelianus suggested that Homer's description of
Tantalus in the Odyssey might have been inspired by rabies,

(07:43):
since Tantalus is tormented by water that he cannot drink.
It's also possible that rabies influenced ancient Greek depictions of Cerberus,
the multi headed dog that guarded the underworld, and that
those depictions of a mad beast with poisoned frothing from
its jaws circled back to influence people's perceptions of rabies.

(08:04):
So through these and other written references, we know that
rabies had spread from wherever it originated, all through India, China,
the Middle East, Greece, Rome, and Egypt by about fifteen
hundred years ago, but we don't really know how wide
spread the disease was in any of these places, or
how many deaths it caused among humans and other animals.

(08:27):
That starts to change in the medieval period, when people
started documenting large outbreaks of the disease within specific animals.
These accounts primarily focused on outbreaks among dogs and other canids,
including wolves and foxes. For example, an outbreak of wolf
raybies struck Franconia in twelve seventy one. A massive outbreak

(08:49):
among red foxes spread over parts of Europe between fifteen
seventy one and fifteen eighty one, leading people to try
to stop the disease by culling them. Sometimes these outbreaks
could spread to other animals, including infecting people when they
were bitten. At this point, we haven't mentioned rabies in
the Americas, and that's because while rabies existed in the

(09:12):
Americas through all this, rabid dogs probably did not, based
on genetic studies of the virus itself. Before European colonization,
rabies in the America's primarily infected bats and skunks. There's
some evidence that indigenous peoples in ancient Central and South
America regarded both bat bites and snake bites as potentially

(09:35):
dangerous and treated bat bites with washing and cauterization with
hot coals to try to prevent disease. Spanish colonists were
reported being bitten by bats in the early fifteen hundreds,
and in fifteen fourteen, Fernandez de Oviedo wrote about several
soldiers dying after being bitten by vampire bats. Dog rabies

(09:58):
is one of many diseases that Europeans introduced to the Americas,
and after that introduction it spread to other animals and
became far more likely to infect people, but that process
did not happen nearly as quickly with rabies as it
did with diseases like smallpox. Rabies typically has an incubation
period of roughly three to eight weeks, although it can

(10:20):
occasionally be much longer. Once symptoms appear, rabies is virtually
always fatal within about ten days. When Europeans first started
sailing to the Americas, the voyage often took more than
two months, so any dogs or other animals that had
been infected before setting sail usually developed symptoms and died

(10:40):
or were killed while still at sea. So that meant
introducing dog rabies to the Americas required a voyage that
was short enough for infected dogs to survive. It also
required a large enough population of dogs and other mammals
within a colony for the disease to keep circulating that
had been introduced. The first recorded outbreak of dog rabies

(11:05):
in the Americas was reported in Mexico City in seventeen
oh nine, and by the end of the eighteenth century,
dog rabies was widespread in most of the places in
the Americas that Europeans had colonized. This in turn spread
the disease to the continent's native animals, with some of
those exposures leading to new strains of the virus that

(11:26):
were adapted to specific species. We'll talk about how a
vaccine was developed to prevent rabies after a sponsor break.
By the eighteenth and nineteenth centuries, outbreaks of rabies were

(11:46):
spread across a lot of the world, in domesticated dogs
and in wild animals. In North America, rabies became so
widespread in skunks that they were nicknamed phobe Cats like
hydrophobe and phobe hens were advertised as a way for
cowboys to avoid being bitten by them in their sleep,
and eighteen oh three, an outbreak among wild foxes in

(12:09):
France spread to dogs, pigs, and people. Bites from rabid
wolves tended to be particularly lethal, in part because attacking
wolves often bit people's faces or necks, meaning the virus
was way closer to their brain, while rabid dogs usually
bit people's hands or arms. There was no cure for

(12:30):
rabies and no way to tell whether a person would
develop it after being bitten, and estimates of how many
people developed rabies after a bite stretch all the way
from five percent to fifty percent. Some of this is
just because of imprecise record keeping, but it's also connected
to how people responded to the disease. In many places,

(12:51):
there was a widespread assumption that any animal that bit
had rabies, and during outbreaks, people tended to hunt down
and kill animals that they thought might be spreading disease.
So a dog that bit someone in the midst of
all of this might be rabid, or it might just
be scared and cornered and trying to defend itself. Around
the world, people tried various herbs and medical preparations to

(13:15):
prevent or cure rabies, and because it was so lethal,
many of these also relied on the idea of divine intervention.
For example, Hubertus, also called Saint Hubert, is the patron
saint of hunting, and one of his reported miracles involved
curing somebody who had been bitten by a rabid dog.

(13:36):
So in much of Europe, people used a piece of
iron called Saint Hubert's key to cauterize bite wounds. As
part of this treatment, a priest would also make a
shallow cut over a person's forehead, place a black bandage
over that, and the person wore that bandage for nine days.
Some people even carried one of these keys around with

(13:57):
them for protection. Long before the development of the germ
theory of disease, people recognized that when someone was bitten
by a rabid animal, something in the animal's saliva was
going into the wound and potentially causing rabies. So some
of the other treatments for bites involved washing the wound,
applying caustic chemicals to it, or cauterizing it, whether it

(14:19):
was with a Saint Hubertus's key or with some other implement.
If these treatments were done immediately after a person was bitten,
they may have helped reduce the chance of developing rabies
by washing away the animals infected saliva. Thoroughly washing the
wound is still step one in rabies prevention today, but

(14:39):
none of this was enough to totally prevent the chance
of developing the fatal disease. People also tried to prevent
rabies by reducing the numbers of animals that could carry
it and transmit it to humans and to other animals.
For example, in eighteen sixty seven, the UK passed the
Metropolitan Streets Act. Among other things, this act empowered police

(15:01):
to collect and muzzle stray dogs, are dogs that were
determined to be dangerous. This reportedly led to a drop
in human cases of rabies in British cities. Also in
the eighteenth and nineteenth centuries, researchers were learning about rabies
and working on ways to prevent it spread. During the
earlier part of this time, researchers didn't yet know what

(15:23):
a virus was. But trying to talk around that got
really clunky. So we are still going to call it
a virus in our discussion today. Yeah, it was a
lot of incredibly stilted sentences before I was like, we're
just calling it a virus, regardless of whether that individual
researcher knew what a virus was. So in seventeen sixty nine,

(15:44):
Italian anatomist and pathologist John MORGANI observed that rabies traveled
via the nerves rather than traveling through the bloodstream. He
made this connection because some patients reported a feeling of
pins and needles or other neurological disturbances around the site
of their original bite wound. MORGANNYU was correct. Once it

(16:07):
enters the body. The rabies virus moves along the nerves
until it gets to the brain and the rest of
the central nervous system. After it gets to the brain,
the rabies virus makes its way to the salivary glands,
where it can cause excessive salivation. And although eighteenth century
researchers didn't quite have that part figured out, they did

(16:27):
know that the disease was spread through saliva. In seventeen
ninety three, Scottish surgeon John Hunter speculated that it would
be possible to use a lancet to intentionally introduce an
infected animal saliva into another animal, but it's not clear
whether he tried this in practice. We also don't know
whether German naturalist George Gottfried Zinka was familiar with Hunter's work,

(16:52):
but in eighteen oh four he brushed saliva from a
rabbit dog onto a cut he had made in the
leg of a health the dog. This previously healthy dog
contracted rabies. He did the same thing with other healthy mammals,
demonstrating that it was possible for the bite of an
infected dog to infect animals of other species. In eighteen

(17:14):
twenty one, French neurophysiologist Francois Magendi reported that he had
infected a previously healthy dog with saliva from a person
who had contracted rabies. Victor Gaultier was a professor at
the National Veterinary School in Lyon, France, and he started
experimenting with rabies in eighteen seventy nine. He found that

(17:37):
it was possible to transmit rabies from a dog to
a rabbit, and then from that rabbit to another rabbit.
Rabbits were smaller and easier to keep than dogs, and
they were less dangerous research subjects than rabbit dogs were.
Gaultier also found that the rabbits had a shorter incubation
period of about eighteen days rather than a month or

(17:58):
more that you might see in a dog. Gualtier did
various experiments with infected animal's saliva, attempting to see whether
he could find some way of using this infectious material
to prevent rabies. In eighteen eighty one, he injected rabies
virus into the jugular veins of sheep and they didn't
develop rabies, And then when he exposed one of them

(18:20):
to saliva from a rabid dog later on, it seemed
like it was immune to the disease. French chemist and
microbiologist Louis Pasteur started working on rabies at about this
same time, and he was inspired by Gautier's success. Pastor
already had an extensive background in this kind of work.
In the eighteen fifties, he had studied yeast and alcohol fermentation,

(18:43):
as well as the ability for microorganisms to contaminate fermenting beverages.
This had contributed to both the germ theory of disease
and the development of pasteurization. In the eighteen sixties, he
had identified a microorganism that was devastating the French silk
in day, and in the eighteen seventies he studied animal
diseases like anthrax and chicken cholera, including developing an anthrax vaccine.

(19:09):
While Pasteur had lots of experience in this kind of research,
he had pretty much no experience in medicine or the
clinical treatment of patience, so he relied on other people
for this knowledge, including French physician and bacteriologist Emil Roux.
A whole team of other scientists and doctors were involved

(19:29):
in this work as well, including Chiles Chamberlain, Emil Duclaux,
Luis Jullier, and Joseph Granche. This is definitely not a
solo effort, and Pasteur was not always excited about crediting
other people for their involvement in it. There are even
some historians who have accused him of stealing other people's ideas.

(19:51):
Much of Pastor's previous work had involved culturing bacteria and
working from those cultures, and he started out trying to
do the same thing with Rabi's. Since Rabi's is caused
by a virus rather than a bacterium, Pastor's efforts to
replicate his earlier process failed. He started working directly with
the saliva of infected animals and then moved on to

(20:13):
working with central nervous system matter. He found that if
he exposed a healthy rabbit to rabies, it developed rabies.
Then if he used that rabbit's central nervous system matter
to expose another rabbit, that second rabbit also developed rabies,
and the second rabbit's infection seemed to be more virulent
than the first. If he did this a third time,

(20:36):
the third rabbit's infection was also more virulent than the
seconds had been. He continued this serial passage of the
virus from rabbit to rabbit until he had a strain
of it that he described as fixed. It was consistent
and how virulent it was, and it had an incubation
period that was set at six or seven days. From there,

(21:00):
mastor Air dried the spinal cords of rabbits that had
died of that highly virulent fixed strain. The longer they dried,
the weaker the virus became. That's a process called attenuation.
When he exposed other animals to a small amount of
this attenuated virus, they seemed to develop a resistance to
rabies rather than becoming ill. From there, Pastors started to

(21:23):
wonder whether it was possible to make an animal more
resistant to rabies after it had already been bitten, preventing
it from developing the disease. Having successfully tested out this
idea in dogs, he tried it on two people, but
he didn't publish on either of these attempts, so they
were not known about until much later. One of these

(21:45):
was a man who had been bitten by a dog,
and while this man survived, it's also likely that he
had not actually been exposed to rabies. The other was
an eleven year old girl who had been bitten in
the face by a puppy, and she had already started
developing rabies symptoms. She died the day after she was
given the treatment. On July fourth, eighteen eighty five, nine

(22:07):
year old Joseph Meister was repeatedly bitten by a dog
in Alces. The dog was believed to be rabid, and
two days later the child was brought to Pest for help.
Emil rou had been heavily involved in Pester's research up
to this point, and he refused to be involved in
the boy's treatment because of ethical concerns. Pastor expressed some

(22:28):
reluctance as well, but Joseph Groanche and Alfred Vaupien of
the Academy de Medcent encouraged him to try, with Granche
administering the treatment since Pastor was not a doctor, Joseph
was given a series of inoculations over the span of
ten days, starting with a very weak preparation and working

(22:48):
up through ones that were less and less attenuated. Three
months later, he had no sign of rabies. Another attempt
was started with another patient shortly after Joseph Meister was
declared to be in the clear. That was Jean Baptiste Jupelee,
a fourteen year old shepherd who had been mauled while
saving a group of younger boys from a dog. Pastor

(23:10):
reported his results to the French Academy of Science on
October twenty sixth, eighteen eighty five, while Jupeel's treatment was
still ongoing. Told about his success with Joseph Meister and
the fact that he had successfully inoculated fifty dogs against
rabies before trying this process on a human. We're going
to talk more about what happened with all of this

(23:31):
after we paused for a quick sponsor break. As a
word of Pastor's success at preventing rabies started to spread,
people started flocking to him for treatment. By the start
of eighteen eighty six, he had treated at least three

(23:54):
hundred and fifty people. They came from all over Europe
and from the United States. In early December of eighteen
eighty five, a dog bit at least seven other dogs
and six children in Newark, New Jersey. Word of Pastor's
work had made it to the US, and a local
doctor published an appeal for funds to send the boys

(24:16):
to Paris for treatment. Four of the boys were sent
to Paris by steamer. The other two were determined to
not have sufficient injuries to need treatment. American news coverage
of these boys tripped to Paris and then their return
to the United States turned rabies vaccine into just a
media sensation, and three of the boys were displayed at

(24:40):
the Globe Museum in the Bowery in New York after
they all got home. Not everyone agreed with what Pasture
and his team were doing. Anti vivisectionists objected to the
use of animals in this research, and as we've said,
not everyone who is bitten by a rabid animal contracts rabies,
and not every animal who bite someone is rabbid. Since

(25:02):
there was still not a test for rabies, determining whether
an animal had it usually involved just waiting to see
if it died, but that wasn't really possible if it
had already been killed, or if it just couldn't be found.
You could also expose a healthy animal to the brain
or saliva of an animal who had bitten someone, but
by the time the healthy animal showed any symptoms, it

(25:24):
was just likely to be too late for the human patient.
So critics made the point that Pasteur was potentially exposing
people to rabies for no reason, and that his inoculation
might cause somebody who had been bitten by a non
rabid dog to then develop rabies because of their treatment.

(25:44):
Critics also noted that some of Pasteur's patients did die.
By November of eighteen eighty six, seventeen hundred patients had
received rabies injections and ten of them had died. The uncertainty,
combined with the death to spark a huge amount of
debate within the medical community about whether what Pasteur was

(26:05):
doing was ethical or even medically necessary. The Academy de
Mensa held a meeting on the subject on January eleventh,
eighteen eighty seven. Although Pastor's critics were vocal, his supporters,
led by doctor Joseph Gronchet, successfully defended his work. The
Institute Pasteur was established on June fourth, eighteen eighty seven,

(26:27):
and it opened on November fourteenth of that year. It
focused on disease research and on providing rabies vaccine. By
eighteen ninety eight, more than twenty thousand people had been
treated at the Pasteur Institute after a possible rabies exposure,
and only ninety six of them had died, or less
than half of a percent of patients. To be clear,

(26:50):
there was a lot about this early version of the
vaccine that was inherently unsafe. It was basically made from
animal brain or spinal cordtish. There could for sure be complications,
but this was still a dramatic improvement over an untreatable
fatal disease. Discoveries about the rabies virus continued after this point.

(27:13):
In nineteen oh three, Italian pathologist Aldecci Negri discovered round
and oval regions in the brains of animals that had
died of rabies, which he called Negri bodies. At the time,
he thought they were some kind of parasite, but they
actually arise as part of the reproductive cycle of the virus.
This paved the way for the first rabies tests. While

(27:35):
there are newer methods for detecting rabies in brain matter today,
negribodies are still sometimes used when those methods are not available.
The most reliable tests do still involve examining an animal's brain,
which is why living animals have to be euthanized to
be tested for rabies. Refinements in the vaccine were also

(27:57):
in the works. Pastors' methods didn't always produce a consistently
potent vaccine, and if it was too potent, it could
cause somebody to contract rabies in the early twentieth century,
researchers started using phenol to kill the virus rather than
attenuating it through air drying. Viruses were cultured in tissues

(28:19):
in nineteen thirty six, which led to tissue cultured vaccines
rather than using brain matter to make them. Today's rabies
vaccines are mostly cultured in human cells or in chick
embryos or some other cellular matter. Although some of Pastor's
colleagues speculated about whether it would be possible to mass

(28:40):
vaccinate dogs or other animals and lower the spread of
rabies to people, serious efforts to do that didn't start
until decades later, but efforts like that have led to
the successful eradication of rabies in some parts of the world.
There are too many rabies free countries today for us
to try to name them all. They include many islands,

(29:01):
including many Caribbean islands, the Canary Islands, the Falkland Islands,
the Galapagos Islands, the UK, Iceland, Japan, and New Zealand.
Several nations in continental Europe are also considered rabies free,
including much of Western Europe. We should note, though, that
rabies free often means rabies free in terrestrial animals. There

(29:25):
can still be rabies or other lissaviruses in bats, specifically,
so even if you are somewhere that is considered rabies free,
being bitten by a bat still warrants medical attention. Just
in general. Don't touch bats with your bare hands. You
don't need to be afraid of bats. They're generally pretty

(29:45):
shy and they're not gonna mess with you if you
don't mess with them. But like, don't go grab one
with your hand, which is so hard because they're so cute.
Not for me because I see one. Like if I
see a bat somewhere that I don't expect to see
a bat, I'm like, that bat is definitely a problem.
I Am not going anywhere near it. I will tell
a bat story in our behind the scenes. Ok. As

(30:07):
we said at the top of the show, Rabies is
still endemic in some parts of the world, including parts
of Asia and Africa. About forty percent of human rabies
deaths occur each year in India, with the vast majority
of those exposures coming from dogs, and some serious outbreaks
among wild animals started long after the rabies vaccine was developed.

(30:28):
For example, rabies was identified in North American raccoons in
nineteen thirty six, and there is an ongoing epidemic of
rabies among raccoons all along the East Coast. There are
efforts to get these and other outbreaks in wild animals
under control, using things like oral rabies vaccine baits. Yeah,
there are also mass vaccination campaigns, a lot of work

(30:51):
on this. A lot of the deaths that occur around
the world happen in children who'd like just wanted to
pet a dog and got bitten, so it is very sad.
It's also possible for one animal to spark a huge
exposure scenario, even in places where rabies is relatively well controlled.
For example, on October fifth, nineteen ninety four, a family

(31:13):
bought a kitten from a pet store in New Hampshire,
and then about three weeks later, this kitten developed seizures
and died. After its death, it was determined to have
had rabies. This kitten had been examined by a veterinarian
and had a certificate of health before it was sold,
but the pet store didn't have clear records of when

(31:34):
animals had arrived there or been sold, so in the end,
six hundred and sixty five people received post exposure prophylaxis
or PEP for rabies. These were people who had come
into contact with that kitten, or who had bought other
animals that had probably had contact with the kitten at

(31:54):
the store, or people who had contact with those animals,
people who worked at the store, people who visited the
store and handled the animals. Really just on and on.
The probable initial source for this whole thing was a
raccoon that may have come into contact with three feral
kittens that were then captured and sold at the store.

(32:16):
As a side note, you may have heard that Raby's
prophylaxis is a horrifying series of incredibly painful shots directly
into the stomach with a gigantic and terrifying needle. It
is not. Older versions of Raby's PEP did involve a
long series of fourteen to twenty one shots, usually given
in the abdomen, but that's just because the abdomen offered

(32:38):
a lot more surface area to work with, not because
the injections went into the stomach through a huge needle. Still,
I mean to be clear, that is a lot of
shots into a tender area, and the vaccine that was
in use at the time could have a range of
unpleasant side effects. Yeah, I would not want to get
fourteen to twenty one shots all around my abdominati think

(33:00):
like it was not a gigantically long needle going into
people's actual stomachs. It's also not what is in use today.
The current recommendation is that a person gets one dose
of human rabies immune globulin and one dose of rabies
vaccine shortly after the bite. The immune globulin is typically

(33:22):
injected near the bite location, and then the vaccine typically
goes into the deltoid region of the arm, where lots
of other vaccines go. Then the person gets three more
doses of vaccine that are spread out in the days
that follow, again as injections into the shoulder area. Also
using a vaccine that is like cultured in tissues and

(33:43):
a lot safer than what was being used in the past.
This process can be a little bit different for children,
or if a person is immuno compromised, or if a
person has been previously vaccinated for rabies. That's something that's
typically only done based on a person's risk for being
exposed to rabies. As another side note, we have been

(34:04):
really really focused on bites here because the overwhelming majority
of rabies exposures come from bites or possibly scratches. There
are some other ways to contract the disease, but they're
extraordinarily rare, like through the eyes or mucous membranes. If
someone is exposed to aerosolized rabies virus in some way,
or because rabies can closely resemble various types of encephalitis,

(34:28):
it is sometimes missed as a diagnosis when doctors don't
know that the person was bitten by an animal. This
has led to an extremely small number of rabies transmissions
through organ transplants, although the risk of this is extremely remote.
After their first report of it happening, many organ procurement
organizations started including screening questions to try to rule out

(34:50):
this possibility. Circling back around to rabies in pop culture,
this was actually a plot line on the TV show Scrubs.
Its sounds truly horrifying, but also like the disease process
that rabies causes, like in the umbrella of encephalitis, and
if a doctor doesn't know that a person was bitten
by an animal or picked up a bat or whatever,

(35:11):
like it's most doctors have never seen a case of
rabies in their career, and it's not the thing that
first comes to mind. In two thousand and four, fifteen
year old Gena Geezy and her medical team made headlines
after she became the first person known to survive rabies
after starting to develop symptoms. She had picked up and

(35:32):
been bitten by a bat, and although her wound was
cleaned with hydrogen peroxide, she wasn't taken in for further treatment.
She started developing symptoms about a month later, and then,
about six days into her illness, reported having been bitten
by the bat. Doctors placed Geezy in a medically induced
coma and gave her anti viral drugs and other treatments.

(35:53):
These treatments continued until tests suggested that her body was
fighting off the virus, and at that point she was
brought up of the coma. She survived this experience, and
news outlets have continued to report on her life into
the year twenty twenty one. At the time, this seemed
like a hopeful sign that what came to be known
as the Milwaukee Protocol would make it possible to cure

(36:15):
people after they started showing symptoms of rabies, but efforts
to replicate that success have been largely unsuccessful. One paper
in the Journal of the Brazilian Society of Tropical Medicine
traced thirty eight published uses of the Milwaukee protocol, including
one use of a similar protocol called the Recifi protocol.

(36:37):
Only eleven of those patients survived, with all but five
of them having moderate to severe complications afterward. This is
certainly an improvement over a disease with an essentially one
hundred percent fatality rate, but these numbers may be deceptively optimistic.
Three of the people who were described as having survived

(36:57):
did make it through the most critical part of the illness,
but they still died. At least one of the patients
may not have actually had rabies, and there's been no
coordinated method for tracking when this protocol has or hasn't
been attempted. It's likely that anyone who tried it and
succeeded would publish their results, but it's also possible that

(37:18):
people who tried it and failed have not yet. There
are some papers like Opinion Commentary written by teams of
doctors that are like this does not work and we
need to stop focusing our effort on it, and others
that are a little bit more like this may need
some other refining before it could work. Aside from all that, though,

(37:40):
all the patients described in these publications spent at least
a month in the hospital with extensive care throughout their stay,
so it's extremely unlikely that this protocol could really be
put into use in the places where human deaths from
rabies are the most prevalent. These places tend to be
rural and poor without a lot of health care infrastructure.

(38:01):
Places where people don't have access to rabies profile axis
are likely to also be places where people don't have
access to a hospital that could support this kind of treatment. Also,
it's extremely clear at this point that coordinated programs of
public education and dog vaccinations and sometimes vaccinations in particular

(38:23):
wild animals, can lower the number of human rabies deaths enormously,
and places that don't have the resources to support those
kinds of programs and initiatives are really likely not to
have the resources to support hundreds or thousands of people
with long term hospital stays and medically induced comas. It's

(38:45):
like even if this worked, it would really be working
for the wealthiest countries in the world and not the
places where treatment is most needed. So all of that said,
the global cost of rabies is roughly eight point six
billion dollars per year, and more than fifteen million people
per year receive Raby's PEP. This protocol can be really expensive.

(39:08):
In the United States, it can cost between twelve hundred
and sixty five hundred dollars. Yeah, that's like one estimate
that I can sew that I saw. I saw some
that were even higher than that. September twenty eighth of
every year is World Raby's Day. That's also the anniversary
of the death of Louis Pasteur. Well, that's a basic
history of rabies, raybees. My hope is that in the

(39:33):
future will at least get to the point where the
places in the world that have lots of free roaming
dogs also have those dogs vaccinated, because that's really where
like so much feeding back into the greater environment and
so much feeding into human cases of rabies, Like it's

(39:55):
all interconnected with the dogs. Yeah. I think we mention
it at the top of our episode on the history
of Veterinary Medicine that one of the vets at my
practice participates in a program where she goes to countries
where the dog population is not well vaccinated and tries
to just do as many vaccinations as they can in

(40:17):
a short period of time. Yeah, they had gone to Malawi,
I think, and Malawi's target is like seventy percent of
the dog population vaccinated, which would do a lot to
reduce the number of human deaths, but still would like
there would still be a reservoir of circulating rabies among
dog populations. There are a lot of sad parts to that,
but one of the saddest parts is like a lot

(40:38):
of a lot of the people who die of rabies
or like just a kid that wanted to pet a dog. Yeah,
thanks so much for joining us on this Saturday. If
you'd like to send us a note, our email addresses
History Podcast at iHeartRadio dot com, and you can subscribe

(40:59):
to the show on the ihea radio app, Apple Podcasts,
or wherever you listen to your favorite shows.