Premature Demise of the Milwaukee Protocol

Paraphrasing Mark Twain, "reports of the demise of the Milwaukee Protocol (MP) [1] are greatly exaggerated."Dr. Jackson self-cites on rabies treatment but has no survivors; the "inexperienced clinicians" have 18 that are laboratory-confirmed and validated by health authorities.His Viewpoint mirrors the debate about the ethics and futility of treating childhood leukemia in 1970 [2].Dr. Jackson attempts to use reports of protocol failure as a rationale for futility.Reports of failures are statistically meaningless for a "universally fatal" encephalitis.Individual survivors remain statistically powerful [3].We agree that survivors remain unpublished.Most survivors are from low-and middle-income countries (LMICs) where clinical workloads, languages, and vertical bureaucracies are barriers.We can only report aggregate data, by intention-to-treat, demonstrating that the MP improved survival in human rabies when compared to contemporary controls (Figure) [4].Dr. Jackson dismisses two reports by the CDC, not us.(We do not count one that he lists.)He eliminates 3 of 19 survivors.We agree that there are more "appropriate" metrics for survival in 2025, but there were no survivors foreseen before 2005 when we defined it.We lose contact with most teams, so survival is censored with a median of 85 days while the 90 th percentile for rabies