Employee Information Regarding Injuries Involving Nonhuman Primates
A. B-Virus (cercopithecine herpesvirus I, BV) is a common
pathogen in monkeys of the genus Macaca (including rhesus,
cynomolgus, bonnet, and stump-tailed macaques). B-Virus
infection in macaques is analogous to that of herpes simplex
virus in humans.
1. Primary infection is generally asymptomatic, although
oral and genital ulcers may occur.
2. The virus establishes latency in sensory nerve ganglia
and periodically reactivates. Reactivation occurs more
frequently when the animal is stressed, ill,
immunocompromised, or in mating season (i.e.
September through December).
3. One to three percent of infected macaques shed B-Virus
at any given time. Frequently, shedding animals do not
have clinical evidence of disease.
B. B-Virus causes a rare but rapidly progressive ascending
encephalomyelitis in humans with a fatality rate of
approximately 70%. Symptoms in humans are variable and
inconsistent, but usually occur within one month following
exposure. The site of the injury directly affects the onset of
symptoms due to the length of the nerve pathways to the brain
(i.e. symptoms related to a splash injury to the eye would
manifest quicker than those from a lower extremity injury).
1. Early manifestations (within 10 days)
a. vesicular eruption near the exposure site
b. pain, itching or numbness at the exposure site
c. regional lymphadenopathy
2. Intermediate manifestations (within 21 days)
a. fever and chills
b. proximally progressive paresthesia from the
f. muscle weakness in the exposed extremity
3. Late manifestations
a. neck stiffness
b. severe headache lasting more than 24 hours
c. diplopia, dysphagia, ataxia, confusion, agitation,
hemiparesis, hemiplegia, and respiratory arrest
C. Potentially infective macaque fluids and tissues include oral,
ocular, and genital secretions, CSF, brain tissue, sensory
ganglia, primary monkey tissue cultures, and possible excreta.
B-Virus has not been recovered from macaque blood.
D. Human infections have followed bite, scratch (including cage
scratch), and splash injuries. Prompt, appropriate first aid may
reduce the risk of infection.
1. High risk injuries include:
a. percutaneous exposure to the macaque’s mucous
membrane secretions. Examples include bite
injuries, needlestick injuries with a needle used in
proximity to the macaque’s mucous membrane
(i.e. tuberculosis skin testing in a macaque’s
b. percutaneous exposure to the macaque’s
neurologic tissue. An example is a laceration
while working with a macaque brain during
c. mucous membrane exposure to the macaque’s
mucous membrane secretions.
E. Post exposure prophylaxis (PEP)
1. PEP in experimentally infected rabbits successfully
suppressed the development of B-Virus associated
disease. PEP in the same experiments also suppressed
the development of specific antibodies to B-Virus (i.e.
seroconversion). As a result, PEP may complicate the
interpretation of negative or indeterminate serologic tests
for B-Virus infection.
2. It is not known whether PEP can prevent B-Virus
infection in humans.
3. The recommended medication for PEP, valacyclovir
(Valtrex®), interferes with the virus’ DNA polymerase.
Valacyclovir may not block infection of host cells that are
directly exposed to the B-Virus because it does not
interrupt the early stages of the infection (i.e. it does not
interrupt the absorption, penetration, uncoating, and
intranuclear circularization of the viral DNA).
II. First Aid
A. First aid should be initiated at the worksite within five minutes
of the injury.
1. Skin exposed to nonhuman primate body fluids is
scrubbed vigorously with a 75% povidone iodine solution
for fifteen minutes. If the individual is allergic to iodine, a
chlorhexidine solution is used.
2. Mucous membranes and eyes contaminated with
nonhuman primate body fluids are irrigated for fifteen
minutes with normal saline or water.
B. Once first aid is completed, the injured worker proceeds
directly to OHS for further medical assessment and treatment.
C. When OHS is closed, the injured worker reports to the
Emergency Department at BMC on the East Newton Campus.
III. Evaluating and Testing the Macaque
A. As soon as possible following the injury, the veterinarian
responsible for the care and management of the nonhuman
primate reviews the monkey’s medical record. The
veterinarian also examines the animal for mucosal (oral or
genital) vesicles, ulcerations or crusts, and for conjunctivitis.
1. DacronTM or Cotton tipped sterile swabs and vials
containing Viral Transport Medium are used to obtain the
2. The containers are labeled with the identity of the
macaque, the body location, and the date the specimen
3. The specimens are kept refrigerated (i.e. wet ice, “cool
packs”) and in an upright position so that the swabs
remain submerged in the viral medium during transport.
B. The veterinarian also obtains a blood sample from the
macaque for B-Virus serology using a serum separator tube.
The blood specimen is labeled with the identity of the
macaque and the date the sample is obtained.
C. The veterinarian submits the clinical information, the swabs,
and the blood sample to B virus Laboratory as soon as they
are available. The veterinarian also provides OHS with
information on the health status of the monkey.
D. The information provided by the veterinarian is entered on the
injury report form and OHS log on injuries involving nonhuman
primates and the patient’s chart.
IV. Initial OHS Visit
A. Anyone with an injury involving nonhuman primates at a BU
facility is eligible for evaluation, treatment, and follow-up
evaluation in OHS. If the individual elects to be treated by
his/her personal health care provider, an OHS physician offers
to consult with the provider.
B. OHS handles injuries involving nonhuman primates as
emergencies. If the employee reports within eight hours of the
injury, the wound is cleaned regardless of First Aid on-site
C. If the injury is a bite or scratch and the nonhuman primate is a
macaque, a swab sample from the worker’s wound is obtained
only after the administration of first aid and is cultured for B-
1. To obtain the viral culture, the OHS nurse gently twirls a
DacronTM/or Cotton tipped sterile swab in the wound and
then inserts it in a vial containing Bartel’s or Viral
Transport Medium. Holding the vial at arm’s length, the
swab is bent towards the nurse until it breaks.
2. The vial is labeled with the patient’s name, the location
cultured, the date the specimen is obtained, and that the
culture was obtained after first aid was administered.
3. If the culture will be sent to the BMC Microbiology
laboratory that day, it is refrigerated. If it will not be sent
that day, it is placed in the -20°C freezer.
D. Using the Report of Injury Involving a Nonhuman Primate
form, the OHS healthcare provider ascertains the following:
1. the time the injury occurred and the time it was reported
2. all relevant safety measures employed at the time of the
3. type of fluid or tissue contacted; individuals exposed to
nonhuman primate (NHP) blood may be at risk for
exposure to NHP retrovirus (i.e. SIV, SRV).
4. type of injury (i.e. percutaneous injury, mucous
membrane or skin exposure),
5. circumstances of the event,
6. the identity of the nonhuman primate involved in the
7. details regarding first aid provided at the work site and at
E. OHS recommends PEP for high-risk injuries and offers PEP to
workers with moderate risk of injuries.
1. Recommendations for treatment are based upon:
a. the type of nonhuman primate fluid or tissue
involved in the injury,
b. the type of injury, and
c. the quality and timeliness of the first aid
d. the health status of the nonhuman primate
2. OHS strives to provide PEP within two hours of the time
of injury. PEP is not offered if the injury is reported more
than five days following the injury. However, all other
monitoring is provided as described below.
3. Valacyclovir is used for PEP. The worker is instructed to
take 1 Gram three times a day for two weeks. If
valacyclovir is unavailable, acyclovir is used. The dose
for acyclovir is 800 mg five times a day. Treatment if
switched to valacyclovir as soon as it is available.
F. Regardless of whether or not PEP is provided, the injured
worker is provided informational handouts on B-Virus and
individualized counseling on the significance of the injury.
1. The worker is informed of the early and intermediate
manifestations of infection with B-Virus. The injured
worker is given a wallet-sized card listing the signs and
symptoms suggestive of a B-Virus infection and
telephone numbers to call for emergency consultation.
2. The worker provides a serum sample for storage at the
initial visit and again at the follow up visits two and four
weeks after the injury.
Serologic testing is performed on paired specimens initial
and specimens taken 2 and 4 weeks later to look for any
evidence suggestive of a B-Virus infection. Microbiology
sends specimens to B virus lab with the appropriate
forms completed by OHS.
3. EH&S is notified [(8-8830) BUMC or (3-4094) Charles
Rivers Campus] of the injury and reviews the incident,
circumstances of the injury and safety precautions
employed at the time of the injury with the employee and
4. The appropriate Incident form is completed and Workers’
Compensation claim form.
5. The employee is provided appointments to return to OHS
(OEM or BUOHC) one, two, and four weeks from the
date of the injury.
G. If the injury is reported when the OHS clinic is closed, the
employee reports to the East Newton Campus Emergency
Department for evaluation and treatment (phone number).
The Emergency Department healthcare provider obtains a
medical history and advises the worker of appropriate first aid
1. After performing First Aid if available, the worker is
directed to proceed to the closest emergency medical
2. If PEP is indicated, the healthcare provider repeats first
aid and initiates PEP (see above) with consultation with B
virus laboratory or ID.
3. The Emergency Department physician also instructs the
worker to report to ROHP @ 617-414-7647 when the clinic next opens to complete
the report of injury and transmits the injury
report to OEM.
V. Follow up OHS Visit
A. The injured worker is re-evaluated one, two, and four weeks
from the date of the injury.
1. The worker is questioned and examined for symptoms
and signs of B-Virus infection.
2. If PEP was initiated, the worker’s compliance with
treatment is assessed and noted in the clinical record.
Anyone who gets PEP must get a serum titer 4 weeks
after the completion of the PEP.
3. A second blood sample is obtained for a serum titer 2-3
weeks and a third serum at 6 weeks following the injury if
there are any concerns and at anytime the patient is
B. NIH herpes virus experts are consulted as needed during the
follow up process.
Dr. Julia Hilliard, Director of the NIH B Virus Lab:
404.651.0808; for emergencies (nights, weekends) 404.358-
8168 or Centers for Disease Control at 404.639.0066.
Employee Information-NHP Injuries updated: 3-1-07
Employee/Personnel: Within 1 Business Day
• All personnel and laboratory workers are encouraged to report any illness to their supervisor
and occupational health directly if they are ill and working with or near agents covered by this
• Supervisors are required to report all illnesses, significant exposures, and absenteeism to the ROHP at 617-414-7647. The above conditions are reportable to Boston Public Health Commission
(BPHC) by OHO or designee.
• All laboratory workers must report any exposures to their supervisor and occupational health
• Workers in laboratories working with agents covered by the BPHC regulations must be
evaluated by the OHO or designee prior to return to work if exposure to agents covered by
these guidelines occurs.
• Worker notifies supervisor of reason for absence from work.
• Supervisor contacts the OHO or designee. If employee is febrile or symptomatic he/she will
need to be evaluated by the OHO or designee. The employee must contact the OHO on day 1
of illness and be evaluated, depending on the symptoms, reporting and also prior to
returning to work.
Occupational Health Officer (OHO) or Designee: Within 1 Business Day
• OHO or designee will perform an occupational health assessment for any employee who: (1)
has been diagnosed, (2) is exhibiting symptoms, or (3) may have been exposed to a
registered agent as defined in this regulation.
• OHO or designee shall immediately notify the BPHC of the assessment, but not later than one
business day of the assessment.
• OHO or designee should evaluate the individual based upon clinical findings and
epidemiological risk factors, including specific lab work being conducted, and make appropriate
• OHO or designee shall report findings of the assessment immediately, but not later than one
• OHO or designee shall report to the BPHC any diagnosis of any disease caused by a high–risk
registered agent pursuant to Section V. Part A of the guidelines, and any violation or breach of
any laboratory procedures or any other incident which the IBC, Project Director or OHO should
reasonably believe was released beyond the work area must be reported within once business
• OHO or designee must evaluate workers in laboratories working with agents covered by the
BPHC regulations if an exposure to agents covered in these guidelines occurs.
• OHO or designee must report significant exposures to BPHC within 1 business day.
• Follow–up information must be provided to BPHC as requested.
• OHO or designee must report to BPHC, if a significantly exposed worker develops illness that
could be related to an agent used in the laboratory and covered by these guidelines.
• OHO or designee should evaluate the individual based upon clinical findings and
epidemiological risk factors, including specific lab work, and make appropriate
• OHO or designee must evaluate any worker in a laboratory using agents covered by these
guidelines who is absent from the workplace due to illness for a period of two or more
• OHO or designee must contact the ill worker to determine whether illness could be related to
an agent covered by these guidelines and used in the laboratory.
• OHO or designee must be reported within 1 business day to the BPHC, if illness may be related
to an agent covered by these guidelines.
Occupational Health Officer (OHO) or Designee: Within 3 Business Days
• If the OHO or designee determines that the illness is caused by an agent that is covered by
these guidelines and may be work–related, BPHC must be consulted within 3 business days
before the worker is allowed to return to work.
• OHO or designee must send BPHC documentation that an exposed employee was cleared to
return to work within 3 business days of clearance.