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That's been organized by stash this evening. We are delighted to have Dr Joe Heh Skin speaking to us about the 2022 M pox outbreak. Just a bit about Doctor Keskin. So, Doctor Joseph Eskin is an S T six in Guiyu and HIV medicine at Chelsea and Westminster Hospital. He is a research fellow with the Chelsea and Westminster Infectious Diseases Research Group and has completed fellowships in viral diagnostics and also with UK HSA and Bash, looking at ST I prevalence in the UK prison population. He was the clinical lead on the successful campaign to end the ban on people living with HIV from joining the UK armed forces and he's worked on em pox in a clinical and research capacity from the first days of the outbreak. So no one better to talk to uh on this topic this evening. Um If you do have any questions, please pop them in the chat and then hopefully, if we have time at the end, we'll be able to discuss some of those. And so without further a do I will hand over to Doctor Keskin now? Thank you. Thanks so much, Tony. Hi, everyone. I'm Jo, I'm one of the Raiders at Chelsea and Westminster. And thank you very much for having me here stashed. It's really lovely to speak to you all. And it's rare we get such a voluntary audience rather than mandatory training days. Um I, uh Tony said I've worked on em pox uh since the beginning, I diagnose the first two cases that Chelsea. Um And so we're almost at the anniversary of the first cases um in 2022. So quite uncommonly, my presentation, if anyone was at the bash F srh training day this year, it's the similar slide deck, but we're going to talk to you in a bit more depth because for once, I've not done too many slides, I won't be rushing through them and I'm very, very happy to take any questions either during or afterwards on em pox on gum HIV, on doing research and you HIV or anything else you might have question wise. So my talk is called one day in May and the reason for that is on the 15th of May last year. And that was the day we notified the W H 03 U K HSA. About four lab confirmed cases of em pox. Uh It was obviously called monkeypox at the time and they had all been diagnosed, three sexual health services, all identified as MSM and all confirmed have it was then called West African played, we're going to talk about that a little bit more. So, um, why am I talking to you? And why did we come across M pox? Well, if you look, they're, I don't know who is from London, who's from outside of London. But the red square with the star in the center is the part of the London borough of Lambeth. And that has the, one of the highest HIV prevalence is in Western Europe. It also had the highest prevalence of em pox within Western Europe. And those three Blue square are crosses even represents the three largest and central London clinics belonging to Chelsea Westminster NHS Foundation Trust. So 50 16 street Soho 10 Hammers with Broadway Charki early in Hammersmith and uh the John Hunter Clinic in Chelsea. And that also is where the cobra clinic is, which is Europe's largest HIV clinic. And so we have a huge cohort of sexual health patient's and people living with HIV. And we saw about 1000 cases of em pox through our services uh since May last year until about probably September October of last year. So we saw just through Chelsea about a quarter of the Uk's cases and 1.5% of the global outbreak, which kept us incredibly busy. So many of you may know about M pox already, some of you may have worked with them pox if um I think a lot of medical students were kept away from any M pox cases as they are with all outbreak infectious disease cases. But I know in many of the other hospitals, it was more genius staff who are sort of thrown forward as cannon fodder and what it is, it's a, it's a day DNA virus, it's double stranded. It's an Ortho pox virus and the most famous Ortho pox virus that most of us sort of heard of was of course smallpox. And up until last year, monkeypox wasn't actually very much on the radar of anyone's, it was a neglected tropical disease. And outside of the region of people who are interested in global health and infectious disease, no one really talked about it very much. And actually its sister viruses, camelpox and cattle pox were far more important from an economic perspective because outbreaks of those can financially ruin communities particularly in Sub Saharan Africa and the Middle East. Um It's got an animal reservoir as all these type of viruses do contrary to the name. And this is part of the reason for changing the name um is that primates like humans are actually non reservoir hosts. So that's not, it's not through the private population that the uh the virus remains persistent in the region. It's, it's probably through bush rodents and tropical forests. But as with all neglected tropical diseases, not much has been done to look for that endemic population. And to prove that on the right hand side there, you can see a timeline. So just governed quite late of 1958. But we've got to remember with all neglected tropical diseases when we stay, discover what we really mean is discovered by white people and written up in the Western medical literature. These are conditions that have obviously existed probably for quite considerable time periods before that. So the real story of em pox is a tale of neglect Shin, but it's also a tail of the success in other areas. So the W H O started smallpox eradication of western Central Africa. And up until then, cases of em pox were probably just viewed as mild smallpox. And it wasn't until it was eradicated that we were able to differentiate between the conditions. And so the first recorded human case of em pox was in 1970. So it was discovered originally in a Copenhagen lab amongst to troops of laboratory monkeys shipped in from Central Africa. And the first recorded human case was in what was then called Zaire and is now called the Democratic Republic of Congo. And that has remained one of the hot spots for em pox in the Sub Saharan African region. Um active monkey pox surveillance took over as smallpox eradication sort of began. And there were six years of really, really decent data from international groups working in those endemic regions. And then in 1986 they pulled the funding and they stopped it another great feature, neglected tropical diseases. And following that, we see what happens when you, you leave a condition present with really poor data and you start to get really disreputable reports and a lack of understanding globally. And so there was a huge outbreak in DRC after years of nothing particular particular clinically. But actually when you do a look back of this outbreak, you've got huge numbers in a very short space of two time, really, really high what are called secondary attack rates. And so that's transmission within households within very brief close contact or within sort of similar residential areas. And that's not really in keeping with them pox. There was also high mortality rate, not really keeping them pox. And all in all, it was felt to be a visa vi outbreak, not an IM pox outbreak at all. And then as neglecting continues, we see the first outbreaks outside of those endemic regions. So 2003, we've got an outbreak in the U S and that was linked to um the transportation of Gambian pouch rats which infected and a group of groundhogs which then went on to infect the local population. There's about a 72 cases in the in the USA outbreak, which is quite quite a large, quite a large global outbreak for something like M pox 2005. Then we've got a sound Sudanese cluster and obviously you can see what's happening. So down at the moment, uh and the challenges to their health care system have been there for quite some time and this was picked up by an MSF hospital. And then in 2017, we got a Nigerian outbreak, which we're gonna talk about in much more detail with that UK first case. So if we just look at some filler genetics here as well, because it's really unimportant, like what we've all been looking at with COVID that we understand the, the viral epigenetics behind these outbreaks. So you've got a division in your viral clays or your viral types of em pox. So that lower section of the map, that kind of sort of bright green color. That's what we used to call central African and Congo basin played and has now been returned played one. And the reason we were, we were we renamed, these are the same reason we renamed parts of COVID as well because geographical blame doesn't help anybody. And it also makes people focus only on travel from those regions and not just considered the disease as a whole. So this is quite a distinct played, not only are they genetically distinct, but they're symptomatically distinct. And so we see much more severe disease patterns with played one M pox. So we see a lot of respiratory symptoms and therefore aerosol trans transmission between individuals. We also see a much higher mortality rate. So that's got about immortality to about 10%. And we talked about the mortality rate is important to consider the region's were discussing and the healthcare provision that may be available to those areas as well as the background, health care of the population. If we look further up the tree, then we've got an immediate split. And so that is that sort of limey green color. And we're moving into what is called played to formally known as West African clave Monkeypox. And this is a much more mild variant. We tend to see this around Nigeria in particular now, but it used to be areas of Cameroon as well. And Cameron is the only country that has both played in it. And so we see a much lower mortality rate um in those areas, about 1% we don't tend to see those respiratory symptoms of the same burden of lesion's. And what we see in the division here is that green, uh that green played is the most common area moving into an orange one which is the linked viral clay did to this outbreak. And then those blue spots represent human to human transmission of em pox rather than zoonotic transmission from animals to human. And this is where you really have to understand this is why, why history is important. This is why looking at society as a whole is important. This is why you can't shut down countries globally. And you've got to understand the flow of people if you wanna understand infectious diseases. So if we look at Nigeria, first case of em pox was in 1971 that was in a child. And again, this was very classic to the cases we saw in the Congo as well. You've got young Children living in bush regions who have lots of contact with either bush meat or potentially with animals in those perry jungle regions. And the first case was a small child who later went on to transmit M pox to their mother, representing the first ever recorded case of human to human M pox transmission. And that was a really, really crucial moment. And then from 1971 to 1919 78 you get these really sporadic cases. And again, these are all ruhr a cases overwhelmingly and small Children who do relatively well actually. And then from 1979 to 2016 onwards, there are absolutely no reported cases in Nigeria at all. And that's very reassuring from, from a a global infectious disease perspective. And then suddenly in 2017, we get this large outbreak and if you look at this outbreak, we've got 100 and 22 confirmed or probable cases. But this time, we've got a very, very different patient cohort. So we move away from those small Children inr oral jungle regions. And suddenly we've got an 84% male cohort with a median age of 29. And these guys are all living in urban areas. These are all young professionals in large towns and cities in Southern Nigeria. And this is a massive switch from all of the M pox cases we've seen before. But this outbreak sort of went under the radar and it wasn't very popular with sort of the Nigerian Ministry of Health. They weren't very keen for uh people to look into this outbreak in any great depth because it didn't really reflect terribly well on their epidemiological surveillance. And so actually, what we now know about this outbreak is the the healthcare professionals looking after these individuals questioned what was linking them. And one of the clear roots that link them was a commonality in the use of sex workers in urban areas. This is this is probably the first actual hint we have of sexual transmission of em pox. Now, what we don't know is the the absolute sexual identification of these individuals. And so we don't know whether this was already driven within MSM communities that at the time, if you think about how Nigeria tends to feel towards LGBTQ plus people, it's not terribly positively. And so the the likelihood of an individual disclosing their true sexual preferences to a healthcare professionals quite low. But what we do have is decent information or decent hints that M pox has already begun to move through sexual transmission and through sexual networks. If we look across, then to the right hand side, we look at the Uk's History of Em Park. So from 1972 2017, we have absolutely no cases of em pox in the UK at all. And that's not terribly surprising. We're not an endemic region. We won't be after this outbreak either. And so people aren't really coming into contact with it. However, you have got a country that is historically and colonia Lee and now through the commonwealth remains very closely linked, that we've got large populations of people who are from Nigeria, who have recently moved to the UK, who have family who remain in Nigeria or have multiple connections to the country. And therefore you get regular, in fact, daily flights from Nigeria to the UK, particularly to London on a daily basis. And so it's not terribly surprising that if you get a large outbreak of a condition in a country that year, less than a year later, you're going to start seeing cases in those closely linked countries. So an outbreak in 2017 leads to our first case in 2018. And this follow, there's a real classic fever in the returning traveler scenario that people get in the membership exams and then they're infectious disease or their G U HIV exams where you have someone who was in Nigeria came over to the UK. They were military attache and within sort of hours, two days of touching down in the UK began to feel very unwell and presented to healthcare services were quite rapidly isolated. And actually the M pox diagnosis was made very quickly. The second case also very uh similar travel from Southern Nigeria. Again, it landed in London and within hours of touching down had become a well and was again isolated and diagnosed. The third case been a bit more unique. This was a healthcare worker links to case to who had no physical contact with the individual. And that, that is a real sort of case of curiosity. Then for epidemiologists to try and figure out what, what that risk poses to future contacts and populations. And in this case, it was a healthcare assistant who was cleaning the room when the individual was not there. And it was felt to be fomite transmission or transmission through surfaces from changing bed sheets. And it's always been accepted that the, the pox scabs within pox conditions are felt to be as transmission uh to represent a highly transmissible um contact. And then from 2020 to 2021 we have really sporadic cases, sort of, you know, one a year. And again, they follow that really sort of standardized fever and the returning traveler. And if you want to be tested for odd things, then, and that's exactly the kind of red flags that you present with uh to a any high fevers and strange travel routes. And that tends to set off lots and lots of alarms. Suddenly you'll, you'll end up in the side room. And so that brings us to May 2022 so on the seventh of May, we have what's called cluster one and this really matches all those cases we've just talked about from 2017 onwards. You've got an individual who arrives in the UK, they developed symptoms before they even got on the plane. Presented to healthcare professionals as soon as they landed and were isolated, had flown from the endemic regions of Nigeria. Tested for Ortho pox virus is M pox comes back as positive and we report the case to the W H O which is a standard procedure for these sort of global notifiable diseases. One week later, then we suddenly get another appearance. And that is quite strange to get at that speed of cases coming through for something like M pox within the UK. What's more peculiar about this is we've got two confirmed cases and one probable case, but they're all within one family, but this family hasn't left the UK. They have no links to patient. One that can be clearly identified and they haven't been to these endemic regions or been in contact with other people who have been. And then even more peculiarly almost one week to, in fact, one week to the day after the cluster, one was identified, we see our cases. Now, what we had seen in Chelsea was we had had two cases appear within the course of about seven days. They had attended their local sexual health clinics with strange all sorts of lesion's. These were on their face and on the genital areas they've been seen by outpatient clinicians who were gu physicians and they were thought to have potentially very, very extensive HSV. So herpes simplex virus infections, possibly visa envy infections as well. Although one clinician, my consultant Dr Rachel Jones did in fact describe them as pox like lesion's, this persisted and eventually one of them was admitted under us at Chelsea Westminster. And I was the HIV inpatient ward dredge at the time. And as it happened, both of our individuals were living with HIV or they're very well controlled. And so at this point, we've got a strange condition that was presented to us. We've isolated them into a side room and we start to do some, some global researching. And what you do when you get these strange cases is you go straight to the W H O and the C D C and the E C D C websites and start to look for outbreaks. And so we did that. And actually far long before M pox came on our radar, we did find the cases of quite severe and peculiar disseminated gonococcal infection. There wasn't presenting as one would normally expect G eye to, to look. And so we thought this might be what had happened. We, there have been cases all across California as well as in Vancouver and three deaths had already happened, which is incredibly uncommon with D G eye. And so we did what you shouldn't do when you've got a category three pathogen in an open uh side room, we went and aspirated some lesion of fluid. We went and biopsy these lesions, we swabbed in culture them with everything we could possibly do. And all our results were coming back as negative. And we had them on broad spectrum antivirals and brought back to antibiotics. And again, they remain pyrexia stable but sort of non specifically unwell how monkeypox came to our forefront of our minds shows the importance of communication in the modern era. And I was on my way back from Southampton on a train on a Saturday with my partner when I was lucky flicking through Twitter and uh UK HSA had released a statement about cluster too with images of what M pox lesions can look like at which point I realized exactly what we were dealing with. And we messaged ahead to our teams at Chelsea Westminster and got off my train early at which point we sent all the swabs off to the rare reported pathogens lab, which is in Colin Dale. We contacted our colleagues up in Newcastle who had the partner of one of our patient's isolated in the high consequence infectious disease unit there. And they also sent off samples. And on the 15th of May, all four confirmed, all four cases were confirmed as having im pox. There were no clear epidemiological links to clusters. One and two, all four cases of in London. The fourth cases in certain areas identified is MSM one, our case, one of our case in the linked case and Newcastle show clear a matching of lesions, two points of sexual contact. And this really, really concerned us and it really concerned UK HSA because this was suggesting that there was going to be transmission within sexual clusters. And so where do we stand now? Well, having had what seven cases in total before 2022 within the space of less than 12 months, we've had 3738 cases across the UK. You can see overwhelmingly that's an England based cohort and overwhelmingly 70% of those all cases been within London, 98.6% are male. So all those fears about onwards transmission too, school groups and to pregnant women never materialized and the median age was 36. And this is a really similar cohort, the one we saw in Southern Nigeria in 2017. What you can see also in this UK HSA chart as well is that we've continued to see cases and significantly lower numbers. But you can see that there's five cases since 2023 that's actually gone up to I think about seven and the majority of these remain acquired within the UK. And so there may well be a low level prevalence of them pock still continuing. So for anyone who hasn't seen monkey pox or M pox, this is what it looks like. Um it's quite variable both in severity and appearance if we start with the top right hand corner, so you can see the images of pox lesions along the penile shaft and around the glands and the foreskin. This was really, really classical. So those top set of pictures show that really nice transition from vehicles into blisters, into broken down pops, ulcers with that central sort of esseker. And we saw a lot of this and you can see there the three pictures below what happens when you get this sort of paraphimosis phenomenon. And it's actually a studio paraphimosis. So we actually admitted these people at the beginning because we were quite worried about vascular restriction to the glands and therefore potentially ischemia and also problems with urination because of the severity of that paraphimosis. And we work very closely with our urological colleagues to manage. And in fact, what you have there is really a very, very intense inflammatory process which will resolve over time. And so we had to, we were able to stop admitting these people. The pictures on the three below show not severe ulcers, but just you can see the quantity of pox like ulcers that can appear in the perianal area. And perianal ulcers were a massive massive issue for us. And this was the most common reason to admit somebody because while you can see those ulcers and you can, they often might appear in far greater intensity. A number, what you can't see is the number of ulcers and the degree of inflammation that's happening in the rectum and proctitis was probably the number one cause for admission to all units across the UK. It was incredibly painful. Um, people had really, really severe at tenesmus, real severe constipation and a lot of pr bleeding. And because one of the Ortho pox phenomenons is that it locally immuni suppresses you, there was also significant potential for abscess formation. A lot of individuals needed surgery as well as significant pain killers. Predominantly opiate based some of the requiring syringe drivers on the bottom left there. That's someone's pharynx. So you can see that consular swelling and any sort of oral ulceration, any ocular ulceration was cause for immediate admission. And the reason for this was that swelling that happens in the rectum also happens within the oral and buccal mucosa as well. And we saw people become incredibly airway compromise within a very short space of time, including an individual who developed severe Ludwig's angina and a massive head and neck debridement of inflammatory tissue and remained under the joint E N T anaesthetics care for quite some time. But finally, we see that nose up on the top left hand corner, you can see the real extent of the scamming that that can happen from that severe inflammation. That's the line underneath. And we saw a lot of this happening on facial lesions, particularly those affecting in the beard area as well. And thankfully because there was significant concerns about the level of scarring that would occur from this outbreak. And most of these lesion's healed without too much residual defects. And so, what did it do if you worked and gone? Well, it was absolutely chaos. Most of our clinics were only starting to get back to some form of normal working practices since COVID, many of us had been shut down and redeployed for a considerable period of time and we lost a lot of staff following that as well. And so in Chelsea Westminster, on the left hand side, sorry, you can see these are our three Central London clinics, two of these were closed to walk in access and we redirected all potential M pox cases to our third clinic was it's adjacent Chelsea Westminster Hospital. We did a tele tele triage and video triage video tree isn't easy when you're working gun because of what you're trying to examine. It's also really difficult and you'll see from the previous pictures to tell the difference between an M pox lesion and molluscum contagiosum lesion and early HSV ulcer, a atypical shankar as well as describing symptoms over the phone that could easily represent multiple other dermatosis as well. And so it was very difficult, but we did our best. We PPE it up everybody. And so every single patient was seen in full category three pathogen PPE. Once we saw you in the M pox clinics, then there was a a, you fell into two different branches, effectively, either you were so sick that we admitted you straight to our inpatient unit in the early days of the outbreak, all in patient's had to be transferred to what is termed the high consequence Infectious Disease Unit, which is a number of specialty infectious disease hospitals around the country and then managed through a network. We then later included Chelsea Westminster in this because of the degree of um the number of patients that were just coming through our services. And then in July where the decision was made to step down the HCV status of em pox to allow for admission to any hospital and take the pressure off those beds. If you weren't really sick, we sent you home and we gave you rescue packs of painkillers of antibiotics and of laxatives. And so when we virtually continue to monitor you, we could, we could start these, if there were suggestions or signs or symptoms of bacterial super infection or severe pain, you then came into our virtual ward. And that to me, I thought was going to be really, really cool. I was isolating as a contact of M pox as were 100 and 75 other staff at Chelsea Westminster. So we lost our entire impatient HIV team, all dermatology registrars, half the radiographers, the entire medical photography services and a huge number of outpatient clinic staff as well. And so most many of us were working from home for the first three weeks, doing 12 hour days trying to monitor all these patient's in the community. And at our, at our peak, we had over 400 patient's on our virtual ward, who, who we were doing daily phone calls, which later progressed into 48 hourly phone calls, then weekly phone calls with daily text messages because of the sheer number of people were trying to contact and we used to monitor all these people for ongoing on progressive progression of symptoms. And then we could escalate them through painkillers and antibiotics virtually, or we could bring them in for assessment through A and E and finally, they were released from isolation to remember, these people were isolating for anything from sort of two weeks, 23 weeks would be the most common and up to significantly longer if your lesions remained open and unhealed treatment wise, we had really nothing. All of our treatment was symptom or was just supportive. There is something called Tecfidera Mat or as the Americans like to call it T pox. It's a viral envelope protein inhibitor. So it acts very early on in the stages of em pox. It's important to get it to people quickly. This was fast track approved. And prior to this outbreak, the experience of using Tecfidera mat in in M pox was one person and there is still high debate over whether it was actually useful or not. It was restricted to inpatient setting. Use of the time the entire supply was held by the Royal Free Hospital and we had to apply to them for compassionate use. And this was cleared through any case of em pox encephalitis, any ocular involvement. And then based on a clinical severity scoring system which was developed, the only side effect really is headaches. There is a platinum something called the platinum trial, which is the community Tecfidera Matt trial where you're 50 50 allocated to take a beer mat or a placebo. And we have yet to see the results of that trial. So research practices changed quite dramatically. If you look at the left hand side of this slightly busy slide, you can see that from 1962 to 2021 on pub med, there were just under 900 papers published on Em Pox in those many, many decades. And in the course of 12 months, they have published 2051 papers on em pox. And you can imagine the quality of the production of many of these papers and they ranged from incredibly impressive large data sets to absolute trash. But what is interesting is if you look through what has is changing in the scientific research community and what people are starting to look at. So everything from public attitudes towards M pox, we looked at very, very quickly to address stigma. People trying to use Twitter and use minding to predict the impacts outbreak by looking for suggestions of strange symptomatic presentations among these communities in the weeks and months. Leading up to this, we had the inclusion of pregnant women in trials um and in guideline development very early on. And that's very uncommon in research. People try to look at self collected swabs which has taken us decades to do in ST I testing and was achieved within months as a research trial within M pox. And finally, the use of data from short video media, social platforms to look at conspiracy theory. And that was really driven by the the bunkers viewpoints that we've seen during COVID. If you want to look at some good quality data from the UK and I'm completely blowing my own trumpet because you'll see him an author of some of these papers. But these were the biggest papers to come out of the UK to look our by UK authors to look at em pox. So everything from um the transmission of monkeypox through sexual contact, which was my pay paper that we wrote very, very quickly, which describes the very first sexual transmission, look moving towards um Chloe Orkin and John Thorne Hills paper on em pox and people with advanced HIV infection, which is a really fantastic paper if you're interested in HIV and suggest that M pox may well be an opportunistic infection. And it probably is and they looked at em pox in women and non binary individuals to ensure those demographics were rapidly included from the beginning, even though they actually did represent a huge proportion of the global cohort. Then a paper we wrote on how you reconfigure sexual health services in response to an outbreak. And then really, really good observation analysis from both community and secondary care settings, both in the UK and across the countries including papers, some guys in Tommy's Chelsea Westminster as well. So vaccination, I mean, we all we got to do is look at the length of time we have taken us to get vaccines for global diseases. Before then we look at the speed that we did that in COVID and then we look at what we did with them pox. So 15th of may we identify that there's potentially uh MSM cohort outbreak by do we already have a vaccine program which is in credible? Now we had orthopoxvirus based vaccines. It wasn't the, it was called in the next uh what we now use is something called, you knows, which is developed by Nordic and obviously has led to lots of conspiracy theories. But that's we developed our vaccine program very, very quickly. So stage when we did at risk groups. So we did a targeted drive of people. We thought we're going to be at high risk of em pox and no one could agree what the definition of at risks at risk groups should be. And I just reviewed a paper for a group which has just been published which looked at the colossal variation of uh definitions of at risk groups as well as uh lesion definitions across Europe. And no one could decide on whether we should be giving vaccines to all the people who had syphilis recently or the people who have gone rear recently. All the people who are on prep and, and the arguments went on and on and on. And then we did opportunistic vaccines for people who came into clinic to see us. Stage two, then moved to routine vaccine clinics and recall. And that's when you saw those large large queues outside guys and Tommy's of people waiting to to go and get jabbed. But by March 2023 we have given 68,374 people, their first dose and 62% of those were from London based clinics. Little bit less a bit of the concerning is the massive drop off as people start to be disinterested. And you can see there, we've only given Twitter like you less than half those people a second dose. Now, there is some real world evidence particularly from this Israeli paper to suggest that actually one dose is pretty effective, but we have no data to secure that. And so what we're really trying to do is drive the those people to come back for their second. One of the reasons for that is we our target winding down all of that targeted vaccine drive and actually what we were going to do is continue opportunistic vaccinations, but ultimately reach a point where only those at risk individuals who are in contact with em pox will receive vaccines. So it'll be used as a post exposure prophylaxis. Um There were colossal issues with vaccine communications across the UK and it was really, really serious national and particularly international inequity and vaccine access. A question that baffled everybody and then caused huge debates and then caused huge argument and still does to some degree is whether in pox is an S D I. And the answer is yes, it is. Um we had big debates at the beginning over whether you could call it a sexually transmitted infection versus a sec transmissible infection. The difference between being a condition that is only or always transmitted during sex versus something which can be transmitted during the act of sex. So for instance, herpes or scabies or pubic lice through very close contact. It's categoric that M pox in this outbreak is an S T I. But I think it's really important. We, we, we emphasize the in this outbreak because there are sort of 50 years' worth of data coming from central and western Africa that doesn't suggest that their plaids are sexually transmissible or have been recorded as sexually transmissible. And so we need more evidence and more data to support that. But for this outbreak, amongst this Klores, it is 100% of ST I and So, where has it all gone? Because it has gone? And you can see we went from, seen three, you know, nearly 4000 cases with it between May and really, uh September. And since January I've only seen six cases or seven cases. And so there's multiple theories behind this vaccination had a huge impact, that's for sure. But we know that the cases had already started to drop off before the vaccine dr started. And so it is not the sole beneficiary of vaccination. Uh There are two probable other major contributors to that drop off. And one is that people who are probably at the highest risk of getting in pox got it. We know M pox was associated with sex inside premises. We know it was associated with major events including dark lands in Belgium, Grand Canaria pride. And when mass Paloma's and people who were at these events, who were going to large exercise premises, who are going to large circuit parties and cruising grounds probably got em pox early and then got a degree of immunity. And so that probably reduced the onwards transmission between those sexually active cohorts. And then a lot of people change their sexual practices. People quite scared quite quickly because we know that the incubation period of em proximately 21 days, there was that very long period of time where you may have this quite awful disease that no one wants and not know about it. And so people did really adjust their sexual practices, not everybody. And they may have been quite low risk in the first place, but they still did that and that still probably had a huge impact. Speaking of impact, um, the MSM community similar to during the HIV and AIDS epidemic, although I think it would be belittling that to compare them too closely, had a massive psychological trauma from this. A lot of that was to do with those hideous headlines you can see from rags like the Daily Mail. And I think if we were to scrap tabloid newspapers in the UK, public health messaging would improve dramatically. And there's a lot of stigma associated with this. There was a lot of concerns at the beginning, we had patient's who refused um to allow us to contact public Health England, which we were actually were legally obliged to do because they had fears of decontamination groups coming to their house. And therefore by, by proxy disclosure, not only of their condition but of their sexuality as well as saying to people, you need to take time off work and isolate. And of course, if you're a man and you call your boss and say I've got to take three weeks off work, I can't come in, I've got to isolate, there was only one thing that was going to cause that during this period of time. And so you're already telling someone, you've got monkeypox and you're already telling someone you're gay, bisexual or amount of sex with men. Just by doing that. There was a real about really, really shocking communication breakdown between the government, which isn't too surprising but also through public health bodies with the community and actually clinics were sort of abandoned and most of us had to provide our own calms about vaccination, about treatments, about how to look for help and testing to our through things like Twitter and social media. But that obviously, man, massively disenfranchise those who don't use those communication routes, staff are burnt out were really, really tired. I'm exhausted. Most of us still haven't quite recovered from COVID when this happened. Most of us still haven't come from M pox now. And financially, it was hugely impactful because G U services are paid on a tariff basis and we couldn't see people who have conditions that we get paid for. And so we're all owed a lot of money to our clinics and we'll then have to provide vaccinations as well. So I think the last I looked, one of our clinics is down about three quarters of a million pounds. So what we do now, um so it is a notifiable disease in the UK claimed too and claimed to be so claimed to be in what was formerly known in the West African monkeypox. And that is the endemic strain and played to be, which is the outbreak strain from last year are no longer considered high consequence infectious disease diseases. So if people come to the UK with them or they get them, you do not have to be transferred to an H said unit. You do not have to be transferred to a specialist I D unit. You can be managed probably recommended by infectious disease or genital urinary physicians who can manage you locally within their units. However, claim one remains an H said. So should you get that you must be transferred to one of those hospitals? We know there's really limited household transmission. We saw loads of people who lived with partners who live with housemates who live with family members who did not have any onward transmission risk. And we were able to manage them really, really safely within their households with good deep decontamination measures. And that massively reassuring not only for people who are undergoing that, but also we're starting to understand the proper transmission routes of these conditions. We didn't see any sustained transmission outside of the MSM sexual networks. We talked about that already. We didn't see this like daily mail drama concern about gay teachers going to school with them pox giving it a lot of Children. And thankfully, we saw no UK debt. That is not something that was replicated the world over. However, on the right hand side, you can see we are in key pride month scenarios. So we've already had Sydney Mardi Gras, we've already had dark lands. We haven't seen upticks of em pox thankfully following those. But we've got your vision in Liverpool and then mighty hoopla and pride in London. And so we may well see, um, some uh symptoms coming out of that and what we really don't know is what does M pox look like in the vaccinated population. So, we know what these dramatic first presentations of em pox look like, but we know vaccines give, you can give you a milder illness trajectory rather than preventing it entirely. And so what a lower symptomatology in pox looks like in a vaccinated community. We have yet to discover what we do know is that despite all of this, despite those 2000 papers that have been written, despite this vaccine drive, we have done absolutely nothing about em pox in Sub Saharan Africa. So all of those vaccines, we've discussed all of those, you know, those vaccines that were described and we had huge debates over everything from inter muscular injections to be able to develop that to subcutaneous, moving to intradermal, to allow for greater use of the dose. Seen, none of those vaccines made it anywhere near the continent of Africa and they certainly ever made it anywhere near endemic regions where this has been plaguing in since 1958. Um There's a diagnostic drought. So how do you diagnose M poxy diagnosed with a PCR machine? What you do if you don't have a PCR machine? Well, then you don't get to diagnose it. The same problem we saw with COVID. I think at the last look, there was something like 800 cases of COVID in the DRC, which is a population of 88 million. And that's just not true. So we if you don't give countries the facilities to make diagnoses and you can't expect them to be able to perform proper epidemiological surveillance. There's a research vacuum, there's been no support for researchers by father has been colossal funding for research of this in European and American nations. The media don't care because the people who are getting this don't look like them. And ultimately you get lots of, lots of people like me talking to you. And though I have a lot of experience in M pox in the outbreak, we've had uh I can't claim to have heard of it prior to 2022. And so all those people, if you managing M pox in the Congo, Cameroon and Nigeria have yet to be given the platform they deserve. And so where do we go? And you probably guessed I quite like soapboxes and standing on them and chanting from them. But we need lots of regional networks for gu medicine because communication and collaboration are key. And we were just talking about this at the British HIV Association conference over the last three days that a lot of specialties, medical specialties are very London centric and they're also very, very focused on huge centers that produce large quantities of data. So if you go to a conference in HIV, medicine or sexual health medicine, you will see the majority of us presenting with posters with data sets and asking questions come from very, very large centers with large populations of HIV, patient's nearby. That does not mean that if you live in a row oral area or a smaller town or a different part of England where your demographics are different. You haven't got massive expertise to share with the rest of the country and something that you are very, very good at. You may be basically in a prison. You may be based in your schools. You may be basically an immigration detention center and so have huge wealth of experience that we need share ing but you just need to get that platform. And so I think if we develop more regional networks where you're supported by clinicians who may have the funding or connections to do that, then that can only be a good thing. Um Generally early medicine is clearly needs a role within the outbreak medicine community which has been predominantly overwhelmed by infectious diseases. However, what we have seen over the last sort of 10 years is outbreaks of sexually transmitted, neglected tropical diseases. So we know that Zika is sexually transmitted. We know that Ebola is sexually transmitted. We know that M pox is sexually transmitted and the list is likely to continue. And as they reach sexual networks with higher transmission rates, we're going to see them in our clinics first. We also are very, very lucky because there's a special, we have huge amounts of trust for within the communities that we work in and serve and they come to us for support and help. We saw that again and again during M pox GPS probably used to have that, but because the media have absolutely shat all over them as a profession, uh they are really struggling and so it's up to us to sort of step up and, and take on that role and I'm just going to finish with this. Um So I follow on Twitter, a guy called Brian Bilson might be to some of his readings. He's a very, very funny poet. So, and if you like sarcastic scathing poetry, have a look at him. But he wrote a poem called Serenity Prayer. And he posted a, he posted a poem a day on Twitter and he posted one saying, send me a slow news day acquired some Tuesday in which nothing much happens of note. And he posted that slightly ironically on May 15th 2022 which was the same day we confirmed M pox in the UK. Uh and I'm gonna stop, then I'm going to hand over for questions or discussion's about anything at all. That's great. Thank you so much, Doctor his skin for such an interesting and engaging session. Um Please do pop any questions in the chat if anyone has any. Um I'll start off by asking, first of all, do you know what the rates of em pox are doing internationally? Obviously, we've seen a significant fall within the UK, but worldwide, what's happening with these specific plaids? So in the endemic regions, they continue to rumble on at low rates where they can do testing. Um And so they've remained relatively static. We saw a real different globally depending on the response rates. So Western Europe's were to fell as a block and that was probably due to the massive vaccine purchase. So while people change their attitudes were able to maintain that for with the vaccination drive and we saw North America lot peaked at similar times to us. But that peak remained really persistently for quite some time. And so they continued to have incredibly high cases well into September where we had already almost disappeared and that's probably got to do with multiple things. There's a lot more internet, you know, there's a lot of international travel. But also I think the point, the biggest crooks for them was healthcare is just shocking in, in the US. And so access to vaccines was really, really poor access to take a fair amount was much higher because you can obviously get it through your private insurance companies. But they, they really really struggled to vaccinate the right people and they really struggled to vaccinate very high risk groups. So some of the higher risk groups for em pops in the US were African American men who have sex with men and they have the rates of the lowest interaction with sexual health services. And even when they try to do vaccine drives in those regions, what they saw was people coming from out of town to take advantage of that. And then the group who really, really struggled to control RM pox outbreak was the Central and South American nations, so particularly Brazil. And so we saw some of the highest rates of em pox globally. We're actually focused in Brazil and that peak that they got sort of around June was maintained right through into October and only began to dip around November. And again, it's unclear but the the drivers felt to be maintaining that peak were poor access to health care and an incredibly conservative government who are very anti LGBTQ. And so a real reluctance amongst the population to present to healthcare settings for fear of what they brought with it as well. But now, globally, we've seen a drop, everyone sort of dropped together. Sure, thank you. So, another question from Ellie who says, thanks so much for such an interesting talk. You mentioned some patient's would not consent to UK HSA notification. And how was this navigated? Yeah, it was navigated difficultly because we, we have this conversation in Guiyu all the time. It's the same about patient consent to G B contacts for people living with HIV. It's the same as partner notification discussion's as well. What's different is this is a notifiable disease and so someone can object all they want. But unfortunately for them, we have a legal obligation to inform the UK health security agency about the diagnosis of this condition, including data about them. And that, that's a, a lot of people find that very unfair. We did have a lot of conversations with people because there was a lot of fear about what that notification was going to involve and actually what it does involve is they just get a phone call from the local health protection team within their burrows if you're in London or your region, if you were outside of the capital. And that's just discussion about your contacts and a little bit to understand about you. There was a lot of fear that people from UK HSA. We're going to show up in Hazmat suits at your flat and sort of hose you down or, or move you to a hospital. And so as we started to allay those fears, um, it's sort of dissipated. But if you look at the people who are most afraid, they were probably the people who were on zero hour contracts who needed to work and really couldn't isolate because they have to work to live. And, and actually the greatest difficulty was navigating those individuals and how you can both support them financially. And socially while trying to prevent onward transmission. And we got a lot of support from London boroughs who, who earmarked funding uh to try and pay people while they're at home as well. That's great. Thank you. And then Nikos asks, do you believe that Ortho poxy viruses have been properly? Genomic Lee and proteomics Klay investigated. And if not, why given the disease burden at a very good question that I'm not sure I can give a very good answer to. I'm not a viral geneticist or a virologist for that matter. My area I like is diagnostics. But uh so yes and no, I suppose it depends which Ortho pox virus you're talking about. I would say the majority would fall into the neglected tropical disease thing, which category which we usually know we've not bothered that much because the people who decide to do these things aren't affected by them. If we specifically talk about M pox, the answer is definitely no, we've got very poor data on the genetics of this prior to this outbreak. However, and there was a lot of concern that what we were seeing was a mutation that was allowing this to be more transmissible. All of the investigations so far, don't highlight any mutations that would be in keeping with um increased transmissibility. And though there were quite a lot of mutations seen compared to previous genetic studies of the claims in the West African region, they were not above and beyond what you would expect to see a genetic mutation just over time. And so it was, it was felt to be that this had found a niche in a network rather than have mutated. And that's what was doing in a service. But have they been properly investigated? Know, I think we need to do a lot more on that and that data will come out over time. There are definitely groups within Europe who are looking at all the different aspects of this outbreak. Thank you. And then a question from Delia, not related to M pox, but as I D unit, is it normal to have contact with refugee communities for screening procedures or prisoners? Um Do you mean is it normal for infectious disease units to see these uh individuals or is it there? I suppose I can answer both. Um So I'm not infectious disease doctor, I'm a do you HIV red and our inpatient unit is a pure HIV ward. So we've got a 20 bed HIV ward. We also see uh TV patient's on that as well and G U patient's who need admission. So every I D units slightly different and it's also slightly changes to pay depending on what your local population is. And so if you're asking, do I D units get involved with screening these individuals? And generally, no. So if you look at, if you look at immigration removal centers, if you look at detention centers which are all pseudo kind of prisons. If you look at refugee hostels and hotels, all of that tend to be done by GPS. And that's usually GPS who are interested in global health and in those communities and they're often then supported by I D physicians. So there are some really good idea physicians, particularly sort of the hospital for tropical diseases who work with these groups and try and support them. And there's also work from people you might not expect as well. So there are groups of dermatologists who are very involved in global health, who do a lot because a huge amount of tropical disease burdens are within dermatologic conditions and presentations. And so they are trying to screen these individuals at the point of arrival in the UK, but that's very, very difficult to do and they're often very reluctant to come to healthcare settings because they think the home office will, will, will deport them by accessing their information. And for prisoners again, prison healthcare is G P led. And so this group is called Practice Plus in Spectrum who run the majority of the prison healthcare within uh England. From an infectious disease perspective. I'm not involved from a GU perspective. We try and do a lot of prison outreach. So within London, each of the prisons is assigned to a GU clinic and we go in and see those individuals in there and that's not case everywhere, but they're really high risk groups because they've been through in credible journeys to get to where they are and often experience a lot of things along the way that puts about even higher risk again. So I'm not sure I've answered your question, but they are a regular part of our cohort of patient's. Thank you and then memorizes. Thank you for an enlightening talk. Um What level of PPE do you use when reviewing M pox patient's? Um that was also a highly contested uh issue for a long, long time. And you can imagine, I, I don't know, are degree of sort of students versus doctors, but I'm sure you will remember COVID and the battles people had in hospitals about what, what we should and shouldn't wear. And I think, I think most people still can't agree on that when it was first appeared, it's called a category three pathogen. And so there are designations within the UK of what you can wear when you come into contact with different category pathogens. So cat three pathogens mean you have to wear a FFP three mask, you have to wear a full length gown with sleeves, you have to wear gloves and you have to wear eye protection in certain areas as well. They'll also wear footwear protection to and in some of the I D units they would have always worn there. We, they all have one scrubs rather than clothing in clinic. That's what we wore at the beginning. And then we began to backtrack about a bit. So we moved away from FFB 32 surgical masks, which are water repellent because actually respiratory transmissions not really indicated in this outbreak at all. We moved to aprons rather than gowns and we dropped the uh eye protection for certain cases. But I, well, I work, I've got glasses on so I kind of wore it anyway. But other people had visors. So for the majority of the outbreak we wore, yeah, advisors, surgical masks, aprons and gloves. That's great. Thank you so much doctor hair skin as we are pretty much at an hour, we will call it a day there. Thanks again for such an engaging talk. Hopefully everyone is feeling enthused about a potential future career in Guiyu medicine. Um, there is a link to the feedback form within the chat, but it will also be emailed out to everyone after this session. Once you've completed that, then you will get your certificate of attendance as well. Thank you, everyone and doctor his skin for giving up your evenings today. Enjoy the rest of your night. Thanks very much. Thank you. Bye.