Over 8000 macaque bites since 2014 but no herpes B virus infection reported from Shimla, India

Sir, Shimla is an international tourist destination in the sub-Himalayan region of northern India. It was the summer capital of British India, and people visit here to have a glimpse of the heritage from that era. The 2017 figures show that Shimla sees a large influx of tourists both domestic (over 3.4 million/year) and foreign (0.16 million/year).[1] According to a tourism survey by the Ministry of Tourism in Himachal Pradesh, the foreign tourists (0.16 million/year) visiting Shimla are from the United Kingdom (15%), the United States (9%), France (6%), the UAE (6%), Spain (5%), Germany (5%), Australia (5%), and Canada (5%).[12] The rhesus macaque monkeys are a major attraction for the tourists visiting Shimla. Macaques move freely among the local crowd and attract the eyes of all tourists [Figure 1]. They are, however, quite aggressive when disturbed and bite anyone who messes with them. Every year, our hospital receives over 600 cases of macaque bites, 75% of which are of category III bites, and over 35% of these victims are tourists.[3] Combining data from other hospitals in Shimla town, the total monkey bites every year are on average 1326 since 2014, an average of 3.6 macaque bites/day.[4] Rabies has been established in dead macaques, and rabies prophylaxis is, therefore, recommended in all cases of macaque bites.[5] Internationally, herpes B virus infection is another major concern after macaque bites.[6] The first case of fatal human infection with herpes B virus from a macaque exposure was reported in 1997 in a 22-year-old female worker at a primate center, who possibly acquired infection through a splash of fecal matter into her right eye. She got cured of herpes B virus infection after antivirals but developed post viral encephalitis and succumbed to this complication.[7] After this incident, the center for disease control convened a working group in 1999 and issued guidelines for antiviral prophylaxis after macaque bite.[6] Thereafter, the published literature expresses a great concern for herpes B virus infection and thus covers all macaque bites with antivirals such as acyclovir or ganciclovir. In our experience with over 8000 rhesus macaque bites since 2014, we have not encountered even a single case of herpes B virus infection after macaque bite. The World Health Organization also does not mention postexposure prophylaxis with antivirals after a macaque bite.[8] In our hospital, we have also never used antivirals for postexposure prophylaxis in macaque bites. Given the incubation period of 2 days to 5 weeks, we are yet to see our first case of herpes B virus infection after a macaque bite. We are, however, routinely giving tetanus vaccination and antibiotic oral co-amoxiclav to cover for bacterial infections to all victims.Figure 1: Rhesus macaque with a goggle snatched from a tourist to be returned in lieu of eatablesSince 35% of the bites occur in tourists who may return to their countries after the bite, we believe that physicians across the world should be aware of this possibility and must start antivirals if the victims show signs suggestive of herpes B infection after the monkey bite. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

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