Preventing zoonotic and zooanthroponotic disease transmission at wild great ape sites: Recommendations from qualitative research at Bwindi Impenetrable National Park.

Employees at wild great ape sites are at high risk of transmitting infectious diseases to endangered great apes. Because of the significant amount of time employees spend near great apes, they are a priority population for the prevention and treatment of zoonotic and zooanthroponotic spillover and need adequate preventive and curative healthcare. Qualitative, semi-structured interviews with 46 staff (rangers and porters) at Bwindi Impenetrable National Park, Uganda (BINP) and key informants from five other wild great ape sites around the world were performed. The objectives of the study were to 1) evaluate health-seeking behavior and health resources used by staff in contact with great apes at Bwindi Impenetrable National Park; 2) evaluate existing occupational health programs for employees working with great apes in other parts of the world; and 3) make recommendations for improvement of occupational health at BINP. Results show that BINP employees do not frequently access preventive healthcare measures, nor do they have easy access to diagnostic testing for infectious diseases of spillover concern. Recommendations include assigning a dedicated healthcare provider for great ape site staff, providing free annual physical exams, and stocking rapid malaria tests and deworming medication in first aid kits at each site.

Non-invasive genomics of respiratory pathogens infecting wild great apes using hybridisation capture.

Human respiratory pathogens have repeatedly caused lethal outbreaks in wild great apes across Africa, leading to population declines. Nonetheless, our knowledge of potential genomic changes associated with pathogen introduction and spread at the human-great ape interface remains sparse. Here, we made use of target enrichment coupled with next generation sequencing to non-invasively investigate five outbreaks of human-introduced respiratory disease in wild chimpanzees living in Taï National Park, Ivory Coast. By retrieving 34 complete viral genomes and three distinct constellations of pneumococcal virulence factors, we provide genomic insights into these spillover events and describe a framework for non-invasive genomic surveillance in wildlife.

Great ape health watch: Enhancing surveillance for emerging infectious diseases in great apes.

Infectious diseases have the potential to extirpate populations of great apes. As the interface between humans and great apes expands, zoonoses pose an increasingly severe threat to already endangered great ape populations. Despite recognition of the threat posed by human pathogens to great apes, health monitoring is only conducted for a small fraction of the world's wild great apes (and mostly those that are habituated) meaning that outbreaks of disease often go unrecognized and therefore unmitigated. This lack of surveillance (even in sites where capacity to conduct surveillance is present) is the most significant limiting factor in our ability to quickly detect and respond to emerging infectious diseases in great apes when they first appear. Accordingly, we must create a surveillance system that links disease outbreaks in humans and great apes in time and space, and enables veterinarians, clinicians, conservation managers, national decision makers, and the global health community to respond quickly to these events. Here, we review existing great ape health surveillance programs in African range habitats to identify successes, gaps, and challenges. We use these findings to argue that standardization of surveillance across sites and geographic scales, that monitors primate health in real-time and generates early warnings of disease outbreaks, is an efficient, low-cost step to conserve great ape populations. Such a surveillance program, which we call "Great Ape Health Watch" would lead to long-term improvements in outbreak preparedness, prevention, detection, and response, while generating valuable data for epidemiological research and sustainable conservation planning. Standardized monitoring of great apes would also make it easier to integrate with human surveillance activities. This approach would empower local stakeholders to link wildlife and human health, allowing for near real-time, bidirectional surveillance at the great ape-human interface.

CardiOvascular examination in awake Orangutans (Pongo pygmaeus pygmaeus): Low-stress Echocardiography including Speckle Tracking imaging (the COOLEST method).

INTRODUCTION: Cardiovascular diseases have been identified as a major cause of mortality and morbidity in Borneo orangutans (Pongo pygmaeus pygmaeus). Transthoracic echocardiography is usually performed under anesthesia in great apes, which may be stressful and increase risks of peri-anesthetic complications in case of cardiac alteration. The aim of the present pilot study was hence to develop a quick and non-stressful echocardiographic method (i.e., the COOLEST method) in awake Borneo orangutans (CardiOvascular examination in awake Orangutans: Low-stress Echocardiography including Speckle Tracking imaging) and assess the variability of corresponding variables. MATERIALS AND METHODS: Four adult Borneo orangutans trained to present their chest to the trainers were involved. A total of 96 TTE examinations were performed on 4 different days by a trained observer examining each orangutan 6 times per day. Each examination included four two-dimensional views, with offline assessment of 28 variables (i.e., two-dimensional (n = 12), M-mode and anatomic M-mode (n = 6), Doppler (n = 7), and speckle tracking imaging (n = 3)), representing a total of 2,688 measurements. A general linear model was used to determine the within-day and between-day coefficients of variation. RESULTS: Mean±SD (minimum-maximum) images acquisition duration was 3.8±1.6 minutes (1.3-6.3). All within-day and between-day coefficients of variation but one (n = 55/56, 98%) were <15%, and most (51/56, 91%) were <10% including those of speckle tracking systolic strain variables (2.7% to 5.4%). DISCUSSION: Heart morphology as well as global and regional myocardial function can be assessed in awake orangutans with good to excellent repeatability and reproducibility. CONCLUSIONS: This non-stressful method may be used for longitudinal cardiac follow-up in awake orangutans.

Population structure, intergroup interaction, and human contact govern infectious disease impacts in mountain gorilla populations.

Infectious zoonotic diseases are a threat to wildlife conservation and global health. They are especially a concern for wild apes, which are vulnerable to many human infectious diseases. As ecotourism, deforestation, and great ape field research increase, the threat of human-sourced infections to wild populations becomes more substantial and could result in devastating population declines. The endangered mountain gorillas (Gorilla beringei beringei) of the Virunga Massif in east-central Africa suffer periodic disease outbreaks and are exposed to infections from human-sourced pathogens. It is important to understand the possible risks of disease introduction and spread in this population and how human contact may facilitate disease transmission. Here we present and evaluate an individual-based, stochastic, discrete-time disease transmission model to predict epidemic outcomes and better understand health risks to the Virunga mountain gorilla population. To model disease transmission we have derived estimates for gorilla contact, interaction, and migration rates. The model shows that the social structure of gorilla populations plays a profound role in governing disease impacts with subdivided populations experiencing less than 25% of the outbreak levels of a single homogeneous population. It predicts that gorilla group dispersal and limited group interactions are strong factors in preventing widespread population-level outbreaks of infectious disease after such diseases have been introduced into the population. However, even a moderate amount of human contact increases disease spread and can lead to population-level outbreaks.

Progress in understanding the phylogeny of the Plasmodium vivax lineage.

There has been some controversy about the evolutionary origin of Plasmodium vivax, particularly whether it is of Asian or African origin. Recently, a new malaria species which closely related to ape P. vivax was found in chimpanzees, in addition, the host switches of P. vivax from ape to human was confirmed. These findings support the African origin of P. vivax. Previous phylogenetic analyses have shown the position of P. vivax within the Asian primate malaria parasite clade. This suggested an Asian origin of P. vivax. Recent analyses using massive gene data, however, positioned P. vivax after the branching of the African Old World monkey parasite P. gonderi, and before the branching of the common ancestor of Asian primate malaria parasites. This position is consistent with an African origin of P. vivax. We here review the history of phylogenetic analyses on P. vivax, validate previous analyses, and finally present a definitive analysis using currently available data that indicate a tree in which P. vivax is positioned at the base of the Asian primate malaria parasite clade, and thus that is consistent with an African origin of P. vivax.

Endangered mountain gorillas and COVID-19: One health lessons for prevention and preparedness during a global pandemic.

The world's 1063 mountain gorillas (Gorilla beringei beringei) live in two subpopulations at the borders of the Democratic Republic of Congo, Rwanda, and Uganda. The majority of mountain gorillas are human-habituated to facilitate tourism and research, which brings mountain gorillas into close proximity of people daily. Wild great apes are proven to be susceptible to human pathogens, including viruses that have caused fatal respiratory disease in mountain gorillas (e.g., human metapneumovirus1 ). This is the result of the close genetic relatedness of humans and gorillas as species, and the structural and genetic similarity in molecular receptors that allow viruses to infect cells2 . At the time of writing, there is no evidence that severe acute respiratory syndrome coronavirus 2, the coronavirus that causes coronavirus disease 19 (COVID-19), has infected a mountain gorilla. However, due to the significant potential for human-to-gorilla transmission, mountain gorilla range States took immediate steps to minimize the COVID-19 threat. These actions included a combination of preventive practice around gorillas and other great apes (e.g., mandatory face mask use, increased "social" minimum distancing from gorillas) as well as human public health measures (e.g., daily health/fever screenings, COVID-19 screening, and quarantines). Minimization of the COVID-19 threat also required socioeconomic decision-making and political will, as all gorilla tourism was suspended by late March 2020 and guidelines developed for tourism reopening. A consortium that collaborates and coordinates on mountain gorilla management and conservation, working within an intergovernmental institutional framework, took a multifaceted One Health approach to address the COVID-19 threat to mountain gorillas by developing a phased contingency plan for prevention and response. The aim of this paper is to describe how range States and partners achieved this collaborative planning effort, with intent that this real-world experience will inform similar actions at other great ape sites.

Rapid transmission of respiratory infections within but not between mountain gorilla groups.

Minimizing disease transmission between humans and wild apes and controlling outbreaks in ape populations is vital to both ape conservation and human health, but information on the transmission of real infections in wild populations is rare. We analyzed respiratory outbreaks in a subpopulation of wild mountain gorillas (Gorilla beringei beringei) between 2004 and 2020. We investigated transmission within groups during 7 outbreaks using social networks based on contact and proximity, and transmission between groups during 15 outbreaks using inter-group encounters, transfers and home range overlap. Patterns of contact and proximity within groups were highly predictable based on gorillas' age and sex. Disease transmission within groups was rapid with a median estimated basic reproductive number (R0) of 4.18 (min = 1.74, max = 9.42), and transmission was not predicted by the social network. Between groups, encounters and transfers did not appear to have enabled disease transmission and the overlap of groups' ranges did not predict concurrent outbreaks. Our findings suggest that gorilla social structure, with many strong connections within groups and weak ties between groups, may enable rapid transmission within a group once an infection is present, but limit the transmission of infections between groups.

Exploring the potential effect of COVID-19 on an endangered great ape.

The current COVID-19 pandemic has created unmeasurable damages to society at a global level, from the irreplaceable loss of life, to the massive economic losses. In addition, the disease threatens further biodiversity loss. Due to their shared physiology with humans, primates, and particularly great apes, are susceptible to the disease. However, it is still uncertain how their populations would respond in case of infection. Here, we combine stochastic population and epidemiological models to simulate the range of potential effects of COVID-19 on the probability of extinction of mountain gorillas. We find that extinction is sharply driven by increases in the basic reproductive number and that the probability of extinction is greatly exacerbated if the immunity lasts less than 6 months. These results stress the need to limit exposure of the mountain gorilla population, the park personnel and visitors, as well as the potential of vaccination campaigns to extend the immunity duration.

Fecal glucocorticoids and gastrointestinal parasite infections in wild western lowland gorillas (Gorilla gorilla gorilla) involved in ecotourism.

Wildlife ecotourism can offer a source of revenue which benefits local development and conservation simultaneously. However, habituation of wildlife for ecotourism can cause long-term elevation of glucocorticoid hormones, which may suppress immune function and increase an animal's vulnerability to disease. We have previously shown that western lowland gorillas (Gorilla gorilla gorilla) undergoing habituation in Dzanga-Sangha Protected Areas, Central African Republic, have higher fecal glucocorticoid metabolite (FGCM) levels than both habituated and unhabituated gorillas. Here, we tested the relationship between FGCM levels and strongylid infections in the same gorillas. If high FGCM levels suppress the immune system, we predicted that FGCM levels will be positively associated with strongylid egg counts and that gorillas undergoing habituation will have the highest strongylid egg counts, relative to both habituated and unhabituated gorillas. We collected fecal samples over 12 months in two habituated gorilla groups, one group undergoing habituation and completely unhabituated gorillas. We established FGCM levels and fecal egg counts of Necator/Oesophagostomum spp. and Mammomonogamus sp. Controlling for seasonal variation and age-sex category in strongylid infections we found no significant relationship between FGCMs and Nectator/Oesophagostomum spp. or Mammomonogamus sp. egg counts in a within group comparison in either a habituated group or a group undergoing habituation. However, across groups, egg counts of Nectator/Oesophagostomum spp. were lowest in unhabituated animals and highest in the group undergoing habituation, matching the differences in FGCM levels among these gorilla groups. Our findings partially support the hypothesis that elevated glucocorticoids reduce a host's ability to control the extent of parasitic infections, and show the importance of non-invasive monitoring of endocrine function and parasite infection in individuals exposed to human pressure including habituation process and ecotourism.

USE OF COMPUTED TOMOGRAPHY (CT) TO DETERMINE THE SENSITIVITY OF CLINICAL SIGNS AS A DIAGNOSTIC TOOL FOR RESPIRATORY DISEASE IN BORNEAN ORANGUTANS (PONGO PYGMAEUS).

Orangutans are noteworthy among great apes in their predilection for chronic, insidious, and ultimately fatal respiratory disease. Termed Orangutan Respiratory Disease Syndrome (ORDS), this cystic fibrosis-like disease is characterized by comorbid conditions of sinusitis, mastoiditis, airsacculitis, bronchiectasis, and recurrent pneumonia. The aim of this retrospective study was to determine the sensitivity of clinical signs in the diagnosis of ORDS in Bornean orangutans (Pongo pygmaeus) compared with the gold standard for diagnosis via computed tomography (CT). We retrospectively compared observed clinical signs with CT imaging in a population of clinically affected animals at an orangutan rescue center in southeastern Borneo. From August 2017 to 2019, this center housed 21 ORDS-affected animals, all of which underwent CT imaging to delineate which areas of the respiratory tract were affected. We reviewed clinical signs recorded in medical records and keeper observation notes for each individual for the period of 2 years prior to the date of the CT scan. A chi-square test of association was used to assess whether the observed clinical signs could predict the results of CT imaging. Results show that clinical signs may not be sensitive indicators in predicting respiratory disease identified by CT imaging. Based on the results of this study, clinical signs appear to be very poor predictors of underlying respiratory pathology in orangutans, based on high P-values, low sensitivity, and low specificity. This result is observed even with clinical signs data gathered over a full 24-mo period prior to CT scan performance. The findings of this study suggest the need for advanced imaging to properly diagnose and manage the most common health issue of captive orangutans.

ACUTE NECROTIZING AND EOSINOPHILIC MYOCARDITIS IN A CHIMPANZEE (PAN TROGLODYTES).

Cardiac disease is of importance in captive chimpanzee (Pan troglodytes) health. Here we report an eosinophilic and necrotizing myocarditis in a 17-y-old chimpanzee with no previous history of cardiac disease that progressed to death within 48 h. Toxic and infectious causes were ruled out. The chimpanzee had eosinophilia at different occasions in previous years. The animal had a severe, diffuse, and acute monophasic necrotizing myocarditis, with a moderate lymphoplasmacytic infiltrate that was rich in eosinophils. Ante- and postmortem investigations are compatible with an unusual eosinophilic myocarditis with clinical evolution and morphology comparable with human eosinophilic myocarditis secondary to hypereosinophilic syndrome.

Variation in selective constraints along the Plasmodium life cycle.

Plasmodium parasites, the cause of malaria, have a complex life cycle, infecting alternatively vertebrate hosts and female Anopheles mosquitoes and undergoing intra- and extra-cellular development in several organs of these hosts. Most of the ~5000 protein-coding genes present in Plasmodium genomes are only expressed at specific life stages, and different genes might therefore be subject to different selective pressures depending on the biological activity of the parasite and its microenvironment at this point in development. Here, we estimate the selective constraints on the protein-coding sequences of all annotated genes of rodent and primate Plasmodium parasites and, using data from scRNA-seq experiments spanning many developmental stages, analyze their variation with regard to when these genes are expressed in the parasite life cycle. Our study reveals extensive variation in selective constraints throughout the parasites' development and highlights stages that are evolving more rapidly than others. These findings provide novel insights into the biology of these parasites and could provide important information to develop better treatment strategies or vaccines against these medically-important organisms.

Heterogeneity in patterns of helminth infections across populations of mountain gorillas (Gorilla beringei beringei).

Conservation efforts have led to the recovery of the endangered mountain gorilla populations. Due to their limited potential for spatial expansion, population densities increased, which may alter the epidemiology of infectious diseases. Recently, clinical gastrointestinal illnesses linked to helminth infections have been recorded in both gorilla populations. To understand drivers and patterns of helminth infections we quantified strongylid and tapeworm infections across both Virunga Massif and Bwindi populations using fecal egg counts. We assessed the impact of age, sex, group size, season and spatial differences used as a proxy, which reflects observed variation in the occurrence of gastrointestinal problems, vegetation types, gorilla subpopulation growth and associated social structure on helminth infections. We revealed striking geographic differences in strongylid infections with higher egg counts mostly in areas with high occurrences of gastrointestinal disease. Increased helminth egg counts were also associated with decreasing group size in some areas. Observed spatial differences may reflect mutual effects of variations in subpopulation growth rates, gorilla social structure, and vegetation associated with altitude across mountain gorilla habitat. Helminth infection intensities in Virunga gorillas were lowest in the youngest and the oldest animals. Elucidating parasite infection patterns of endangered species with low genetic diversity is crucial for their conservation management.

Genetic characterization of nodular worm infections in Asian Apes.

Parasitic nematodes of Oesophagostomum spp., commonly known, as 'nodular worms' are emerging as the most widely distributed and prevalent zoonotic nematodes. Oesophagostomum infections are well documented in African non-human primates; however, the taxonomy, distribution and transmission of Oesophagostomum in Asian non-human primates are not adequately studied. To better understand which Oesophagostomum species infect Asian non-human primates and determine their phylogeny we analysed 55 faecal samples from 50 orangutan and 5 gibbon individuals from Borneo and Sumatra. Both microscopy and molecular results revealed that semi-wild animals had higher Oesophagostomum infection prevalence than free ranging animals. Based on sequence genotyping analysis targeting the Internal transcribed spacer 2 of rDNA, we report for the first time the presence of O. aculeatum in Sumatran apes. Population genetic analysis shows that there is significant genetic differentiation between Bornean and Sumatran O. aculeatum populations. Our results clearly reveal that O. aculeatum in free-ranging animals have a higher genetic variation than those in semi-wild animals, demonstrating that O. aculeatum is circulating naturally in wildlife and zoonotic transmission is possible. Further studies should be conducted to better understand the epidemiology and dynamics of Oesophagostomum transmission between humans, non-human primates and other wild species and livestock in Southeast Asia.

USE OF A HUMAN INDIRECT IMMUNOFLUORESCENCE ANTIBODY ASSAY FOR BALAMUTHIA MANDRILLARIS IN A GROUP OF CAPTIVE NORTHWEST BORNEAN ORANGUTANS (PONGO PYGMAEUS PYGMAEUS).

Granulomatous amoebic encephalitis caused by the free-living amoeba Balamuthia mandrillaris is a highly fatal disease that was first isolated from a mandrill (Mandrillus sphinx), and has since been diagnosed in several nonhuman primates including orangutans. Indirect immunofluorescence antibody (IFA) techniques for Balamuthia have been used in the fields of human medicine and epidemiology both for exposure assessment and screening of clinical patients for antemortem diagnosis. Stored serum samples from five captive Northwest Bornean orangutans (Pongo pygmaeus pygmaeus), including one who had died from B. mandrillaris infection, housed at a single facility were screened with a human IFA assay for B. mandrillaris. Only the single, clinically affected individual was seropositive, and the results suggest that the use of the available human B. mandrillaris IFA assay is a novel diagnostic option for detection of Balamuthia antibodies in this species. A validated screening serological test could be used in individuals exhibiting signs consistent with granulomatous amoebic encephalitis to facilitate earlier antemortem diagnosis of Balamuthia infection, which is critical if treatment is to be pursued. This pilot study presents the use of serological detection methods for B. mandrillaris screening in a nonhuman primate. Subsequent use of the B. mandrillaris IFA assay in the larger captive population should be pursued for validation of the test and to provide further information on seroprevalence and evaluation of risk factors for exposure to Balamuthia and subsequent development of disease.

Diversity of parasites in two captive chimpanzee populations in southern Gabon.

Captive chimpanzees living in confined environments like sanctuaries or primatology centers are frequently affected by gastrointestinal parasites. Some of these are likely to be transmitted to humans and may seriously affect public health. However little information is currently available on the gastrointestinal parasites of primates living in such environments. Here, we characterize the diversity and prevalence of gastrointestinal parasites in two populations of captive chimpanzees living in south-eastern Gabon. Our study reveals that at least nine parasite species infect the chimpanzees with high prevalence, including several helminths (Ascaris spp., Enterobius spp., Strongyloides spp., Trichuris spp., Hymenolepis spp., Mammomonogamus spp), three protozoa (Balantioides spp., Entamoeba spp. and Troglodytella spp) and several unidentified parasites. All the parasite taxa we identified had previously been identified in other primates, including humans. Age, sex and site type may influence infection rates and/or parasite diversity found in a particular host.

Notes on Morphology and Life History of Probstmayria gombensis (Nematoda: Cosmocercoidea: Atractidae), Parasitic in Eastern Chimpanzees, Pan troglodytes schweinfurthii, in Bulindi, Uganda.

Probstmayria gombensis File, 1976 (Nematoda: Cosmocercoidea: Atractidae) individuals discharged in the feces of eastern chimpanzees, Pan troglodytes schweinfurthii, in Bulindi, Uganda, were examined morphologically. Adults and fourth-stage larvae, all females, found in the feces, and the third-stage larvae excised from the uterus of the gravid females were described. By close observation of the molting worms, it was considered that the uterine third-stage larvae attain molting phase, and then are laid to become fourth-stage larvae. Nutrients required for larval development in the uterus seem to be supplied by the mother after the eggshell is formed. After some growth in the host intestine, the fourth-stage larvae undergo the final molt to the adult stage. The genital primordium was very small in the early fourth-stage larvae but rapidly developed with embryonation in the pre-molt and molting phases. Such precocity suggests parthenogenetic reproduction without insemination by males. This style may enhance rapid autoinfection in the host intestine under the condition of male worm scarcity. Several ellipsoidal pseudocoelomocytes with granules of unknown function were found ventral to the intestine of the adults, fourth-stage larvae, and third-stage larvae.

A Sarcina bacterium linked to lethal disease in sanctuary chimpanzees in Sierra Leone.

Human and animal infections with bacteria of the genus Sarcina (family Clostridiaceae) are associated with gastric dilation and emphysematous gastritis. However, the potential roles of sarcinae as commensals or pathogens remain unclear. Here, we investigate a lethal disease of unknown etiology that affects sanctuary chimpanzees (Pan troglodytes verus) in Sierra Leone. The disease, which we have named "epizootic neurologic and gastroenteric syndrome" (ENGS), is characterized by neurologic and gastrointestinal signs and results in death of the animals, even after medical treatment. Using a case-control study design, we show that ENGS is strongly associated with Sarcina infection. The microorganism is distinct from Sarcina ventriculi and other known members of its genus, based on bacterial morphology and growth characteristics. Whole-genome sequencing confirms this distinction and reveals the presence of genetic features that may account for the unusual virulence of the bacterium. Therefore, we propose that this organism be considered the representative of a new species, named "Candidatus Sarcina troglodytae". Our results suggest that a heretofore unrecognized complex of related sarcinae likely exists, some of which may be highly virulent. However, the potential role of "Ca. S. troglodytae" in the etiology of ENGS, alone or in combination with other factors, remains a topic for future research.

MANAGEMENT OF MEDICAL COMPLICATIONS ASSOCIATED WITH A PRESUMED TETANUS INFECTION IN A NORTHWEST BORNEAN ORANGUTAN (PONGO PYGMAEUS PYGMAEUS).

An 18-yr-old female orangutan (Pongo pygmaeus pygmaeus) developed opisthotonus after sustaining conspecific bite wounds 3 wk earlier. The orangutan developed progressive tetraparesis and dysphagia, despite normal mentation, suggestive of tetanus. A tetanus vaccine had been administered at 2 yr of age, but none since. Brain magnetic resonance imaging, computed tomography, cerebral spinal fluid tap, and bloodwork were unremarkable. Viral, Baylisascaris, and tetanus toxin testing were negative. A femoral central venous catheter (CVC) was placed to provide medications, fluids, and parenteral nutrition. The orangutan received human tetanus immunoglobulin, tetanus toxoid, penicillin, methocarbamol, and analgesia. After 1 wk, the catheterized limb became edematous; a deep vein thrombosis (DVT) was diagnosed ultrasonographically. A cephalic CVC was placed, the limb casted, intravenous therapy reinitiated, and enoxaparin started. The orangutan became mobile days later, and progressively improved. Despite no compliance with enoxaparin, the DVT resolved without residual signs. This is the first reported case of presumptive tetanus and DVT in a great ape.