Jovi Stuart
Good Evening everyone, and welcome to tonight's webinar, Stay Ahead in Sexual Health - Navigating Mpox and Doxy-PEP in your practice. We are joined tonight by speakers, Dr Vincent Cornelisse, Dr Tobias Vickers, Matthew Vaughan, and Dr Vani Arjunamani. My name is Jovi and I am your RACGP representative for this evening.
Before we get started, I would like to make an acknowledgement of country. We recognise the traditional custodians of the land and sea on which we live and work, and we pay our respects to elders past, present and emerging. I would also like to acknowledge any Aboriginal and Torres Strait Islander colleagues that have joined us online tonight. For me, I am dialling in from Guringai country, located on Sydney's North shore. I would like to formally introduce to you our facilitator for this evening, Dr Vani Arjunamani who is a GP with a focus in evidence-based chronic disease management and preventative healthcare in high risk populations with a passion to encourage chronic disease management in women's health. As an RACGP supervisor, she imparts a systematic approach to multi-morbidity to her registrars and champions, general practice to medical students from the University of Sydney. I will now hand over to Vani to introduce the rest of the speakers and to go over the learning objectives. Over to you Vani.
Dr Vani Arjunamani
Thank you Jovi. Welcome everyone. We have a very exciting topic today and it will be presented by Dr Vincent Cornelisse, who is the Medical director of HIV and Sexual Health Services as well as North Coast Population and Public Health Directorate. He is a staff specialist in sexual health medicine at New South Wales Health. He will be joined by Dr Tobias Vickers, who is advanced trainee with Sexual Health Medicine Sydney and at the sexual health centre, and he is a data scientist with Kirby Institute. There will be also a community perspective provided by Matthew Vaughan. He is an Acorn director of HIV and Sexual Health Division. Now I will pass it on to the learning objectives. By the end of this CPD activity, you will be able to list new resources and guidelines that support effective management of STIs. Outline current epidemiology of Mpox and risk factors for transmission in New South Wales, manage its clinical presentations, differential diagnosis, vaccination and testing for it. We will also be able to describe how and when to use Doxy-PEP to reduce the incidence of certain bacterial sexually transmitted infections and implement a practical approach to Doxy-PEP prescribing in appropriate patients. Now I would like to hand over to Dr Tobias Vickers.
Dr Tobias Vickers
Hi, everyone. I am Toby. I am one of the advanced trainees at Sydney sexual Health. I am just going to very quickly run through some statistics with you. We are just going to start in syphilis and we are specifically talking about infectious syphilis here. You can see that there has been increasing and steady rise in the notifications of infectious syphilis over the past decade, and we are predominantly this is being reported among males but especially men who have sex with men in the last five years, but we have seen a change in the epidemiology of syphilis, and we have noted more infections among heterosexual populations, including women of reproductive age. Going on to the next slide. Looking at specifically infectious syphilis in women of reproductive age, you can see this is a little bit of a scary graph. The numbers are rising quite rapidly over the past decade, and I will just draw your attention to the light teal colour at the bottom. This is 28 pregnant women in 2023 who have been diagnosed with syphilis whilst they were pregnant, and then there has been about 155 women with syphilis who were not pregnant, but of reproductive age. We go to the next slide. The big issue about this is really congenital syphilis, and we really had not seen cases before 2017, but we are starting to get cases now of congenital syphilis in New South Wales. This is really quite quite concerning, and obviously syphilis during pregnancy, left untreated, leads to mother to child transmission and the devastating effects of congenital syphilis being preterm birth, low birth weight, major congenital abnormalities, foetal loss and stillbirth, as well as neonatal death. I think the main key feature of these numbers is really that New South Wales Health is recommending testing for syphilis in the second trimester of pregnancy in addition to the first trimester. Mostly because treatment during pregnancy can really avert congenital syphilis. We go to the next slide. We are just going to jump straight into a different STI, gonorrhoea. Gonorrhoea notifications have fluctuated over the past decade, but the rate began to increase in 2022 after two years of decline coinciding with COVID. We have been experiencing a 20% increase in cases between 2022 and 2023. The point about this on the next slide is just that we are getting more antimicrobial resistant gonorrhoea. This is really concerning, and you can see towards the end of the graph from May 23 that we are getting azithromycin resistant gonorrhoea, and that is really important to collect your cultures when you are either thinking that a patient has gonorrhoea and instituting empiric treatment, or you have called a patient back and you are treating them for gonorrhoea, please collect cultures. This really helps in understanding the epidemiology of antimicrobial resistance. In my head, whenever we I pull out the ceftriaxone, it is really a stop and think moment. Have I done a culture for this person? I think the other thing just to draw your attention to is a requesting a throat MCS or rectal MCS. Sometimes it is not enough for the lab to see gonorrhoea, and really, the crucial thing is on the request form writing suspected gonorrhoea or that you want a gonorrhoea MCS or editing your best practice or medical software to include a prefill, just because certain plates need to be done in the lab to grow gonorrhoea effectively just because it is a bit fastidious, so that that culture based susceptibility testing is really crucial for our ongoing AMR surveillance. I am just going to do 1 or 2 minutes on HIV, and really the key message here is the dark blue that you see running along the bottom. This is non-S100 GP, so non-S100 prescribing GPs, and you can see that really in the Australian born population and the overseas born population, about 30 to 40% of new HIV diagnoses are occurring in this area of the sector, and I think that is absolutely crucial for people to continue doing testing and it just shows the fantastic work that has been going on so far in general practice. On the next slide, we have been seeing an overall decline in diagnoses, which is fantastic, however, this is there has pockets. We are seeing that this is not being seen the same way in greater Western Sydney and particularly in overseas born men who have sex with men. You can see second row and second column that end bar is heading upwards, which is a not a good sign. On to the next slide. Really in the STI guidelines, there is really a significant risk for syphilis in heterosexual people, and the recommendation is that there is serology done for HIV and syphilis for all STI screening. I think it we know try and really think about either swabs or just a pee in a pot kind of test. We need to include the blood borne virus, and syphilis screening in that, and just because of the increase in syphilis among women of reproductive age, making sure we are doing that testing in the first and second trimester, taking a sexual health history is really important with that and then making sure gonorrhoea culture, if you are treating patients for gonorrhoea or suspecting gonorrhoea. Just on to the STI testing tools, there are resources to support the STI testing and contact tracing in general practice. This tool has been recently updated in August this year. It is fantastic. It lists ways you can initiate conversations about sexual health. It has got a really easy to read table outlining different patient groups and the recommended tests, and also it provides guidance on where to seek management, and advice for positive results. Just moving on to the other part of the guidelines, which is the Australian STI Management Guidelines for use in primary care. Just on the next slide. This is a fantastic website. I think it is really useful, especially when you are dealing with clinical presentations, syndromic management. It will really help rationalise and understand what tests to do and what initial treatment is recommended. It goes through management of those positive results and how to contact trace, and they are regularly updated as recommendations change. Just on the next slide about contact tracing, I think we just bring this up as important because I guess it is important to acknowledge that some people do not exchange contact details anymore, so contact tracing can be quite complex or difficult, especially with anonymous sexual contacts. There are lots of resources in being able to recommend patients to do their own contact tracing, but if you are coming up against complex cases, SHIL or the sexual health info link can definitely help, particularly with syphilis. They have the ability and authority to conduct searches through social media platforms as well as alerting exposed sexual partners, reaching out to them, even if you are not sure is a really, really useful way to initiate that. I will hand on to Vincent, who is going to run through some Doxy-PEP information on those stats.
Dr Vincent Cornelisse
Thank you Toby. I have been asked to speak a little bit about Doxy-PEP. Toby, thank you for setting the scene so effectively and I guess to summarise in one or two lines, we are in Australia and many other parts of the world facing a situation where we have significantly higher and increasing rates of bacterial STIs, and we are particularly concerned about syphilis, which as Toby said, primarily, is still seen amongst men who have sex with men, but we are now starting to see cases amongst women and congenital syphilis. Obviously over the years we have spent much time and effort trying to combat this, using frequent testing for people who might be at risk, but now we have a potential new tool in our toolbox to help combat syphilis and that is Doxy-PEP or doxycycline post-exposure prophylaxis. It is fairly simple. It is doxycycline which you all have used before. It is a single 200 mg dose taken after sex. After any sexual exposure that might have put that person at risk of an STI, particularly as I say, Syphilis. Ideally it is taken within 24 hours after sex, but can be taken up to three days or 72 hours after sex, and now there has been a lot of discussion around how do we use this? We know from randomised controlled trials that it is very effective at preventing bacterial STIs such as chlamydia and syphilis. It is probably not as effective at preventing gonorrhoea due to some sort of intrinsic and increasing perhaps tetracycline resistance in gonorrhoea isolates, especially in Australia, when we compare that to the tetracycline resistance rates in Europe and the US. You probably will not be particularly effective for gonorrhoea, but it is certainly very effective for chlamydia and syphilis. It is important to note that of course syphilis is the STI amongst gay and bisexual men that carries the greatest morbidity in terms of people getting secondary syphilis and even we have seen cases of neurosyphilis, and in contrast, amongst gay and bisexual men, the majority of chlamydia and gonorrhoea infections are the asymptomatic or not particularly traumatic as in they generally do not cause complications. We know that already and this is based on some community surveys, we know that there is already a high demand for Doxy-PEP amongst gay and bisexual men because gay and bisexual men in Australia are generally very health literate and they have many have already heard about Doxy-PEP and how that can keep them safe from STIs.
Let us go to the next slide. Now I will not spend a lot of time on this slide because you will all get copies of these slides at the end of tonight. You can have a look at this yourself, but basically there has been a couple of randomised controlled trials looking at the use of Doxy-PEP at preventing bacterial STIs, and subsequently there was a systematic review and meta analysis, and that is what we are looking at here. In a nutshell, Doxy-PEP used by gay and bisexual men will reduce the incidence of chlamydia by 81%, and it will reduce the incidence of syphilis by 77%. These are massive reductions in incidence as a result of Doxy-PEP use, and again, just to reinforce that this is just two tablets two times 100 mg taken as a stat dose after sex. We are not talking about people taking Doxycycline every day necessarily or necessarily having particularly enjoyable sex life. Again, the decrease in gonorrhoea was only 45%, and as I said in Australia this might not translate to any significant effectiveness.
Next slide please. Vani posed this question. What does that mean in terms of number needed to treat, and Michael Trager, who is an epidemiologist in Melbourne, he did this very clever study when he was working at Harvard University last year and used their dataset to calculate numbers needed to treat, and just very briefly, as you can see on the left graph, we have got the numbers needed to treat to prevent one case of syphilis if someone uses Doxy-PEP for one year as in not again, not every day, but during that one year period uses it after sex. To prevent one case of syphilis over a year, the number needed to treat is 9.5. If you give it to people who have recently been diagnosed with syphilis. Number need to treat of 9.5. That is pretty good I think we would all agree, and then if we look in the graph on the right, if you want to know the number needed to treat to prevent any bacterial STI over a one-year period then the number needed to treat, if you select people who have recently had a diagnosis of syphilis, it is two. If you are just looking at giving Doxy-PEP to people who have had syphilis, you only need to give it to two people in order to prevent an STI over the subsequent 12 months, so I think we all agree that that is a pretty good number needed to treat.
Let us go to the next slide. Of course we need to balance these benefits with evidence for harm. Generally, Doxy-PEP is very well tolerated. There were some gastrointestinal side effects during the trial, and you know we all know the side effects of Doxycycline, esophagitis. Again to highlight this with most of these people did not use Doxycycline every day, it was just done as required after sex so as you would expect, you then get less side effects than if you were then comparing that people who use it every day. There were no significant side effects reported at all. There have been a lot of questions around what does this mean for antimicrobial resistance? We all want to be very good antimicrobial stewards, and again the same systematic review found some increase in resistance in target and non-target organisms when used for STIs, but that was also when looking at use for malaria prophylaxis and treatment for acne and other indications. In the STI specific trials, there was a very small, I cannot remember the exact number, but a very small increase in antimicrobial resistance in non-target organisms. These are a strep and staph carried by people and MRSA, very small, probably not clinically significant. Importantly also, there was no increase in resistance in chlamydia and syphilis, and as we have already talked about, the majority of gonorrhoea isolates in Australia are already resistant to tetracycline. We would not expect a further increase or at least it is not relevant anyway. The other matter that has been investigated is, does this have an effect on the gut microbiome, which is, of course an area of research that is very relevant at the moment. Again, this is difficult work to do. We have limited data. They did look at this during a six month follow up study and they showed no effect on any microbiome measures in that study. It looks safe at the moment, but of course, this is pending further data as we continue to monitor the implementation of Doxy-PEP in our communities. Just for some community perspectives, can I please ask you to chip in here
Matthew Vaughan
Yeah, absolutely. Thanks, Vincent, and thanks, everybody. I think it is important to say that we know that there has already community members that are engaging in Doxy-PEP, so they are already taking it. We hear this through anecdotally through the number of workshops that we do. It is really important that we have messaging about this out in community to do it safely. GPs play a really critical role in the implementation of Doxy-PEP, particularly here in New South Wales and throughout Australia, and what we saw through the introduction of HIV Prep was that there were many GPs that were not familiar or were not aware of what this meant, and so this is why we are starting to talk now about the importance of Doxy-PEP and getting education about it and what that means. This is not something that we are talking about for everybody necessarily. For a lot of people, they will be very happy with their regular condom use and their chosen HIV prevention strategy. However, particularly for some people where they are using other biomedical preventions, Doxy-PEP has a really pivotal role to play in reducing STIs, and so I encourage you, particularly as you have got patients coming forward to talk to you about this to be aware of that. They are obviously seeking it out, and, using language or that is comfortable and empowering so that they are able to go home and protect themselves from STIs is going to be really key, And your key to that. Thanks, Vincent.
Dr Vincent Cornelisse
Thank you. Matt. Let us go to the next slide. For those of you who are super keen and interested in the nitty gritty details, the earlier this year published the consensus statement on Doxy-PEP for use in Australia. It is available in the MJA and it is open access, so it is easily accessible by anyone, just Google MJA Doxy-PEP and I am sure it will come up. This paper is quite detailed and it runs through all the background data, and the most relevant studies. What we did in this paper was develop some proposed indications for Doxy-PEP. This is what is I guess most relevant for clinicians, and as Matt pointed out so eloquently, we are not looking at implementing Doxy-PEP in the same way that we implemented HIV Prep. So HIV Prep was very much focused on let us get it out to anyone who has got some risk of HIV because if we are going to achieve elimination of HIV transmission in Australia, we really need to kind of blanket cover people with HIV Prep. This is framed much differently to that sort of epidemiological approach. To propose indications for Doxy-PEP are for example, if someone has recently had a diagnosis of syphilis, then we know that giving them Doxy-PEP will significantly reduce their risk of getting syphilis again in the subsequent 6 to 12 months because we know that the strongest predictor for getting syphilis is having had syphilis. If you have had syphilis, then you are obviously sexually active in a network in which syphilis is circulating, and hence there is a fairly good chance you will come into contact with it again. Other indications again, based on this number needed to treat data from Michael Trager, other indications were if someone has had two or more recent other bacterial STI diagnoses, so for example, you have seen them over the last 3 to 6 months and they have come in once with chlamydia and they have come in another time with gonorrhoea, they probably would benefit from going on Doxy-PEP for a period of 6 to 12 months. Another indication is a person who identifies an upcoming period of heightened STI risk, so for example, you might see a patient who has not had any STIs recently, but they are planning to go on a holiday to Mykonos and they are going to have a great time in Mykonos. They are going to have lots of sex. They might benefit from going on Doxy-PEP for their upcoming holiday, because there has nothing quite like a diagnosis of gonorrhoea and syphilis to spoil the holiday. Other proposed indications include a couple men who have sex with men but who also have sex with women not necessarily at the same time, but sort of concurrently. The consideration there is partly that for those men it might be important to reduce their risk of chlamydia in order to protect their female sexual partners because of course, while gonorrhoea and chlamydia are fairly inconsequential, infections most of the time for gay and bisexual men. For women, that is a very different story. Of course, women can get pelvic inflammatory disease from these infections, so those guys might want to use Doxy-PEP to help protect their female partners. And finally, one of the proposed indications was that if someone presents for HIV post-exposure prophylaxis, then perhaps we should also consider giving them Doxy-PEP for that encounter. This is all much detailed in the consensus statement. I would encourage you to have a look at it.
Next slide please. Now in response to the consensus statement, New South Wales Health very proactively took it upon themselves to develop a shared decision making tool. This is available online for use by clinicians, and it is very much being designed to help stimulate and guide the conversation between the clinician and the patient around the pros and the cons of Doxy-PEP. It talks through the evidence, talks about how to take it and by outlining the pros and the cons, the patient and the doctor can together come to a mutually agreed decision on whether it would be appropriate for that person to trial Doxy-PEP. This was put together by the Expert Advisory Panel and is consisted of sexual health clinicians, public health clinicians, general practice, antimicrobial stewardship experts to really get an informed approach to this new methodology. Again, just to highlight that the people who are most likely to benefit from Doxy-PEP are gay, bisexual and other men who have sex with men as well as transgender women, and that it may also benefit people who take prep and commercial sex workers after a condom breaks.
Next slide please. Again, as I said, it runs through how to take Doxy-PEP a 200 mg as a single dose up to 72 hours after sex. It recommended that the ongoing need for Doxy-PEP should be reassessed every six months, and this should be sort of understood from the outset like it might be suitable for someone to commence on Doxy-PEP, but then this should be reviewed six months later with their doctor. Their circumstances may have changed, their relationship status may have changed, and then it would be worthwhile reviewing whether it is necessary to continue with Doxy-PEP. In terms of prescribing, people can get, of course, a PBS prescription for Doxycycline, but that is only seven tablets with one repeat, which for most people probably does not last very long. What you can do instead is write a private prescription for 28 tablets, and then aim to provide sufficient repeats to last up to six months. Again, that is a conversation with the patient, how often are you having sex? How often do you think you might need Doxy-PEP, and then working out the quantity that may last up to six months.
Next slide please. Just to give a more of an epidemiological perspective because obviously we know a fair bit about what Doxy-PEP can do for an individual who is at risk of STIs, but this really interesting study out of San Francisco showed also what it can do for an entire community. This is looking at the syphilis rates in San Francisco pre and post the introduction of Doxy-PEP. San Francisco was a very early adopter of the Doxy-PEP data, and they produced public health guidance to indicate basically what their advice was that every gay and bisexual man in San Francisco should start Doxy-PEP, that is kind of it in a nutshell, and as you can see, so there has a vertical line through this graph which points to the time when this advice was implemented, and as you can see, prior to the introduction of the Doxy-PEP advice, there was a gradual ongoing increase in syphilis cases, and after the introduction of the Doxy-PEP advice, there was a fairly dramatic and sustained decrease in syphilis cases, and ultimately it resulted in a 51% reduction in syphilis cases in the community. So this can certainly have a very powerful impact on syphilis transmission in our communities, and again just highlights that this could be a very useful tool in our ongoing fight against syphilis. Vani, was there a question that you wanted to ask? I just saw something in the chat box. That is all on Doxy-PEP, but we can obviously, have time for questions at the end.
The next slide is just go to our next topic, and that is the focus on Mpox. Now, you have probably been exposed to some of these media messages over the last two and a bit years since we first started seeing Mpox, but it is certainly increased over the last six months.
Let us go to the next slide. This is the current Mpox situation globally. We have got two clades, circulating clade one and clade two, very creatively named. The clade that we have mainly seen around the world is the clade 2B, which has been increasing globally since May 2022, and that has covered multiple countries. As you can see, all these sort of orangy colours is countries with claimed to be cases, and it is primarily been amongst men and primarily amongst men who have sex with men. This is very much an epidemic of sexually transmitted Mpox globally. The case fatality rate in the current outbreak of clade 2B is very low. It is less than 0.1%. At that contrast, to the clade 1B Mpox outbreak, so that is the countries in green and a couple of those blue stripe countries. It has primarily been seen in the Democratic Republic of Congo. We have got clade 1A, clade 1B and this at least in the DRC, seems to have a much higher case fatality rate and it has got a different transmission patterns we are seeing it in families and children, whereas as I said, clade two outbreak has been amongst men who have sex with men.
Next slide please. Now just to put this into some nice bar graphs. As you can see on the left here, we have got 2022. These are all New South Wales cases. In 2022, we had an outbreak that we were very excited, about and it was a lot of talk and a lot of work to contain it because we saw this new outbreak of a new disease and we very rapidly rolled out lots of vaccinations and had lots of conversations with the affected community. It was a very collaborative effort to contain it and contain it we did. By late 2022, early 2023, it was essentially gone out of Australia. We were not seeing any more cases. Now, unfortunately, here on the right, we have got the numbers in 2024. As you can see, the 2024 numbers far outstrip the 2022 numbers. We have got a much bigger outbreak now. We have had 389 cases in New South Wales since June. This is very concerning. Again, this has primarily been amongst men who have sex with men. Up until yesterday it was only men that were getting Mpox, but I believe that is now changing or has slightly changed, as in with one case. Currently, what is happening is that 33% are being diagnosed by GPs. This is again why we are doing this webinar tonight or at least why we are talking about this topic is that this is something that you might see in your practice. Hence, it is important that you are able to recognise this as Mpox and then be able to test for it appropriately.
Next slide please. Mpox is transmitted. What I will say is certainly when Mpox first popped its head up in 2022, there was a lot of concern about what this might mean. What is this? How is this transmitted? It is an orthopoxvirus. It is related to smallpox. Does it transmit the same way as smallpox? Do we need to worry about respiratory droplet transmission? Do we need to worry about fomite transmission? As in, can it be transmitted through bedsheets and contaminated surfaces? That was 2022. I am very confident now when I say that Mpox or at least the global Mpox outbreak is an outbreak of sexually transmitted Mpox. It is transmitted through close skin-to-skin contact and it is transmitted through exchange of bodily fluids. I think these other potential modes of transmission are so rare that they are almost hardly worth considering. What I should say is that people with Mpox can be infectious for up to four days prior to the onset of symptoms, and that is obviously an important fact when we consider contact tracing, as in when we see someone with a new Mpox Infection, how far back do we go in terms of notifying sexual contacts?
Next slide please. I think, Toby, that one is for you.
Dr Tobias Vickers
Yeah. Thanks, Vincent. I am just going to run through some of the Mpox presentations and a few case studies that we have seen at Sydney Sexual Health. I have had the glorious job of being the reg for a few days in Sydney Sexual health, which involves being dressed up in a lot of PPE and sweating for a long period of the day. In terms of the clinical presentations we have seen, it definitely starts with this prodromal fever, myalgia, headache and very notable lymphadenopathy that is variable in people who come in and report those symptoms mostly around their vaccination status. I think we do discuss it a little bit later, but depending on if people have been partially vaccinated or fully vaccinated or not vaccinated at all, I think the prodromal time and the prodromal symptoms can be quite subtle, then a rash appears. and honestly, I have been tricked a lot. There are things that I have thought are absolutely Mpox without question, and they are not. There are things that I have looked at somebody's arm or leg with this small red macule that looks like one pinpoint folliculitis type lesion and it is Mpox. I think you have really got to stay on guard with the clinical presentation and the person that is presenting in front of you just because he symptoms can be really mild and atypical. I will run through some of those cases that were a bit like that.
Symptoms usually begin about 7 to 14 days after exposure, can be as long as up to 21 days. It includes rash, pimple like lesions or sores on the genitals, around the bottom, on the buttocks. They can be on the face, arms, legs. The ulcers can also be in the mouth like sores or lesions. It definitely presents as a proctitis so you can get a presentation of rectal pain which can occur without any other signs as well. The fever, headache, muscle aches and swollen lymph nodes often comes along at the same time as when they come into to clinic. The rash, I would say, starts as like a red macule that really develops into a pustule. Then I find that kind of at day 3 or 4, there is like a central necrotic core. You get these rolled edge necrotic ulcer that very much looks like syphilis as well. Make sure you are taking a sexual history consistent with Mpox history. Asking about these symptoms, just because it can look really similar to herpes, syphilis, tonsillitis. The last point is most of these are going to be a self-limiting infection. People may dismiss the initial symptoms and come in at any point during that process as well.
Just moving on to the next slide. This is a 42-year-old gentleman living with HIV who came to clinic. He saw me. This is essentially most of my clinical notes in terms of how we document this. He had two days of reporting white dots on his penis. It was not very painful. He was undetectable on his HIV antiretrovirals, and he had noted some inguinal nodes on his right side. He gave kind of a vague history of fever maybe this morning. Maybe he felt a bit cold and some vague myalgias. No overseas travel, had not been vaccinated. Basically, on examination, you can see this kind of rubbery ulcer just at the coronal sulcus. I could feel quite significant tender lymphadenopathy on his right side. I have to say it seemed obvious when you put all the fever and the report of these myalgias together, but honestly, looking at that picture and trying to figure out what that ulcer is, I would not pick that as monkeypox. I think when we think about a genital ulcer now where you would normally go straight to is this herpes, is this syphilis, you really need to include monkeypox as that third differential and a third main differential.
We can go to the next slide. This is a little bit more of an atypical case. This was a 34-year-old man who came in one week after for rectal chlamydia treatment. He was coming to get his doxycycline, but he presented to the nurse with a right submandibular lump, and he thought this was after having a JYNNEOS vaccine, the vaccination for Mpox, which happened one week earlier, but it happened in the left arm and he now had this lymph node on the right. It was a bit strange, and the node popped up the day after he had the vaccination. He put that temporal association together. No changes in swallowing or breathing. He felt a bit unwell the day after the vaccine. He had not had any other oral ulcers. No rash. No pain anywhere. I examined this lump. I thought this was maybe a lymph node, but probably like a dental abscess of some kind. He had pretty poor dentition and decay across the lower quadrant. He had just been given ceph and azithromycin, and the ceph and azithromycin was for empiric gonorrhoea treatment. I basically just did an oral Mpox PCR just in case because of this strange lymph node, but was going to refer him off to a dentist, and had already written the referral. This came back monkeypox positive. This big lymph node was really indicating that he did become unwell in the days later and developed some rash on his body as well. They can be really subtle presentations of things that you would not normally always think that this is going to be an STI or this is going to be monkeypox.
Just on to the next slide. These are just some other images of Mpox that we have managed to obtain in clinic. The first one, another penile lesion. The other three are essentially what some of them look like across the body. I would say the one on the wrist is probably the most suspicious looking. The other two are a bit difficult to determine, but I think it is really just to keep your eyes open to any kind of viral rash and symptoms consistent with this.
Just looking at the next slide. Testing people for Mpox. At this point, although there are really varied presentations, the directions really test all sexually active people with symptoms that are consistent. When you see a genital ulcer, just like you would think herpes or syphilis, that third indication, so thinking about Mpox. Asymptomatic people should not be tested as part of routine STI screening. That includes contacts who are asymptomatic. I am going to go a little bit off script in terms of the PPE. Just from my own experience in the clinic, if people are viremic, so they have fevers, they are coughing, they are unwell, we do put a mask on them and see them in masks, and that is just routine, not N95 masks. We then use gloves to examine. At Sydney Sexual Health, we do not use a full PPE setup at the moment just because we are seeing so many ulcers day to day, it just becomes a bit impractical. I think the PPE recommendations are due to change quite soon, but currently, the PPE recommendations are to be in a gown, gloves and surgical mask with eye protection. We collect dry PCR swabs for people. The same swab that you would do a syphilis and herpes swab on. I think just double check with your labs about what is their preference for their own swabs. You can also collect fluid or deroof a pustule or crust and send that in a urine container or a urine jar to the lab.
Just on to the next slide. People who have confirmed monkeypox, they need to abstain from sex for the duration of their infection. They should use condoms for the following 12 weeks after recovery. This is based around some research that there was Mpox DNA in semen up to about 9 to 10 weeks after. I think the 12 weeks makes sense just as an easy number to tell people. No donation of blood or other human tissue or breast milk or organs while unwell or for the 12 weeks after. If you do have a return traveller from Africa and at Sydney Sexual Health, we put that at a four-week kind of mark. Return travellers within four weeks. If you suspect there are symptoms like this, you really need to think is this Clade 1b and that is an urgent call to the public health unit just because that is very different and carries with it different risks.
Just on to the next slide. We are going to chat through treatment. Almost all of the cases, they really do not require specific antiviral treatment. It is really just supportive management and antibiotics. If there is secondary infection, sometimes you can get Mpox lesions on eyes or ophthalmic review, there is an antiviral called tecovirimat which is used in hospitalised patients for really severe Mpox, but I think in community medicine, what we have been managing, it is really pain management to be honest, and then also the education and counselling around contacts and their requirements.
Case clearance, you might get this question from the public health unit where they want you to clear a case. You can clear a case when all of the lesions have crusted and the scabs have formed and naturally fallen off, and there is a new fresh layer of skin for all of the lesions on their body. Essentially you can say that that is medically then clear. The PHUs can follow up with cases and they can provide advice to you as well. If you are testing someone for Mpox, you can advise that potentially the public health unit will give them a call. I always say you are not in trouble. This is really just understanding what is going on with this infection more recently.
Just looking at the next slide when we are talking about complications. You can get a keratitis, the secondary bacterial infections, especially perianal abscesses. We saw one of those this week in a severe proctitis. At the worst end of the spectrum, certainly disseminated disease in immunosuppressed people, particularly with CD4 under 200. If people are requiring complex pain management for severe pain, thinking about referral to hospital for that. We have had 24 patients hospitalised this year and 18 of those cases were not vaccinated and 4 were partially vaccinated.
Just going on to Mpox vaccination, Mpox vaccination is free and it is available for eligible people in New South Wales. The vaccination is called JYNNEOS. We use it both as primary prevention but also in contacts who have not been vaccinated. They can receive post-exposure preventative vaccination. The course is two doses and you give them 28 days apart. It is not a routine travel vaccination at the moment, but potentially there is information on the New South Wales Health website for people travelling to countries where Clade 1 is circulating. In terms of who, we are certainly targeting gay and bisexual men, sex workers and the sexual partners of those people. Also, in our clinic, certainly some people have taken it up, the staff have taken up vaccination, but healthcare workers are at risk of exposure and can consider vaccination. In terms of post-exposure preventative vaccination, there is different case definitions for what a high and medium risk contact is, and that is on the page just listed at the PHU that really says the high and medium risk contacts can come for vaccination as well. In terms of managing Mpox contacts, they really should just be monitoring for signs and symptoms for 21 days. You can direct them to a sexual health centre or offer to get them vaccinated. You can test if symptoms present, and the PHUs can contact known contacts and provide advice as well.
Just moving on to summary and GP calls to action. Consider Mpox as a differential diagnosis in sexually active people with symptoms, especially gay and bisexual men. Testing all sexually active people with symptoms because the symptoms may be subtle and recommend vaccination in your eligible populations and advice about Mpox contacts that they may be eligible for urgent post-exposure vaccination. Matt is just going to touch quickly on the PrEP shortage as well and some community perspective.
Matthew Vaughan
Thanks, Toby. I just wanted to let people know that we do have active communications happening with community about Mpox. You are likely to see people that may be coming forward to your clinic that are concerned about Mpox, and as we heard from Dr Cornelisse, about 30% of cases are being detected through GPs. I wanted to let you know that this advertising is happening all across the state, but particularly targeting inner city areas and where we are seeing cases come up. It might be that some people are coming forward and not necessarily wanting to disclose their full sexual history. Just being very aware and alert for those symptoms as Dr Vickers went through as well because this is very different to Covid. There is a lot of stigma that is attached with Mpox and not everybody is going to be wanting to be forthcoming about the number of sexual partners that they have had or their weekend sexual activities or through the week. So It is something to be very mindful of when people are coming forward and either asking you about the vaccine or concerned about Mpox, but vaccine uptake, as you have heard tonight, is really critical for gay and bisexual men, sex workers and anybody that might be having sex with either of these groups. High vaccination rates are our best bet at preventing any further outbreaks and controlling this one that we have at the moment. Vincent, are you talking about this rather than me, the PrEP shortage?
Dr Vincent Cornelisse
I do not mind. I am happy for you to keep going, but tell me to jump in any time.
Matthew Vaughan
We can do it together just so that doctors are aware that we have heard some community reports of a lack of availability of HIV pre-exposure prophylaxis. This has been due to some limitations and supply chain issues with supplies approved by the TGA, which has meant that some community members are either having to shop around for their HIV PrEP or are unable to get it. New South Wales Health, in particular, have taken some immediate steps to ensure supply in the short term. At the moment, what the current timeline that we have is hopefully should be resuming supply next to normal between October and November. I am aware that the TGA have also approved an additional supplier under a different section to meet the supply needs of the country. If you have got patients that are coming forward and saying, "I am having a bit of difficulty to get PrEP" or if you are writing a prescription, please do encourage them to not wait until the last minute to get their scripts filled and let them know that they might need to shop around. If they are having trouble getting it they can call the New South Wales Sexual Health info line and that will give them the nearest either sexual health clinic, hospital pharmacy or community based pharmacy that has a supply of HIV PrEP. Thank you.
Dr Vincent Cornelisse
Thanks, Matt. Just to add to that, the supply chain issue is not affecting online pharmacies. As some of you will know, people are legally allowed to import PrEP for personal use if they have a valid prescription. Those online pharmacies are continuing to ship to Australia, but of course it does mean that people need to make sure they, as Matt pointed out, need to be organised and order their PrEP well in advance of needing it because it can take a couple of weeks for the PrEP to arrive that way. The other thing to point out is that now might be an ideal opportunity for some people to switch to on-demand PrEP rather than daily PrEP because obviously on-demand PrEP tends to use fewer tablets than daily PrEP. If anyone has any questions about that, please let me know.
Dr Vani Arjunamani
I might just ask the questions. There are some very interesting questions in the Q&A. I will come back to you and Toby for the Mpox questions, but this is back to DoxyPEP. The question was is there much data and what happens if they are allergic to doxy? If you can answer that, Vincent.
Dr Vincent Cornelisse
Is there much data around allergies to doxy?
Dr Vani Arjunamani
No. Just much data on using DoxyPEP, and the second part to that question was what to do if they are allergic to DoxyPEP.
Dr Vincent Cornelisse
There is quite a lot of data on using DoxyPEP. I am not a purist when it comes to using DoxyPEP and using DoxyPrEP, to be honest. Technically, thanks Toby for pointing that out so we can clarify. using DoxyPEP technically is using doxycycline 100 mg every day in the anticipation of having sex and wanting to reduce your STI risk. That was the subject of some studies in Australia that was the subject of the Syphilaxis Study. DoxyPEP is what I have described before where you use two tablets ideally within 24, but up to 72 hours after sex. Hence, PEP for post-exposure prophylaxis and PrEP for pre-exposure prophylaxis. DoxyPEP has been the subject of a few large randomised trials. That is where most of our data comes from in terms of effectiveness and also in terms of safety. We certainly do have a substantial amount of high quality data for DoxyPEP in general in terms of effectiveness and safety. That is all outlined in our consensus statement should you care to read it. In terms of your question around allergies, doxycycline allergies are uncommon. I cannot even remember the last time I met someone who had a true doxycycline allergy, and of course all we are doing is using doxycycline. That does not seem to be much of an issue. Certainly, not serious allergies. Of course, getting photosensitivity can be common, but hopefully it would be less common with a DoxyPEP regimen where you are not taking it every day compared to using doxycycline every day for, say, acne or malaria prophylaxis. Of course, people do need to be mindful that they should have the doxycycline because it is a double dose, two tablets, make sure they have it with either a big glass of water or a meal and not lie down after taking it to avoid oesophagitis and potential risk of oesophageal ulcers.
Dr Vani Arjunamani
Thank you, Vincent. This might more in the interest of time on Mpox. The question to you, Toby, was where are the swabs taken, and the second question is, do you think a booster vaccination for Mpox may be offered in the future, and is there any data on waning antibody levels?
Dr Tobias Vickers
We take swabs if there are body ulcers or body lesions that you can see, we will do a direct dry PCR swab on that, and essentially just rub vigorously over the lesion. If there are ulcers on the genitals, we will take a swab from that. Proctitis, we will take a clinician collected anal swab. Most of the time there are external ulcers to swab, but in proctitis presentations currently at Sydney Sexual Health, we are doing an Mpox PCR regardless. You can also do a throat swab for Mpox as well. I would probably say if you are seeing lesions that the highest yield is going to be directly on the ulcer, and taking dry PCR swabs for that. Booster vaccinations, there is no recommendation for booster vaccinations for genius at the moment, so it is purely the two doses. There is research being done at Westmead, I believe, about antibody levels, and it is possible that it may be added in the future but at the moment two doses and that is it.
Dr Vincent Cornelisse
If I could just add sorry just I know we are nearly finished. Obviously there are waning antibody levels and we are seeing Mpox infections in people who are fully vaccinated and have had two doses at least 28 days apart, the important message though, regarding that is that all the severe Mpox infections that we have seen, as in people who have had severe complications have been in people who have not been fully vaccinated. So even if Mpox vaccines might not fully prevent against getting Mpox, they certainly provide a significant protective effect against getting severe Mpox manifestations. We cannot guarantee that people will not get them, but we do encourage them to get vaccinated, and as Toby pointed out, full course is two vaccines at least 28 days apart. We have got lots of people who got their first dose in 2022 and did not come back for a second dose. It is never too late to come back for a second dose, so please encourage people to get their second dose even if it is a year or two years after their first dose.
Dr Vani Arjunamani
Thank you Vincent, thank you Toby and thank you Matthew. I will hand it back to Jovi.
Jovi Stuart
Thanks Vani. I would also like to extend my thanks to our speakers Toby, Vincent, Matt and Vani of course, and everyone who has joined us online tonight. We do hope you enjoy the presentation, and just a quick reminder that as this is a CPD accredited activity and to be allocated your CPD hour, you must complete the survey following this webinar. That is all we have time for today session. Thank you and good night.