Cercopithecine herpesvirus 1 (B Virus) Infection

Resulting from Ocular Exposure

 Key Points 

• Mucocutaneous exposure to biological fluid from macaque monkeys can result in infection with

Cercopithecine herpesvirus 1, commonly known as B virus.

• Eye splashes appear to be common in the primate industry.

• Dendritic corneal lesions characteristic of other ocular herpes virus infections may not be present.

• All personnel who work with macaques should wear eyewear conforming to established standards for

eye and splash protection.

• If exposure prevention fails, the adequacy and timeliness of wound or exposure decontamination

procedures are critical factors in determining the risk for infection.

 De scrip tion of Haz ard 

On Oc to ber 29, 1997, a 22-year-old re searcher at a pri mate-center field sta tion was as sist ing with a rou tine

group cap ture of rhe sus ma caques (Macaca mulatta) in a free-ranging cor ral. Per son nel con duct ing the cap ture

wore uni forms, dis pos able la tex gloves, and sur gi cal masks. Eye pro tec tion was not worn. Dur ing the trans fer of 

an un iden ti fied ma caque into a squeeze cage, un de ter mined liq uid from the an i mal en tered the re searcher’s eye.

The worker wiped her eye at the time of ex po sure. Ap prox i mately 45 min utes later she flushed her eye with tap

wa ter for 2–3 min utes. There was no med i cal treat ment or con sul ta tion at the time of the ex po sure. The re -

searcher sub se quently de vel oped a Cercopithecine herpesvirus 1 (B vi rus) in fec tion; de spite in ten sive an ti vi ral

ther apy, she died on De cem ber 10, 1997. This in ci dent is the first doc u mented case of a B vi rus in fec tion re sulting from an oc u lar ex po sure to ma caque se cre tions.

On No vem ber 8, 1997, the re searcher sought med i cal at ten tion for the first time be cause the ex posed eye was

red and swol len. At this time, the emer gency de part ment phy si cian spe cif i cally looked for den dritic lesions of 

the cor nea that are char ac ter is tic of oc u lar her pes in fec tions. Al though den dritic cor neal le sions were re ported in 

a pre vi ous fa tal B vi rus in fec tion, they were not seen in the pres ent case. On the ba sis of the re ported cir cumstances of the con tact, it was ini tially con cluded that B vi rus in fec tion was un likely. This case is re ported in the

fol low ing:

CDC (Cen ters for Dis ease Con trol and Pre ven tion) [1998]. Fa tal Cercopithecine herpesvirus 1

(B Vi rus) In fec tion Fol low ing a Mucocutaneous Ex po sure and In terim Rec om men da tions for

Worker Pro tec tion. Mor bid ity and Mor tal ity Weekly Re port (MMWR) 47(49):1073–1076,1083;

De cem ber 18, 1998.

HAZARD ID

HID 5
About B Virus

B vi rus in fects ≥70% of sur veyed cap tive adult macaques, but not other non hu man pri mates (NHPs). Like hu -

mans in fected with Herpesvirus sim plex vi rus, mon keys in fected with B vi rus have a life long in fec tion, with in -

ter mit tent re ac ti va tion and shed ding of the vi rus in sa liva, conjunctival fluid, or uro gen i tal se cre tions. Al though

vi rus shed ding is more fre quent dur ing the mat ing sea son (roughly March to June) and when an an i mal is ill, un -

der stress, or immunosuppressed, there are of ten no signs of shed ding. Ma caques should al ways be re garded as

po ten tially in fec tious.

There have been ap prox i mately 40 known cases of fa tal hu man B vi rus in fec tion de scribed in the Eng lish lan -

guage lit er a ture. Pre vi ously re ported hu man in fec tions usu ally have been at trib uted to ma caque bites or

scratches, in ju ries from nee dles used near a ma caque’s mu cous mem branes or cen tral ner vous sys tem, or con -

tact with in fec tious prod ucts from the ma caques. In cu ba tion pe ri ods may be as short as 2 days, but more com -

monly they are 2 to 5 weeks. Most doc u mented in fec tions have oc curred among bio med i cal re search em ploy ees

who worked with ma caques. Lab o ra tory work ers han dling only in fected cen tral ner vous sys tem or pri mary

mon key kid ney cell lines have also been ex posed and, in at least one in stance, in fected. One case of person-to-person trans mis sion has been re ported.

 Recommendations for Preventing B Virus Infections

Pub lished rec om men da tions for the pre ven tion and treat ment of B vi rus in fec tions in ex posed per sons in clude

the fol low ing:

CDC (Centers for Disease Control and Prevention) [1987]. Guidelines for the Prevention of

Herpesvirus simiae (B Virus) Infection in Monkey Handlers. Morbidity and Mortality Weekly

Report (MMWR) 36(41):680–683, 687–689; October 23, 1987.

Holmes GP, et al. [1995]. Guidelines for the Prevention and Treatment of B-Virus Infections in

Exposed Persons. Clinical Infectious Diseases 20:421–439.

Pro tec tive eyewear cri te ria have been es tab lished by the Amer i can Na tional Stan dards Institute (ANSI):

ANSI [1989]. Practice for Occupational and Educational Eye and Face Protection, Z87.1–1989.

American Society of Safety Engineers, Des Plaines, IL.

Actions You Should Take

Pre venting worker ex po sure to biohazardous ma te rial is the best pro tec tion against in fec tion. All or ga ni za tions

that work with ma caques or other NHPs should ob tain the doc u ments cited in this re port (as well as other guide -

lines and ed u ca tional ma te ri als) and re view the oc cu pa tional health haz ards as so ci ated with work ing with

NHPs. Em ployers should en sure that worker pro tec tion pro grams, pol i cies, and pro ce dures are in place to con -

trol infection risks from NHPs. Em ployers should con duct train ing and pe ri odic as sess ments to en sure that

worker pro tec tion pro grams are ef fec tive. In par tic u lar, all em ploy ees who come into con tact with ma caques or

ma caque tis sues should be trained about the risks of B vi rus and other in fec tions and the im por tance of pre ventive mea sures.
Each in sti tu tion work ing with NHPs should de velop a writ ten, com pre hen sive per sonal pro tec tive equipment

(PPE) pro gram that clearly iden ti fies the PPE re quired for each spe cific task or work ing area of the facility

and ad dresses train ing, in spec tion and main te nance, and pe ri odic as sess ment of pro gram ef fec tiveness. Man datory PPE should be se lected based on a thor ough worksite haz ard as sess ment that con sid ers all work pro ce dures

and as so ci ated haz ards (in clud ing biohazards), po ten tial routes of ex po sure, and po ten tial ad verse health

out comes.

Re views of in ju ries and biohazard ex po sures among work ers ex posed to NHPs sug gest that mucocutaneous

con tact with NHP body flu ids is com mon; in one sur vey, 16 of 17 con tacts with pri mate body flu ids in volved

oc u lar ex po sure. Al though the 1987 Cen ters for Dis ease Con trol and Pre ven tion (CDC) Guide lines for the Pre -

ven tion of Herpesvirus simiae (B vi rus) In fec tion in Mon key Han dlers dis cour ages han dling fully awake ma -

caques, ma caque han dlers should be pro tected with ap pro pri ate eye pro tec tion when it is nec es sary to re move

phys i cally ac tive an i mals from cages. The in ci dent de scribed in this re port in di cates that proper eye pro tec tion

should also be man da tory dur ing ac tiv i ties such as en ter ing ar eas con tain ing ma caques, con duct ing cap tures,

and trans port ing caged ma caques. Other ac tiv i ties that require eye pro tec tion should be de ter mined by the haz -

ard as sess ment. Ap pro pri ate pro tec tive eyewear se lec tion should be based on a num ber of fac tors, in clud ing the

na ture and ex tent of the haz ard, na ture of the work, as so ci ated de gree of risk, and re quire ments of the in di vid ual

user. Pro tec tive eyewear should meet or ex ceed the cri te ria es tab lished by ANSI. Eye pro tec tion must be com -

fort able, ac com mo date the need for cor rec tive lenses (eye glasses), and be ad just able to en sure a se cure fit. It

may be nec es sary to pro vide sev eral dif fer ent types, styles, and sizes. Per sonal eye glasses are not PPE.

Pro tec tive gog gles de signed for splash pro tec tion (avail able with antifog lenses for hu mid en vi ron ments and in

mod els that pre serve pe riph eral vi sion) should be worn to pro tect the eyes against splash haz ards in com bi na tion

with a mask de signed to pro tect other mu cous mem branes. Faceshields are com monly con sid ered sec ond ary

eye pro tec tors that are worn in com bi na tion with pro tec tive gog gles. Al though pre vi ous guide lines for the pre -

ven tion of B vi rus in di cate that faceshields may be suf fi cient, oc u lar ex po sures have oc curred to work ers wear -

ing faceshields. In one in ci dent, an an i mal tech ni cian was splashed in the eye with an un known fluid while

wear ing a com bi na tion sur gi cal mask/faceshield dur ing the trans fer of a mon key within cages. The “faceshield”

worn dur ing this ex po sure, a sur gi cal mask with at tached plas tic eye shield, did not pro vide ad e quate pro tec tion.

To min i mize the po ten tial for mu cous mem brane ex po sure, faceshields must pre vent drop let splashes to the

head from run ning down into the eyes and pre vent mu cous mem brane ex po sure around the edges (sides, top,

and bot tom to be low the chin). De ci sions to use faceshields as the sole means for pre vent ing oc u lar ex po sure

should be made only af ter full con sid er ation of both the lim i ta tions of faceshields and Oc cu pa tional Safety and

Health Ad min is tra tion (OSHA) regulations.

If ex po sure pre ven tion fails, the ad e quacy and time li ness of wound or ex po sure de con tam i na tion pro ce dures are 

crit i cal fac tors de ter min ing the risk of in fec tion. In sti tu tions that house or con duct pro ce dures in volv ing ma -

caques or po ten tially con tam i nated tis sues should de velop in sti tu tion-specific postexposure pro ce dures. Such

pro ce dures will en sure ap pro pri ate di ag nos tic test ing and in fec tion con trol. First, an i mal han dlers should be in -

structed to im me di ately and thor oughly cleanse all bites, scratches, and/or mucosal sur faces or abraded skin ex -

posed to ma caque bi o logic ma te ri als and to re port these ex po sures im me di ately. Fol lowing an eye ex po sure,

ex ist ing guide lines rec om mend im me di ately flush ing the eye for at least 15 min utes. Ex isting guide lines should

also be fol lowed for cleans ing bites, scratches, or other wounds. Sec ond, postexposure pro ce dures should pro -

vide po ten tially ex posed work ers with di rect and rapid ac cess to lo cal phy si cians knowl edge able about the in -

fec tious risks of ex po sure to NHPs, haz ards of B vi rus in fec tion, signs and symp toms, and treat ment, as well as

other biohazards as so ci ated with NHPs. These phy si cians should be avail able on an on-call ba sis in the event of

an ex po sure. The em ployer should en sure that di rect ac cess to the knowl edge able con sul tant is avail able

immediately fol low ing ex po sures and at any time the worker is con cerned that po ten tial oc cu pational ex posure to B vi rus may be rel e vant to worker symp toms. When pos si ble, a vet er i nar ian should as sess the clin i cal
and virologic sta tus of the source an i mal. Postexposure pro ce dures should also in clude rout ing di ag nos tic spec imens to the B Vi rus Re search and Re source Lab o ra tory (at Geor gia State Uni ver sity in At lanta).

Med i cal per son nel who eval u ate pri mate han dlers with con junc ti vi tis af ter an eye ex po sure to po ten tially in fectious ma te rial should be aware that the ab sence of den dritic le sions of the cor nea, like the ab sence of herpetic

skin ves i cles, does not re li ably rule out B vi rus in fec tion.

These rec om men da tions will be re viewed and may be re vised or aug mented fol low ing additional con sid eration by a work ing group to be con vened by the CDC Of fice of Health and Safety.

 For More Information

Ad di tional in for ma tion about B vi rus and pre ven tive mea sures can be ob tained from the following:

National Institute for Occupational Safety and Health (NIOSH) at 1–800–356–4674, or visit the NIOSH

Homepage on the World Wide Web at http://www.cdc.gov/niosh

B Virus Research and Resource Laboratory, Georgia State University, P.O. Box 4118, Atlanta,

GA 30302–4118; 404–651–0808

Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30333; 404–639–2888

(Callers should indicate the need for additional information about B virus.)

 Acknowledgments

The prin ci pal con tri bu tors to this pub li ca tion are Max Kiefer, MS, CIH; Scott Deitchman, MD, MPH; Rich ard

Ehrenberg, MD; and Jerome Flesch, MS, of NIOSH; and Louisa Chap man, MD, MSPH, of the Na tional Cen ter

for In fec tious Dis eases. Desk top pub lish ing pro vided by Kristina Dragon and Su san Kaelin of NIOSH.

May 1999 DHHS (NIOSH) Publication No. 99–100

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service

Centers for Disease Control and Prevention

National Institute for Occupational Safety and Health

CDC

CENTERS FOR DISEASE CONTROL

AND PREVENTION