​Back in 2018 I wrote a blog called “Don’t monkey around with the pox”. The subject was a disease called Monkey Pox, and I wrote it because the UK had recently diagnosed the first 2 cases ever in the UK. The patients were both from Nigeria. Monkey Pox is a rare infection though, and it wasn’t clear if we would see other cases again… until now…!

​At the beginning of May this year a new case of Monkey Pox was diagnosed in a patient who had recently come to the UK from Nigeria. Then towards the middle of May 2 further cases of Monkey Pox were diagnosed in the same household, but these patients had no contact with the first case, or any travel history, and in fact it’s not clear where they acquired their infections from. All very worrying…
 
Then a further 4 cases have been diagnosed! Also unrelated to the previous cases and with no obvious source for the infection… however these cases have all occurred in gay or bisexual men who have sex with men (MSM).
 
This is extremely concerning! We have now had 6 cases of Monkey Pox in people who have not been to Africa and who have no obvious source for the infection. This means we have an unknown source of infection in the UK population. On top of this we now have cases in a group of the population where spread may occur more readily through sexual activity. It is very unlikely that these 7 cases are going to be the last cases identified!
 
So, time for an update… what has changed since the blog in 2018?
 
Epidemiology
Monkey Pox is still a rare infection. In the Democratic Republic of the Congo where most cases have been reported, surveillance studies during “outbreaks” have shown an incidence of past infection between 0.001-0.05% of the population, that’s about 1 in 100,000, but that’s when they are looking for cases during an outbreak, not all the time, so the true rate could be lower than this.
 
There are 2 main types of Monkey Pox, West African and Central African. West African causes a milder infection with a mortality of about 1%; Central African is more severe with a mortality of about 10%. Fortunately for us, the cases in the UK so far have all been the West African type and are therefore mild infections.
 
Person-to-person transmission is rare, with a household secondary case rate of 8%, but transmission can still occur from touching infective lesions, respiratory droplets and possibly also sexual contact.
 
Case definition
The current UK case definition for a probable case of Monkey Pox is:

• Symptoms including: fever >38.5oC, headache, myalgia, arthralgia, back pain or lymphadenopathy

PLUS

• Contact with a case of Monkey Pox within 21 days of symptom onset OR travel to West Africa or Central Africa within 21 days of symptom onset OR MSM

 
The rash of Monkey Pox is vesicular (small fluid filled blisters) starting 1-5 days after onset of fever. It usually starts on the face or genitalia and then spreads to the rest of the body. It may look similar to chicken pox. Skin lesions eventually scab over, dry and then fall off.
 
Any patient meeting the case definition should be URGENTLY discussed with the Health Security Agency (HSA) in the UK, previously known as Public Health England, as well as the High Security Infectious Diseases Unit at the Royal Free Hospital London and the Imported Fever Service at Porton Down. This is for a surveillance activity rather than “infection severity” at the moment but as we all know, new infections that can spread can become a problem!
 
Treatment
There is no specific treatment for Monkey Pox, and most cases are mild and self-limiting. In severe cases the drug Cidofovir has been used. Cidofovir is a nucleoside analogue drug; it mimics a component of the virus’s genetics which when incorporated into the new virus particle causes a fault and the virus can’t reproduce. The main problems with Cidofovir are that it is only available intravenously and it is very toxic to kidneys.
 
There are now 2 new experimental drugs for treating pox-illnesses like Monkey Pox (and even Smallpox!) that might be available for very unwell patients in an off-license capacity:

• Brincidofovir is a derivative of Cidofovir which is orally bioavailable and is less toxic to kidneys
• Tecovirimat is a novel drug that is also orally bioavailable but works by preventing newly reproduced virus from wrapping up into a small package prior to release – there is experimental evidence that Tecovirimat and Brincidofovir are synergistic with each other (the combined effect is greater than either on its own)

 
Prevention
The main methods of prevention are avoidance of exposure to infected animals and people, good infection control practice and vaccination (the Smallpox vaccine is 85% effective at preventing Monkey Pox).
 
There are no definitive infection control policies for this infection yet, but in the meantime the following for respiratory spread infections would be appropriate:

​In the event of a sustained outbreak in the UK it is possible that the HSA might start to ring vaccinate at risk people (e.g. MSM population) to prevent spread of the virus within the wider population.
 
Now we wait to see what happens. Will there be further cases? Will the virus become established in the MSM population? If it does we could be in for another viral “pandemic”… oh joy!
 
Oops since writing this on Tuesday we now have 20 cases in the UK… did I say watch this space?!

I can just imagine the conversation:
 
“Goldberger, I need you to go down South and investigate an outbreak” demanded the Surgeon General.
 
“Yes Sir!”, replied Dr Joseph Goldberger, “Errr, what outbreak am I investigating Sir?”
 
“The leprosy-like skin infection outbreak that no one has ever been able to discover a cause for of course, it’s affecting millions of people down there.”
 
“Yes Sir!” replied Dr Goldberger again, whilst probably thinking with a sinking heart “OMG, this sounds like a nightmare…”
 
But when you work for an organisation such as the US Public Health Service in 1915 and your boss tells you to do something you pack your bags and off you go. So he did…

​“In the winter of 1906 I was called on to investigate a household epidemic of typhoid fever which had broken out in the latter part of August at Oyster Bay, New York”
 
Wow! They don’t write journal articles like that anymore. It sounds like an opening from a Sherlock Holmes story, or some other detective or investigator dreamed up by H.P. Lovecraft. Instead, it’s the opening sentence of a scientific article entitled “The work of a chronic typhoid germ distributor” from the Journal of the American Medical Association (JAMA) way back in 1907, by a chap called George Soper (the hero of our story), and it deals with one of the most famous/infamous outbreaks of typhoid of modern times.
 
Cue dramatic music…!

Back in 1986 a certain ex-film star, and former President of the United States, set in motion an annual event known as International Infection Prevention Week (IIPW). I had no idea Ronald Reagan was the person who started this, but apparently, he was! Okay, so along with trying to save lives he was also keen on reducing the amount of money being spent dealing with healthcare associated infections, but let’s give him the benefit of the doubt and say it was mainly about saving lives.
 
Since its inception IIPW has spread around the globe and now is an annual event in such diverse places as Australia, the United Kingdom, the Middle East, and Southeast Asia.
 
Each year IIPW has a theme. Recent themes include Vaccines are Everybody’s Business in 2019, Protecting Patients Everywhere in 2018, Antibiotic Resistance in 2017 and Break the Chain of Infection in 2016.
 
This year’s theme is “Make Your Intention Infection Prevention” …catchy huh? Our Infection Control Team has been running around the hospital sporting fancy T-shirts looking like “professional footballers”!
 
They told me that the idea behind this year’s theme is to encourage everyone, the general population as well as healthcare workers, to put infection control practices at the heart of what they do; make them an instinctive and everyday part of how we go about our lives.
 
Now this may seem obvious, surely everyone does this already …but do they? How many people wash their hands regularly? How many people self-isolate when they are unwell? How many people carry tissues around in case they sneeze? My suspicion is …not many!
 
Let’s look at the elephant in the room …Covid-19 (clearly my favourite topic!).
 
Below is a graph from the Department of Health (UK) website showing the cumulative number of cases of Covid-19 in the UK since the pandemic began. 

Earlier this year we all went into lockdown… remember? Not like the current lockdown where most people seem to be carrying on regardless, I mean when the streets were eerily quiet, and our capital cities looked like a set from a post-apocalyptic movie.
 
During this time, I remember seeing news stories about the positive impact of the Covid-19 pandemic on the environment as everyone moved indoors, cars stayed off the roads and heavy industry shut down. There were striking pictures of Nitric Oxide levels over China showing a massive reduction in the production of greenhouse gases. It seemed that something good may come out of the pandemic, almost as if the Earth was pressing the reset button and taking back control.

We’re all waiting for a vaccine against SARS Cov2, right? Once we have a vaccine, we can all get back to normal and 2020 will be a period of time that we look back on as a bad time in our lives. Well this is what I hear a lot of people saying… SPOILER ALERT! I think we need a reality check; the new normal is NOT going to look like the old normal.

More and more of us are being affected by imposed quarantine measures (sometimes at very short notice!). Holiday plans are all over the place (we are not going to the Drakensberg’s, our flight is cancelled, UK residents are banned and there is 14 days of quarantine even if we could get in! Boom, our holiday’s gone BUST!). There is mass quarantining on a global scale. But added to this is the fact that in the UK you must also quarantine yourself if you are exposed to a person with Covid-19. No ifs, no buts, do not pass “Go”, do not “collect £200”. But where does the term quarantine come from, what does it mean and are we “actually” using it correctly?

Everyone I see around the hospital asks me how the Microbiology department and the Microbiologists are coping. They are concerned that WE are flooded with work… and yes we are busy… BUT we are not frontline staff dealing with acutely sick patients or GPs in primary care struggling to deal with Covid-19 whilst juggling all of their other patients!
 
I am especially in awe of how my primary care colleagues are dealing with Covid-19.
 
Primary care must be unbelievably hard right now. Not only are GPs still having to manage their normal case loads of chronic illnesses but they are also the first line of contact for many people who have been infected with SARS Coronavirus 2 (SARS Cov2). AND they are doing this remotely using telephone and videoconferencing!!! The Editor Chief in Charge (aka my wife) will tell you just how useless I would be at that… I don’t even own a smartphone; in fact I can barely use the TV remote control!

“We have a lady with puerperal fever. She’s 2 days post-delivery and pretty unwell. Critical Care are reviewing her now and we’d like some advice about the best antibiotics to give her” said the Obstetrics Registrar.
 
Excellent thought the Microbiologist; they’re being proactive about a serious problem.
 
“If she’s not allergic to anything then IV Benzylpeniciilin and Clindamycin. Have you looked for retained products and done a DNC?” asked the Microbiologist.
 
“She’s really unwell, we don’t really want to take her to theatre. We might damage the uterus” replied the Registrar.
 
“She’s unlikely to improve if you don’t,” said the Microbiologist sympathetically. “You need to remove as much infected material as you can. I know it sounds brutal but it’s really important”.
 
“Okay,” said the Registrar sounding doubtful, “my Consultant is with the patient at the moment so I’ll go and tell them what you have advised. Thanks for your help.”
 
The Microbiologist put down the phone and put down his pen. Time to visit the obstetric ward and see what is going on…