Author: Azeem Majeed

I am Professor of Primary Care and Public Health, and Head of the Department of Primary Care & Public Health at Imperial College London. I am also involved in postgraduate education and training in both general practice and public health, and I am the Course Director of the Imperial College Master of Public Health (MPH) programme.

Human monkeypox: diagnosis and management

On 23 July 2022, the World Health Organisation (WHO) declared monkeypox a public health emergency of international concern. By 15 December, over 82 500 confirmed cases of human monkeypox across 110 countries had been identified, with 98% of cases emerging in 103 non-endemic countries. Notably, most patients present without clear epidemiological links and non-specific clinical characteristics. We offer an overview of human monkeypox and of the assessment, diagnosis, and management of confirmed cases and at-risk patients based primarily on guidance from the WHO and the UK Health Security Agency (UKHSA).

What is monkeypox?

The monkeypox virus is a zoonotic orthopoxvirus related to the variola virus that causes smallpox. Its main reservoirs are rodents, apes, and monkeys. It was first described in humans in 1970 in the Democratic Republic of Congo (DRC). The following 11 countries have historically reported cases of monkeypox (that is, considered endemic for monkeypox virus): Benin, Cameroon, Central African Republic, Congo, Côte d’Ivoire, DRC, Gabon, Liberia, Nigeria, Sierra Leone, and South Sudan. However, there are insufficient data to delineate the differences between endemic and non-endemic regions. Further, the mode of transmission, presentation, and management during the current outbreak is similar in all regions.

Key management points

  • Consider coinfections with monkeypox and other sexually transmitted infections among patients presenting with an acute rash or skin lesions and systemic symptoms
  • While it is safe to manage monkeypox patients virtually, they may need advice to maintain infection control measures and interventions to manage complications
  • A specialist infectious disease unit with access to novel antivirals such as tecovirimat and cidofovir should manage high risk patients
  • Healthcare workers should be aware of the stigma surrounding monkeypox, which may result in reduced health-seeking behaviours; healthcare staff should screen patients sensitively, using inclusive language to avoid alienating patients

Read more in our article in the British Medical Journal.

Uptake of influenza vaccination in pregnancy

Our study published today in the British Journal of General Practice shows how the uptake of flu vaccination in pregnancy varies with age, ethnicity and socio-economic deprivation.

Pregnant women are at an increased risk from influenza (flu), yet uptake of  Seasonal influenza vaccination (SIV) during pregnancy remains low, despite increases since 2010.

Getting the flu vaccine when pregnant is important, because it reduces the risk of severe disease, complications and adverse outcomes for both mother and child such as pre-term birth. However, uptake was lower among women living in more deprived areas, women who were younger or older than average, Black women and those with undocumented ethnicity.

Although the flu vaccine is safe and recommended for pregnant women, misconceptions about safety play a role in pregnant women not being vaccinated and flu vaccination levels among pregnant women are suboptimal worldwide.

In the UK, since 2010, the Joint Committee on Vaccination and Immunisation (JCVI) has recommended that pregnant women get the flu vaccine to provide protection during the winter flu season. Despite these recommendations, data from Public Health England (now the YK Health Security Agency) showed that in 2020-21, fewer than half of pregnant women were vaccinated.

Previous studies of influenza vaccine uptake during pregnancy have either used data from a single care provider, or from surveys. Our retrospective cohort study looked at 450,000 pregnancies among 260,000 women in North West London, over a ten year period. By applying statistical models to data on women’s age, ethnicity, health conditions and socio-economic deprivation, we were able to identify groups with lower uptake of the flu vaccine.

Misconceptions about the safety and efficacy of antenatal vaccinations play a role in pregnant women being unvaccinated, while recommendation by health professionals improves uptake. To ensure access to vaccines, for high uptake among pregnant women, strong primary care systems are needed and targeted approaches are recommended to reducing inequalities in access to vaccination and should focus on women of Black ethnicity, younger and older women, and women living in deprived areas.

Update for Primary Care Clinical Team 19 January 2023

1. Covid-19 statistics update

After a peak in December, Covid-19 cases, hospital admissions and deaths have begun to decline in January 2023. We are though likely to see further waves of infection later in the year.

2. Covid-19 vaccine boosters

Uptake of Covid-19 boosters has plateaued at a lower level than we hoped for. In England, around 64.4% of people aged 50 and over have received a booster in the current campaign. In Lambeth, only 40% of people aged 50 and over have received a Covid-19 booster, well below the national average. Pleas encourage patients to attend for a booster if they are eligible.

3. Covid-19 treatments

Some people at highest risk of becoming seriously ill from COVID-19 are eligible for antiviral treatments on the NHS. These include some patients with cancer, blood conditions, kidney disease, liver disease and autoimmune conditions, among others.  GP reception staff must arrange an appointment with the clinical team if a patient calls and says they are eligible for these treatments, have tested positive for COVID-19 and have not been contacted about treatment.

My view is that the NHS England treatment pathway is flawed. Asking patients to contact their general practice delays the start of treatment and adds to GP workload. Patients should have been asked to contact their local CMDU directly if they have not been contacted about treatment after a positive Covid-19 test. Any failure by the local CMDU to contact a patient should be seen as an SEA.

 4. Influenza

The latest UKHSA report shows that influenza admissions in London have started to fall from their peak in February. See recent Evening Standard article. https://www.standard.co.uk/news/london/london-past-peak-flu-wave-nhs-azeem-majeed-b1053535.html

We were expecting a larger flu wave in the Winter of 2022-23 because of the greater social missing this winter and the low levels of flu over the previous 2 years.

5.  NHS pressures

The NHS in England has experienced exceptionally high pressures in recent weeks, leading to the Prime Minister holding an emergency NHS summit on Saturday 7 January. We await the outcome of the summit. Strike action is adding to NHS pressures. We need to consider a team how we can support our patients and manage workload.

Transforming health through the metaverse

A real change is on the horizon. In October 2021, Facebook announced that it would rebrand itself as ‘Meta’, and this generated high levels of public interest in the metaverse for the first time. Definitions for the metaverse vary and there is still much uncertainty in its eventual future manifestation. It is perhaps best defined as a fully immersive parallel digital reality where users will be able to interact at a scale previously unimagined.1 The advent of the metaverse could have transformational impact on every aspect of human life, from our social interactions to what we ascribe real value to. Just as the Internet has completely transformed health, the metaverse will redefine virtual and physical possibilities in health.2 This will have major implications for our health and for healthcare delivery. The coming of age of the metaverse is in due largely to the maturation of technological advances in artificial intelligence and devices that enable the delivery of mixed, augmented and virtual reality, along with cryptography, the catalyst behind web3, and increased computing power.

Read the full article in the Journal of the Royal Society of Medicine.

Primary care update on Group A Streptococcal infections in the UK

There has been an increase Group A Streptococcal (GAS) infections in recent months, which has led to at least 8 deaths in children. Although GAS rates are higher than expected for this time of year, they have been higher at periods over the last decade. GAS causes a range of infections including Scarlet Fever and also more severe invasive disease.

For more information on management, see: Scarlet fever: a guide for general practitioners. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5649319/
The Centor score can be used to assess the probability of an illness being GAS pharyngitis: Tonsillar exudates, tender anterior cervical adenopathy, absence of cough, history of fever (>38 °C). Penicillin V (or Amoxicillin) is the preferred treatment unless contra-indicated in which case an alternative such as a cephalosporin or clarithromycin can be given.

Scarlet Fever and invasive GAS disease are notifiable and should be reported to the local health protection unit. Contacts (although at higher risk of GAS infection) do not generally need antibiotics unless symptomatic. See contact tracing flowchart for details. Health protection teams are responsible for contact tracing.

This guidance was updated in 2008 and may change again.
https://www.gov.uk/government/publications/invasive-group-a-streptococcal-disease-managing-community-contacts

Antibiotics should only be administered:
1. To mother and baby if either develops invasive group A streptococcal disease in the neonatal period (first 28 days of life);
2. To close contacts if they have symptoms suggestive of localised Group A streptococcal infection, i.e. sore throat, fever, skin infection;
3. To the entire household if there are two or more cases of invasive group A streptococcal disease within a 30 day time period.

Oral Penicillin V is the drug of first choice where chemoprophylaxis is indicated. Azithromycin is a suitable alternative for those allergic to penicillin. Some areas of England are now reporting shortages of liquid antibiotics.

Group A streptococcal infections in the UK

There is currently considerable media coverage and some public anxiety in the UK about Group A streptococcal (GAS) infections. Journalists who write about cases of infectious diseases need to understand the principles of the Poisson distribution. Events such as infections can sometimes cluster in time or space due to chance, and not because there is an underlying cause behind the cluster of cases.

Some journalists and doctors are stating that the cases of Group A streptococcal infections we are currently seeing in the UK are from lower levels of immunity because of Covid-19 control measures over the last 2.5 years. This is not necessarily the case and needs further investigation. The UK has experienced large outbreaks of Group A streptococcal infections in the past. For example, the UK had a large outbreak of Group A streptococcal infections between September 2015 and April 2016 (the largest since 1969), resulting in PHE issuing an alert.

The current cluster of Group A streptococcal infections won’t be the last we will see in the UK. Outbreaks of this and other infections will continue to occur. What is important is that our public health agencies and the NHS have the capacity to investigate and manage any outbreaks.

Developing a shared definition of self-driven healthcare

Witing in the Journal of the Royal Society of Medicine, myself, Austen El-Osta and Chris Rowe set out a vision for building sustainable, self-driven healthcare spanning primary care, secondary care and the wider health and social care system has been set out by medical innovators. Self-driven healthcare (SDH) is an umbrella term introduced by Innovate UK, the UK’s national innovation agency, to conceptualise aspects of healthcare delivery that can support people in becoming more engaged in managing their own health and wellbeing, rather than being passive receivers of healthcare.

In our paper, we describe an SDH ecosystem that supports individuals to take more ownership of their health and wellbeing and in recording their own data (e.g. weight, blood pressure) using a phone app, tablet, computer or Bluetooth device. This self-generated data would then be uploaded onto a secure online SDH portal which holds all their health records, including those generated in the wider healthcare system.

Individuals would also enter other data such as what medication they had taken that day, the food they had eaten or the exercise they had done. They may even have a range of other devices that automatically record and upload useful information, such as environmental data about local air quality that day. A personalised dashboard would automatically present the user with their ‘digital twin’ and the portal may also be enabled to routinely offered insights and actionable advice, including microlearning and behaviour change interventions and a holistic picture of the person’s overall health and wellbeing status.

The SDH approach must create better access to all sections of the community rather than just wealthier and more technically literate individuals. It is also crucial that the SDH movement does not exacerbate inequalities due to the digital divide. How SDH is adopted in the future is very important, especially when it is applied to help enhance the consumer health system by trying to link it effectively with state-funded NHS health and social care systems. It will be important to determine if these online environments will be provided by expanding the NHS App, for example, or by commercial companies.

Supporting healthcare workers with work related stress and burnout

A recent article in the British Medical Journal discusses work-related stress and burnout in healthcare workers. These are important problems in the NHS workforce in the UK a well as amongst healthcare workers in other countries. Addressing the underlying cause, which may relate to factors such as workplace demand, relationships, and support is necessary for sustained recovery and full engagement with work.

Healthcare workers may experience guilt or shame due to stigma, preventing them from seeking help if they experience work related mental illness. Time off work and workplace changes to control the triggers may be necessary to allow recovery and sustainable return to work.

Healthcare workers experiencing work related stress can seek support from colleagues, their own GP, occupational health, and specialised services for healthcare workers such as local mental health and wellbeing hubs and NHS Practitioner Health.

Diagnosis and management of Monkeypox in primary care

Our recent article in the Journal of the Royal Society of Medicine  discuses the diagnosis and management of Monkeypox in UK primary care settings but is also relevant to primary care clinicians working in other countries outside West and Central Africa that have  seen Monkeypox cases in 2022.

Since its discovery in 1958 in monkeys, the Monkeypox virus has been rarely found outside west and central Africa until the current global outbreak. The first human case of the virus was in an infant from the Democratic Republic of Congo (DRC) in 1970; the infection has since spread to other regions, primarily in Africa. The first case of the current outbreak was confirmed on 6 May 2022, in the UK and was linked to travel to Nigeria. Two subsequent UK cases were detected a week later; however, neither affected individuals reported contact with the primary case in the UK nor travel to Africa.

On 23 July 2022, the World Health Organization (WHO) declared the current Monkeypox outbreak a public health emergency of international concern, as the number of cases increased rapidly around the world. As of 9 September 2022, 57,016 cases have been confirmed in 96 non-endemic regions, with the UK having one of the highest number of cases worldwide (3484 cases).

As we understand more about the current outbreak, particularly the community transmission of the virus, primary care clinicians may be the first point of healthcare access. Therefore, awareness of the signs and symptoms of the disease and current management strategies is crucial to providing optimal care and advice to patients.

Why shingles vaccine is important for people in their 70s

Much of the discussion about vaccination in the UK is on Covid-19 and flu vaccines or vaccines for children. But there are also other important vaccines for adults – such as for shingles – where there is scope to increase uptake and improve health outcomes for older people and the immunocompromised.

Shingles is caused by the reactivation of latent varicella zoster virus (VZV); sometimes decades after the primary chickenpox infection. For some people – particularly the elderly and the immunocompromised – shingles can be a very unpleasant illness with significant complications.

In the UK, two vaccines are licensed for shingles:

– Zostavax which contains live, attenuated virus and which is given as a single dose.

– Shingrix which is a recombinant vaccine and which his given in two doses.

The main target group for shingles vaccination in the UK is people aged 70-79 years. Most people in this group will receive the Zostavax vaccine. People in this age group who are immunocompromised should receive the Shingrix vaccine. The rationale for vaccinating the elderly is because complication rates are much higher in this group. For example, hospital admission rates for shingles (zoster) are around 20 times higher in people aged 75 and over than those aged 15-59.

When people turn 70, they should receive an invitation for shingles vaccination from their GP. If they didn’t take up the offer of a vaccination at that time, they can still get a shingles vaccination until they are 79. Once they turn 80, you will no longer be eligible for shingles vaccination. Shingles is a disease that has many complications in the elderly. It can result in considerable pain and discomfort and reduce your mobility. In more severe cases, it may require hospital treatment as an outpatient or inpatient. Vaccination reduces these risks substantially.