during 20012014 , epidemiologic data on nhp  related injuries and associated rabies pep treatment were prospectively collected for patients of the marseille rabies treatment centre .
demographics , place of exposure , travel characteristics , clinical data , and rabies pep were documented .
a total of 135 cases of persons injured by nhps reported during a 14-year period were included , representing an average 10 cases / year ( range 416 cases / year ) , with a tendency to increase over time ( figure , panel a ) .
exposures were more frequently reported during july  october ( figure , panel b ) .
the f / m sex ratio of patients was 1.1 , and the mean age was 30 years ( median  27 years ; range 370 years ) ; 20.7% of patients were < 15 years of age ( table 1 ) .
of the 135 patients , 2 had complete and 1 incomplete preexposure vaccination against rabies .
most exposures ( n = 120 , 88.9% ) occurred outside of france , notably in southeast asia ( n = 82 ) ; most cases occurred in thailand ( n = 48 ) and indonesia ( n = 25 ) .
most exposures in thailand were on monkey beach on koh phi phi island and in the lopburi monkey temple ; most exposures in indonesia were in the ubud monkey forest in bali ( table 2 ) .
most persons injured abroad were tourists with a mean travel duration of 21 days ( median 17 days ; range 3180 days ) .
the mean time between the first date of travel and exposure was 10 days ( median 8 days ; range 150 days ) .
number of injuries to humans by nonhuman primates requiring rabies postexposure prophylaxis , marseille rabies treatment centre , marseille , france , 20012014 .
a ) logarithmic regression was used to calculate a line of best fit of y = 2,3191ln(x ) + 5.4699 ( black line ) .
b ) cumulative occurrence by month . * vietnam ( 5 ) , india ( 4 ) cambodia ( 3 ) , myanmar ( 1 ) , sri - lanka ( 1 ) . 
madagascar ( 4 ) , kenya ( 4 ) , botswana ( 1 ) , cameroon ( 1 ) , central african republic ( 1 ) .  
brazil ( 2 ) , anguilla ( 1 ) , dominican republic ( 1 ) , mexico ( 1 ) , peru ( 1 ) . 
persons , or their descendants , who have immigrated to marseille from another country who were exposed while visiting friends and relatives in their country of origin ( 3 ) , expatriate ( 1 ) , humanitarian worker ( 1 ) , and student ( 1 ) . 
injuries most commonly occurred on the upper limbs ( 57.8% ) ; subsequent occurrences of injury were on lower limbs ( 28.9% ) , head ( 5.9% ) , trunk ( 3.7% ) , or multiple sites ( 2.2% ) .
most injuries ( 66.7% ) were severe transdermal type 3 injuries according to the who classification , resulting from severe bites ( 1 ) ; the remaining ( 33.3% ) were type 2 injuries ( minor abrasions and scratches without bleeding ) .
according to who guidelines ( 1 ) , rabies immune globulin ( rig ) was indicated for 65.2% of patients who had type 3 injuries and no previous vaccination against rabies . among patients injured abroad ,
58 ( 48.3% ) started rabies pep abroad ; the mean time between injury and treatment was 1 day ( median 0 days ; range 021 days ) .
most ( 77.6% ) underwent the essen protocol and 17.2% underwent the zagreb protocol ( 1 ) ; and 5.2% underwent the 7-dose mouse brain vaccine protocol ( local subcutaneous and intradermal protocol used in north africa : seven 1.0-ml subcutaneous injections from day 0 through day 6 , followed by 2-site 0.1-ml intradermal injections on days 10 , 14 , 29 , and 90 ) .
a total of 35 patients ( 25.9% ) had an indication for rig , of whom 8 ( 22.9% ) received the rig abroad . among the 27 remaining patients , the mean time between first injection of vaccine abroad and the first consultation in france was 12 days ( median 12 days ; range 331 days ) .
an additional 6 patients ( 17.1% ) received rig in france , and the remaining 21 patients ( 60.0% ) did not .
of those 21 patients , 20 sought follow - up medical consultation in france > 7 days after the first vaccine was provided abroad ; the initiation of rig is contraindicated if > 7 days have passed since vaccine initiation ( 5 ) .
a total of 62 patients started their treatment in france with a mean time between injury and treatment of 15 days ( median 11 days ; range 2123 days ) .
most underwent the essen protocol ( 71.0% ) , followed by the zagreb protocol ( 27.4% ) .
one patient who received complete preventive vaccination received 2 booster doses at days 0 and 3 .
of 44 patients for whom rig was indicated , 39 ( 88.6% ) received rig .
an estimated 31% of injuries requiring rabies pep among international travelers are caused by nhps , which rank second after dogs in most studies and first in studies conducted among travelers returning from southeast asia ( 2 ) . in a recent geosentinel survey involving 2,697 travelers requiring rabies pep , nhps accounted for 66% of animal bites occurring in southeast asia , and tourists made up a disproportionately large portion of the nhp exposures ( 92% ) ( 6 ) .
bites by nhps can transmit other potentially life - threatening zoonoses , such as the herpes b virus ( cercopithecine herpesvirus 1 ) .
the human herpes b virus infections that have been described have all occurred after contact with macaques in a biomedical research setting ( 7 ) .
however , samples of > 80% of macaques at the monkey forest in bali tested positive for antibodies against the herpes b virus , a naturally occurring infectious agent that is endemic among macaque monkeys from asia ( 8) .
appropriate b virus prophylaxis may be considered for travelers injured by asian macaques , although this treatment is not applicable to those injured by new world nhps ( 3,4 ) . in this study
, we observed that most exposures occurred among adult tourists to southeast asia during the summer months , which probably reflects travel volume .
furthermore , we identified 2 major tourist destinations in thailand and 1 in indonesia as locations where monkeys were most likely to bite tourists , reflecting the regional distribution of both monkey and tourist populations .
most patients were taking relatively short trips and were bitten within the first 10 days after their arrival . indeed
an estimated 6% of visitors to bali monkey temples are bitten by macaque monkeys ( 9 ) .
no detailed information is available about documented cases of rabies among monkeys at these tourist destinations ; however , confirmed cases have been reported in monkeys as well as in gibbons and langurs in thailand ( panichabhongse p. , the epidemiology of rabies in thailand [ thesis ] .
we show that most of the cases involved persons who had not received preexposure immunization and that 33% of patients for whom rig was indicated did not receive rig .
only a small proportion of travelers received rig in the country of exposure , which reflects the limited supply of this biological agent in many countries .  
unvaccinated western travelers who are unaware of the risk for rabies regularly engage in contact with animals during their trips , often resulting in expensive pep . to decrease the need for rabies pep after animal bites , it is crucial that travelers to countries in which rabies is endemic be fully informed of this specific risk , which can be easily minimized by avoiding contact with animals , avoiding feeding them , avoiding smiling at them ( showing teeth is a sign of aggression ) , avoiding dropping something that a monkey has grabbed , and avoiding showing fear .
our findings indicate that tourists should be given strong warnings before travel to visit koh phi phi , lopburi , or ubud .
 most exposures of residents of marseille to nonhuman primates occurred among unvaccinated adult travelers to southeast asia within the first 10 days of their arrival at 2 major tourist locations in thailand and 1 in indonesia . 
 a small proportion of travelers received rabies immunoglobulin in the country of exposure . 
The Study
Conclusions