The Duty Microbiologist had just got to the duty desk when the phone rang, 09:02 no time to even pour a cup of coffee… this was going to be a bad day!
 
The ward doctor from Phlegming Ward was treating an unknown illness in a patient who had just returned from a holiday from the Indian Subcontinent.
 
It sounded bad… they were septic, with low blood pressure and a very high lactate. The Critical Care Outreach Team were on their way but the team were worried the normal IV Amoxicillin, Gentamicin and Metronidazole for sepsis wasn’t working!
 
“Change to Meropenem, give a dose of Amikacin stat and isolate the patient ASAP. Also send us a blood culture, sputum and urine and we’ll see what we can grow. As there is a risk of enteric fever, make sure you write High Risk on the request form please!”
 
However, at the same time the Sister from Phlegming Ward was calling the Infection Control Nurses to say she thought they might have an outbreak as they had a number of patients that had all been in the same bay who were now all suddenly septic!
 
The Infection Control Nurses told the Sister they’d drop everything and hurry along to assess the situation; so they brought forward elevenses to a 10am cake break and then off they went… which is pretty speedy for IC! (…I am going to be in so much trouble for writing that!!!)
                                                     
When they arrived on Phlegming Ward the corridor looked dark and gloomy. The overhead strip lights flickered on and off like a broken strobe light at an 80s disco. A trail of bright pink slime oozed its way across the broken floor tiles disappearing off into the distance. Nothing moved; everything was silent. The ICNs looked through the doors to see carnage. To be fair it was often a chaotic place where no one ever washed up their coffee cups, so mould outbreaks were common. They entered the ward. This seemed different; the patients looked terrible, emaciated and sunken eyed which, although food was being cut back to make hospital savings, shouldn’t be noticeable quiet yet. There was also blood and vomit everywhere, as well as some funny looking bright pink stains no one quite knew what to make of, and the over-worked staff looked like they had finally lost the plot! 

In 1988 the World Health Organisation announced its intention to eradicate polio by 2000. It was a lofty goal but one that was achievable as polio only infects humans, and so if they can stop polio spreading between people then it can be eradicated, and the way to stop spreading polio is to vaccinate against it.

Haemophilia is back in the news with the UK government being advised most strongly by Sir Brian Langstaff, in the Infected Blood Inquiry Interim Report, to issue immediate £100,000 compensation to the men, women and children treated by the National Health Service for conditions like haemophilia, who were given infected blood and infected blood products since 1970.

No, I’m serious… what is Covid? I hear it all the time. Someone coughs, is it Covid? Someone sneezes, is it Covid? Some say they feel a bit under the weather, is it Covid? I even had the discussion with my parents at the weekend… ECIC (aka my wife) has a bit of a cold and they say, “has she got Covid?”
 
So, what is Covid?
To start with, “Covid” isn’t anything. The actual name for the disease cause by the Severe Acute Respiratory Coronavirus type 2 (SARS CoV2) was Covid-19; it was an acronym for COronaVirus Infectious Disease 2019. But now it has been reduced to a snappier “Covid”.
 
I have also been asked if someone has “caught covid”…NO! You cannot catch Covid-19, you can catch SARS CoV2, that is the name of the virus. It is so reminiscent of the horror show that was HIV back in the 1980s… even senior health professionals thought you could catch AIDS (Acquired Immune Deficiency Syndrome) …NO! You cannot catch AIDS, you can catch Human Immunodeficiency Virus (HIV). Covid-19 and AIDS are the names of the clinical diseases, not the causative viruses.
 
So, when we think about Covid-19 being a disease, a group of symptoms if you like, then the question “what is Covid-19?” actually starts to make more sense. 

​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?!

“Urine bugs may be a sign of aggressive prostate cancer”, that was the headline on the BBC news and so I had to take a look. The BBC reports that “scientists have identified urine bacteria which are linked to aggressive prostate cancer” and that “clearing the infection might prevent bad tumours”; the researchers claim they have demonstrated “an association between the presence of bacteria in urine sediments and higher D’Amico risk prostate cancer patients” and that “specific anaerobic bacteria genera have prognostic potential”

The Microbiologist listened, getting increasingly confused. The speaker was saying that the newborn needed to drink its mother’s colostrum milk otherwise it wouldn’t have ANY antibodies. But this didn’t make sense to the Microbiologist; transfer of antibodies to the fetus via the placenta is a fundamental aspect of the immune protection a mother can give her newborn baby. We even rely on transfer by immunising in pregnancy for pertussis (whooping cough) and Covid-19 so that IgG antibody can develop in the mother, cross the placenta, and protect the baby after it has been born. It’s a FACT!
 
And yet, there was the speaker saying that this newborn HAD to receive its mother’s colostrum or it would have NO antibody. They even took a blood sample from the newborn to check it had antibodies AFTER it had had the colostrum.
 
“Why are you frowning?” asked the ECIC (AKA Wife).
 
“It doesn’t make sense” muttered the Microbiologist, “you get antibody in babies by transplacental transfer, not drinking milk.”
 
“So, you’re saying the experts are wrong and you’re right?”
 
“No, I’m just confused.”
 
“Well, that’s because you’re not a vet.” Continuing to mutter under her breathe “didn’t I say I’ll marry you ONLY if you NEVER act in a medical manner towards my cats…”
 
She had been “warned” about medical interference and the “know-it-all” attitude of medics by her vet!!!
 
Oh, sorry, did I not say? We were watching This Farming Life (one of our favourite TV shows) and they were talking about Clydesdale foals and whether they must be given the colostrum from the mare!

Sunday night is “Antiques Roadshow night” in our house, every Sunday in the UK the BBC1 broadcast an hour of people bringing their various family heirlooms or jumble sale bargains to antique experts for a brief chat about what they are and how much they are worth. I enjoy the social history side of the show although I find the occasional “money-grabbing” a bit depressing.
 
Last Sunday, 20th February, was a bit different as I saw a trailer showing something unusual and medical… queue my curiosity! I was glued to the program in anticipation.
 
It was the last item on the show, and it had been brought in by some school children and their Headmaster and it was this:

I’ve had to reduce the amount of time I spend watching the news as it’s really not good for my mental health. Not only that, but ECIC is getting increasingly irritated with me muttering and grumbling at the various Covid-19 stories, and she’s right, I should “just let it go”.
 
One (of the many) things that irritates me is when someone says a new variant is “more transmissible”. Why does it irritate me? Well, it’s an incorrect term. Transmissible means “being able to be spread from one person to another”, well we know SARS CoV2 is transmissible… but it cannot be “more transmissible”, it is either transmissible or it is not. More transmissible would mean that it was better able to “move” from one person to another and we have no evidence of that at all… it hasn’t suddenly sprouted wings!