Orf (ecthyma contagiosum) is an infection of the skin caused by a DNA virus of the genus Parapoxvirus, family Poxviridae. Skin lesions (e.g., vesicles, blisters, pustules, erosions, ulcers, papules, nodules) occur at sites of inoculation of the virus 3–15 days after infection. Hands are usually affected (1). The differential diagnosis for orf includes milker’s nodule, anthrax, tularemia, fish tank granuloma, cutaneous leishmaniasis, pyogenic granuloma, and keratoacanthoma (1). The disease spontaneously heals within 6 weeks, although pain, bacterial superinfections, and regional lymphadenitis are possible (1). Treatment is based on topical antiseptics (1).

Orf virus usually infects sheep and goats. Humans are infected by handling infected meat from these animals; orf is considered an occupational disease in shepherds, shearers, veterinarians, butchers, and cooks (1). In the last few years, orf has occurred after the Muslim Feast of Sacrifice (Eid al-Adha) (1–10). In 2014, we reported a case of orf that appeared after sheep slaughtering for this feast (1). During 2015–2018, we observed 7 additional cases in Muslim men 18–61 years of age who were of Moroccan, Tunisian, or Egyptian origin. They had been infected 2–3 weeks after lamb slaughtering for the feast (Table). One patient was a butcher. In all patients, 1 hand and/or fingers were involved. In 4 patients, orf presented with erythematous pustules; 3 of these patients had ulcerated nodules. In all patients, clinical diagnosis was confirmed by histopathologic examinations.

Orf acquired during the Feast of Sacrifice was reported in 1982 in Turkey (2). Other cases were subsequently reported in France (3,10), Belgium (4,5), Italy (1), Turkey (6,7,9), and the United States (8). Epidemics also were reported: in Belgium, 23 cases in 2000 and 44 cases in 2001 (4,5), and in Turkey, 9 cases in 2005 and 29 cases in 2009 (6,7).

In most reported cases, orf appeared days or weeks after the Feast of Sacrifice. This feast is celebrated 2 months and 10 days after the end of Ramadan; the exact date varies (4). During the feast, many Muslim families kill a lamb, which has to be bled alive (4). Only men may kill the lamb. Orf occurs more often in men; however, it occurs also in women, who often handle the infected meat with bare hands during preparation and cooking.

In conclusion, in the metropolitan area of Milan, where ≈250,000 Muslims reside, we recently observed 7 patients with orf acquired during the Feast of Sacrifice. Prevention measures are difficult. For example, most of the Muslims living in the metropolitan area of Milan are Moroccans, who travel to Italy by car, carrying the infected meat; thus, no prevention measures have been taken.

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