Document Detail

Monkey bites among US military members, Afghanistan, 2011.
Jump to Full Text
MedLine Citation:
PMID:  23017939     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
Bites from Macaca mulatta monkeys, native to Afghanistan, can cause serious infections. To determine risk for US military members in Afghanistan, we reviewed records for September-December 2011. Among 126 animal bites and exposures, 10 were monkey bites. Command emphasis is vital for preventing monkey bites; provider training and bite reporting promote postexposure treatment.
Authors:
Luke E Mease; Katheryn A Baker
Related Documents :
1452999 - Acanthocephalan infection in man in northern nigeria.
23438459 - 'cysticercosis storm' in feedlot cattle in north-west new south wales.
21506849 - Seasonality of parasitic copepods on the bullseye puffer sphoeroides annulatus (pisces:...
21524959 - Infection in liver transplant recipients-analysis of 68 cases at teaching hospital in t...
21268989 - Seasonality of batrachochytrium dendrobatidis infection in direct-developing frogs sugg...
21470079 - Clostridium difficile infection: a new threat on our doorstep.
7773189 - N-glycosylated polypeptides synthesized in the early phase of acnpv infected insect cells.
2918429 - Effects of concurrent infections on growth, development, distribution, and infectivity ...
22714619 - An unusual case of recurrent pneumonia.
Publication Detail:
Type:  Journal Article    
Journal Detail:
Title:  Emerging infectious diseases     Volume:  18     ISSN:  1080-6059     ISO Abbreviation:  Emerging Infect. Dis.     Publication Date:  2012 Oct 
Date Detail:
Created Date:  2012-09-28     Completed Date:  2013-02-19     Revised Date:  2013-07-11    
Medline Journal Info:
Nlm Unique ID:  9508155     Medline TA:  Emerg Infect Dis     Country:  United States    
Other Details:
Languages:  eng     Pagination:  1647-9     Citation Subset:  IM    
Affiliation:
US Army Combined Joint Task Force–1, Bagram Air Field, Afghanistan. luke.mease@us.army.mil
Export Citation:
APA/MLA Format     Download EndNote     Download BibTex
MeSH Terms
Descriptor/Qualifier:
Adult
Afghanistan / epidemiology
Animals
Bites and Stings / complications,  drug therapy,  epidemiology*
Female
Humans
Macaca mulatta*
Male
Military Personnel / statistics & numerical data*
United States
Young Adult
Comments/Corrections
Comment In:
Emerg Infect Dis. 2013 Apr;19(4):691-2   [PMID:  23762913 ]
Emerg Infect Dis. 2013 Apr;19(4):691   [PMID:  23750611 ]

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

Full Text
Journal Information
Journal ID (nlm-ta): Emerg Infect Dis
Journal ID (iso-abbrev): Emerging Infect. Dis
Journal ID (publisher-id): EID
ISSN: 1080-6040
ISSN: 1080-6059
Publisher: Centers for Disease Control and Prevention
Article Information
Download PDF

Print publication date: Month: 10 Year: 2012
Volume: 18 Issue: 10
First Page: 1647 Last Page: 1649
PubMed Id: 23017939
ID: 3471630
Publisher Id: 12-0419
DOI: 10.3201/eid1810.120419

Monkey Bites among US Military Members, Afghanistan, 2011 Alternate Title:Monkey Bites among US Military Members
Luke E. Mease1
Katheryn A. Baker2
US Army Combined Joint Task Force–1, Bagram Air Field, Afghanistan
Correspondence: Address for correspondence: Luke E. Mease, Army Health Clinic, 5116 Kister Ave, Dugway, UT 84022, USA; email: luke.mease@us.army.mil

Military members deployed to Afghanistan face many risks; among these are bites from Macacamulatta monkeys and possible subsequent infections. In August 2011, a 24-year-old US Army soldier died of a rabies infection contracted while in eastern Afghanistan. This tragedy highlights the threat that animal bites pose to deployed military members.

During 2001–2010, a total of 643 animal bites among deployed US military members were reported (1). Dogs were implicated in 50% of these bites, but several other animals pose risk as well. Prominent among these is the nonhuman primate M. mulatta (rhesus macaque), native to and commonly kept as a pet in Afghanistan (2) (Figure). Risks from M.mulatta monkey bites include physical trauma and/or infection with B-virus (Macacine herpesvirus 1), oral bacteria (including Clostridium tetani), and rabies virus. Although not well characterized in Afghanistan, the risk for exposure to M.mulatta monkeys has been described (3) for researchers (4), tourism workers (5), and US pet owners (6). We examined this risk for US military members deployed to eastern Afghanistan. The work presented herein was reviewed and deemed exempt from internal review board oversight by the Joint Combat Casualty Research Team, the human subjects review board responsible for oversight of human subjects research affecting US military members in Afghanistan.


The Study

Information about all reported animal bites and exposures affecting US military and coalition personnel is collected by preventive medicine officers assigned to Combined Joint Task Force–1 in eastern Afghanistan. We evaluated these records to identify and describe monkey bites and high-risk exposures among US military members serving in eastern Afghanistan during September–December 2011. For this study, eastern Afghanistan refers to North Atlantic Treaty Organization Regional Command East, which covers ≈43,000 square miles (110,000 km2). The US military population in eastern Afghanistan during the study period was ≈23,500 persons. Case information obtained included patient age, sex, rank, branch of military service, animal exposures, and treatment details.

We evaluated the cases for the 5 parameters that comprise appropriate initial treatment according to the literature. The parameters are wound care (appropriate cleansing of the wound) (7), antiviral medications for B-virus (valacyclovir) (8), antimicrobial drugs for oral bacteria (amoxicillin/clavulanic acid or clindamycin plus sulfamethoxazole/trimethoprim) (3), verification of up-to-date tetanus vaccination status or vaccine administration in accordance with Advisory Committee on Immunization Practices guidelines (9), and rabies postexposure prophylaxis (PEP). US military policy advised that rabies PEP should adhere to World Health Organization guidelines (10), which recommend giving human rabies immunoglobulin plus 5 doses of rabies vaccine. In accordance with the same policy, adherence to Advisory Committee on Immunization Practices guidelines for rabies PEP with human rabies immunoglobulin plus 4 doses of rabies vaccine was also acceptable (11).

When appropriate initial treatment was not administered, subsequent follow-up was conducted to ensure that patients received required treatment. Appropriate treatment was accomplished by contacting and coordinating with the responsible provider, the patients, and their commanders.

During the study period, we identified 126 cases of animal bites or serious exposures (involving animal neural tissue or saliva affecting the mucosal surfaces or open wounds of the patient). Among these cases, 10 were cases of monkey bites.

Among the 10 military members who had been bitten by monkeys, age range was 22–44 years (Table); most (7) were <30 years of age, and 8 were male. All were junior enlisted or noncommissioned officers; 8 were members of the Army, and 2 were members of the Air Force (Table).

In terms of treatment, 6 received appropriate wound care and washing, 5 received appropriate B-virus prophylaxis, and 8 received appropriate antimicrobial drugs (Table). In terms of prophylaxis, only 4 were evaluated for tetanus status, and 8 received appropriate rabies PEP. Beyond the initial trauma and follow-up visits for rabies PEP, no visits for any illness possibly associated with the bite or exposure were recorded.

All cases involved different monkeys, 8 of which were kept as pets. Of these 8 pet monkeys, 4 belonged to Afghan National Security Forces (ANSF), 3 belonged to Afghan civilians, and 1 belonged to US military members. For the other 2, no ownership data were available; they could have been wild or pets. One monkey was euthanized and sent to US Army Veterinary Laboratory Europe for testing; brain samples were negative for rabies and B-virus.


Conclusions

Our identification of 126 reported bites or exposures over just 4 months suggests that the 643 animal bites reported for all deployed US military members for the past decade greatly underestimate the true number of animal bites in this population. The number of bites and exposures identified in this study might represent more accurate reporting because of increased attention to animal bites after the US soldier died in August 2011. It is possible that before that time, only more severe bites and exposures were reported but that after that time, more lower-risk exposures might have been reported.

The risk for monkey bites in other populations has been described. The 10 monkey bites reported in this study demonstrate that US and coalition military members in Afghanistan are also at risk for the trauma and the B-virus, bacterial, tetanus, and rabies infections that can result from monkey bites and exposures. The demographics of the population bitten (Army, age <30 years, and male) is representative of the underlying population at risk.

Most monkey-bite patients received appropriate care. This care is laudable, considering the recognized difficulties in treating monkey bites (12). Some patients, however, did not receive appropriate medical treatment initially. Because treatment of monkey bites is not a standard part of US medical education, inadequate treatment could reflect insufficient training and lack of familiarity among US-trained health care providers. It is imperative that before providers are deployed to Afghanistan, they receive proper instruction on the care of animal bites and exposures. Appropriate reporting of any animal bite to military preventive medicine personnel is crucial because it permits oversight of care and timely correction of deficiencies.

Most (7/10) monkeys involved were pets owned by ANSF or Afghan civilians. As the mission in Afghanistan shifts from combat to ANSF mentoring and reconstruction, US and coalition troops will come into increasingly close contact with ANSF and Afghan civilians. Accordingly, the likelihood of deployed US military members being exposed to monkeys in Afghanistan will probably increase. However, although risk for contact with monkeys might increase, an increase in bites is not inevitable. Explicit orders prohibit deployed US military members from adopting local mascots and from interacting with animals or pets owned by ANSF or Afghan civilians. To mitigate the risk for animal bites, it is crucial that commanders enforce these regulations (13).

The risk of being bitten by a monkey could increase as US forces work more closely with ANSF and Afghan civilians. Bites could be prevented by appropriate emphasis from command and enforcement of existing policies prohibiting pet adoption and animal contact. Treatment of patients who are bitten could be improved by further training of military health care providers on appropriate treatment for animal bites, including monkey bites.


Notes

Suggested citation for this article: Mease LE, Baker KA. Monkey bites among US military members, Afghanistan, 2011. Emerg Infect Dis [Internet]. 2012 Oct [date cited]. http://dx.doi.org/10.3201/eid1810.120419

1Current affiliation: Army Health Clinic, Dugway Proving Ground, Utah, USA.

2Current affiliation: General Leonard Wood Army Community Hospital, Fort Leonard Wood, Missouri, USA.

Acknowledgments

We thank David Broussard, Ronald Havard, Jason Lennen, and James Reynolds for their review and critique of this study and report. We thank James Geracci for his review of this report and for his leadership.

The work reported here was performed by L.E.M. and K.A.B. as part of their duties in the US Army, Combined Joint Task Force-1, Afghanistan. They have no financial or nonfinancial competing interests.

Dr Mease was the Division Preventive Medicine Officer for Combined Joint Task Force–1, Afghanistan and is the officer in charge at the Army Health Clinic in Utah. His research interests include vector-borne diseases and dermatologic disorders in military and occupational settings.

Ms Baker was the Division Army Public Health Nurse for the Combined Joint Task Force-1, Afghanistan, and is a staff public health nurse at the Community Health Resource Center, General Leonard Wood Army Community Hospital in Missouri. Her research interests include human papillomavirus, sexually transmitted diseases, and latent tuberculosis infection in military settings.


References
1. . Armed Forces Health Surveillance Center. Animal bites, active and reserve components, U.S. Armed Forces, 2001–2010.MSMR.Year: 2011;18:12–521988341
2. . StevensK, DehganA, KarlstetterM, RawanF, TawhidMI, OstrowskiS, et al. Large mammals surviving conflict in the eastern forests of Afghanistan.Oryx. Year: 2011;45:265–7110.1017/S0030605310000517
3. . AbrahamianFM, GoldsteinEJMicrobiology of animal bite wound infections.Clin Microbiol Rev. Year: 2011;24:231–4610.1128/CMR.00041-1021482724
4. . EstepRD, MessaoudiI, WongSWSimian herpesviruses and their risk to humans.Vaccine. Year: 2010;28(Suppl 2):B78–8410.1016/j.vaccine.2009.11.02620510749
5. . EngelGA, Jones-EngelL, SchillaciMA, SuaryanaKG, PutraA, FuentesA, et al. Human exposure to herpesvirus B–seropositive macaques, Bali, Indonesia.Emerg Infect Dis. Year: 2002;8:789–9510.3201/eid0808.01046712141963
6. . OstrowskiSR, LeslieMJ, ParrottT, AbeltS, PiercyPEB-virus from pet macaque monkeys: an emerging threat in the United States?Emerg Infect Dis. Year: 1998;4:117–2110.3201/eid0401.9801179452406
7. . Centers for Disease Control and Prevention CDC health information for international travel 2012. The yellow book. Gary W. Brunette, editor. New York: Oxford University Press; Year: 2012
8. . CohenJI, DavenportDS, StewartJA, DeitchmanS, HilliardJK, ChapmanLERecommendations for prevention of and therapy for exposure to B virus (Cercopithecine herpesvirus 1).Clin Infect Dis. Year: 2002;35:1191–20310.1086/34475412410479
9. . Centers for Disease Control and Prevention Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccine from the Advisory Committee on Immunization Practices, 2010.MMWR Morb Mortal Wkly Rep. Year: 2011;60:13–521228763
10. . World Health Organization. Rabies vaccines: WHO position paper—recommendations.Vaccine. Year: 2010;28:7140–210.1016/j.vaccine.2010.08.08220831913
11. . Centers for Disease Control and Prevention Use of a reduced (4-dose) vaccine schedule for postexposure prophylaxis to prevent human rabies—recommendations of the Advisory Committee on Immunization Practices.Ann Emerg Med. Year: 2010;56:64–710.1016/j.annemergmed.2010.05.02020648715
12. . TregleRWJr, LoeCL, EarhartRHIII, d'AutremontSBCercopithecine herpesvirus 1 risk in a child bitten by a bonnet macaque monkey.J Emerg Med. Year: 2011;41:e89–9010.1016/j.jemermed.2010.02.01120347250
13. . ChretienJPProtecting service members in war–non-battle morbidity and command responsibility.N Engl J Med. Year: 2012;366:677–910.1056/NEJMp111298122356320

Figures

[Figure ID: F1]
Figure 

Pet monkey (Macaca mulatta), Afghanistan, 2011. Photograph courtesy of Ronald Havard.



Tables
[TableWrap ID: T1] Table  Characteristics of US military members bitten by monkeys, eastern Afghanistan, September–December, 2011*
Patient no. Age, y/sex Military branch Treatment received
Monkey ownership
Wound care Valacyclovir Antimicrobial drug Tetanus vaccine Rabies vaccine, HRIG
1 39/M Army + + + + ANSF
2 27/M Army + + + + + CIV†
3 22/M Army + + + CIV
4 44/F Army + + CIV
5 31/M Army + + + + ANSF
6 26/M Air Force + US military
7 26/M Army + + ANSF
8 27/M Army + + + + ANSF
9 22/M Army + + Unknown
10 25/F Air Force + + + + Unknown

*HRIG, human rabies immunoglobulin; –, not administered; +, administered; ANSF, Afghan National Security Forces; CIV, Afghan civilian.
†Monkey euthanized. Brain, tested at US Army Veterinary Laboratory Europe, was negative for rabies and B-virus.



Article Categories:
  • Dispatch
Article Categories:
  • Dispatch

Keywords: Keywords: animal bite, monkey, Simian, nonhuman primate, rabies, rabies postexposure prophylaxis, herpes B virus, Macacine herpesvirus 1, tetanus, military, Afghanistan, B-virus, viruses, zoonoses.

Previous Document:  Integrative physiology of depression and antidepressant drug action: Implications for serotonergic m...
Next Document:  Clostridium difficile clinical isolates exhibit variable susceptibility and proteome alterations upo...