No More Monkey Business In Florida
Dear Friends & Neighbors,
Rhesus Macaque with two babies in Shimla Himachal Pradesh near the Jake Temple.(photo attribution: Aiwok, presented at WindermereSun.com)
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Back in the 1930’s, the manager of the glass bottom boat operation, Colonel Tooey, was reported to have released about six rhesus macaques in hope that they would attract tourists and increase revenue for the boat tours at Silver Springs State Park of Florida. But in a recent study published on Wednesday indicated that some of the roaming monkeys in Florida are excreting virus that can be dangerous to humans. Scientists studying a growing population of rhesus macaques in Silver Springs State Park said that these monkeys may pass the herpes B virus through their saliva and other bodily fluids, posing great risk in spreading the disease. Below is an excerpt from CDC (Centers for Disease Control and Prevention) about infection associate with herpes B virus via rhesus macaques, in italics:
Based on findings published in the CDC journal Emerging Infectious Diseases, researchers from the universities of Florida and Washington warned Florida’s wildlife agency that the infected monkeys should be considered a public health concern. Florida Fish and Wildlife Conservation Commission officials stated that they support the removal of these monkeys from the state.
B Virus (herpes B, monkey B virus, herpesvirus simile, and herpesvirus B)
B virus infection is caused by a herpes virus. B virus is also commonly referred to as herpes B, monkey B virus, herpesvirus simiae, and herpesvirus B.
The virus is found among macaque monkeys, including rhesus macaques, pig-tailed macaques, and cynomolgus monkeys (also called crab-eating or long-tailed macaques). Macaque monkeys are thought to be the natural host for the virus. Macaques infected with B virus usually have no or only mild symptoms. Macaques housed in primate facilities usually become B virus positive by the time they reach adulthood. However, infection in macaques can only be transmitted during active viral shedding through body fluids.
Infection with B virus is extremely rare in humans. When it does occur, the infection can result in severe brain damage or death if the patient is not treated soon after exposure (see Risks for Infection and Treatment sections). Infection in humans is typically caused by animal bites or scratches or by mucosal contact with body fluid or tissue.
Prevention
There are no vaccines available for B virus. Experimental vaccines have been evaluated in animal models, but none are being considered for human trial.
With the substantial increase in the use of macaque models for research (e.g., HIV), the number of potential human exposures to B virus has likewise increased. This has led to the publication of guidelines, which have been updated several times, by expert panels of virologists, veterinarians, and physicians—the Recommendations for Prevention of and Therapy for Exposure to B virus (Cercopithecine Herpesvirus 1 in Clinical Infectious Diseases, 2002.
Principal Recommendations for Prevention
While exposures that involve unpredictable, potentially aggressive animals are not completely preventable, adherence to appropriate laboratory and animal facility protocols will greatly reduce the risk of B virus transmission.
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Work with B virus–susceptible monkeys should be done using humane restraint methods that reduce the potential for bites and scratches.
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Proper personal protective equipment, including a lab coat, gloves, and a face shield, must be used when working with macaque monkeys.
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Any bites, scratches, or exposure to the tissues or secretions of macaques must be cleansed immediately, as detailed in the Recommendations mentioned above.
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Following B virus exposure, samples from both the exposed human and the implicated macaque should be sent for B virus diagnostic testing (see Specimen Collection section).
For more detailed information, refer to the Recommendations for Prevention of and Therapy for Exposure to B virus (Cercopithecine Herpesvirus 1) as well as other resources listed in the Resources and Publications section.
Transmission
B virus infection in humans usually occurs as a result of bites or scratches from macaques—a genus of Old World monkeys that serve as the natural host—or from direct or indirect contact of broken skin or mucous membranes with infected monkey tissues or fluids. The virus can be present in the saliva, feces, urine, or nervous tissue of infected monkeys and may be found in cell cultures derived from infected monkeys.
Possible routes of transmission to humans include
- Bite or scratch from an infected animal
- Needlestick from contaminated syringe
- Scratch or cut from contaminated cage or other sharp-edged surface
- Exposure to nervous tissue or skull of infected animal (especially brain)
B virus can survive for hours on the surface of objects, particularly on surfaces that are moist. The injury need not be severe for infection to occur, although less severe wounds (those that don’t break the skin) are thought to carry a lower risk of transmission.
Risk of B virus transmission to humans should be considered in the context of how rare infection occurs, even among broadly infected populations of animals. Hundreds of macaque bites and scratches occur annually in primate facilities in the United States, but B virus infection in humans is rare. In a study of more than 300 animal care workers, among whom, 166 reported possible transmission exposures to macaques, none of the workers were found to be B virus positive.
Only one case of human-to-human transmission has been documented; the case, which was reported in a study of a B virus outbreak involving four persons in Florida, resulted from direct physical contact with lesions (see Epidemiologic Notes and Reports B-virus Infection in Humans — Pensacola, Florida. Morbidity and Mortality Weekly Report 1987). Among the four persons, three were animal handlers (two suffered bite wounds and one had close contact with the sick macaque but was not injured or exposed to other bodily fluids and did not develop symptoms). The fourth person was the wife of one of the animal handlers. She used an ointment to treat her husband’s lesions and subsequently used it on herself to treat contact dermatitis. She seroconverted to B virus but never developed symptoms. The study found no evidence of B virus infection among 130 close contacts of the four patients, healthcare workers, or primate workers. Moreover, even though B virus seroprevalence among adult macaques is >70%, only a few people in the study developed laboratory evidence of B virus exposure. Thus, transmission of this virus, both human-to-human and primate-to-human, is quite rare.
Signs and Symptoms
Monkeys infected with B virus usually have no or only mild symptoms. In humans, however, B virus infection can result in acute ascending encephalomyelitis (inflammation of the brain and spinal cord), resulting in death or severe neurologic impairment.
Disease onset in B virus–infected humans typically occurs within 1 month of exposure, although the actual incubation period can be a little as 3 to 7 days. Symptoms associated with B virus infection include
- Vesicular skin lesions (small blisters) at or near the site of exposure
- Localized neurologic symptoms (pain, numbness, itching) near the wound site
- Flu-like aches and pains
- Fever and chills
- Headaches lasting more than 24 hours
- Fatigue
- Muscular incoordination
- Shortness of breath
Initial symptoms include fever, headache, and vesicular skin lesions at the site of exposure. Neurologic symptoms vary. Respiratory involvement and death can occur 1 day to 3 weeks after symptom onset.
Disease progression depends on the location of the exposure (usually a bite or scratch) and on the number of infectious virus particles spread during exposure. Although vesicular lesions have sometimes been observed at the exposure site, they do not always occur. The first signs of disease typically are flu-like symptoms such as fever, muscle ache, fatigue, and headache. Other symptoms that have been observed include lymphadenitis (inflamed lymph nodes), lymphangities (infection of lymph vessels), nausea and vomiting, abdominal pain, and hiccups. Once the virus spreads to the central nervous system (CNS), a variety of neurologic signs develop, including hyperesthesias (increase in sensitivity to stimuli), ataxia (lack of voluntary control of muscle movements), diplopia (double vision), agitation, and ascending flaccid paralysis (extreme weakness due to reduced muscle tone). CNS involvement is a sign of serious illness. Most patients with CNS complications will die even with antiviral therapy and supportive care, and those who survive usually suffer serious long-term neurologic problems. Respiratory failure associated with ascending paralysis is the most common cause of death.
Given the number of potential exposures for animal care workers, asymptomatic or mild human B virus infection are thought to occur, but no evidence for asymptomatic B virus infection or for latent infection has been observed in humans. Antibodies produced in response to the human herpesviruses HSV-1 and HSV-2 (present in >80% of adults) are capable of neutralizing B virus in vitro but are not protective against B virus infection. Moreover, such antibodies complicate diagnostic testing for B virus due to their high level of cross-reactivity (i.e., they increase the potential for both false-positive and false-negative results).
First Aid Treatment
Although B virus infection in humans is extremely rare, when it does occur, it is often fatal unless treated right away—about 70% of untreated patients die of complications associated with the infection.
Diligence in recognizing possible exposures, followed by recommended first aid and rapid diagnosis of B virus infection, are the keys to controlling human B virus infection.
First Aid
First aid should begin immediately:
- Cleanse the exposed area by thoroughly washing and gently scrubbing the area or wound with soap, concentrated solution of detergent, povidone-iodine, or chlorhexidine and water for 15 minutes, and then
- Irrigate the washed area with running water for 15-20 minutes.
WARNING: a specimen for PCR testing should not be obtained from the wound area prior to washing the site because it could force virus more deeply into the wound, reducing the effectiveness of the cleansing protocol.
After the site is cleansed, a serum specimen should be obtained from the patient to provide a baseline antibody level. See Specimen Collection and B virus Detection.
Treatment Criteria
The decision about whether to implement antiviral therapy or not should take into account the following criteria [adapted from the Recommendations for Prevention of and Therapy for Exposure to B virus (Cercopithecine Herpesvirus 1), published in Clinical Infectious Diseases in 2002]:
- Type and physical condition of the implicated animal. Only monkeys of the macaque family serve as the natural reservoir for B virus infection. No other primates carry any risk of B virus transmission unless they have had the opportunity to become infected by a macaque. Infected macaques will not ordinarily be shedding B virus. Animals with lesions consistent with B virus infection (fluid-filled blisters on the skin) and animals that are immunocompromised or stressed are far likelier to be excreting virus.
- Thoroughness and timeliness of wound cleansing procedure. Wounds that have been cleansed within 5 minutes of exposure and that have been cleansed for at least 15 full minutes are less likely to lead to B virus infection. Delay in cleansing or inadequate cleansing of the wound increases the risk of infection.
- Nature of the wound. Bites or scratches that break the skin, and particularly deep puncture wounds, are considered higher risk than wounds that are superficial and thus more easily cleansed. Wounds to the head, neck, or torso provide potentially rapid access to the CNS and thus should be considered higher risk. Prophylaxis is recommended for this type of wound regardless of its severity. Superficial wounds to the extremities are less likely to lead to fatal disease, and antiviral treatment is considered less urgent when this happens.
- Exposure to materials that have come into contact with macaques. Accidental needlesticks with syringes that have come into contact with the CNS, eyelids, or mucosa of macaques are considered to carry a high risk of infection. Punctures from needles exposed to the blood of macaques are considered relatively low risk. Scratches resulting from contact with possibly contaminated objects, such as animal cages, are considered to carry a low risk for infection.
It should be stressed, however, that in none of these potential exposures can the risk of infection be considered zero. As such, the decision to treat with antivirals should be made at the physician’s discretion, with liberal consideration of the patient’s wishes and concerns.
People with a known risk of exposure should be monitored for symptoms regardless of whether a treatment regimen has or has not been implemented. The animal thought to be responsible for the exposure should be examined for evidence of disease, and serologic and PCR testing should be done to look for evidence of B virus infection and shedding.
Exposure Scenarios and Treatment Options
Specific exposure scenarios and the corresponding urgency for post-exposure antiviral treatment, as proposed in the Recommendations for Prevention of and Therapy for Exposure to B virus (Cercopithecine Herpesvirus 1), are as follows:
Treatment is recommended
- Skin exposure (where the skin is broken) or mucosal exposure (with or without injury) to a high-risk source (e.g., a macaque that is ill, immunocompromised, known to be shedding virus, or has lesions compatible with B virus infection).
- Inadequately cleansed skin exposure (where the skin is broken) or mucosal exposure (with or without injury).
- Laceration of the head, neck, or torso.
- Deep puncture bite.
- Needlestick associated with tissue or fluid from the nervous system, lesions suspicious for B virus, eyelids, or mucosa.
- Puncture or laceration with objects (a) contaminated either with fluid from monkey oral or genital lesions or with nervous system tissues or (b) known to contain B virus.
- A culture taken after the wound was cleansed tests positive for B virus.
Treatment should be considered
- A break in the skin that has been adequately cleaned.
- Needlestick involving blood from an ill or immunocompromised macaque.
- Puncture or laceration occurring after exposure to (a) objects contaminated with body fluid (other than that from a lesion) or (b) a possibly infected cell culture.
Treatment is not recommended
- Skin exposure in which the skin remains intact.
- Exposure associated with non-macaque species of non-human primates, unless they were in a situation where they could have been infected by a macaque.
Antiviral Therapy
Recommended dosages for specific antivirals are as follows.
Prophylaxis for exposure to B virus
- Valacylovir—1g by mouth every 8 hours for 14 days, or
- Acyclovir—800 mg by mouth 5 times daily for 14 days
Treatment of B virus infection
- With no CNS symptoms
- Acyclovir—12.5–15 mg/kg intravenously every 8 hours, or
- Ganciclovir—5 mg/kg intravenously every 12 hours
- With CNS symptoms
- Ganciclovir—5 mg/kg intravenously every 12 hours
Herpesvirus antivirals have been shown to effectively protect rabbits from lethal infectious doses of B virus, but no comparable studies of efficacy in humans have been possible.
On external surfaces, B virus is susceptible to 1% sodium hypochlorite, 70% ethanol, 2% glutaraldehyde, and formaldehyde. The virus can also be inactivated by heat treatment at 50°–60°C for at least 30 minutes, by lipid solvents, by exposure to acidic pH, and by detergents.
B virus can remain viable in monkey CNS tissue and saliva and in monkey kidney cell cultures. The virus can also survive up to 7 days at 37°C or for weeks at 4°C, and it is stable at −70°C. Although survival studies under conditions of virus desiccation (i.e., dry surfaces) have not been performed, it is presumed that survival times will be comparable to those of other mammalian herpesviruses (with typical survival times of 3–6 hours).
There are no vaccines available for B virus. Experimental vaccines have been evaluated in animal models, but none are being considered for human trial.
For more information on Herpes B virus, please refer to CDC web site on this topic.
Gathered, written, and posted by Windermere Sun-Susan Sun Nunamaker
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