Mpox in Australia: What GPs Need to Know Now

Welcome to the Good GP Podcast. My name is Dr. Rami Rahman. I'm a GP based in Perth and a practice owner, and your host for this episode, where we bring you practical, evidence-based conversations to help your work in general practice. Today, I'm delighted to be joined by Dr. Fergus McCain.

Fergus is a colleague and a specialist general practitioner, medical governor of Western Australia's AIDS Council, the M Clinic, and an S one hundred prescriber. So Fergus, thank you so much for joining us here today.

in a monkey. Its host is actually a sort of a Gambian giant pouched rat sort of thing. And it was originally given that title of monkeypox, which we've tried to steer away from to avoid the stigma that came with that. And so it's a virus It's got two significant clades, clade one and clade two. The clade two is seen as the more milder version. That's the one that we've gotten an outbreak of since 2022. There have been a couple of outbreaks over the decades.

But the one in two thousand and twenty two happens to have found a community and a cohort where the transmission has taken off between human to human because of the close skin to skin. contact. So it's an orthopox virus that's related in the family of smallpox that from two thousand and twenty two got into it the MSM, the men who have sex with men population and seems to have found a population where it can transmit. And so we've had a couple of outbreaks

in Australia since two thousand and twenty two. I think if you were just having a chat with a public health physician and they asked you what's the ideal population, but if they had to deal with a transmittable infection outbreak, they'd say the MSM population, they're fantastic. They're incredibly obliging and coherent. They follow all the instructions. They come in. They come in, get tested. The the uptake for the vaccine is fantastic.

and they're very compliant with contact tracing and with isolation. So we've managed over the time since two thousand and twenty two, particularly here in WA, to control the outbreaks incredibly effectively. We're very compliant cohort to the caseload and a very effective public health response. So there's been numbers grumbling, I think a couple of th thousand, maybe a thousand, five thousand seven hundred cases a year nationally, most of those over East.

In WA we've had little pockets of outbreaks. Last year I think we had twenty seven cases. This year we've had thirty one cases so far. seven in one week. I had three on a Saturday two weeks ago. So there's definitely a little outbreak occurring. And we're now in WA and and my understanding is this has happened over East as well.

We're now starting to get small numbers in again, it's still sexual transmission, but it's not in the MSM population. So we've had a number of cases in heterosexual men and a number of cases in cisgender heterosexual women.

and we didn't have any background virus sort of grumbling in the community. I think last year or maybe eighteen months ago we lost control of that and that there's a small amount of grumbling virus going on in the background. But I think that's definitely been the case for longer. over East, particularly in New South Wales and in Victoria. And so because the population is the uptake in the vaccine has been so good, it's so controlled really to

just this low level background incidence that sometimes flares. And again, because particularly here, uh again, uh colleagues over East would have to say describe what's going on over there, but our public health response is phenomenal. They really put a lot of effort, resource into trying to encapsulate any particular outbreak and limit it.

So yeah, I think it's there, it's there in the background and it's probably here with us to stay. And the really the message is look out for it, no n which we'll get onto I'm sure, but look out for it, know what to do and to vaccinate and vaccinate.

And then uh that's the pro drum and then a rash that tends to start centrally, particularly in your face, and then moves out peripherally. That's the sort of classic description of its presentation prior to the two thousand and twenty two outbreak in our MSM population.

That's not the classic presentation that we see at all. And I think that's for a number of different reasons. Not least is that we've got very fit, healthy men. It it tends to be th this is becoming broader, but we're talking about uh thirty to forty year olds usually, not always, the most common age group is thirty to four year olds men who have sex with men. much higher incidence in people or HIV, even with an undetectable viral load and a good CD forecant, which we're not really sure why.

And that they present with a less severe illness. So they may have that protrome, they may have the rash, the lesions, but they may not. If they do have the lesions, they tend to be more focused on the side of inoculation. If they've contracted it through all sex, they may have them in the mouth. If they've contracted it through insertive sex, they may be in the urethra, around the pubis, around the penis.

or if they've had receptive anal sex, if they've contracted it through receptive anal sex, th it'll be around the anus. Or sometimes there was a very good study back in two thousand and twenty two that looked at a European cohort of over five thousand Patients who presented with proctitis, and 30% of them had no ProDrome and no lesions. They just had severe proctitis. So they had this sort of presentation that our GPs that are listening might associate with anal HSV.

where you might not see the lesions, but the patient comes in quite distressed state with very significant anal pain and very painful to even swap.

and have a very open, non-judgmental approach to asking questions about a person's sexual health. And if you feel uncomfortable with it, open it up for us with a little a lead in saying, look, I'm gonna take a sexual health history, are you happy with that? And then you need to ask very oh and most people are very comfortable having that conversation then. And you're asking what are your sexual practices? And if they say they're MSM, do you top bottom? Are you verse?

what sort of sexual activity have you had? And so, you know, you'd say, I need to know what to test, where to swab. So can you just let me know about what your sexual practices are? Have a very open and frank conversation. which one directs you and allows you to assess risk and to what you need to test. But it also just gets rid of all those barriers and it's for the patients so that they feel comfortable and they feel that it's a nonjudgmental space.

Right? Yeah. So that's the first thing. The first thing is ask the right questions. And then if you do suspect it, so if they're in that cohort, the MSM, sexually active in the last three weeks, so the sort of classic thing was if they've had a fever, a rash and had sex in the last three weeks. think about MPOX. And now you've got to think a little bit broader, so you don't just think MSM, although that is definitely by far and away the highest risk.

than some bisexual men or women who have partners who are bisexual or men who are very sexually active and might attend sex parties or sex on premises sites or beats. they're all a higher risk. And so you ask all those sort of questions to assess that risk first. If you've got to that point and you've got somebody who's got a sexual risk in the last three weeks,

has perhaps got the prodromal symptoms or even not, but has some lesions. What they should probably do then is use universal principles, put a mask on. It's very difficult to contract this virus through respiratory droplets, but it is potentially possible.

So put a mask on if the patient's happy to and you want to, you could ask the patient to put a mask on. And then you're going to take a full STI. You're not going to send them to the lab to do this. You're going to do this yourself. So you're not going to spread the risk at that point. You're gonna take a swab of the lesions. Do not use a scalpel to de-roof the lesion. The only cases that I know of doctors contracting this virus.

our occupational contraction is through using a blade and cutting themselves with the blade. So try and rub the lesion vigorously with a dry swap. The literature will say try and de roof it sometimes, but I've never done that. I just rub it vigorously with a dry swab. I mean in terms of the transmission risk, I think for the first time since I was a junior and working at ENT uh a few weeks ago, I had a patient walk into the room and as he walked into the room he sneezed all over me.

and apologized profusely and I thought of fine, don't worry about it and then I asked him why he'd come in and he had at the triage at the desk, the nursing triage, had missed in fairness, his story changed. And it was became very quickly evident that the lesions I was looking at were MPOX lesions and when I did his nasopharyngeal swab, it was positive. Now I've been vaccinated because I've got such a potential exposure, but I didn't catch anything, didn't get any symptoms.

It's definitely not easy to catch and the handful of cases that are reported in the literature that are non sexual are much more direct in terms like fomite transmission. So basically what you can do is put a mask on, put a mask on the patient, swab the lesions, and then also do a first void urine for chlamydia and Gonorrhea, do it, ask the patient to do their own rectal swab for a chlamydia and gonorrhea, or if they've got rectal symptoms, you do it. You have to examine them and do it.

And also do a dry throat swab for chlamydia and gonorrhea and a nasopharyngeal swab for MPO. If you're happy to and you've the time to and you've got the ability to do the phlebotomy for HIV and syphilis,

If you don't, then don't worry about that. That can be done later on. But we would recommend don't send them to the phlebotomist to do all that. Do it once you're in the robe, right? And then after that, if you've suspended MPOX, that which you at that point you may you obviously do because you've done the testing. you need to advise them to go home and isolate until the results not have any sexual contact

Wear a mask if they go out. It's a bit like the COVID advice, wear a mask when they go out, if they go shopping and stuff like that and wait twenty four hours before don't have any sexual contact and wait twenty four hours before the results come back usually fairly quickly from the lab.

and ask them if they've got a partner at home to separate bedrooms and separate bathroom and kitchen utensil the type. They don't have to live in an the other side of the house or anything, but just to be a little bit m more circumspect about close contact and definitely no skin to skin contact. And then public health will take over if the test comes back positive.

or Doxy Pep now, for instance, you could add into that list. You think, okay, you're assessing their risk and their sexual activity as a risk, so they should be offered the vaccine. Sex workers were also offered the vaccine. So female sex workers were also offered the vaccine. And then we offered it occupationally to our staff that were frontline staff, the doctors and nurses that might be in the room with the patient. That's broadened out now.

So particularly now because that population it's spreading. So it's still in the sexual transmission sphere, but that's actually now it's spreading out into the more fluid society that we have and probably have always had. We just have terms for it and we describe it now and I'm a bit more open about it. So we've got men who have sex with men and women. We've got women who are partners of men who they know they have sex with men.

We've got women and men that go to sex on premises sites or beats or sex parties. And so anybody, male or female, whose sexual activity puts them at risk, they should be offered the vaccine. Nationally, I'm not sure of the numbers. We've eighteen thousand vaccines in WA, so we've no problem with supply, so I'm assuming no other state has problems with supply. They were resource accessed nationally. They're available at places like this, the sexual health clinic.

The GP practices with a high caseload will have them in the fridge all the time. Any GP practice that feels that they might have a high caseload, they can order them in easily through the same way that you order your usual vaccines. We do in WA for instance our busiest

MPOX vaccine clinic is in the Perth Steamworks, which is a sex on premises site that for decades we've put nurses in there doing testing and since the MPOX outbreak we now do vaccines in there and I do a CREP and a PEP clinic in there on a Thursday night. So we provide testing and services on site. So we've a lot of people come just for the vaccine to there and the venue owner lets them come in for nothing. If they're coming in for that, they don't have to pay the door fee.

So there's lots of places to access it really. And I suppose if you're a rural GP or an isolated GP in a clinic where this is not usual, you can get their advice through your public health service. Two vaccines a month apart? It's a live, attenuated, non replicable vaccine. It's a third generation smallpox vaccine.

And that's also got good cover for MPOX. You can give it to immunosuppressed people, so that's not a contraindication. Actually, an immunosuppressed patient is more likely to have the severe consequences of MPOX. The Clayed Two version of Mpox, which is seen as the milder one, has still had four hundred and ninety-three deaths since the outbreak in two thousand and twenty two. It is not completely harmless.

There is a antiviral that's held federally. We have a supply in WAS, every state will have supply that is used for severe cases who are immunoseppressed, particularly on whether or encephalitis or pneumonia, or we've had I think we've used it once in WA as far as I'm aware for a corneal infection, right?

that would all be accessed through your local infectious diseases service. But one vaccine offers different studies say different things, but like fifty-eight to eighty-six percent protection, two vaccines, eighty to ninety percent protection.

And the thing that's important that fits into the question you asked originally too and how they may present, because our uptake has been so good, most of my patients, I think I've managed twenty-seven, twenty-nine cases now, and most of those have been vaccinated. So they're part of that sort of ten to eighteen percent of people that have the vaccine hasn't fully protected them. And that means a couple of things. Most of them have a mild illness, most may have a delayed presentation and quite a

subclinical presentation. So you need to be more vigilant. Don't just think they're vaccinated, so I'm not going to test or think about it, right? And that's an important part of the conversation that you want to have with the patient before you give them the vaccine.

So for both of those bases, we offer it to the staff that's the doctors and the nursing staff that may be involved and find themselves testing or in the room with somebody who's coming in with those symptoms if they want it.

Right. And then I think in terms of it's a take-home message, the one thing you or maybe two things I'd like people to try and remember from the podcast in terms of MPOX would be fever, rash and high risk sex in the last three weeks. think of empox and lesion, of course, and with the caveat being that if somebody comes with painful proctitis and they've no prodrome and no lesions, still test for us. And you do that's with a rectal swab. So I think that's probably that's enough.