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Original Anothai.Pmd Chula Med J Vol. 64 No. 1 January - March 2020;29-37 DOI : 10.14456/clmj.2020.4 Original article Incidences and characteristics of monkey-related injuries among locals and tourists in Mueng District, Lopburi Province, 2013 - 2017 Anothai Juttuporna, Sarunya Hengprapromb*, Thanapoom Rattananupongb aProgram in Health Research and Management, Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand bDepartment of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand Background: Conflicts between monkeys and humans are increasing, mainly because of urbanization and deforestation. Mueng district of Lopburi Province is one of the greatest conflict areas in Thailand, where public health concerns of zoonoses transmission from monkey - bites and scratches are high. Currently, there is no epidemiological research of monkey-related injuries in Thailand. Objectives: The purposes of this study were to determine the incidence of monkey-related injuries and investigate the trends and characteristics of the injured cases in Mueng District, Lopburi Province, in 2013 - 2017. Methods: A cross - sectional analytical study was conducted to compare monkey-related injuries and investigate the incidences between locals, Thai, and foreign tourists by collecting secondary data from medical records in 3 hospitals in the study area. The cumulative incidences were used to calculate relative risk between the tourists and the locals. The characteristics of the injury cases are presented by frequency and percentage. Results: Yearly incidences of locals, Thais, and foreign tourists were in the ranges of 9.16 - 18.33, 190.16 - 379.13, and 254.07 – 736.91 per 100,000 population, respectively. The trend of injury was remarkably higher in foreign tourists. Recently, in 2016 - 2017, Thai and foreign tourists had relative risks of injury estimated as 20 and 40 times compared to that of the locals, respectively. Time, place and circumstance of injury, and wound site suggested monkey provisioning with food as the main risk factor of monkey-related injuries. Conclusion: The incidences of monkey-related injuries was highest in foreign tourists, followed by Thai tourists. Preventive measures should primarily focus on the tourists, such as training on safety behaviors with monkey, promoting pre- and post-exposure prophylaxis, and providing safeguards, warning signs, and first aids stations at monkey provisioning sites. Keywords: Epidemiology, incidence, monkey - bites, Lopburi Province, Thailand, long-tailed macaque. A new concern about emerging infectious diseases wildlife. This situation promotes infectious agents to (EID) has been continuously rising globally. Most cross-species transmission between humans EID are zoonotic disease, and most of zoonotic and monkeys.(3, 4) Monkey-bites can pose a risk of diseases come from wildlife.(1) In Thailand, one of zoonoses from the herpes B virus, rabies virus, simian the most common urban wildlife is free-ranging retroviruses, Clostridium tetani, and various groups monkeys, so called the long-tailed macaque (Macaca of bacteria inside the monkey oral cavity.(5 - 7) Although fascicularis).(2) Because they are not within the there is no case reported of herpes B virus and rabies possession or control of humans, they are considered virus transmission from monkeys in Thailand, the severity of infection from both viruses is very (6, 8) *Correspondence to: Sarunya Hengpraprom, Department high. Simian retroviruses have potential to develop of Preventive and Social Medicine, Faculty of Medicine, new emerging infectious diseases in human. An Chulalongkorn University, Bangkok10330, Thailand. example, simian immunodeficiency virus (SIV), E-mail: [email protected] was one species of simian retroviruses that was Received: February 12, 2019 Revised: March 8, 2019 transmitted to humans and mutated to become the (3) Accepted: May 3, 2019 human immunodeficiency virus (HIV). Clostridium 30 A. Juttuporn, et al. Chula Med J tetani can be found in the feces of monkeys and have code. Then medical records of W55 and W54 cases a potential risk to infect humans via bite and scratch.(9) were explored to differentiate other animal bite cases Monkey - bites can pose a risk of bacterial soft tissue from monkey - bite cases. Further, data of monkey - infection that require broad-spectrum antibiotic bite cases were collected from the rabies exposure prophylaxis, similar to human bites,(6) and the risk of cases report system, provided by the Department of zoonoses mentioned above is not uncommon, because Disease Control, to sync with hospital medical records among mammal bites in Thailand, monkey - bites rank for completeness of data. Exclusion criteria for case the third following those from dogs and cats.(6, 10) selection included: 1) medical records that were not There are many conflicts between monkeys and available; 2) data did not indicate monkey as a cause humans throughout Thailand, such as bite, scratch, of injury; and 3) injuries that occurred in Lopburi Zoo. robbing, and vandalism from monkey. Lopburi The last criterion was proposed because the Province is one of the most critical areas, especially characteristics and circumstances of captive monkeys in the old town of Lopburi Province, where the locals in the zoo were completely different from those live with monkeys and tourists travel for monkey of free-ranging monkeys in most parts of Lopburi tourism and food provisioning; thus, interaction Province. between humans and monkeys is very high in this The population at risk in each study group was area.(2, 11, 12) defined by address and race. The locals were people Currently, there is no research on the epidemiology who live in the Mueng District, Lopburi Province. The of monkey bites in Thailand. So far, this is the first numbers of mid-year local population during 2013 - study that uses epidemiological methods to assess 2017 were provided by the Bureau of Registration the risk to locals, Thai tourists, and foreign tourists Administration. Thai tourists were any Thai people of monkey - bites. To compare the risks among whose addresses were outside Mueng District, the 3 study groups, we use cumulative incidence as Lopburi Province. Foreign tourist were any non-Thai an outcome. Further, monkey bites trend and people that have address outside Mueng District, characteristics of the bite cases will be explored. Lopburi Province. The numbers of Thai and foreign Results from the study will benefit the public health tourists during 2013 - 2017 were provided by the 4th sector and local governments in Lopburi Province, regional office of the Department of Fine Arts, Lopburi helping them to prioritize and plan preventive measures Province. Each month, the 4th regional office collected for monkey - bites, and being an original study to be the number of visitors from 5 governed tourist applied in other areas that also have urban wildlife landmarks: Phra Prang Sam Yot, King Narai’s Palace, conflicts. Wat Phra Si Rattana Mahathat, Vichayen House, and Yen Hall. We calculated the median number of visitors Materials and methods in each year to estimate mid-year tourist population. A cross-sectional study was conducted to The cumulative incidence is calculated from compare monkey-bites between locals, Thai, the number of bite cases divided by the mid-year and foreign tourists. This study collected numbers population in each of the study groups. Then incidences of monkey - bite cases during 2013 - 2017 from 3 were compared among Thai and foreign tourists and hospitals in Mueng District, Lopburi Province: King locals using locals as a reference group to calculate Narai Hospital (government tertiary hospital), relative risk with a 95% confidence interval. The bite Anandamahidol Hospital (military tertiary hospital), trend was presented by line graph. The characteristics and the Royal Thai Air Force Wing 2 Hospital (military of bite cases are presented by frequency and secondary hospital). We used the 10th revision of the percentage. The characteristics consist of 3 parts: 1) International Statistical Classification of Diseases and personal history, 2) injury history, and 3) treatment Related Health Problems (ICD-10) to search for history. The proportions of each characteristic factor the monkey-bite cases by the ICD-10 codes “W55” were compared among the 3 study groups by Fisher’s (Contact with other mammals), and “W54” (Contact exact test at the significant level of 0.05. SPSS version with dogs). Most monkey-bite cases were recorded 22.0 (IBM Corp. 2013. IBM SPSS Statistics for as W55, but we included W54 to cover monkey - bite Windows, Version 22.0. Armonk, NY: IBM Corp.) cases that were mistakenly recorded with the dog bite was used to analyze the statistics. Vol. 64 No. 1 Incidences and characteristics of monkey-related injuries among locals and tourists in 31 January - March 2020 Mueng District, Lopburi Province, 2013 - 2017 Results Cumulative incidences Numbers of bite cases and numbers of population Cumulative incidence of locals, Thai, and foreign at risk tourists ranged from of 9.16 - 18.33, 190.16 – 379.13, Data collection from ICD-10 and medical records and 254.07 – 736.91 per 100 000 population, in 3 hospitals showed 493 monkey - bite cases from respectively. The incidence of tourists was clearly 2013 - 2017. After exclusion of 9 bite cases that higher than that of the locals; however, foreign tourists occurred in the Lopburi Zoo, 484 cases were included had the highest incidences in almost every year in our study. Classifying by race and address: 185 cases (Figure 2). Results from the relative risk calculation were locals; 179 cases were Thai tourists; 120 cases showed that in 2016 – 2017 Thai and foreign tourists were foreign tourists, and only 2 of 484 cases could were 20 and 40 times more likely to get injured be synchronized with data from the rabies exposure compared to the locals, respectively (Table 1). cases report system (Figure 1). The number of cases ranged from 62 - 146 per year. Mid-year local Monkey - bite trends populations ranged from 250,829 - 251,282.
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