Monkey bites among U.S. military members, Afghanistan, 2011.

To the Editor: We take serious issue with the dispatch by Mease and Baker on monkey bites among US military members in Afghanistan during 2011 (). In particular, we are troubled by the first paragraph. The dispatch opens by listing bites from rhesus macaques (Macaca mulatta) as one of the many risks faced by military personnel deployed to Afghanistan. Although technically a true statement, it is misleading in its perspective. Since 2001, ≈2,000 US soldiers have died in Afghanistan and another ≈18,000 have been wounded in action (). The authors juxtapose this toll with minor injuries incurred by 10 soldiers who flouted explicit rules prohibiting contact with pet monkeys.

None of the bitten soldiers were reported to have sequelae. Furthermore, the first paragraph leaves the impression that a US Army soldier who died of rabies while serving in eastern Afghanistan may have contracted the disease from a macaque. This finding would be an extremely unlikely occurrence.

We have yet to see a single credible report of macaque-to-human transmission of rabies. In fact, we have yet to see a report of naturally acquired rabies infection in a macaque. Similarly, although antiviral prophylaxis is routinely prescribed to persons bitten by rhesus monkeys, there is not a single report of herpes B virus infection in a human outside the laboratory/zoo context, although thousands of persons are likely bitten by macaques in Asia every year (,).

In contrast, zoonotic transmission of simian foamy virus, a retrovirus ubiquitous in nonhuman primates, has been shown to occur from macaques to humans, probably through monkey bites, although this virus has not been shown to cause disease in humans (). Although it is advisable to avoid contact with monkeys, risk for disease transmission should be placed in proper perspective. Exaggerating risks of bites has, in the past, led to irrational culling of entire populations of macaques ().

In Response: In response to the letter by Engel et al. (), we concur that combat-related deaths and illness are a greater risk than monkey bites for deployed military personnel. Furthermore, we agree that risk for monkey bites should be considered in perspective with other risks faced by deployed personnel. We also believe that action taken to decrease macaque populations in response to risks mentioned would be irrational and inappropriate; in a country affected by war, wildlife conservation efforts are needed. We did not intend to imply that the rabies-associated death mentioned in our article was caused by contact with a macaque (). As reported elsewhere, the patient likely contracted rabies from a dog bite ().

Nonetheless, we believe that risk for monkey bites deserves the attention of deployed medical providers. Risks for bacterial infection and major local trauma are critical for any macaque bite. We acknowledge that risk for contracting viral disease (rabies or B virus infection) from macaques in the wild is probably low, but we believe that it merits consideration.

Social conditions in Afghanistan have prevented any substantial rabies prevention program. Consequently, prevalence of rabies among wild animals and pets is unknown and could be higher than in other countries. Absence of any documented human deaths from B virus in a country with a developing medical system and a high mortality rate does not confirm absence of risk. B virus has been shown to be fatal in other areas, particularly in countries with greater medical diagnostic capacity ().

Engel et al. suggest that recorded monkey bites occurred because affected persons flouted rules prohibiting contact with local animals. Given the unpredictable nature of operations in Afghanistan, it is impossible to determine fault for the animal bites detailed. Furthermore, blaming bite victims may be counterproductive, exacerbating underreporting and discouraging deployed personnel from seeking needed care. We believe that the role of command support and responsibility cannot be overemphasized in preventing deployed personnel from interacting with local animals (). We thank Engel et al. for providing additional perspective on the risk for monkey bites to personnel deployed in Afghanistan.